腹腔镜下结肠切除、直肠内拖出术治疗巨结肠类缘病

目的探讨腹腔镜下结肠部分或次全切除、直肠内拖出术治疗巨结肠类缘病的可行性。方法1999年10月-2006年5月，对保守治疗无效或复发的38例先天性巨结肠类缘病（Hirschsprung’s disease-allied disorder，HAD）和先天性巨结肠（Hirschsprung’s disease，HD）合并HAD的患儿在腹腔镜下行结肠部分或次全结肠切除、直肠内拖出术。分别在脐缘、右上、右下、左中腹刺入4个5mm trocar，行结肠次全切除时，左侧需建立2个操作孔，分别在左上及左中下腹。腹腔镜下分别游离降结肠、横结肠、升结肠及回盲部侧腹膜，肛门手术按改良Soave方法。结果38例均在腹腔镜下完成手术。9例行左半结肠切除，手术时问110—180min，平均135min；29例行结肠次全切除并按Deloyers法将升结肠逆时针转位270。下拖，保留的升结肠长度7—13cm，平均11．5cm，手术时间140—220min，平均175min。术中出血15～70ml，平均35ml。病理诊断肠神经元性发育异常10例，神经节细胞减少症3例，神经节细胞未成熟症4例，未分类型9例，HD合并IND6例，HD合并HG2例，HD合并IGC4例。38例术后随访6个月一7年，平均3年5个月，29例次全结肠切除患儿3个月内每日大便4—18次，6—10个月后渐转为每日2～3次，9例左半结肠切除患儿术后6个月后每13大便1—2次，无吻合口狭窄，无便秘复发。结论腹腔镜下结肠部分或次全切除经肛门拖出根治术治疗HAD安全、有效、可行，手术创伤较小，但需要一定的腹腔镜操作经验。     

改良Soave术治疗新生儿和婴儿先天性巨结肠

目的评价经肛门改良Soave术式治疗新生儿和婴儿先天性巨结肠的手术效果。方法 17例经组织学确诊为短段型及部分常见型先天性巨结肠患儿行经肛门改良Soave巨结肠根治术。在直肠后壁齿状线上1cm、直肠前壁齿状线上2～3 cm呈斜面切开直肠黏膜,向近端游离直肠黏膜管进入腹腔,切除腹膜外直肠肌鞘达肛提肌水平,残留肌鞘后壁做“V”形切除,游离近端结肠,拖出正常结肠与肛门斜行吻合。结果本组平均手术时间(160±45)min,术中平均出血(45±35)ml, 无术中并发症。术后未发现小肠结肠炎、吻合口漏、肛周感染及吻合口狭窄等并发症。随访4个月- 3年,所有患儿排便成形,无便秘、无污粪。结论经肛门改良Soave术式治疗新生儿和婴儿先天性巨结肠安全有效。     

先天性巨结肠的腹腔镜治疗体会

【摘要】 目的 探讨腹腔镜技术在小儿先天性巨结肠治疗中的应用。方法 对12例先天性巨结肠患儿行腹腔镜Swenson手术,其中短段型3例,普通型8例,长段型1例。结果 12例患者均在腹腔镜下完成手术,无中转开腹病例。手术切除痉挛段和扩张段病变肠管送病理检查,其中最短者约15cm,最长者约60cm。术后病理均显示符合先天性巨结肠诊断。所有病例均未出现吻合口漏、尿潴留、肛周感染等并发症。术后随访3-12个月,所有病例排便功能恢复良好,而且无失禁和便秘症状。结论 腹腔镜先天性巨结肠根治术创伤小、术后恢复快,手术安全,效果满意。     

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目的 探讨先天性肛门闭锁（IA）合并先天性巨结肠（HD）的诊治策略，提高肛门成形术后腹胀，便秘的诊治水平。方法 对1980－1999年162例IA术后腹胀，便秘的4例患儿的临床资料进行分析。结果 4例患儿中3例为低位IA，一期经会阴肛门成形术后出现腹胀，便秘，2例存在肛门狭窄，另1例为高位IA并多发畸形。术前诊断为IA合并HD行巨结肠根治术3例，其中1例肛门狭窄合并急性机械性肠梗阻于术中取材冰冻诊断为HD，术后病理诊断为继发性巨结肠；保守治疗1例为肛门狭窄并发继发性巨结肠，经扩肛和灌肠后症状消失。最后诊断为IA合并HD2例。4例均获得满意的治疗效果。结论 肛门狭窄是肛门成形术后腹胀，便秘的常见原因，IA合并HD极少见，，可通过肛门指检，钡灌肠和病理组织学检查进行诊断与鉴别。     

经肛门入路Soave手术治疗先天性巨结肠(附9例报告)

目的:总结经肛门入路Soave手术治疗先天性巨结肠的经验体会.方法:采用经肛门入路Soave方式行先天性巨结肠根治术9例.结果:全部病例手术顺利,术后无大便失禁、肛门狭窄及复发等并发症.结论:经肛门入路Soave手术治疗先天性巨结肠具有创伤小、恢复快等优点,临床应用时应掌握其适应证.     

吻合器在先天性巨结肠外科手术中的应用

目的 探讨先天性巨结肠术中使用吻合器的技巧及优点.方法 回顾性分析应用吻合器治疗先天性巨结肠12例患者的临床资料.采用改良式Soave切除近端病变肠管,经肛门直肠黏膜与近端肠管端端吻合器吻合.结果 所有患者均顺利完成手术,全组无吻合口瘘、出血及吻合口狭窄等严重并发症发生.1例术后大便次数增多,经口服肠道收敛药物治疗后,排便正常.12例均获得随访,随访时间6～60个月,平均31个月,疗效满意.结论 改良式Soave手术结合吻合器吻合,是一种操作简单,创伤小、术后并发症少的手术,对于年长儿童及成人的先天性巨结肠患者具有较高的实用价值.     

改良Swenson术治疗22例先天性巨结肠临床观察

目的探讨改良Swenson术治疗非洲尼日尔先天性巨结肠（Hirschsprungcs Disease,HD）的有效性和安全性。方法对2006年11月至2008年11月在非洲尼日尔援外工作期间采用改良Swenson术治疗22例先天性巨结肠（HD）患儿进行回顾性分析,对术后并发症情况进行评价。结果本组22例患儿均达到最大限度地保留肛门括约肌,保留其正常排便功能,术后无吻合口漏、切口裂开、感染等早期并发症及术后随访患儿无复发、肠梗阻、吻合口狭窄、大便失禁、腹泻、便秘、污裤等晚期并发症。结论改良Swenson术适用于常见型、短段型及长段型先天性巨结肠,具有较高的有效性和安全性。     

保留扩张而不肥厚结肠的腹腔镜辅助小儿先天性巨结肠根治术

目的探讨保留扩张而不肥厚结肠的腹腔镜辅助下小儿先天性巨结肠根治术的疗效。方法 2006年5月～2008年11月15例先天性巨结肠小儿接受腹腔镜手术治疗,其中常见型13例,短段型2例。脐部、右上腹和右下腹各切口置5mmtrocar,腹腔镜辅助下用腔镜器械,腹腔内游离病变结肠,保留扩张而不肥厚结肠,然后经直肠将病变结肠拖出肛门外切除,将近端扩张而不肥厚的结肠断端与齿状线上直肠黏膜切缘处吻合。结果 15例患儿均经腹腔镜顺利完成手术,无中转开腹。手术时间100～180min,平均130.4min;术中出血量20～50ml。术后1～2d排气,术后第3天进食,7～9d出院。切除结肠组织病理诊断显示扩张但不肥厚或轻度肥厚的结肠含正常神经节细胞。15例随访6～12个月,平均9.5月,患儿6个月后每日大便1～2次,无便秘复发、污粪、狭窄,12例术后3～6个月复查钡灌肠显示扩张的肠管恢复正常。结论腹腔镜辅助下保留扩张但不肥厚或扩张伴轻度肥厚结肠的巨结肠根治术创伤小,安全、有效、可行。     

保留扩张结肠的腹腔镜辅助先天性巨结肠根治术

目的:总结保留扩张而不肥厚结肠的腹腔镜辅助手术治疗先天性巨结肠的疗效及经验。方法:15例先天性巨结肠患儿在腹腔镜辅助下于腹腔内游离病变结肠,保留扩张而不肥厚的结肠,经直肠将病变结肠拖出肛门外切除,将近端扩张而不肥厚的结肠断端与齿状线上直肠粘膜切缘处吻合。结果:15例患儿均顺利完成腹腔镜手术,无中转开腹。平均手术时间约2h,术中出血20～50ml。术后1～2d排气,术后第3天进食,7～9d出院。切除结肠组织病理示扩张但不肥厚或轻度肥厚的结肠含正常神经节细胞。随访6～12个月,患儿6个月后每日大便1～2次,无便秘复发、污粪、狭窄等。12例术后3～6个月钡灌肠复查示扩张的肠管恢复正常。结论:腹腔镜辅助施行保留扩张但不肥厚或扩张伴轻度肥厚结肠的巨结肠根治术,手术游离、切除结肠范围缩小、创伤减轻,更具有手术创伤小、康复快的优点。     

腹腔镜辅助治疗先天性巨结肠20例报告

目的:探讨经肛门行腹腔镜辅助Soave's巨结肠根治术治疗先天性巨结肠的疗效。方法:2007年1月至2008年8月我们为20例先天性巨结肠患儿施行经肛门腹腔镜辅助Soave's巨结肠根治术。结果:20例均顺利完成手术,术中出血少,愈合后疤痕不明显。术后4d进食,7～10d出院。术后患儿均自解大便,无吻合口狭窄。结论:腹腔镜辅助治疗先天性巨结肠是治疗长段型巨结肠的一种新的标准术式。     

成人先天性巨结肠症的诊断和治疗

目的成人先天性巨结肠症的诊断和手术方法的探讨。方法对本院31例成人先天性巨结肠症的临床表现,诊断和手术方法,进行了回顾性分析。结果 29例行 Swenson 手术,1例 Duhamel 手术,术后并发吻合口瘘5例(16.7%)。早期吻合口狭窄2例,28例获得随访,完全恢复正常排便功能23例(78%),4例轻度排便失禁,1例完全排便失禁。结论成人巨结肠症手术后并发症较婴幼儿高。全结肠显著肥厚扩张时,保留回盲部的手术,术后并发吻合口瘘的发生率高;采用全结肠直肠切除回肠直肠末端吻合,并作预防性回肠造瘘术,可预防吻合口瘘的发生。     

慢传输型便秘的外科治疗(附31例报告)

目的 探讨慢传输型便秘外科治疗方法.方法 2004年1月至2010年8月对31例慢传输型便秘病人采用大肠次全切除、直肠低位前切除术、升结肠直肠低位吻合术及末端回肠预防性造口术.结果 全组无死亡病例,未发生肠瘘、盆腔感染、吻合口狭窄、粘连性肠梗阻、肛门失禁等并发症.30例排便功能满意,每天大便次数平均4次;1例术后便秘...     

反穿刺技术在完全腹腔镜结直肠切除术中的应用

目的:探讨反穿刺技术在全腹腔镜结直肠手术中的应用及其可行性、安全性、短期疗效。方法:2013年2月至2013年7月利用反穿刺技术完成全腹腔镜乙状结肠癌切除吻合术7例、全腹腔镜直肠癌切除吻合术(前切除术)10例、全腹腔镜直肠脱垂复位加固定术2例、子宫内膜异位症1例。术中通过主操作孔将吻合器钉砧放入腹腔,应用反穿刺技术将钉砧置入吻合肠管的近端,在腹腔内完成病变肠段的切除,近端结肠与远端直肠的端端吻合,标本经自然腔道或在随后的腹部手术时取出。结果:20例患者均顺利完成完全腹腔镜手术,手术时间140~300 min,平均(210±32.8)min;术中出血量20~100 ml,平均(50±17.6)ml;术后住院5~12 d,平均(7.8±1.36)d。术后发生主操作孔感染1例,均未发生腹腔感染、吻合口漏、吻合口出血及吻合口狭窄。术后随访3~6个月,无远处转移、复发、肛门失禁等。结论:利用反穿刺技术可完成腹腔镜结直肠手术中近端结肠-远端直肠的吻合,如病灶可经自然腔道取出,则可免去腹壁的辅助切口,完成完全腹腔镜手术。利用反穿刺技术行肠管吻合是安全、可行的,掌握一定的手术适应证,其临床治疗效果较满意。     

The problematic Soave cuff in Hirschsprung disease: Manifestations and treatment

Purpose

Following a Soave pull-through for Hirschsprung disease (HD), some children struggle with obstructive symptoms. We hypothesized that these symptoms could result from a functional obstruction of the pull through caused by the Soave cuff, and that cuff resection might improve bowel emptying.

Methods

We reviewed patients referred to our center from 2008 to 2012 with obstructive problems following a Soave pull-through for HD (CCHMC IRB # 2011–2019). Only patients with an obstructing Soave cuff were analyzed. Patients with other reasons for obstruction (anastomotic stricture, transition zone, aganglionic segment) were excluded.

Results

Thirty-six patients underwent reoperation at our center for obstructive symptoms after an initial Soave pull-through. Seventeen of these patients had a Soave cuff only as the potential source of obstruction. Pre-operative symptoms included enterocolitis (10), constipation (6), and failure to thrive (1). Nine patients (53%) required irrigations to manage distension or enterocolitis pre-operatively. 14/17 patients (82%) had a palpable cuff on rectal exam. Eight patients (47%) had radiographic evidence of a cuff demonstrated by distal narrowing (4) or a prominent presacral space (4). Four children (23%) underwent excision of the cuff only. Thirteen (76%) had removal of the cuff and proximally dilated colon [(average length 7.2 cm) (12 performed transanally, and five needed laparotomy as well.)] Post-operatively, episodes of enterocolitis were reduced to zero, and need for irrigation to treat distension was reduced by 50%. Nine patients have voluntary bowel movements, and five are clean on enemas. 3/6 patients with pre-operative constipation or impaction now empty without enemas. (Follow up 1–17 months, mean 7 months.)

Conclusions

Recurrent enterocolitis, constipation, or failure to thrive can indicate a functional obstruction due to a Soave cuff when no other pathologic cause exists. Physical exam or contrast enema can identify a problematic cuff. Reoperation with cuff resection can dramatically improve bowel emptying.     

直肠癌切除术后吻合口狭窄14例分析

目的分析直肠癌切除术后吻合口狭窄的原因。方法 直肠癌切除术后吻合口狭窄患者14例,11例行吻合口狭窄环切开术,1例行尿道探条扩张术2次,1例行经腹直肠吻合口狭窄环切除、回肠造口术,1例肿瘤盆腔复发压迫吻合口,行乙状结肠造口术。结果 11例吻合口狭窄环切开术患者术后继续手指扩肛,无直肠吻合口狭窄症状。尿道探条扩张术的患者,术后20天行回肠保护性造口还纳术,能够排出稀便。结论吻合口狭窄原因为保护性回肠造口术、吻合口感染和吻合口漏、肿瘤复发、术后盆腔放疗、吻合技术。手术方法主要是吻合口狭窄环切开术、尿道探条扩张术和经腹直肠吻合口狭窄环切除术。     

直肠后矢状纵切及心形吻合治疗先天性巨结肠

目的 提高先天性巨结肠的手术疗效。方法 回顾1992年8月至2002年8月应用直肠后矢状纵切、心形吻合技术治疗诊断明确的先天性巨结肠患儿106例，分析疗效及并发症防治。结果 106例患儿术后全部随访2个月～10年，并发小肠结肠炎5例，偶有污粪2例，便秘复发3例，无盆腔、腹腔感染及吻合口狭窄发生。结论 应用直肠后矢状纵切、心形吻合技术治疗先天性巨结肠，可提高手术疗效，减少并发症。     

Role of anorectal myectomy in the treatment of short segment Hirschsprung's disease in young adults

Basic pathological disorder in Hirschsprung's disease (HD) comes into being by the abnormal innervations of the aganglionic distal intestine. The nonserious forms of this congenital disease may reach the young by proceeding with chronic, obstinate constipation that does not respond to diet. Myectomy of the short segment of aganglionic part may provide diagnostic and therapeutic value. Between 1993 and 2003, anorectal posterior myectomy was performed in 19 patients diagnosed with HD. The mean age of patients was 23 years. Previous or concomitant anterior resection was added to the procedure in seven cases due to dolicomegacolon. In addition to the deficiency of anorectal inhibitor reflex (ARIR) among all patients, the frequency of defecation was 12.5 days (range, 6-30 days) before operation. Anorectal length before widening was an average of 5.5 cm (range, 2-8 cm). All pathologic specimens were found to be aganglionic. Postoperatively, the mean of first regular defecation interval was 1.5 days (range, 1-3 days). Involution of rectum was evaluated with a rectal examination and barium enema X-rays during follow-up. ARIR of patients also returned to normal. In conclusion, anorectal posterior myectomy is an effective operation in diagnosis and treatment of short-segment HD. Furthermore, colon resection annexed to this operation, in the condition of dolicomegacolon, is also used to remove obstinate constipation.     

Stercoral perforation of the colon in sigmoid colostomy patients: Two case reports

INTRODUCTIONStercoral perforation of the colon has rarely been reported. Only 3 cases of stercoral perforation of the colon proximal to an end colostomy have been reported. We present two cases of stercoral perforation of the colon in end colostomy patients.PRESENTATION OF CASEA 70-year-old man who had undergone abdomino-perineal excision for anal cancer was referred for left lower quadrant pain and fever. Stercoral perforation was discovered along the distal descending colon, proximal to the end sigmoid colostomy. The patient underwent segmental resection of the colon and revision of the stoma and was discharged on postoperative day 32. A 71-year-old woman who had undergone abdomino-perineal excision for distal rectal cancer with preoperative chemoradiation presented fever with 2 days of low abdominal pain. The patient had sacral bone and lung metastases from rectal cancer and suffered from chronic constipation. Stercoral perforation was found around the sigmoid colon, just proximal to the end sigmoid colostomy. The patient underwent simple repair of the perforated colon through the parastomal incision. On postoperative day 8, leakage occurred at the repair site. Segmental resection of the colon and revision of the stoma were performed. She was discharged 44 days after the initial surgery.DISCUSSIONSegmental resection of the perforated colon, rather than simple repair, appears to improve postoperative outcomes.CONCLUSIONAs the number of cancer survivors increases, appropriate management of constipation is important to prevent stercoral perforation during follow-up.     

Prognosis after surgical treatment for granulomatous enteritis and colitis

To assess the rate of recurrence of Crohn's enterocolitis, 118 patients with Crohn's disease of the small intestine, the small and large intestine, or only the large intestine who had surgery were assessed. Of 53 patients with disease confined to the small intestine, 25 had recurrence, while 19 of 37 patients with disease of the small and large intestine had recurrence. Of 16 patients with localized Crohn's disease of the colon who had limited resection, 11 had recurrence. None of the 28 patients with Crohn's disease of the colon or rectum, followed up for 5 years, had recurrence in the small intestine. This study demonstrates that (1) limited resection for Crohn's disease of the colon leads to a significant recurrence rate, and (2) in patients with Crohn's disease localized to the colon, follow-up for at least 5 years revealed no recurrence in the small intestine.