腹腔镜辅助治疗中高位肛门直肠畸形疗效评价

目的 探讨腹腔镜辅助治疗中高位肛门直肠畸形的疗效.方法 回顾分析了2002年9月至2009年9月我科采用腹腔镜辅助肛门直肠成形术(LAARP)治疗的中高位肛门直肠畸形患儿34例,其中男27例、女7例.除1例一穴肛息儿和1例直肠尿道球部瘘患儿Ⅰ期行肛门成形术以外,其余患儿均在出生后行结肠造瘘术,腹腔镜主要用于腹部直肠末端的分离、瘘管的处理以及盆底隧道的形成,手术平均年龄为6.3个月.30例患儿术后获得随访,术后随访时间1～7年,平均3.5年,随访1～2年者11例,2～7年的病例19例,对30例患儿手术后并发症以及排便次数、大便控制能力、污便以及便秘的情况进行调查,并应用Kelly评分进行评价.结果 随访时间大于2年的病例中17例患儿获得较为满意的排便功能,其中5例患儿经过排便功能训练已达到完全正常;10例患儿可实现较为满意的排便控制,偶有污便(每1～2周一次),其中2例患儿出现轻度便秘;排便控制较差,经常有污便或失禁者2例.该组患儿经过有效的肠道管理均可以实现满意的社会生活,该组Kelly评分平均为4.32±1.45.随访时间1～2年的病例均有不同程度的污便,8例患儿排便控制能力较差,经常有污便.排便次数增多(大于3～4次);3例患儿排便控制功能较好,偶有污便,排便次数维持在每天I～2次.该组Kelly评分1.91±1.37.结论 腹腔镜治疗肛门直肠畸形疗效满意,并随着术后年龄的增长,排便控制功能显著提高.

Abstract：

Objective To evaluate postoperative anal functions of patients with intermediate or high anorectal malformations who underwent laparoscopic-assisted anorectal pull-through (LAARP).Methods Thirty four patients (27males、7 females) who underwent LAARP in our department between September 2002 and September 2009 were analyzed Initial colostomy in the newborn period was performed in all patients except 1 cloaca and 1 male patient with rectobular fistula. Laparoscope was used for mobilizing the rectum and repairing the fistula. The average age of operation was 6. 3 months (range from 2 to 24 months). Thirty patients were followed up successfully for 1 to 7 years (average 3. 5 years). Nineteen patients were followed up for more than 2 years while the other 11 patients less than 2 years. Complications and anorectal functions are assesed by questionnaires, including the fecal continence, the degree of soiling and the frequency of bowel openings. All patients were evaluated with Kelly score. Results Most of the patients who were followed up for more than 2 years have satisfactory fecal continence except for two cases. The average Kelly score was 4. 32 ± 1. 45. Patients who were followed up for less than 2 years had various degree of soiling. Eight patients had severe fecal incontinence and regular soiling, with bowel movements are more than 5 times per day. Only 3 patients had acceptable fecal continence, with occasional staining. The bowel movement was 1-2 times per day. The average Kelly score was 1. 91 ± 1. 37. Conclusions The procedure of LAARP can produce satisfactory fecal continence. The continence improves with age.     

腹腔镜辅助高位肛门直肠畸形成形术后中期随访研究

Objective To evaluate postoperative anorectal functions of patients with high-type anoreetal malformations who underwent laparoscopically assisted anorectal pull-through (LAARP). Methods From Jan 2002 to Dec 2005, LAARP was performed on 10 patients with high-type anorectal malformations. All the patients were followed up and their clinical data were compared with patients who underwent posterior sagittal anorectoplasty (PSARP) (n = 12) performed before 2002. All pa-tients underwent colostomy at newborn period. Anorectal functions were evaluated with Kelly's clinical scoring and anoreetal manometry. At follow-up, the age of patients ranged from 3 to 5 years and from 5 to 6 years in the LAARP group and in the PSARP group respectively. Results The age at evaluation in the LAARP group was significantly younger than that in the PSARP group (47. 2 ± 8. 3 months vs 74. 5 ± 9. 3 months, P<0. 05). Kelly's clinical score was 3. 7 ± 0. 9 vs 3. 4± 0. 8 for the LAARP group and PSARP group respectively. The results of resting anal pressure and high pressure zone length showed that no significant difference was noted between the two groups, while the positive rate of rec-toanal inhibitory reflex in the LAARP group was significantly higher than that in the PSARP group (80 % vs 41%, P<0. 05). Conclusions Midterm follow-up study revealed that satisfactory fecal con-tinence can be achieved in patients with high-type anorectal malformations treated with LAARP, which may be an effective alternative. However, long-term follow-up is needed to evaluate the anorec-tal functions of patients treated with LAARP or PSARP     

先天性肛门直肠畸形术后便秘合并巨结肠的临床特点及处理

目的 总结先天性肛门直肠畸形术后顽固性便秘合并巨结肠的临床特点和治疗效果.方法 回顾性分析2005年8月至2010年7月收治的顽固性便秘合并巨结肠23例临床资料,男10例,女13例.首次手术年龄3 d至6岁,术前诊断均为中低位肛门直肠畸形.23例患儿均以肛门成形术后便秘就诊.下消化道气钡造影显示下端结肠及直肠扩张,无移行段,排钡延迟.本次手术年龄1岁2个月至15岁8个月.均采用Soave巨结肠根治术.结果 术前见肛门外观大致正常13例,外观正常合并直肠尿道瘘1例,肛门开口位置前移6例,瘢痕回缩2例,肛门外口狭窄1例.术中进入盆腔后即为扩张肠管,系膜增生增厚,肠壁血管增生粗大.13例单纯经会阴手术,10例经腹会阴手术,其中1例同时回肠末端造瘘.9例巨结肠切除同时,再次行肛门成形术,1例巨结肠切除同时行前矢状入路直肠尿道瘘修补术.病理检查15例切除肠管远近段,可见神经节细胞者,8例肠管远端无神经节细胞者,23例均见肌层增生肥厚,肌纤维变性,肌层排列紊乱.二次术后随诊肛门功能李氏评分5～6分.结论 先天性肛门直肠畸形术后顽固性便秘往往并发巨结肠改变,影像显示为肠管局限性扩张、僵硬和动力紊乱.采取手术治疗,切除病变肠管,做必要的肛门解剖缺陷修复,术后效果良好.

Abstract：

Objective To summarize the experience of diagnosis and treatment of intractable constipation in children with repaired anorectal malformation.Methods Between August 2005 and July 2010,23 children with a history of anorectal malformation (ARM) repair were diagnosed with intractable constipation,and underwent surgical treatment at this center.The patients,including 10 boys and 13 girls,underwent primary surgeries to repair low or intermediate type of ARMs.Their ages at the primary surgery ranged from 3 days to 6 years old.Physical examinations found normal appearance of anus on 14 children including 1 with rectourethral fistula,anus antelocation on 6,cicatricial retraction of anus on 2,and anal stricture on 1.The positive barium enema revealed the dilated distal colon and rectum without transition zones,and delayed barium transit time.The patients' age at the second surgery ranged from 1 year and 2 months to 15 years and 8 months old.Results Dilated distal colon and rectum,with increased intestinal wall and mesentery thickness as well as proliferated blood vessels,was found during surgery on all patients.However,no transition zone was observed.To remove the dilated intestine,transanal Soave procedure was performed on 13 children,and the other 10 underwent abdomino-perineal Soave procedure including 1 had additional ileostomy.Besides the megacolon resection,9 patients also underwent anoplasty,and rectourethral fistula was also repaired on 1 patient.At the distal end of the removed intestine,pathological examination revealed ganglion cells in 15 patients,and no ganglion cells in 8 patients.Hypertrophy,degeneration and derangement of the intestinal smooth muscle cells were also observed.After reoperation,patients' anal function was graded as 5 or 6 according to Lizheng's anal function scoring criteria.Conclusions Intractable constipation after ARM repair is usually caused by acquired megacolon.It can be cured by megacolon resection.     

腹腔镜辅助肛门直肠成形术致后尿道憩室的预防措施探讨CSCD

Objective To explore the preventive measures of posterior urethral diverticulum (PUD) after laparoscopic assisted anorectoplasty (LAARP). Methods From August 2013 to December 2018, perioperative and postoperative clinical data were reviewed for 6 children with anorectal malformation (ARM) developing PUD after LAARP. PubMed database was searched for all published English literatures of PUD after ARM surgery from 2000 to 2021. Since international naming of PUD is not standardized, there are two major names, i. e. remnant of original fistula and PUD. Thus retrieval keywords were anorectal malformation, remnant of original fistula and PUD. Results The diagnostic age was 17 months to 5 years after LAARP. The clinical manifestations included mucuria, recurrent urinary tract infection and dysuria, etc. Computed tomography (CT) and retrograde urethrography revealed prerectal cyst. A total of 13 articles were retrieved, reporting 102 cases of PUD after ARM surgery. The age was 1 — 44 years and the diameter of PUD 3 —70 mm. The major clinical symptoms were frequent urination, dysuria, recurrent urinary tract infection, urinary calculi, hematuria and urinary incontinence, etc. Some non-symptomatic cases were only discovered accidentally during follow-ups. ARM procedures included LAARP (n = 36), posterior sagittal anorectopasty (PSARP,n = 15), abdominoperineal pull-through (n=15) and APP (n=50). Conclusion PUD is a rare complication after ARM surgery. And potential risks of PUD may be minimized by strengthening perioperative managements and improving surgical techniques. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.     

腹腔镜下高位肛门闭锁肛门成形术及中期临床评估

目的 评估腹腔镜下高位肛门闭锁成形术后临床疗效和直肠肛门功能.方法 2004年6月至2007年9月收治高位肛门闭锁患儿61例,33例行腹腔镜下肛门成形术(LAARP),平均年龄5.3个月;28例行后矢状入路肛门成形术(PSARP),平均年龄4.9个月.随访包括手术时间、住院时间和并发症.手术后3～4年对患儿进行排便功能的Kelly评分(KCS)、磁共振成像(MRI)和直肠肛管向量测压(AVVM)评估.结果 LAARP和PSARP组手术时间分别为(112.5±12.4)min和(120.4±18.5)min(P＞0.05),LAARP组住院时间(11.3±2.1)d短于PSARP组(14.6±2.3)d(P＜0.01).两组患儿KCS无显著差异(3.52±1.42比3.49±0.82,P＞0.05).MRI显示:LAARP组33例患儿中在I线上和M线上各有1例存在直肠位置偏移;PSARP组28例患儿中I线上有4例存在直肠位置偏移,M线上有3例存在直肠位置偏移.直肠肛管向量测压结果显示:与PSARP组相比,LAARP组非对称指数小,向量容积大,静息时和收缩时肛管压力高(P＜0.05).但高压带长度(15.2±5.8比15.1±6.2 mm)和直肠肛管抑制反射阳性率(84.8%比85.7%)无显著差异.结论 高位肛门闭锁患儿LAARP术后排便控制满意,与PSARP相比,LAARP术后住院时间短、直肠位置更准确.长期随访对评估LAARP术后功能非常必要.

Abstract：

Objective To evaluate the clinical outcomes and postoperative anal function in infants with congenital high imperforate anus who underwent laparoscopically assisted anorectal pullthrough (LAARP). Methods From January 2004 to July 2007,33 consecutive patients (28 males and 5 females,age ranging from 3 to 10 months) with high imperforate anus underwent LAARP. Clinical data of the LAARP group were retrospectively compared with those treated by posterior sagittal anorectoplasty ( PSARP,n = 28) at the same time period. Anorectal function of these patients was evaluated using the Kelly's score,anorectal vector volume manometry(AWM) and magnetic resonance imaging (MRI) at the age of 3. 1 to 4. 4 years. Results The operative time in LAARP and PSARP groups was 112. 5 ± 12.4 and 120.4 ± 18.5 min (P ＞ 0. 05), respectively. The length of hospital stay in LAARP group was shorter than that of PSARP group (11. 3 ± 2. 1 vs. 14. 6 ± 2. 3 days,P＜0. 01). No significant difference was observed between LAARP and PSARP groups regarding Kelly's score (3. 52 ± 1. 42 vs. 3. 49 ± 0. 82). Although MRI revealed the lower rate of poorly aligned rectum in LAARP group than PSARP group at both I-line (3. 0% vs. 14. 3%) and M-line (3. 0% vs. 10. 7%) levels,no statistically significant difference was noted (P＞0. 05). Compared with the PSARP group, lower asymmetric index, larger vector volume, and higher anal canal pressure at rest and during voluntary squeeze were observed in LAARP group (P＜0. 05), without significant differences in the length of high-pressure zone (15. 2 ± 5. 8 vs. 15. 1 ± 6. 2 mm) and the presence of rectoanal relaxation reflex (84. 8% vs. 85.7%). Conclusions Satisfactory fecal continence can be achieved in patients with high/intermediate type imperforate anus after LAARP. LAARP has some advantages over PSARP, including shorter hospital stay and better position of rectum. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

先天性肛门闭锁伴直肠前庭瘘经肛穴肛门成形术与矢状入路肛门成形术后近期及远期并发症的Meta分析

目的运用Meta分析方法评价经肛穴肛门成形术(anal dimple anorectoplasty, ADARP)、前矢状入路肛门成形术(anterior sagittal anorectoplasty, ASARP)、后矢状入路肛门成形术(posterior sagittal anorectoplasty, PSARP)治疗先天性肛门闭锁伴直肠前庭瘘的临床效果。方法计算机检索万方数据库、中国知网等中文数据库(检索式:直肠前庭瘘、肛门前庭瘘、前庭瘘、舟状窝瘘)和PubMed、Web of Science等英文数据库(检索式:vestibular fistula, rectovestibular fistula, anovestibular fistula), 收集2002—2020年公开发表的关于ASARP、PSARP、ADARP治疗先天性肛门闭锁伴直肠前庭瘘的文献。通过阅读文献标题及摘要进行初步筛查, 再进行二次筛选。用Stata 13.0对文献数据进行Meta分析, 主要包括术后近期并发症(伤口感染、伤口裂开、直肠回缩、肛门狭窄、直肠脱垂和瘘口复发)和远期并发症(便秘和污粪)的发生...     

先天性巨结肠根治术后医源性直肠阴道瘘的再手术治疗CSCD

Objective To explore the causes of iatrogenic rectovaginal fistula after pull-through in Hirschsprung’s disease (HD) and summarize the experiences and efficacies of reoperation. Methods From December 2007 to December 2020 , retrospective review was conducted for clinical data of 6 HD children with iatrogenic rectovaginal fistula after pull-through. The surgical procedures for repairing rectovaginal fistula included transabdominal and transanal Soave , transperineal or transanal surgery. Results A total of six girls were included. Clinical manifestation was vaginal excretion. Injuries occurred in initial surgery (n =4) and during redo pull-through (n =2). The reasons for re-operation were postoperative abdominal hemorrhage and aganglionic segment residue. Rectovaginal fistula with anastomotic retraction and stenosis were successfully repaired by transabdominal and transanal Soave procedure in single time(n =4). The remaining two cases underwent simple local repair of rectovaginal fistula , including fistula closure after anal repair twice (n =1) and failed closure after five local (perineal/anal) repairs (n =1). Conclusion Rectovaginal fistula after pull-through in HD is a serious iatrogenic injury. It should be separated close to rectal submucosa/rectal wall to avoid vaginal injury. Transabdominal and transanal Soave procedure has a high success rate for repairing rectovaginal fistula and managing anastomotic retraction and stenosis. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.     

Ⅰ期改良Pe(n)a术治疗新生儿中高位先天性肛门直肠畸形

目的 探讨Ⅰ期改良Pe(n)a术治疗新生儿中高位先天性肛门直肠畸形的临床可行性及有效性.方法对48例先天性肛门直肠畸形的新生儿行Ⅰ期Pe(n)a术,其中31例进行2个月至4年4个月随访,对临床及随访资料进行回顾性分析.结果术后1例因肺部感染加重出现呼吸循环衰竭死亡,2例切口部分裂开,余恢复良好.31例坚持随访2个月至4年4个月,3例便秘,3例稀便时污粪,1例用力时污粪,2例直肠黏膜脱垂,1例切口感染,1例肛门狭窄(未坚持扩肛所致).无完全大便失禁、瘘管复发、尿潴留等并发症出现.17例中高位肛门直肠畸形术后行肛门直肠测压检查,有3例存在RAIR.结论Ⅰ期Pe(n)a术治疗先天性肛门直肠畸形,术后肛门功能良好,早中期疗效满意,Ⅰ期Pe(n)a术是一种创伤小、花费少、美观、简洁的手术方式.

Abstract：

Objective The aim of this study was to examine the feasibility, safety, cost- effectiveness , and medium-term outcome of one-stage repair of intermediate and high imperforate anus in the newborn. Methods This is a retrospective review of forty eight consecutive newborns who underwent one-stage anorectoplasty during the newborn period at the children's hospital of Chongqing medical University between January 2006 and March 2010. Thirty one of 48 patients were followed-up for 2 months to 4 years 4 months, followed-up data on the retrospective analysis. Results Forty-five patients had excellent results. One case died of respiratory and circulatory failure, the other two suffered from part incision dehiscence. Twelve of Thirty-one of the 48 cases has been followed-up for 2 months to 4 years and 6 months. No fecal incontinence,fistula recurrence,urinary retention has been observed. 3 cases has had constipation, 4 patients has soiled his diapers between bowel movements, 2 cases has had rectal mucosa prolapse, 1 patient has had wound infection, 1 patient has had stricture of anus without dilating of the anus. 17 cases underwent Anorectal manometry,only 4 exist RAIR. Conclusions Complete 1-stage repair using the Pe(n)a to treat high-type and intermediate-type anorectal malformations can be offered the same results as the traditional Pe(n)a. Also.it is safe and feasible.     

加速康复外科技术在肛门闭锁并直肠前庭瘘中的应用CSCD

Objective To explore the efficacy and safety of enhanced recovery after surgery (ERAS) in children with anal atresia and rectal vestibular fistula. Methods From January 2017 to October 2021, prospective review was conducted for 50 children with anal atresia and rectal vestibular fistula undergoing transanal analoplasty. They were randomized into two groups of ERAS and non-ERAS (n =25 each). ERAS group received enema once in the morning of operation day, oral 12.6% carbohydrate liquid 2 h pre-operation, intraoperative heat preservation, target-oriented rehydration ,no indwelling catheter post-operation, postoperative analgesia and other new measures; non-ERAS group had traditional perioperative treatment. Blood glucose at the beginning of anesthesia, blood glucose 24 h post-operation, white blood cell count ( WBC), C-reactive protein (CRP), time of initial exhaust and defecation post-operation, amount of intraoperative infusion, time of postoperative intravenous infusion ,time of postoperative hospitalization, expenditure of hospitalization incidence of complications and readmission rate at Day 30 post-discharge were compared between two groups. Results No significant inter-group differences existed in average age, weight, preoperative WBC, CRP, hemoglobin, albumin, prealbumin or blood glucose at admission. Blood glucose at the beginning of anesthesia in ERAS and non-ERAS groups was (4.92±0.50) and (4.53 ±0.42) mmol/L, blood glucose (5.03 ±0.66) and (5.96±41.18) mmol/L at 24 h post-operation. WBC at 24h post-operation (9.97 3.24) x 10°/L and (8.28 ±3.51) x 10°/L;CRP at 24 h post-operation (3.63±4.00) and (9.03±15.77) mg/L;initial postoperative exhaust and defecation time (12.1 ±6.4) and (14.0 ±9.3) h;intraoperative infusion volume (83.1 ±32.2) and (136. 1±68.4) mL;postoperative intravenous infusion time (4.68 ±1.25) and (6.6 ±1.68) days; postoperative hospital stay (7.12 ± 1.56) and (10.56 ±3.58) days; hospitalization expense (13 314. 34 ±2 856.86) and (16 088.69 ±3 282.34) CNY ;complications occurred (n =3,12%) and (n =6,24%) ;overall satisfaction was 88% and 60%. Both groups were cured and discharged and there was no re-admission within 30 days post-discharge. No inter-group differences existed in initial exhaust or defecation time, WBC and CRP at 24 h post-operation (P >0.05).In nonERASgroup, blood glucose declined at the beginning of anesthesia while postoperative blood glucose level rose with statistical difference (P <0. 05) ; overall satisfaction of ERAS group was higher than that of non-ERAS group with statistical difference (P lt; 0.05). Conclusion Conceptual application of ERAS is both safe and effective in children with anal atresia with rectovestibular fistula. It can effectively shorten the average time of hospital stay, curtain the length of postoperative hospitalization and lower hospitalization expenditure. A wider popularization is worthy. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.     

臀大肌瓣移位在治疗神经源性大便失禁中的作用

目的 探讨臀大肌瓣移位肛提肌加强术在治疗儿童神经源性大便失禁中的作用.方法 2006年1月至2009年12月在我院行臀大肌瓣移位肛提肌加强术13例,其中男9例,女4例,手术年龄7～16岁,平均13.2岁,患儿术前均有明确的脊髓拴系松解手术史,在手术前均行盆底肌电图检查、盆底肌MR、结肠传输试验检查,严格掌握手术适应证,手术前后均行肛门直肠测压、临床疗效评价.结果 术后12例患儿获得随访,术前盆底肌电图均表现为神经源性损害,且为失代偿期.结肠传输试验表现为混合型10例,出口梗阻型3例,盆底肌MR见13例患儿肛提肌发育不对称或肛提肌不能清楚显示,肛门直肠测压手术前后均未见明显变化,临床评分结果示13例患儿均表现为完全性大便失禁,评分差,术后患儿的临床表现优0例,良8例,差4例.结论 臀大肌瓣移位肛提肌加强术有利于改善神经源性大便失禁的排便状况.

Abstract：

Objective To study the efficacy of gluteus maximus flap transposition for the treatment of neurogenic fecal incontinence in children.Methods Between January 2006 and December 2009,7 males and 4 females were diagnosed with neurogenic fecal incontinence and underwent surgery at this center.Their age ranged from 7 to 16 years old (mean age,13.2 years).All the children had a history of tethered spinal cord release surgery.Before surgery,all patients had pelvic floor electromyography,colonic transit test,anorectal manometry,and pelvic floor MRI.The patients were followed up after surgery.The clinical data were retrospectively analyzed to evaluate the efficacy of the surgery.Results Pelvic floor electromyography found the uncompensated nerve function impairment before surgery.Colonic transit test found 10 patients had neurogenic fecal incontinence,and 3 had outlet obstruction.Anorectal manometry measurements of these patients didn't have any changes after surgery.The anorectal function was scored fair on 8 patients,and poor on 4.Conclusions Gluteus maximus flap transposition is effective to improve the anorectal function on the patients with neurogenic fecal incontinence.     

后人字切口手术治疗中低位肛门闭锁合并会阴瘘

目的探讨限制性后人字入路直肠肛门及外括约肌成形术治疗中低位肛门闭锁合并会阴瘘的临床应用价值。方法统计本院2010年2月至2013年6月收治的先天性肛门闭锁合并会阴瘘患儿47例,均采用限制性（3 cm 以内）切口,显露瘘管及直肠下端,在直肠下端的后方,将肛门外括约肌复合体部分切开,将两侧的肌纤维环包于直肠下端半周,完成外括约肌成形术。在中线后切瘘管及直肠壁2 cm,与正常肛隐窝处完成肛门成形术。结果本组47例肛门闭锁合并会阴瘘患儿经该术式获得良好的效果,术后全部病例均获随访,除2例因瘢痕体质出现肛门瘢痕性狭窄和1例因继发直肠扩张术后发生便秘外,全部患儿恢复自主排便,无便失禁及黏膜外翻等并发症,肛门外观良好。结论该术式操作简单,局部创伤小,术后避免了直肠回缩,并发症少,不需扩肛,随访疗效满意。     

腹腔镜下肛门直肠畸形术后再手术原因分析及对策

目的:探讨腹腔镜辅助下治疗先天性肛门直肠畸形术后再手术原因及对策,以及并发症与不同部位直肠泌尿系瘘的关系。方法:回顾性分析2013年1月至2018年12月间123例在3～4月龄行腹腔镜辅助下治疗的先天性肛门闭锁患儿的临床资料。本组患儿在新生儿期已行横结肠或乙状结肠造瘘。其中直肠膀胱瘘32例,直肠前列腺球部瘘48例,直肠...     

Laparoscopic assisted endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula

Rectourethral or rectovaginal fistula is a troublesome complication after anorectal surgery. The pelvic and perineal dissection may be difficult because of severe fibrosis adhesion around the fistula. The authors applied a novel technique: a combined laparoscopic assisted abdominal and posterior sagittal approach (PSA) to perform the redo surgery. Three boys and two girls (3–13 years old): case 1 had rectovaginal fistula after rectal dialation and modified Swenson’s procedure; case 2 had rectovestibular fistula after twice perineal anorectoplasty; case 3 had rectourethral fistula after twice anorectoplasty; case 4 was imperforate anus with Hirschsprung’s disease and rectourethral fistula that had been misdiagnosed; case 5 had rectourethral fistula after abdominoperineoanoplasty and Mollard procedure and posterior sagittal anorectoplasty. Laparoscopic assisted abdominal dissection was done first to mobilize the colon as far as the mid pelvis, and the normal colon was marked with a suture. The lower pelvic dissection was performed through the posterior sagittal route, the proximal rectum was mobilized and servered, the distal rectum was left undisected, endorectal mucosectomy with electric ablation was performed, then the fistula was closed from inside the rectum, and the stump of the colon was pulled through the rectum, the stump and the dentate line were anastomosed extraanally. Colostomy was done in case 2 and case 5. The postoperative follow-up showed no recurrent fistula, and all patients had attained normal voluntary bowel actions, but one child had infrequent minor soiling. Laparoscopic assisted endorectal pull-through of the intact colon can offer precise dissection, minimal abdominal injure, and spare troublesome mobilization of the fistula, and can prevent the recurrent of fistula. Posterior sagittal approach provides a direct repair of the fistula and anastomosis.     

Postoperative internal sphincter function in anorectal malformations — a manometric study

An anorectal manometric assessment of 30 patients with operated high or intermediate anorectal malformations was performed in order to study internal sphincter function in the reconstructed anal canal. In 14 patients (group I, mean age 3.1 years) the rectal blind pouch and fistula, when present, were used in the reconstruction of the anal canal by posterior sagittal anorectoplasty (12 cases) or sacroperineal pull-through (2 cases). In 16 cases (group II, mean age 8.8 years) the anal canal was reconstructed from proximal rectum or sigmoid by sacroabdominoperineal pull-through. In 11 of the 14 patients in group I manometric findings suggested the presence of a functioning internal sphincter. The pattern of anal slow-wave activity and rectoanal inhibitory reflex was normal. None of the patients in group II had a rectoanal inhibitory reflex and the slow-wave activity was of a colonic type. The resting anorectal pressure profiles were significantly higher in group I than in group II (mean 38 cm H₂O vs. 25 cm H₂O). The fecal continence of patients in group I was superior to those in group II despite their much younger ages. The findings of this study indicate that in anorectal malformations there is internal sphincter function in the distal rectal blind pouch and that it can and should be preserved when the anal canal is reconstructed.     

Perineal skin bridge and levator muscle preservation in neutral sagittal anorectoplasty (NSARP) for vestibular fistula

The incision in limited posterior sagittal anorectoplasty for vestibular fistula (VF) extends from the coccyx to the fistula with the rectum identified by partial sagittal division of the levator muscle. In anterior sagittal anorectoplasty, the perineal incision extends from the fistula opening to the posterior margin of the external sphincter complex while preserving intact the levator muscle. We describe a modification of the operation for repair of VF, the neutral sagittal anorectoplasty (NSARP), which preserves both a perineal skin bridge between the neo-anus and the posterior fourchette and the levator muscle. Leaving the perineal skin bridge and the levator muscle intact could be important both from the aspects of perineal wound-healing and functional outcome. The skin incision in NSARP extends from the coccyx to the anterior limit of the external sphincter muscle complex as defined by muscle stimulation. An artery forceps passed through the VF facilitates the location and exposure of the rectum. The levator muscle is left intact. The dissection and closure of the VF is done entirely from within the opened rectum. There is an intact perineal skin bridge between the neo-anus and the posterior fourchette at the completion of the NSARP. In 12 consecutive patients with VF, NSARP prevented the risk of wound complications occurring between the neo-anus and the posterior fourchette. A diverting colostomy was safely avoided in our last five patients. NSARP does not involve any division of the levator muscle and it also retains an undisturbed wad of tissue that could function as the perineal body. All five patients who are 3 years or older demonstrate voluntary bowel movements. Preserving the perineal skin bridge and the levator muscle in NSARP have contributed to the improvement of aesthetic appearance of the perineum and faecal continence in our patients.     

先天性肛门直肠崎形鼠仔的病理特点

为了解先天性肛门直肠畸形的病理改变，用乙烯硫脲（ＥＴＵ）诱发大白鼠产生肛门闭锁畸形鼠仔，观察其盆腔病理改变。结果：低位肛门闭锁肛门内括约肌正常；高、中位有瘘型肛门闭锁存在内括约肌，但直肠前壁短小，畸形位置越低，内括约肌面积越大；高、中位无瘘型肛门闭锁无内括约肌。有瘘型肛门闭锁及低位肛门闭锁直肠远端或瘘管内覆未角化的复层上皮或角化的鳞状上皮，为正常肛管的异位。肛门闭锁畸形鼠仔外括约肌缺如、异位或正常，肛提肌薄弱。肛门闭锁畸形术中应充分保留瘘管近端及直肠盲端组织。     

腹腔镜在高位肛门闭锁成形术中应用价值的探讨

目的 探讨腹腔镜辅助下对高位肛门闭锁患儿行Ⅰ期肛门成形术的价值。方法 先天性高位肛门闭锁患儿10例，男孩8例，年龄分别为1～3d的4例；年龄6个月并在新生儿期行乙状结肠造瘘的患儿4例；女孩2例，年龄分别为1d和3个月，为合并直肠闭锁的肛门闭锁和一穴肛畸形。对于6例无造瘘患儿，术中首先腹腔镜监视下，游离直肠，分离结扎断离直肠尿道(阴道)瘘管；然后通过盆底肌肉中心形成隧道，将直肠从中脱出，与会阴皮肤吻合。对于行乙状结肠造瘘手术后的4例患儿，腹腔镜下关闭断离瘘管后，切除造瘘口以远的直肠，将近端的结肠从盆底肌肉中心形成隧道脱出。结果 10例患儿均在腹腔镜辅助下Ⅰ期完成肛门成形术，腹腔镜手术操作时间平均67．8min(45～90min)，出血量平均8．3ml(5～20m1)，无需要输血者。未出现明显的术中并发症，所有患儿术后恢复顺利，于术后11d去除尿管和膀胱造瘘管，无尿道瘘憩室发生，1例乙状结肠造瘘手术后的患儿发生腹部切口感染。术后随访3至26个月，1例患儿手术后1个月出现肛门狭窄，于术后3个月行狭窄段切除术治愈。另外9例无并发症发生，目前患儿排便控制功能良好。结论 腹腔镜辅助肛门成形术是治疗高位肛门闭锁有效方法，有手术打击小、处理直肠泌尿系瘘方便、辨认盆底肌中心准确、对肌肉损伤小等优点，免除患儿分期手术之苦。     

前矢状入路直肠肛门成形术治疗女婴无肛前庭瘘的疗效观察

目的评价前矢状入路直肠肛门成形术治疗女婴无肛前庭瘘的疗效。方法自会阴前矢状入路游离瘘口,游离直肠侧壁及直肠后壁,保留直肠末端瘘口不受损伤,保证瘘口内括约肌结构完整,使直肠末端置于外括约肌中心无张力重建会阴体,恢复女童正常会阴外观。结果本组86例一期手术获成功,经近远期随访,会阴体外观及肛门功能均达到满意的效果。结论前矢状入路直肠肛门成形术治疗女婴无肛前庭瘘,直视下重建肛门直肠,完整保留了直肠瘘口及直肠盲袋,获得了满意的排便功能。     

Anorectal malformations — results of treatment and long-term follow-up in 208 patients

During a 20-year period (1964–1983) 208 patients with anorectal malformations (143 males, 65 females) were treated; 98 had low and 110 had high or intermediate malformations. Associated anomalies were detected in 67.8%. The overall mortality in the series was 14.4%; most deaths were related to associated anomalies and/or prematurity. Four different procedures were used for high and intermediate anomalies: (1) abdominoperineal (18 cases); (2) sacroabdominoperineal (38); (3) sacroperineal (8); and (4) posterior sagittal anorectoplasty (7). Neonatal anoplasty was used to correct male low anomalies. Female low and intermediate anomalies with vestibular fistula were treated with anal transposition. More than one-half of the patients with high or intermediate anomalies had complications related to surgical therapy. Major secondary surgery was performed in 41 cases (12 resections of megarectum, 29 late sphincter reconstructions). Of the living patients, 90% (159/178) were followed up for 5–25 years. A majority (93%) of the patients with low anomalies had a good outcome at the last follow-up examination. In patients with high and intermediate anomalies continence improved with time; the greatest improvement occurred after 10 years of age. At the last follow-up examination 73% of the patients with high or intermediate anomalies had acceptable social continence. Manometric evaluation revealed a rectoanal inhibitory reflex in all assessed patients with a low anomaly, indicating a functioning internal sphincter. In patients with intermediate and high anomalies a rectoanal inhibitory reflex was found only when full-thickness terminal bowel had been used in the reconstruction (by perineal and posterior sagittal repair); presence of the reflex correlated with superior fecal control. Acceptable fecal continence may be achieved in the majority of patients with anorectal anomalies. Operative methods that optimally utilize the voluntary sphincters and preserve the potential internal sphincter in the terminal rectal pouch seem to facilitate earlier development of fecal continence. Offprint requests to: R. Rintala     

Normal anorectal musculatures and changes in anorectal malformation

We investigated the anorectal musclulature in normal children and anorectal malformations (ARM) to evaluate its role in bowel control mechanism. Pelves of 50 neonates died of ARM-unrelated diseases and 16 patients with anorectal malformations (8 high, 5 intermediate, and 3 low ARMs) were dissected and analyzed. Normal anorectal musculature was divided into three muscular tubes: the internal sphincter tube (IAST), longitudinal muscle tube (LMT) and transverse muscle tube (TMT). The LMT came from the outer longitudinal smooth muscle fiber of the rectum and the striated muscle fiber of the levator ani, and the TMT composed of the puborectalis and the external anal sphincter. However, in ARM, the IAST was absent and the LMT, the center of the sphincter muscle complex, was only from the levator ani and could be divided into the pelvic portion and the perineal portion. The former, from the upper rim of the puborectalis to the bulbar urethral, became narrowed and dislocated anteriorly near to the posterior urethra in high ARM and rectal pouch in intermediate ARM. The latter, below the bulbar urethra to the anal dimple, was fused to a column both in high and intermediate ARM. The columnar perineal LMT run downwards and then split, penetrated the superficial part of EAS and terminated at the deep aspect of the skin, to form the anal dimple, which represents the center of the perineal LMT from the perineal aspect. The length of the LMT was longer in high and intermediate ARM than the normal neonate. The columnar perineal LMT and narrowed pelvic LMT could be possibly identified by laparoscopic and perineal approaches retrospectively and widened to allow the passage of the rectum through. The anorectal musculature in ARM is composed of agenesic LMT and TMT and the narrowed LMT gives anatomical evidence of the center, where the neorectum should pull through.