小婴儿I期经肛门巨结肠根治术

目的研究分析I期经肛门治疗小婴儿先天性巨结肠的临床效果。方法12例患先天性巨结肠小婴儿,11例I期经肛门完成根治术,手术年龄32d～158d。手术采用截石位或俯卧位,于直肠后壁齿状线上0.5cm～1.0cm,前壁齿状线上1.5cm～3.0cm切开直肠粘膜,向近端游离直肠粘膜达腹膜返折,环形切开肌鞘,游离近端结肠,拖出正常结肠与肛门斜形吻合。结果平均手术时间95min,均于12h内排便,无术中术后并发症。随访2个月～1年,临床效果良,无污便。结论I期经肛门巨结肠根治术安全简单,临床效果好,适于在小婴儿中开展。     

小婴儿Ⅰ期经肛门巨结肠根治术

目的 研究分析Ⅰ期经肛门治疗小婴儿先天性巨结肠的临床效果。方法 12例患先天性巨结肠小婴儿，11例Ⅰ期经肛门完成根治术，手术年龄32d～158d。手术采用截石位或俯卧位，于直肠后壁齿状线上0．5cm～1．0cm，前壁齿状线上1．5cm～3．0cm切开直肠粘膜，向近端游离直肠粘膜达腹膜返折，环形切开肌鞘，游离近端结肠，拖出正常结肠与肛门斜形吻合。结果 平均手术时间95min，均于12h内排便，无术中术后并发症。随访2个月—1年，临床效果良，无污便。结论 Ⅰ期经肛门巨结肠根治术安全简单，临床效果好，适于在小婴儿中开展。     

腹腔镜在新生儿及小婴儿巨结肠根治术中的应用

目的：介绍腹腔镜在新生儿及小婴儿巨结肠根治术中的应用经验,方法：先天性巨结肠患儿30例,手术年龄11－90d,体重2．5－5．7kg。手术中建立人工CO2气腹,腹部置3个套管至腹腔,腹腔镜直视下分离病变的结肠及近端直肠系膜至盆底,手术转至会阴部,于肛门齿状线上5－10nm环行切开直肠粘膜,下施并向上分离直肠粘膜约20－25mm,此处切断直肠肌鞘,分离直肠至腹内直肠游离处,将病变肠段由肛门拖出切除,近端结肠切缘与直肠粘膜齿状线上切缘吻合,结果：平均手术时间153．5min,术后次日开始进食,患儿恢复顺利,平均出院时间为术后7．4d,近期随访效果良好,结论：腹镜腔巨结肠根治术手术打击小,术后患儿恢复快,此法治疗新生儿及小婴儿巨结肠是安全可行的。     

经肛门Ⅰ期结肠拖出术治疗新生儿及婴幼儿先天性巨结肠

目的 介绍经肛门Ⅰ期结肠拖出术治疗新生儿及婴幼儿先天性巨结肠的初步经验。方法 患儿全麻后取截石位，扩肛后，牵开肛门。在直肠齿状线上0．5cm处游离直肠粘膜，形成粘膜管后，继续向近端游离，达腹膜返折后环形切断肌鞘一周，劈开肌鞘后壁，并切除部分肌条。进入腹腔后，直视下游离直肠、结肠的移行段和扩张段，妥善结扎系膜血管，达正常结肠后切断，拖出结肠浆肌层与保留肌鞘间断固定，结肠断端及直肠齿状线切缘缝合固定。结果 7例均顺利完成手术，手术时间90min-100min，出血约15ml～30ml，术中均未输血。7例均经病理证实为先天性巨结肠症，平均切除肠管13cm～25cm。1例于术后6d出现小肠结肠炎，治疗后好转，其余6例恢复顺利。术后2周开始扩肛，全部病例随访2个月—1年，每日排大便2～4次，无便秘复发、腹胀，无吻合口狭窄，无污粪，无肛周感染、肠管同缩等并发症。结论 经肛门Ⅰ期结肠拖出术治疗先天性巨结肠，具有手术创伤小、操作简单、术后恢复快、并发症少等优点，适用于新生儿及婴幼儿短段型及普通型先天性巨结肠的治疗。     

腹膜返折上方入路经肛门巨结肠根治术

目的 介绍一种经肛门巨结肠根治术的新入路。方法 26例巨结肠患儿采用腹膜返折上方入路经肛门根治术，于腹膜返折上方将直肠牵下，环行切断即入腹分别游离近远端，切除病变，远端保留前壁距齿状线2．5cm，后壁距齿状线1．0cm，近远端斜行吻合。结果 平均手术时间110min，平均出血20ml。随访5月～2年，25例排便正常，1例排便轻度失禁，经处理恢复正常。结论 经腹膜返折上方入路的方法直观、确切，容易掌握。     

改良Soave术治疗婴儿和新生儿先天性巨结肠27例

目的总结改良Soave根治术治疗婴儿和新生儿先天性巨结肠的手术体会。方法对27例10d￣3个月的先天性巨结肠患儿行改良Soave根治术,其中14例常见型巨结肠经肛门直接拖出,4例因根治术前肠穿孔行结肠造瘘术。腹部不切开肠管亦不剥离肌鞘,而是转至会阴部操作,保留肌鞘后壁距齿状线0.5cm,前壁距齿状线2￣3cm。结果术后无内括约肌征候群及肌鞘感染,每月随访1次,无便秘、腹胀及失禁现象,大便控制良好。结论改良Soave根治术应用于小婴儿和新生儿先天性巨结肠,创伤小,恢复快,减轻了患儿痛苦,术后可获得良好的排便控制功能,近期疗效满意。     

肛门直肠肌鞘部分切除预防巨结肠根治术后肠炎

目的探讨直肠肌鞘部分切除对预防巨结肠根治术后继发巨结肠性肠炎的作用。方法对37例先天性巨结肠患儿在行肛门根治术的同时行直肠后壁肌鞘切除。结果本组36例,获随访35例,随访时间4～24个月,仅1例患儿于术后1个月有一次肠炎病史,术后肠炎发生率为2.7%,比术前明显减少。肛门直肠测压结果显示,先天性巨结肠患儿手术前的肛管静息压力比对照组明显增高(p<0.05);手术后肛管静息压力比手术前明显减低(p<0.01),术后6个月内患儿的肛管静息压力有上升趋势,与对照组比较差异不显著。结论本研究结果表明肛门直肠肌鞘部分切除术安全易行,可以有效地预防术后继发巨结肠性肠炎的发生。     

经肛门Ⅰ期根治巨结肠及应用解剖研究

目的：为提高巨结肠治疗效果,探讨经肛门Ⅰ期巨结肠根治手术的方法及并发症的防治措施。方法：对13例先天性巨结肠经肛门Ⅰ期根治,手术方法为:经齿状线上0.5 cm逐层梯度切开分离粘膜、环肌、纵肌,进入盆腔,处理结肠系膜及韧带,拖出并切除病变肠管,将近端结肠与齿状线上创面吻合。并对5例小儿尸体进行肛门直肠应用解剖研究。结果：全部手术获得成功,随访6～15月,肛门无狭窄,排便正常,无污粪。解剖研究发现:婴幼儿直肠前及两侧腹膜反折较后侧低,距肛门约5～6 cm,直肠与尿道或阴道之间组织较致密,间隙较小。结论：经肛门直肠采用粘膜、环肌、纵肌梯级分离推进式进入Ⅰ期根治小儿巨结肠,可避免损伤尿道及邻近器官,减少术后并发症。适用于普通型、短段型及部分长段型巨结肠。     

经肛门手术治疗小儿先天性巨结肠症15例治疗体会

目的探讨小儿先天性巨结肠症肛门手术治疗的适应证、方法、疗效和随访结果。方法采用经肛门直肠肌鞘内病变黏膜切除，保留直肠肌鞘6cm左右，沿结肠壁处理肠系膜血管，结肠拖出并在齿状线以上吻合。结果手术时间平均75min(50～100min)，均于术后48h内进食，平均术后住院6天，随访2～18个月，患儿排便情况1～5次／d，无明显大便失禁和肛门狭窄(术后坚持扩肛6个月)。结论本术式简单，效果好，并发症少。     

经肛门行改良Swenson巨结肠根治术疗效分析

目的 对7年来所做的143例手术做一总结回顾.方法 143例经钡剂灌肠、直肠测压或直肠活检确诊.患儿取截石位,经肛门插入一把卵圆钳,于耻骨结节(腹膜返折)上方钳住直肠壁下牵将直肠套叠翻出,在翻出的直肠内壁处缝合牵引线两圈,于两圈线间全层切断直肠.远端后壁全层游离,并背切至齿状线上0.5～1.0 cm,前壁游离至齿状线上方2.5～3.5 cm,近端边下牵边游离,切除病变肠管.近远端行双层吻合,吻合口呈心形.结果 平均手术时间70 min,平均出血量10 ml,无中转开腹,术后不需扩肛,术后1个月平均排便2～3次/d,术后3个月平均排便1～2次/d.1例因术中背切远端直肠后壁过于靠近齿状线,术后出现轻度便失禁,经再次缝合内括约肌痊愈;1例术后5 d出现吻合口后壁撕裂、血便,经保守治疗痊愈;4例发生小肠结肠炎,保守治疗痊愈.1例术后复发,经再手术治愈.结论 经肛门巨结肠根治结直肠全层吻合术安全、可靠、操作简便、术后效果好.     

Transanal endorectal coloanal anastomosis for Hirschsprung's disease

In adults, transanal endorectal colo- or ileoanal anastomosis has recently been advocated for low rectal malignancies and restorative proctocolectomy in ulcerative colitis and familial polyposis. Since 1987, we have used this approach in 20 patients for operative correction of Hirschsprung's disease. In 13 patients the definitive operation was performed before the age of 6 months. A rectosigmoidectomy to the undilated colon was performed transabdominally. The rectum was dissected caudally to the upper border of the levator muscles. Mucosal proctectomy was performed transanally beginning 3–5 mm above the pectinate line. The submucosal dissection extended proximally for a distance of 5 cm. The rectum was excised transanally so that a 2–3-cm muscular cuff remained. The ganglionic colon was pulled through and sutured to the mucosal edge. There have been no operative complications. The postoperative follow-up period ranges from 9 months to 4 years. The preliminary functional results suggest that the patients gain early normal, age-appropriate bowel function postoperatively, without soiling or residual constipation. Correspondence to: R. Rintala     

腹腔镜治疗直肠乙状结肠型先天性巨结肠122例疗效分析

目的 探讨腹腔镜治疗直肠乙状结肠型先天性巨结肠(HD)的临床经验和近远期疗效.方法 2001～2010年本院收治直肠乙状结肠型HD患儿122例,年龄15 d至12岁.均应用3个或4个Trocar行腹腔镜辅助经肛门Soave拖出术.先在腹腔镜下行浆肌层活检明确无神经节细胞肠段和有神经节细胞肠段,然后在腹腔镜辅助下经肛...     

经肛门结肠拖出根治小儿乙状结肠冗长症

目的总结经肛门结肠拖出根治小儿乙状结肠冗长症的手术过程、疗效及短期随访。方法我院2000～2005年经该术式治疗小儿乙状结肠冗长症19例，乙状结肠冗长症有典型的便秘症状，钡灌肠显示19例乙状结肠比正常对照组平均长25cm；直肠肛管测压显示直肠肛管松弛反射存在，呈“W”型特殊波型；组织化学检查无乙酰胆碱酯酶阳性的副交感神经纤维。结果19例经肛门拖出切除结肠肠管20～52cm，平均切除结肠肠管28cm。均于术后2～3d开始进食，术后1个月随访每日排便6～8次，其中15例行钡灌肠检查未见结肠扩张，24h无钡剂潴留。6个月随访（17例）每日排便1～3次，无污粪。结论经肛门结肠拖出根治小儿乙状结肠冗长症手术安全有效，具有创伤小、操作简单、近期疗效良好的特点。     

腹腔镜经脐及肛门自然腔道巨结肠根治术临床分析

目的 探讨经脐单孔腹腔镜监视下联合经肛门直肠内拖出结肠切除术治疗先天性巨结肠及其类缘性疾病的可行性和临床疗效.方法 2010年3～11月,对15例常见型和长段型先天性巨结肠及其类缘病患儿实施经脐单孔腹腔镜监视下联合经肛门直肠肌鞘入路游离左半结肠或全部结肠,然后拖出在体外完成直肠乙状结肠或次全结肠切除术.结果 全部患儿...     

Soave procedure for infants with Hirschsprung's disease

Objective Traditionally the surgical treatment of Hirschsprung’s disease (H.D) includes preliminary colostomy in normally innervated bowel followed by one of several pull through procedures. The transanal single stage Soave procedure eliminated the need for preliminary colostomy and intraabdominal dissection. It is a recent concept in the management of this disease, and this is the first experience to be reported from India.Methods: Four children aged 3 weeks to one year underwent transanal pull through procedure over a two month period. A rectal mucosectomy was performed starting 0.5 cm. proximal to the dentate line and extending proximally to the level of intraperitoneal rectum. The muscular sleeve was divided circumferentially to allow the full thickness mobilization of the proximal colon. Ganglion cells were confirmed by frozen section and bowel was transected. The rectal muscular cuff was divided longitudinally and the anastomosis was completed.Results: Operative time including the frozen section averaged 160 minutes and average length of the bowel resected was 22 cm. There were no postoperative complications and all patients were discharged on seventh postoperative day. Median follow-up was 5 months (4–6 months) and stool output ranged from 2–4 per day.Conclusion: The authors conclude that a single stage transanal Soave’s pull through for Hirschsprung’s Disease can be performed successfully in infants. When compared to conventional pull through procedure, it has the potential advantage of lower cost, less risk of damage to pelvic structures, absence of any abdominal incision, a lower incidence of intraperitoneal bleeding and adhesion formation. The preliminary functional results suggest that the patients gain early bowel function post operatively without soiling or constipation     

What is the most common complication after one-stage transanal pull-through in infants with Hirschsprung’s disease?

Background  

Hirschsprung’s disease (HD) is a relatively common congenital disease that could be suspected by clinical symptoms, abdominal plain X-ray, and finally diagnosed by rectal biopsy. In 80% cases, rectosigmoid junction is involved. Recently, one-stage transanal pull-through (TAPT) procedure has been popular and may have several complications.     

Our experience with transanal endorectal pull-through in Hirschsprung's disease.

AIM: The aim of the study was to evaluate the functional results, complications, the problems caused, and the outcomes of the transanal endorectal pull-through (TEPT) operation in Hirschsprung's disease. PATIENTS AND METHODS: The 22 patients who were operated for Hirschsprung's disease with TEPT between November 2003 and September 2006 were reviewed retrospectively. The patients were evaluated for age, gender, operational findings, duration of hospitalization and functional outcomes after the operation. RESULTS: A total of 22 patients, sixteen males (72.7 %) and 6 females (27.3 %) aged 23 days to 11 years (mean 19.3 +/- 6.9 months), were operated using TEPT over a 34-month period. The mean length of the resected aganglionic segment was 23 +/- 2.4 cm; the shortest segment was 7 cm and the longest 40 cm. The postoperative hospital stay was 3 - 10 days, oral feeding was started at 1 - 4 days, the first bowel movement was at 1 - 7 days and the number of daily movements for patients in whom the colostomy was closed was 2 - 5. The mean postoperative follow-up period was 18 +/- 2.4 months (1 - 33 months). Two patients (9 %) were hospitalized once for enterocolitis. One patient had a constipation problem that resolved with medical treatment. One patient needed colostomy for anastomosis leakage on the 5th postoperative day, followed by a redo pull-through using a posterior sagittal approach. None of the patients had a continence problem. No urethral damage was observed and there were no abscesses at the muscular cuff. We observed that mucosal dissection was more difficult in the rectal biopsy area. CONCLUSIONS: Although only recently accepted, TEPT has quickly found a place in clinical practice as it is based on an operational technique whose results are well identified and accepted and with which there is extensive experience. It seems that TEPT has the advantages of having no additional problems compared to the classical techniques with respect to complications and functional outcomes while providing better patient comfort and cosmetic outcomes. We conclude that TEPT may be preferred in appropriate cases and will evolve to become a more practical and effective technique.     

Transanal pull-through for Hirschsprung disease

Hirschsprung (HSCR) disease is a relatively common neonatal developmental disorder of the enteric nervous system and is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the distal intestine. This results in absent peristalsis in the affected bowel, and the development of a functional intestinal obstruction. The pathogenesis and genetic basis of the disease is yet unclear. The surgical treatment of HSCR has evolved significantly since 1949 when Swenson first proposed a trans-abdominal pull-through procedure. The transanal pull-through consists of a rectal mucosectomy, resection of the aganglionic bowel and a colo-anal anastomosis. Recent literature and clinically controversies of this minimally invasive one-stage procedure are reviewed. Although follow up is still relatively short the preliminary results appear very favorable and cost effective.     

经肛门拖出及辅助腹部小切口根治长段型巨结肠33例报告

目的探讨经肛门拖出及/或选择性辅加腹部小切口根治长段型巨结肠的可行性与疗效。方法2001年1月～2005年3月经用该术式治疗婴儿长段型巨结肠33例。其中病变段位于乙状结肠上段16例,降结肠11例,脾曲4例,横结肠右侧2例。全组病例均经钡剂灌肠、肛门直肠测压、手术及病理检查确诊。实施I期手术32例,II期手术1例。结果17例单独经肛门拖出结肠,16例辅加腹部3～5cm小切口协助完成手术。切除病变结肠平均长度为39.2cm(32～63cm)。平均手术时间为145min(110～190min)。出血约10～50ml。术后恢复良好,6例出现肛周轻度红肿、糜烂,均于术后6～11d痊愈出院。30例经3个月～4.5年随访,生长发育良好,3个月内每日排便4～8次,6个月后每日2～3次。5例发生结肠炎,经保守治疗痊愈。轻度污粪及便秘各1例。无腹部并发症及吻合口狭窄。结论经肛门结肠拖出术根治婴儿长段型巨结肠方法可行,且安全、有效,操作较简便。对病变位于降结肠以上、结肠系膜较短者,可辅加腹部小切口协助完成手术,值得推荐。