肛门失禁的括约肌重建：—实践与选择

目的 总结肛门失禁（主要为儿童）行括约肌重建的临床经验并针对性提出括约肌重建的方法。方法 回顾１９９２￣１９９７年对３１例完全性肛门失禁的治疗,其中２５例为先天性肛门闭锁术后,２例为会阴损伤术后,４例为盆腔和会阴术后。对此组病例采取不同的括约肌重建术,包括神经压榨股薄肌转移肛门外括约肌重建２５次,臀大肌转移５次,Ｐｕｒｉ－Ｎｉｘｏｎ提肛肌成形术１次,肛门内括约肌成形６次。结果 对２５例进行平均２５     

改良股薄肌转移代外括约肌行肛门重建治疗肛门闭锁术后大便失禁

目的 评估改良股薄肌转移代肛门外括约肌重建术治疗肛门闭锁术后大便失禁的临床效果.方法 回顾性分析自2003年8月至2012年8月于山东大学第二医院小儿外科收治的31名行改良股薄肌代肛门外括约肌治疗大便失禁患儿的病例资料,围绕术前及术后大便临床表现进行病历分析.并依据术前倒立位腹部平片显示的闭锁程度将入选病例分为三组.所有入选病例的手术前、后临床表现均采用克利夫兰大便失禁程度评分系统进行评分并分级.按照其资料的分布及性质,手术前后的比较依据正态性分布情况选用配对t检验或者非参数检验,组间的比较采用依据正态性分布情况和方差齐性选用成组设计方差分析,两两比较采用LSD方法.结果 入选病例术后随访6～87个月,平均33.9个月,22例患儿获得大便排放的自主性控制,大便失禁评分明显降低,与术前相比差异具有统计学意义;肛门直肠测压结果显示肛管最大收缩压及肛管静息压明显增加,手术前后差异具有统计学差异;直肠静息压手术前后未见明显变化,差异无明显统计学意义.结论 改良股薄肌转移代肛门外扩约肌通过提高肛管收缩压及肛管静息压以维持肛管的严密闭合达到大便排放的自主控制,是治疗肛门闭锁术后大便失禁的有效方法.     

利用残留肛门外括约肌治疗小儿肛门成形术后大便失禁

小儿大便失禁是由于损伤了肛门、肛门括约肌或相应的神经,其病因包括先大性和后天性因素,先天性因素包括神经系统发育障碍和肛门直肠畸形,后天性因素有肛门外伤、感染、手术损伤等,其中肛门成形术后仍有大便失禁的病例不少见,且治疗难度大,患儿不但生活很不方便,而且心理发育和社会能力都受到极大影响,目前对此类疾病治疗方法多样,如肛门括约肌重建术、股薄肌移植肛门括约肌重建术、人工肛门括约肌植入术、顺行可控性灌肠等,但治疗效果仍不理想,为寻找一种创伤小、治疗效果好的手术方法,我院对16例肛门成形术后大便失禁的患儿进行了手术治疗,效果满意,现报道如下.     

肛门外括约肌重建术后盆底肌训练的临床意义

目的 评价盆底肌训练在肌原性大便失禁肛门外括约肌重建术后的应用价值.方法 大便失禁患儿27例,年龄5～12岁,男17例,女10例,均为先天性肛门闭锁术后.临床评分均为差,全部病例行股薄肌肛门外括约肌重建术,术后3个月16例行盆底肌生物反馈训练,2周后在家中自行盆底肌收缩训练.11例未坚持行盆底肌训练.结果 术前训练组肛管静息压、肛管收缩压、持续收缩时间分别为(16.7±4.9)mmHg、(61.6±14.6)mmHg和(2.3±0.7)s,未训练组分别为(15.5±4.1)mmHg、(59.3±13.0)mmHg和(2.2±0.7)s,两组间无明显差别;1年后训练组肛管静息压、肛管收缩压、持续收缩时间分别为(35.4±8.7)mmHg、(150.6±17.8)mmHg和(7.2±1.2)s,肛门功能评价优12例,良3例,差1例,未训练组分别为(21.1±3.1)mmHg、(94.7±12.7)mmHg和(4.6±0.8)s,肛门功能评价优3例,良6例,差2例,均好于术前,但训练组治疗效果要明显好于未训练组.结论 股薄肌肛门外括约肌重建可改善肌原性大便失禁的肛门控便功能,但手术后坚持行盆底肌训练对于手术疗效的提高有重要价值.在大便失禁的治疗时不能单纯依赖手术,还要充分重视重建括约肌的功能训练.     

神经压榨股薄肌转移治疗小儿直肠尿道瘘

小儿直肠尿道瘘主要是由于肛门成形术行肛周解剖时损伤尿道或术后感染所引起 ,此类患儿不少都经过多次手术 ,肛周瘢痕多 ,肛门括约肌功能不全 (先天性发育不良 /或手术损伤 ) ,常合并大便失禁 ,如单纯行瘘修补术 ,手术效果常不理想 ,本文总结近年来采用神经压榨股薄肌转移治疗小儿直肠尿道瘘 ,获得满意效果 ,报告如下。临床资料1990年 2月～ 1998年 10月共收治直肠尿道瘘患儿 12例 ,均为先天性无肛肛门成形术术后所引起 ,全部曾行手术治疗 1～ 3次 ,年龄 3～ 13岁 ,平均 8岁。临床表现为小便时有尿从肛门口流出 ,其中 4例大部分尿液从肛门口…     

儿童陈旧性肛门直肠损伤15例分析

目的 探讨儿童陈旧性肛门直肠损伤的特点及外科治疗方法。方法 对15例陈旧性肛门直肠损伤的临床资料进行同顾性分析。结果 肛门排便功能障碍是陈旧性肛门直肠损伤的主要临床表现手术方式：会阴部肛门成形术5例,去神经带血管股薄肌移植肛门外括约肌成形术4例,掌长肌游离移值4例,后矢状入路肛门外括约肌成形术2例,腹骶会阴直肠拖出成形1例,臀大肌移植术1例。本组病例术后除1例污粪外,余均获得良好的排便控制能力。结论 直肠肛门损伤再次手术处理要遵循个性化原则,根据损伤程度不同选择恰当的手术方式可有效地改善排便功能障碍。     

神经压榨的股薄肌,肛门外括约肌成形术：动物实验与临床

根据近年来建立的肌肉超神经支配理论，进行动物实验，证明：暂时性失神经状态的骨骼肌可以通过周围肌肉神经再生和自家神经恢复而获双重神经支配；又从平滑肌和骨骼肌肌电相互影响效应，指出重建括约控制功能时两类肌肉直接接触愈着的重要性，从而确立神经压榨股薄肌、肛门外括约肌成形的理论依据。介绍手术重点注意事项。临床上对大便失禁患儿施行该手术治疗１２例，效果明显。     

股薄肌成形术联合排便训练治疗患儿大便失禁

目的总结股薄肌成形术联合肛门排便训练治疗患儿大便失禁的操作经验和远期疗效。方法回顾性分析1996年4月-2011年4月本院收治的23例行股薄肌成形术联合术后排便训练的大便失禁患儿病例资料。其中男14例,女9例;初发19例,复发4例。先天性无肛行肛门成形术14例,先天性巨结肠术后大便失禁7例,外伤2例。大便失禁患儿分为3组,其中完全失禁6例,稀便失禁8例,肛周污便9例。23例患儿均进行了股薄肌成形术并术后肛门排便训练。术后定期随访,分别测量术前和术后2周、6个月和2 a各组患儿的肛门静息压和最大收缩压,并用SPSS 13.0统计学软件进行对比分析。结果 23例患儿均成功实施了股薄肌成形术,并坚持术后的排便训练,术后通过2～14 a随访,主观症状效果明显满意者13例,有效7例,完全无效者3例,满意率达86.95%(20/23例)。各组患者术后肛门静息压和最大收缩压较术前均有明显改善(Pa<0.05),经过肛门排便训练2 a后测值较术后早期有明显改善(P<0.05)。结论股薄肌成形术联合术后肛门排便训练能够有效改善小儿大便失禁的症状和生活质量。实用儿科临床杂志,2012,27(6):465-466,472     

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。     

复合肌肉移植治疗小儿大便失禁

目的 探讨小儿大便失禁的治疗方法。方法 本组１２例,男１０例,女２例。年龄６－１２岁。均采用双侧髂腰肌加强盆底肌、股薄肌肛门成形术治疗。术后禁食４－５天,切口暴露,随时清除创口和肛门分泌物,保持肛门处清洁,术后３周开始肛门功能训练,结果 要后随访６个月－４年,９例无污粪、３便稀便时有污粪。临床评分５－６分。客观评分４－５分。结论 复全肌肉移植是治疗小儿大便失禁的较好方法。     

经尾路巨直肠及乙状结肠切除术在治疗肛门成形术后顽固性便秘中的应用

目的 探讨经尾路行巨直肠及乙状结肠切除术治疗肛门成形术后顽固性便秘的可行性。方法 患儿6例，年龄2～18岁，均为先天性肛门闭锁行会阴肛门成形术后合并顽固性便秘和充盈性大便失禁。钡灌肠示：直肠及乙状结肠高度扩张，蠕动差。6例患儿均经尾路切除直肠及远端乙状结肠，同时行肛门成形术。结果 平均手术时间205min(125min～265min)，切除扩张肠管长度23．3cm(10cm～40cm)。术后2月～4月后，6例患儿均可控制排便：12月～30月随访结果示：患儿便秘均消失。6例中4例患1度污便，另2例2度污便，无其他术后并发症。结论 尾路切除巨直肠及乙状结肠是治疗无肛术后顽固性便秘的有效方法。     

Recent innovations in the management of fecal incontinence

The importance of having a reproducible scoring system to objectively assess the severity of fecal incontinence and its response to treatment is stressed, and a number of methods are described. The approach to conservative treatment and investigation is outlined. Recent advances in the surgical management of fecal incontinence including the electrically stimulated gracilis neosphincter, sacral nerve stimulation, the artificial anal sphincter, internal anal sphincter augmentation, rectal augmentation, and antegrade colonic irrigation are described in detail.     

电刺激生物反馈治疗先天性巨结肠术后大便失禁的疗效分析

目的探讨电刺激生物反馈治疗先天性巨结肠改良Soave术后大便失禁的近期和远期疗效。方法采用加拿大产Laborie生物电反馈刺激仪,对37例先天性巨结肠改良Soave术后大便失禁的患儿进行盆底肌电刺激、生物反馈治疗。37例中,普通型31例,长段型5例,全结肠型无神经节细胞症1例。新生儿期手术2例,3~6个月手术23例,6个月至1岁手术6例,1岁以后手术6例。所有患儿在医院接受10次以上生物反馈治疗,每周2次,并每天在家进行盆底肌收缩训练。结果 37例均获随访,随访时间1~4年,37例中,经10次生物反馈治疗后,症状完全消失34例(91.89%),其中有8例(21.62%)半年后又出现污粪现象,再次予10次生物反馈治疗后,症状完全消失;3例(8.11%)仍有污粪现象,其中2例为新生儿期手术后一直污粪的患儿,经3个疗程生物反馈治疗后明显好转,在腹泻时仍会出现污粪现象。结论内括约肌损伤可能是先天性巨结肠改良Soave术后大便污粪的原因之一,电刺激生物反馈疗法是一种可靠、无创、有效的治疗方法。     

Optimal parameters for effective electrical stimulation of the anal sphincters in a child with fecal incontinence: preliminary report

The purpose of the present study was to examine the optimal parameters for electrical stimulation of the anal sphincters to improve fecal incontinence in a child after abdominoperineal anorectoplasty for imperforate anus. A pair of coiled-wire electrodes was implanted bilaterally into the deep external sphincter, and alternating bidirectional, biphasic pulses of regulated current were applied. Anal pressure increased in response to an increase in pulse amplitude, width, or frequency, but fell again rapidly when the pulse frequency was higher than 10 Hz. Assuming that an anal pressure of 30 mmHg was necessary to improve anal continence and that tissue damage caused by electrical stimulation and muscle fatigue should be minimized, pulse frequency of 5 Hz and pulse width of 0.1–0.3 ms were determined to be desirable parameters for effective electrical anal sphincter stimulation.     

限制性后人字入路直肠肛门成形及外括约肌成形术治疗中低位无肛合并直肠会阴瘘

目的 针对中低位无肛合并直肠会阴瘘的患儿改良一种新的手术方法,使之较现行的方法如Pena、后切术更加简便、更符合生理以减少手术并发症.方法 切口采用限制性(即限制在3 cm以内)后人字切口,显露瘘管和直肠下端,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.完成外括约肌成形术,在中线后切瘘管及直肠壁,于正常肛隐窝处完成肛门成形.结果 24例先天性无肛合并直肠会阴瘘(X线侧位片直肠盲端在P-C线或至Ⅰ线间)患儿进行了该手术,术后全部病例进行随诊:除1例5岁患儿术后便秘,全部患儿恢复自主排便,可控制,无失禁及溢粪.1例患儿术后肛门切口轻度感染经切开引流治愈.结论 该手术较Pe(n)a手术操作更加简便,局部创伤小,术后避免直肠回缩,减少了术后并发症,且术后不必扩肛;不同于传统的"后切术",术中进行肛门外括约肌成形,术后随诊疗效满意.

Abstract：

Objective To study the clinical outcomes of anorectoplasty and external anal sphincterplasty via posterior approach with Y-shaped incision to repair intermediate and low anorectal malformation complicated with rectal perineal fistula in children. Methods Twenty four patients with intermediate and low anorectal malformation complicated with rectal perineal fistula were enrolled in this study. Via the posterior approach, a Y-shaped incision (＜3 cm) was made to expose the lower rectum and fistula. The external anal sphincter was identified and dissected at the posterior aspect of the lower rectum. The external anal sphincterplasty was performed by overlapping the ends of the muscle around the lower rectum. The rectal perineal fistula was resected and anorectoplasty was performed. Results All surgeries were successfully performed. Voluntary bowel movement and fecal continence was restored on 23 patients after surgery. One 5 years old patient still had constipation. Mild incision infection was found on 1 patient, and was cured after opening the incision and draining the pus. No fecal incontinence or anastomotic stricture was noted. Conclusions Compared with Pena surgery, anorectoplasty and external anal sphincterplasty via posterior approach with Y-shaped incision is less complicated and invasive to repair intermediate and low anorectal malformation complicated with rectal perineal fistula. By using this procedure, better sphincter shape and fecal function is achieved on patients.     

Electromyographic studies on the external anal sphincter in children with operated anorectal malformations.

Fecal incontinence is a common problem after surgical repair in patients with anorectal malformations. A normally functioning external anal sphincter (EAS) mechanism is a major factor for continence. The aim of this study was to assess the function of the EAS in children with operated anorectal malformations by electromyography (EMG) and to refine the sphincter function further. The study group consisted of 8 patients with incontinence problems who were operated for anorectal malformations. The electrical activity of EAS was evaluated by EMG using concentric needle electrodes in all subjects. The presence, localization, integrity and activity of the sphincter were assessed. Seven of 8 patients showed electrical activity of the EAS. Sphincter localization was found to be appropriate in six children. Five children showed a well preserved sphincter integrity and 2 of them disclosed normal EMG activity. In cases of localization or integrity abnormalities, secondary corrective surgery was planned, while in patients showing only abnormal EMG activity, biofeedback treatment was given. In cases of fecal incontinence in patients with operated anorectal malformations, electromyographic study shows the type of sphincter abnormality and further helps to make a decision whether to improve the EAS function with conservative treatment or surgically.     

人工泵式肛门括约肌节制排便的最适肠管约束压选择

人工泵式括约肌是一种治疗大便失禁的新方法,为探明人工泵式括约肌的最佳肠管约束压,将离体和在体肠管的端以人工泵式括约肌的袖套包裹,分别向袖套内注水1.5ml、2.0ml、2.5ml和3.0ml,然后向近端肠腔内注水直到出现渗漏,记录不同肠管容积下的肠腔内压及最大肠腔容积,结果：当袖套内注水达2.5ml时,肠管约束压可达到155cmH2O,其肠腔内压和肠腔内容积均高于1.5mml和2.0ml组;当袖套内注水达3.0ml时,肠腔内压略高于2.5ml组,而两组所能维持的肠腔内液体容积均为40ml;在体实验于术后2周、4周、6周和8周复查无明显改变。结果表明。袖套内注水2.5ml可获得最适肠管约束压,人工泵式括约肌节制排便有良好效果。