远端乙状结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的疗效评价

目的探讨远端结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的术后疗效。方法将我院2008年10月~2014年10月10例新生儿期在外院行远端结肠造瘘术的中高位肛门闭锁患儿,二期在我院行腹腔镜辅助肛门成形术设为A组,10例合并直肠尿道瘘,2例合并双侧输尿管膀胱返流,术中游离远端结肠,合并尿道瘘者于瘘管颈部缝扎后离断直肠尿道瘘管,远端结肠下托至肛门口有张力,将远端结肠切除行近端结肠拖出成形肛门。选择2008年6月~2014年6月20例中高位肛门闭锁行经典三期手术(造瘘-腹腔镜辅助下直肠拖出肛门成形术-关瘘)设为B组作为对照,比较2组术后肛肠测压指标,术后1年肛周肌群厚度和Kelly评分。结果 A组随访12~60个月,(35±6)个月;B组随访15~60个月,(46±4)个月。2组肛门直肠组织的形态无明显差异。A、B组肛管静息压分别为(25.85±3.68)、(26.93±4.54)mm Hg,无统计学差异(t=-0.651,P=0.520);A组最大收缩压(35.90±8.44)、B组(41.14±9.60)mm Hg,无统计学差异(t=-1.464,P=0.154);2组肛管持续收缩长度分别为(12.53±0.75)、(12.67±0.78)mm,无统计学差异(t=-0.469,P=0.643);2组直肠内超声观察肛门外括约肌、耻骨直肠肌的厚度分别为(1.93±0.36)、(2.12±0.43)mm,无统计学差异(t=-1.200,P=0.240);2组肛门排便功能的Kelly评分比较无显著统计学差异(Z=-0.334,P=0.738)。结论远端结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的疗效与经典三期手术相仿,而且方便患儿护理、缩短疗程,可以作为中高位肛门闭锁的手术选择。     

腹腔镜技术在小儿肛门闭锁中的应用

目的探讨腹腔镜辅助下先天性高位、中位肛门闭锁患儿手术的可行性。方法 6例先天性高位、中位肛门闭锁患儿,均在腹腔镜监视下游离出直肠盲端及瘘管,切断瘘管,腹腔镜下修补尿瘘或阴道瘘。电刺激找到盆底肌肉中心点,做成一隧道,将直肠盲端从此隧道内拖出,与肛穴缘皮肤吻合。结果 6例均在腹腔镜辅助下完成直肠肛门成形术。腹腔镜手术操作时间35～74 min（平均46.5 min）,术中出血量〈15 ml,住院时间10～18 d（平均14.5 d）。无并发症发生。术后随访6～12个月,无肛门失禁、直肠后间隙感染等并发症,均能够正常排便。肛门功能评分优4例,良2例。结论腹腔镜辅助下直肠肛门成形术是一种安全、有效的方法,处理瘘管方便,辨认盆底肌中心准确,手术后可获得良好的排便功能,具有创伤小、恢复快、疗效优等特点。     

腹腔镜辅助中位肛门闭锁成形术11例报告

目的 探讨腹腔镜辅助中位肛门闭锁成形术的可行性。方法 腹腔镜监视下,游离松解直肠;断离修补直肠尿道（阴道）瘘管,其中6例经腹腔镜离断修补,4例经会阴切口离断修补;然后在电刺激仪的引导下经会阴肌肉中心1.0cm左右小切口向盆底肌肉中心分离形成隧道,最后将直肠从隧道中拖出,与会阴皮肤吻合,同时关闭结肠造瘘口。结果 11例患儿均在腹腔镜辅助下完成肛门成形术,腹腔镜手术操作时间平均32.8min（25～78min）,出血量平均5.3ml（2～10ml）,无需要输血者。术后11d去除尿管或膀胱造瘘管,无尿道瘘或憩室出现,无切口感染发生。11例术后随访3～66个月,平均45个月。根据肛门功能临床评分标准评分（6分法）,排便优8例（72.7%）,良3例（27.3%）。结论 腹腔镜辅助中位肛门闭锁成形术处理直肠泌尿系瘘方便,辨认盆底肌中心准确及避免切口污染等优点,是治疗中位肛门闭锁有效方法。     

腹腔镜高位肛门闭锁一期成形术4例报告

目的 探讨腹腔镜辅助下高位肛门闭锁一期肛门成形术的可行性。方法先天性高位肛门闭锁患儿4例，男3例，年龄1天～3天；女1例，年龄3个月，为先天性-穴肛畸形。术中首先腹腔镜监视下，游离直肠，分离结扎断离直肠尿道瘘管；然后通过穿刺盆底肌肉中心形成隧道，将直肠从中脱出，与会阴皮肤吻合。结果4例均在腹腔镜辅助下一期完成肛门成形术，腹腔镜手术操作时间40分钟～90分钟，平均718分钟。出血量(5—20)ml，平均8．3ml。无需要输血，未出现术中并发症。所有病人术后恢复顺利，于术后11天去除尿管和膀胱造瘘管，无尿道瘘憩室发生，无切口感染。术后随访3月至1年，I例手术后1月出现肛门狭窄，于术后3月行狭窄段切除术治愈。另外3例无并发症发生，目前4例排便控制功能良好。结论腹腔镜铺助肛门一期成形术是治疗高位肛门闭锁的有效方法，手术打击小，处理直肠泌尿系瘘方便，辨认盆底肌中心准确，可免除患儿分期手术。     

肛门闭锁直肠尿道瘘的治疗

目的:探讨肛门闭锁并有直肠尿道瘘病儿的合理治疗方案以提高治愈率。方法:总结分析1984～1994年收治的先天性闭肛合并直肠尿道瘘新生儿40例,闭肛术后残留直肠尿道瘘12例共52例的手术治疗方法及效果。结果:41例新生儿期先行结肠造瘘,二期骶会阴肛门成形术同时行尿瘘修补术者,39例治愈;11例新生儿期肛门成形术后残留直肠尿道瘘者,经尿道瘘修补术,8例治愈。结论:先天性肛门闭锁合并直肠尿道患儿,宜先施行结肠造瘘,Ⅱ期再经骶会阴肛门成形,尿瘘修补术。对肛门成形术后残留尿道瘘者,经会阴人路尿瘘修补术为最常用术式,术前先行结肠造瘘以预防切口感染致手术失败,经直肠腔内粘膜覆盖修补尿瘘有操作简单,且无需先行结肠造瘘的优点。     

先天性肛门直肠畸形的病理改变及临床意义

不少学者对肛门直肠畸形病儿的盆腔结构进行解剖组织学研究证明,该畸形不仅肛门直肠本身有闭锁和发育不全,同时盆底肌肉也有不同程度的病理改变,肛门直肠畸形的位置越高,这种改变越明显,越严重。 耻骨直肠肌改变:Stephens对29例肛门直肠畸形病人尸体进行解剖,发现2例高位肛门直肠畸形的男婴,耻骨直肠肌依附于尿道后壁。1例直肠阴道瘘者,该肌附着于阴道后壁并向前移位。而在患前庭瘘和肛门闭锁的病例中,该肌处于正常位置。并指出耻     

Hem-o-10k在腹腔镜肛门成形术中的应用

目的探讨Hem-o—lok在腹腔镜肛门成形术处理直肠尿道瘘中的价值。方法2012年1月～2013年12月采用腹腔镜治疗15例中高位肛门闭锁,在距球部、膜部或膀胱颈部尿道0．5cm处应用Hem—o—lok夹闭瘘管处理直肠尿道瘘。结果均在腹腔镜辅助下完成肛门成形＋尿道瘘修补术,腹腔镜手术（包括会阴手术）操作时间90～150min（平均120rain）。出血量10～20ml（平均15m1）,无需要输血者,无术中并发症发生。术后7d拔除尿管,无排尿困难。15例随访2～12个月（平均5个月）,术后排尿功能基本正常,无尿道瘘复发,无尿道狭窄发生,肛门外观正常,2例患儿轻度直肠黏膜脱垂。结论腹腔镜辅助下Hem-o-lok夹闭处理直肠尿道瘘,更加精准、方便,降低手术难度,可取得满意的治疗效果。     

肛门闭锁术后残留直肠尿道瘘的治疗

目的 :探讨肛门闭锁术后残留直肠尿道瘘的手术方式及疗效。方法 :8例本病患儿 ,根据病变情况分别采用直肠内直肠尿道瘘修补及经腹会阴联合术式行乙状结肠部分切除、直肠粘膜剥离、瘘管结扎、结肠经直肠肌鞘内拖出肛门成形术治疗。结果 :术后全部治愈出院 ,随访 1～ 6年无复发 ,疗效满意。结论 :上述两种术式较其他术式具有修补牢靠、术式简单、不易复发等优点 ,是目前修补直肠尿道瘘较理想术式之一。     

重建直肠角肛门成形术治疗肛门直肠闭锁

１９８６年,高春芳首先将重建直肠角式人工肛门应用于直肠癌根治术中［１］,术后肛门功能恢复满意。受此启发,１９８８～１９９６年,我们采用重建直肠角、经腹会阴一期肛门成形术,治疗高位先天性肛门直肠闭锁伴阴道、尿道及舟状窝瘘５８例。术后随访２～８年,其排便功能满意。本文介绍该手术方式并总结５８例的治疗体会。１　临床资料本组新生儿２０例,１岁１５例,３岁１０例,６岁８例,１２岁５例。男３２例,女２６例。根据Ｘ线检查及手术所见,按肛门直肠畸形国际分类标准［２］,本组５８例直肠盲端均在耻骨尾骨线（ＰＣ线）…     

经肛门结肠拖下术治疗小儿直肠阴道瘘

目的：总结经肛门浆以鞘内结肠拖出术加内括约肌成形术治疗小儿直肠阴道瘘的手术效果，方法：自1999年采用该术式治疗小儿直肠阴道瘘15例，12例为第一次手术，3例为复发瘘，结果：手术时间平均72（60／90）min，术中出血约5－10ml，术后24h内恢复肠道功能，2d开始进食，平均住院时间7．4d，术后1月每日排便4－8次，6月后每日排便1－2次，无1例瘘复发。结论：经肛门浆肌层鞘内结肠拖下术结合内括约肌成形术治疗小儿直肠阴道瘘，手术创伤小，操作简单，复发率低，近期疗效好。     

Findings of pelvic musculature and efficacy of laparoscopic muscle stimulator in laparoscopy-assisted anorectal pull-through for high imperforate anus

Background: Laparoscopic findings of levator muscle and the efficacy of laparoscopic muscle stimulator (LMS) in infants with high imperforate anus have not been reported. Methods: Twelve patients underwent laparoscopically assisted anorectoplasty for high imperforate anus. Following laparoscopic dissection of the distal rectum and division of the fistula, levator muscles in the pelvic floor were stimulated with a 5-mm-diameter LMS. Dilatation was done by inserting a guidewire and balloon catheter through the center of the levator muscle sling and muscle complex. Rectal pull-through and anastomosis between the rectum and anus were successfully completed. Results: LMS showed good contraction of levator muscles and enhanced accurate midline placement of pull-through rectum. LMS was particularly useful in observing weak muscles in infants with rectovesical fistula. Conclusions: Laparoscopy and LMS offer excellent visualization of the pelvic musculature and precise tract of rectal pull-through. Fecal continence will be assessed by long-term follow-up.     

Anorectal Agenesis with a Rectourethral Fistula Diagnosed in an Adult: Report of a Case

We report an unusual case of anorectal agenesis with a rectourethral fistula diagnosed in a 48-year-old man. The patient presented after noticing hematuria, although he had been aware of urinary leakage from his colostomy with occasional fecal urine for about 4 years. He had had a double-barrel colostomy created soon after birth for an imperforate anus, with revision at the age of 4 years to correct a prolapse of the stoma, but his malformation had never been repaired. We performed a physical examination, which did not reveal a perineal fistula, but urethrocystography demonstrated high anorectal agenesis with a rectourethral fistula. Thus, we resected the rectourethral fistula and created an end-colostomy. The patient had an uneventful postoperative course, and was discharged in good health on postoperative day 19. To our knowledge, this is the oldest patient to be diagnosed with anorectal agenesis and undergo resection of a rectourethral fistula.     

Hyperchloremic acidosis in an infant with imperforate anus and rectourethral fistula

A case of hyperchloremic acidosis in an infant with imperforate anus and rectourethral fistula, showing lethargy, tachypnea, vomiting, and dehydration, is reported. Surgical correction by abdominoperineal pull-through and division of the rectourethral fistula was performed after doing a cystocutaneostomy to eliminate the diversion of urine into the rectum.     

Laparoscopically assisted anorectal pull-through for high imperforate anus: three years' experience

PURPOSE: We describe our three-year experience with the laparoscopically assisted anorectal pullthrough for high imperforate anus using laparoscopic muscle electrostimulation. MATERIALS AND METHODS: From March 2001 to January 2004, 7 patients with a diagnosis of high anorectal malformation underwent laparoscopically assisted anorectal pull-through. The patients, all males aged from 4 to 9 months (mean age, 5.8 months), presented with a rectourethral fistula. The associated malformations noted were sacral malformation, laryngeal stenosis, urethral duplication, multicystic kidney, nonpalpable testis, and esophageal atresia. All patients were treated with a colostomy in the newborn period followed by a delayed laparoscopically assisted anorectal pullthrough. Laparoscopy included stimulation of the puborectal muscle, using a modified Pe?a electrostimulator introduced through a trocar. All patients underwent a postoperative period of anal dilatation. RESULTS: In 6 cases the laparoscopically assisted anorectal pull-through was successful; there was 1 conversion to the open technique, due to strong tension from the colostomy. CONCLUSION: Although longer follow-up to evaluate continence is to come, laparoscopically assisted anorectal pull-through should be considered for the correction of the high imperforate anus and, according to our experience, it represents the gold standard. It offers the advantage of good visualization of the fistula and the surrounding structures and minimally invasive abdominal and perineal wounds.With the laparoscopic Pe?a stimulator the direct observation of the contraction of the puborectalis sling allows an evaluation of the functional contractility and an accurate colonic pullthrough in the center of the muscle complex.     

Posterior sagittal approach for repair of rectourethral fistula occurring after perineal surgery for imperforated anus at birth

PURPOSE: Posterior sagittal approach was used for the repair of 11 cases of rectourethral fistula between 1992 and 1998. METHODS: All these patients had rectourethral fistula as a result of perineal procedure performed for imperforate anus at the time of birth. In addition to the fistula repair, an associated anorectal stenosis (3 cases) and urethral stricture 11 case) also were corrected with this approach. All the patients underwent surgery under cover of a protective colostomy. RESULTS: Successful repair was achieved in all patients, and the follow-up period ranged from 10 months to 7 years. As far as bladder and bowel control, urinary control was normal in all 11 patients, whereas bowel control was normal in 10 cases. One patient who had severe scarring of anal sphincters caused by infection in the previous surgery still suffers occasional perianal soiling after 18 months of follow-up. CONCLUSIONS: Posterior sagittal approach not only gives adequate exposure but also suits the basic principles of fistula repair, namely, completely separating the rectum from urethra and leaving normal rectal wall behind the urethral sutures thus eliminating the possibility of recurrence. In addition to fistula repair, one can also correct associated problems like anorectal stenosis or urethral stricture, and a mislocated rectum can be relocated within the sphincter complex.     

Imperforate anus in male children: a new operation of primary perineal rectourethroanoplasty

From experience in managing 348 patients with imperforate anus and after considering the existing literature, there appeared to be the possibility of performing a safe primary correction of supralevator anorectal anomalies via a perineal approach in the neonatal period in males. A total of 39 patients have been treated by the new operation, and in 31 of these patients the operation was carried out at birth. With a stiff catheter in the urethra, via a horizontal 'H'-shaped perineal incision and through the puborectalis sling, the rectum was mobilised and the fistula transfixed. The rectum was brought through the sling and sutured to the perineum so that perineal skin entered the new anal canal. In a few patients an abdominal approach was required at the same time. There were few postoperative complications. Subsequent X-rays showed good urethral and pelvic floor anatomy and function. Twenty-five of the babies are now over 2 years old. Of these, 84% are continent for solid faeces and 68% for liquid faeces. The perineal approach permits satisfactory identification of the puborectalis, rectum and fistula in most babies. Cutting the pelvic floor is not satisfactory. Introducing perineal skin into the anal canal is important. Early operation enables the child to learn to use its perineum. It is difficult to know whether the results in this series are attributable to the type of operation or its timing.     

High-pouch imperforate anus treated by electromagnetic bougienage and subsequent perineal repair.

Four male infants with imperforate anus were treated by electromagnetic bougienage and subsequent perineal anoplasty with division of rectourethral fistula. Each had high-pouch imperforate anus of the supralevator type, with rectourethral fishtula at or above the level of the membranous urethra. Perineal anoplasty was accomplished in all four, with division of the rectourethral fistula, avoiding the need to do a sacral-abdominal-perineal procedure, as had been customary previously in similar cases.     

Use of MRI in evaluation of anorectal anomalies

Congenital anorectal anomalies present with a wide spectrum of anatomical deformity. The level of atresia, the extent of the development of the pelvic musculature, and the presence of associated anomalies all greatly influence treatment options. Further complexity may be introduced by previous attempts at correction. Magnetic resonance imaging (MRI) recently has been suggested as an effective tool in evaluation of such patients for surgical repair. Thirteen patients undergoing evaluation for either primary or secondary operations for imperforate anus were studied with MRI. Age range was newborn to 26 years. These patients had anorectal deformities in various stages of treatment--from newly diagnosed imperforate anus in the newborn to patients who had undergone previous surgical repair of their deformity with poor results. In newborns, MRI was very useful in assessing the level of atresia and determining whether perineal repair was advisable. In older patients with high atresias, MRI was useful in planning operative strategy and predicting the outcome by providing information about the pelvic musculature. This information was directly related to the size of the patient, ie, the larger, and therefore the older the patient, the more detail MRI provided about the pelvic musculature. Especially in secondary cases, this information proved to be helpful in determining the cause of the initial failure, ie, lack of adequate pelvic musculature or poor placement of the distal colon in relation to the striated muscle complex at the initial operation. MRI demonstrated previous unsuspected lesions such as tethered cord, sacral deformity or urinary tract abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)