先天性巨结肠症直肠肛管纵切心形吻合术12例报告

对12例先天性巨结肠患儿采用腹内不断结肠经直肠内套出结肠,直肠肛管纵切,结肠直肠前高后低心形吻合不用夹具的手术方法。患儿平均住院30d,吻合口狭窄1例,1月后作狭窄部切开;1例发生尿潴留,3个月后恢复,2例肛门污粪,全组钡灌肠复查结肠无狭窄及扩张,肛门排便功能正常,直肠肛管纵切心形吻合术根治先天性巨结肠症,不造成腹腔感染,不用夹具,术后肛门排便功能恢复快,并发症少。     

修复性直肠结肠切除和低位前切除伴结肠肛管吻合术后的肛管直肠功能

修复性直肠结肠切除一回肠袋手术仍有17％～59％发生排便失禁,而低位前切除一结肠肛管吻合术也有肛门失禁的问题。作者在17列修复性直肠结肠切除一回肠袋肛管吻合器吻合术(RP组)的手术前后、10     

经肛门巨结肠根治切除术后结肠形态及功能的初步评价

目的探讨经肛门巨结肠根治术后结肠形态及功能的变化。方法对58例经肛门巨结肠根治术后儿童进行排便功能问卷调查、钡灌肠X线和结肠传输时间检查,评价其结肠形态及功能的变化。结果本组58例儿童均有便意,54例排便良好,4例便频或稀便,9例污便,5例便秘, 2例患有小肠结肠炎,无便失禁。钡灌肠X线显示结肠形态恢复良好,乙状结肠迂曲减少或消失,与切除肠段的长短相关。全部病例术后直肠肛管角(度)较术前及对照组显著开大[(123±15)°比 (85±8)°比(79±12)°,P<0．01],有症状组更为显著[(136±16)°比(111±14)°,P<0．05]。全部病例术后全结肠传输时间较术前均明显缩短[(27±8)h比>168 h,P<0．01],与对照组比较略有降低但不显著[(27±8)h比(29±8)h,P>0．05],有症状组显著缩短[(25±6)h比(29±8)h,P< 0．05]。结论经肛门巨结肠根治术后结肠功能良好。少数患儿排便功能障碍可能与术后乙状结肠曲减少或消失、“新直肠”储便功能代偿不全以及拖出结肠致直肠肛管角开大有关。     

新生儿先天性巨结肠症26例诊治体会

目的 探讨新生日龄小于28 d先天性巨结肠症(HD)的诊断和处理方法.方法 回顾2003～2007年收治的新生儿HD病历26例,结合病史、结肠造影、手术、病理检查及随访所见进行临床分析.结果 26例病例中16例采用手术治疗,其中Soave术2例,直肠肛管纵切心型吻合术13例,结肠造瘘术1例.术后14例治愈,死亡2例.非手术治疗10例,通过灌洗灌肠扩肛半年至1年而排便正常,无需手术治疗.结论 对新生儿HD的诊断要结合钡剂灌肠造影、直肠黏膜活检、肛门直肠测压(ARMM)等综合检查以提高诊断准确率,Ⅰ期根治术是发展方向,造瘘术只用作最后手段.不同类型的新生儿HD选择不同的手术方式是治疗的原则.     

两种巨结肠根治术后肛门功能与直肠肛管测压的研究

目的探讨改良Swenson巨结肠根治术和经肛门Soave巨结肠根治术术后患儿排便控制及直肠肛管测压改变情况。方法回顾33例改良Swenson巨结肠根治术和20例经肛门Soave巨结肠根治术患儿,术后平均随访4年(3个月～8.5年),对患儿大便控制能力、便秘发生情况及肛门直肠测压结果进行比较。结果改良Swenson术组术后排便控制情况与经肛门Soave术组差异无统计学意义(P>0.05);肛门直肠测压检查:直肠肛管抑制反射恢复率改良Swenson术组较经肛门Soave术高,差异有统计学意义(P<0.05)。直肠静息压、感觉阈值和最大直肠耐受容量两组差异无统计学意义(P>0.05)。结论经肛门Soave巨结肠根治术治疗小儿巨结肠,具有创伤小、出血少、术后恢复快、无肠粘连等优点且术后可获得同样好的排便控制功能。     

成人先天性巨结肠的诊断与外科治疗

目的探讨成人先天性巨结肠的诊断与外科治疗。方法回顾性分析1992年6月至2004年6月问收治的15例成人先天性巨结肠患者的临床资料。结果15例患者年龄17．54岁。人院前有9．5个月至50．0年(平均21．4年)的长期便秘、腹胀史；6例患者有急性腹痛史；均无脱水或营养不良表现。钡剂灌肠可见肠管狭窄段和扩张段。予以Soave手术2例，次全结肠切除加结肛吻合术13例；术后所有患者排便功能优良。结论自幼长期慢性便秘史和钡灌肠检查是诊断的主要依据；结肠次全切除加结肛吻合术是安全有效的手术方式。     

先天性巨结肠手术后排便造影检查的临床意义

目的评价排便造影检查在先天性巨结肠 (HD)术后随访的临床意义。方法对30例行HD根治手术治疗患儿行排便造影检查 ,并获得手术后的排便功能情况 ,行腹部和肛门指诊检查及肛管直肠测压检查。结果按照临床评分标准 ,本组 30例中“优者”4例 (13% ) ,即无任何排便异常者 ;“良好”2 1例 (70 % ) ,有较轻度的排便异常 ;“一般”5例 (17% ) ,有明显的排便异常 ;无“差”病例 ,即无排便严重障碍和完全失禁者。排便造影显示静息状态时直肠肛管角及直肠骶曲在“一般”组与对照组之间比较差异有显著意义 (P <0 0 5 )。“一般”组与对照组比较肛管长度缩短 (P <0 0 5 )。结论HD根治术后患儿排便功能良好 ,并随时间的延长排便功能可继续好转 ,排便控制建立在拖下结肠“直肠、乙状结肠化”的过程。术后大便储袋的形成、直肠肛管角和直肠骶尾曲在排便控制中起重要作用。排便造影比传统的钡灌肠更能确切地了解排便功能 ,对评价HD术后功能有重要价值。     

先天性巨结肠Z型吻合术后远期疗效

治疗先天性巨结肠的Duhamel术式的优点是对膀优、生殖器和直肠前壁的影响较小、肠狭窄少且手术简单，其缺点之一是术后形成直肠盲襻。主要为消除直肠盲标的Z型吻合术于1963年设计，在肛门齿状线上将直肠后壁与下拉的结肠吻合，然后在腹膜反折处将近端直肠与结肠吻合，在两吻合口之间纵向切开吻合。因侧面观吻合口呈Z型而得名。本研究旨在评价过去35年间，行Z型吻合病人术后远期的排泄功能，包括排便情况、直肠肛管测压、钡灌肠及生活质量。方法1963～1997年127例先天性巨结肠行Z型吻合，存活122例（96％）。4例死于术后早期并发症，二例术…     

婴幼儿经肛门巨结肠根治术后直肠肛管三维向量测压的研究

目的探讨经肛门巨结肠根治术后直肠肛管三维向量测压改变,以评价其肛门括约肌功能。方法对58例在婴幼儿期接受经肛门巨结肠根治术儿童进行随访,平均随访时间为15．8个月,全部为普通型巨结肠。对所有患儿进行排便功能问卷调查,根据临床症状分为无症状组和有症状组,并进行肛门括约肌三维重建,做肛管最大压力、向量容积、对称指数和直肠肛管反射检查。结果临床问卷调查显示58例均有便意,54例排便次数平均为1～2次／d,仅4例8～10次／d,9例污便, 5例便秘,2例有小肠结肠炎,无便失禁。直肠肛管反射3例阳性,2例弱阳性。便秘组的最大静息压 (mmHg)明显高于无症状组和对照组[(167±36)比(157±47)比(152±33),P<0．05;(211±36)比 (200±65)比(190±38),P<0．05]。污便组向量容积(cm×cmHg2)和对称指数较术前及对照组显著降低[(381±109)比(520±254)比(662±31),P<0．05;(0．69±0．32)比(0．75±0．19)比(0．70± 0．07),P<0．05]。便秘组对称指数高于对照组[(0．74±0．02)比(0．70±0．07),P<0．05]。结论婴幼儿经肛门巨结肠根治术后肛门括约肌功能良好。少数病例排便功能障碍的发生可能与术后“新直肠”储便功能代偿不全及(或)肛门括约肌痉挛失迟缓或损伤修复有关。     

腹腔镜辅助下改良Swenson巨结肠根治术手术配合

先天性巨结肠是儿外科常见病。近年来 ,随着腹腔镜手术的发展 ,改变了以往的结肠造瘘、二期根治及造瘘的手术方式。 1 999年 1 1月至 2 0 0 1年 5月 ,我院行腹腔镜辅助下改良 Swenson巨结肠根治术(直肠肛管背侧纵切口鸡心领斜形吻合手术 ) 1 9例 ,取得良好效果。1　临床资料1 9例先天性巨结肠患儿 ,男 1 3例、女 6例 ,年龄 6～ 33个月。1 8例为普通型巨结肠 ,1例为长段型巨结肠。所有患儿经直肠粘膜活检、直肠肛管测压和钡剂灌肠确诊。腹腔内手术由腹腔镜系统及超声刀完成 ,会阴部手术采用改良 Swenson手术。手术时间为 ( 2 2 0± 5 0 ) mi…     

Posterior sagittal anorectoplasty for failed imperforate anus surgery: lessons learned from secondary repairs

PURPOSE: The aim of this study was to evaluate secondary operations using a posterior sagittal approach in patients with fecal incontinence and impaction after primary repair of anorectal malformations. METHODS: Twenty patients (14 boys, 6 girls) who had previous failed surgery for imperforate anus underwent secondary operations. The indications for surgery included fecal incontinence (n = 16) and fecal impaction (n = 4). Patients ranged in age from 2 to 30 years (mean, 11 years), with 4 over the age of 20 years. The primary procedures included abdominosacroperineal (n = 7), sacroperineal (n = 10), and perineal (n = 3) pull-throughs. At surgery, none of the patients underwent a diverting colostomy. The rectum was mobilized from the surrounding structures through a posterior sagittal approach. The surgical findings included anteriorly displaced anus (n = 17), laterally displaced anus (n = 3), mesenteric fat surrounding the rectum (n = 4), mega-rectosigmoid (n = 2), and others (n = 3). The rectum underwent reconstruction, which involved relocation of the rectum and anus to surround them with the muscle complex. RESULTS: Patients underwent follow-up for periods ranging from 8 months to 6 years after surgery (mean, 3 years). To evaluate the functional results, fecal continence scores (Templeton and Ditesheim) were calculated for incontinent patients. Of the 16 incontinent patients, 12 achieved continence and 4 some improvement. Of the 4 patients with fecal impaction, 2 achieved daily voluntary bowel movement, whereas the other 2 have mild constipation and need occasional enemas. CONCLUSIONS: Our study suggests that (1) a secondary operation through a posterior sagittal approach can restore fecal continence and is efficacious even in adolescents and adults and (2) a posterior sagittal procedure can be safely performed without a diverting colostomy.     

生物反馈联合电刺激治疗小儿充溢性大便失禁的疗效观察

目的:探讨生物反馈联合电刺激治疗小儿充溢性大便失禁的近期疗效.方法:应用生物反馈电刺激仪,对20例充溢性大便失禁患儿进行综合治疗(实验组),包括功能性大便失禁患儿10例(A组),神经源性大便失禁10例(B组),治疗时间20～30 min,每周治疗5次,20次为1个疗程.另选10例脊髓栓系松解术后引起的充溢性大便失禁患儿仅行盆底肌训练作为对照组(C组).治疗前后均行临床失禁程度分级,肛门直肠测压及盆底肌电图检查.结果:随访3～5年,平均4.5年.A、B 2组患儿治疗后临床评分4.8±0.6,3.4±0.5;肛门最大收缩压(187.5±5.5)mm Hg,(130.8±3.9)mm Hg;持续收缩时间(9.3±1.3)s,(5.1±1.2)s;直肠感觉阈值(23.5±5.7)mL,(34.9±3.9)mL;肛门外括约肌收缩振幅(286.6±58.3)μV,(228.5±33.1)μV;阴部神经潜伏期(34.8±10.5)ms,(47.4±8.0)ms,与治疗前比较差异均有统计学意义(P<0.05),功能性大便失禁患儿疗效优于神经源性大便失禁患儿,神经源性综合训练组优于神经源性对照组(P<0.05).结论:生物反馈联合电刺激训练是治疗充溢性大便失禁一种可以选择的有效方法.     

重建肛门外括肌和直肠肛管角治疗先天性肛门闭锁肛门成形术后大便失禁(附32例报告)

目的:观察重建肛门外括肌和直肠肛管角治疗先天性肛门闭锁肛门成形术后大便失禁的临床疗效。方法:对32例先天性肛门闭锁肛门成形术后大便失禁患者用股薄肌重建肛门外括肌并重建直肠肛管角。结果:32例患者术后随访1年,肛门功能优19例,良9例,较好4例,无效者未发现,总满意率为87·5%(28/32)。结论:用股薄肌重建肛门外括肌并重建直肠肛管角,术后患者肛门功能满意率高,患者生活质量明显提高。     

Bowel control after surgery for Hirschsprung's disease

Bowel control was studied in 66 children operated by Ikeda's Z-shaped anastomosis for Hirschsprung's disease. At the age of 2 or 3 years, mild constipation was recognized in 16% of the children, incontinence in 12% and soiling in 28%. However, these disorders reduced as the patients grew up and finally over 7 years, constipation was seen in 8% of the patients, incontinence in 8% and soiling in 19%. According to barium enema, megarectum was seen in all constipated children but one, though slight megarectum was sometimes seen even in normal or incontinent children. Frequently, anal canal was wide and leakage of barium through the anus was seen in incontinent or soiling children. Anal canal pressure was high in constipated group, low in soiling group and the lowest in incontinent group. The appearance rate of rhythmical wave of anal canal and recto-anal reflex was the same among all groups. Our treatment of the constipation and incontinence is daily bowel movement using laxative, suppository or enema. For the incontinent patients without rectal sensation, biofeedback method or electrical stimulation is applied.     

肛门直肠畸形术后排粪失禁患儿盆腔磁共振成像表现及其临床意义

目的通过肛门直肠畸形术后排粪失禁患儿的盆腔MRI表现,了解盆底肌的形态,直肠、肛管的形态和位置,以及脊髓和骶骨的发育,为分析排粪失禁的原因及制订治疗方案提供客观依据。方法回顾性分析2009年9月至2011年12月间山东大学第二医院收治的34例肛门直肠畸形术后排粪失禁患儿的临床和影像资料,其中男2l例,女13例,年龄3,14岁。应用1．5TMR扫描仪,常规行轴位、冠状位及矢状位扫描,观察肛门括约肌、耻骨直肠肌和提肛肌、直肠、肛管的形态,以及脊髓、骶骨的发育情况。结果MRI检查提示：肛门外括约肌发育不良18例,耻骨直肠肌发育不良23例,肛提肌发育不良27例;直肠位置异常6例,直肠扩张12例,肛直角增大11例;肛管周围脂肪组织5例;合并神经管闭合不全2例,Currarino综合征2例,骶骨发育不全11例,直肠尿道瘘2例。以上影像学结果均经临床最终证实。结论MRI可清楚显示肛门外括约肌、耻骨直肠肌和肛提肌的形态,以及直肠和肛管的形态和位置,同时还可显示脊髓和骶骨的发育情况,是评价肛门直肠畸形术后排粪失禁患儿非常有价值的检查方法。     

The electrically stimulated gracilis neosphincter incorporated as part of total anorectal reconstruction after abdominoperineal excision of the rectum.

OBJECTIVE: The authors investigated the feasibility and effectiveness of combining electrically stimulated gracilis neoanal (ESGN) sphincter and a coloperineal anastomosis in selected patients after abdominoperineal excision of the rectum (APER). SUMMARY BACKGROUND DATA: The ESGN is effective in the treatment of idiopathic fecal incontinence. METHODS: Between March 1989 and September 1993, 12 patients (9 men, 3 women) with a median age of 59.25 years (range, 45-70) underwent the procedure. The underlying disease was adenocarcinoma in 10, anal malignant melanoma in 1, and a sweat gland tumor in the other. In all patients, a sphincter saving resection was contraindicated. The procedure was performed in stages. Stage 1 involved a conventional APER with the formation of a perineal stoma. Eleven patients underwent a vascular delay procedure. All patients were defunctioned. In stage 2, the gracilis was mobilized, transposed around the anal canal, and the electrodes and hardware needed for electrical stimulation were implanted. Once muscle conversion was complete, the defunctioning stoma was closed. RESULTS: Eight patients were closed successfully. In seven of the eight patients, complete physiologic measurements were taken. Median basal and maximum neosphincter pressures were 30 and 122 cm H2O, respectively, at the start of electrical stimulation and 22.5 and 76.2 cm H2O, respectively, after 1 year. Median functioning neosphincter pressure was 36 cm H2O at 1 year. All of the patients whose stomas were closed experienced episodes of incontinence to solid stool and wore pads for persistent fecal soiling. They all reported difficulty in evacuation. Despite imperfect continence, no patient wished to go back to life with a stoma. CONCLUSIONS: The incorporation of ESGN as part of total anorectal reconstruction is technically feasible. The majority of patients are satisfied with their function and pleased to avoid a permanent stoma.     

Preservation of continence after ileoanal anastomosis by the coordination of ileal pouch and anal canal motor activity.

Nocturnal incontinence may occur after ileoanal anastomosis and may be related to loss of an effective anal canal pressure barrier during sleep; how pressure and contractions in the proximal bowel influence this barrier is unknown. Our aim was to evaluate the relationship between anal canal pressure and contractions and contractile activity of the pouch in continent subjects after ileal pouch-anal anastomosis (IPAA) and of the rectum in normal controls. A fully ambulatory system for 24-hour pressure recording was used. A flexible transducer catheter was introduced endoscopically so that sensors were at 2, 3, 8, 12, 16, and 24 cm from the anal orifice in 12 healthy controls (7 men, 5 women, mean age: 35 years) and 7 fully continent IPAA patients (4 men, 3 women, mean age: 34 years) more than 12 months postoperatively. Twenty-four hour spontaneous motor activity was stored in a 2.5 megabyte (MB) digital portable recorder. Mean anal canal pressure was calculated, and rectal motor complexes and ileal pouch large pressure waves were characterized. During sleep, resting anal canal pressures were similar in the two groups (72 +/- 12 mm Hg in controls versus 66 +/- 9 mm Hg in IPAA patients [mean +/- standard deviation (SD)], p = NS), but anal canal pressure showed cyclic relaxations (periodicity: 95 +/- 11 min in controls, 54 +/- 18 min in IPAA patients, p less than 0.05), during which the mean pressure trough was 15 +/- 4 mm Hg in controls and 14 +/- 5 mm Hg in IPAA patients (p = NS). In the control patients, during sleep, a mean of six rectal motor complexes were identified (range: 3 to 9). In patients with IPAA, during sleep, a mean of eight large pressure waves per hour were identified (range: 2 to 20). Importantly, in both controls and patients, rectal motor complexes or large pressure waves were always accompanied by rapid return of anal canal pressure from trough to basal values and increased contractile activity. We concluded that, in healthy patients and in continent patients after IPAA, motor activity of the rectum and of the ileal pouch was associated with changes in pressure and contractile activity of the anal canal so that rectal- and neorectal-anal canal pressure gradient, and, in turn, fecal continence were preserved.     

V-Y island flaps for repair of large perianal defects.

BACKGROUND: Some perianal diseases such as Paget disease and Bowen disease are extensive and require a wide circumferential excision including the entire anoderm of the anal canal. METHODS: We describe a technique of V-Y island flaps to cover the large perianal defects and the denuded anal canal. It is important to excise the base of the flaps in order to fit them into the anal canal. RESULTS: There were 10 women and 5 men with an average age of 54 years (range 32 to 77). The mean follow-up was 45 months (range 6 to 92). The underlying pathology included various kinds of neoplastic and nonneoplastic diseases. There were no major complications such as flap loss or infection. Most complications were minor, including superficial wound separation, flap hematoma, and anal stricture. Although initially all patients had some degree of incontinence for gas and liquid stool or discharge, none of them had significant fecal incontinence at the time of last follow-up. A diverting ileostomy or colostomy was created in 5 patients. Its role was not clear but it did help in the management of the wounds and minimized the pain.     

Short-term v long-term quality of life in children following repair of high imperforate anus

In children with high imperforate anus, their quality of life (QOL) is directly related to their success or failure in attaining fecal continence (FC). At the Children's Hospital of Philadelphia, 120 patients were treated for high imperforate anus. Sixty-one patients were available for long-term follow-up ranging from 2.5 to 24 years. The patients were analyzed in three separate time periods. The purpose of the study was to (1) establish a reproducible quantitative and qualitative scoring system for evaluating QOL; (2) identify clinical techniques for maximizing fecal continence; and (3) develop an algorithm for long-term management of children with persistent fecal incontinence. QOL scores and FC scores were similar for males and females. Patient age, however, proved to be a particularly important factor in QOL. As the length of follow-up increased, there was a significant difference in the percentage of those patients with a QOL score higher than FC score; 57% for the youngest patients v 15% and 7% for the older patients (P less than .01). Ninety-two percent of patients who were 10 years old or less had very supportive families. These families used a number of stratagems to minimize incontinent problems: liners in underpants, enemas, meticulous perineal hygiene, and avoidance of certain foods. After 10 years of age, a child's FC score became a major determinant of his QOL. Older children with fecal incontinence could no longer be shielded by parents and were not well tolerated by teachers and peers. From this study, an algorithm is proposed for children with impaired FC.(ABSTRACT TRUNCATED AT 250 WORDS)