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。     

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。     

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。     

直肠内结肠拖出斜弧形吻合术治疗小儿先天性巨结肠19例

目的探讨小儿先天性巨结肠新的手术方法。方法采用直肠内结肠拖出,结、直肠斜弧形吻合术治疗小儿先天性巨结肠19例。结果全部经过顺利,无一例吻合口瘘。术后随访,16例排便正常,2例肛管狭窄,系直肠前壁保留过短之故,1例常排稀便,系结肠切除过多所致。结论结肠、直肠/肛管前后壁斜弧形吻合间距只要不短于3cm,术后不会发生肛管狭窄。该术式用于治疗小儿先天性巨结肠具有手术操作简单、易掌握、创伤小、术后痛苦及并发症少等优点。     

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。     

电视腹腔镜先天性巨结肠根治术

目的:总结电视腹腔镜根治先天性巨结肠的经验,并与开腹手术比较其优越性。方法:用电视腹腔镜辅助行先天性巨结肠根治术(Swenson改良术)6例,平均年龄1岁,均为气管内插管,用电视腹腔镜完成腹腔内病变肠管切除的全部操作,将切除病变肠管经直肠内拉出至直肠外,经会阴部完成结肠管与直肠吻合术。结果:平均手术时间2.5～3h,平均出血量10ml,术后肠蠕动恢复快,本组病例最早12h恢复肠蠕动,术后平均住院8.5d,均痊愈出院。结论:由电视腹腔镜行先天性巨结肠根治术效果好,安全可靠。     

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…     

普通型先天性巨结肠 Duhamel手术18例分析

自1998年起,我们在应用Duhamel手术治疗普通型先天性巨结肠(hirschsprung′sdisease ,HD)时,保留虽有继发性扩张、但不肥厚的结肠,使本术式更简单易行,临床效果满意,报告如下。临床资料本组18例,男13例,女5例。其中9个月至6岁9例,7～14岁6例,17～19岁3例。本组病例均有腹胀,便秘及长期协助排便史。其中2例分别在6个月、12个月前因HD于外院急诊做乙状结肠双腔造口。1例在本院因HD急诊行扩张、肥厚乙状结肠切除,扩张伴轻度肥厚降结肠造口(Hartmann)手术,3个月后行二期根治。6例合并粪石,7例伴轻度贫血及营养不良。1.术前治疗:通常术前1～3…     

腹腔镜辅助治疗先天性巨结肠：附12例报告

目的探讨腹腔镜辅助治疗先天性巨结肠的疗效。方法回顾性分析近2年来行腹腔镜辅助先天性巨结肠根治术12例患者的临床资料。结果12例患儿中男8例,女4例;年龄4个月至13岁。常见型6例,短段型4例,长段型2例。手术均获成功,无中转开腹,手术出血量少,手术时间80~130 min,平均100 min,愈合后疤痕不明显,无并发症发生。结论腹腔镜辅助先天性巨结肠根治术治疗先天性巨结肠是可行、有效的。     

腹腔镜辅助下改良Swenson治疗婴幼儿巨结肠

目的探讨腹腔镜辅助下改良Swenson治疗婴幼儿巨结肠的可行性和有效性。方法应用腹腔镜辅助下改良Swenson法治疗婴幼儿先天性巨结肠13例,采用三孔或四孔腹腔镜法,设定CO2压力为8~10mmHg,取结肠浆肌层组织做病理诊断,Ligasure离断直肠及乙状结肠系膜,远端分离至齿状线上0.5~1.0cm,将病变狭窄段、移行段扩张肠管经直肠肛门内翻拖出切除,结肠直肠全层前高后低心形斜吻合,3例采用强生直径21mm吻合器。结果13例均在腹腔镜下顺利完成手术,手术时间85~161min,平均115min。出血量<12ml。均无术中并发症。术后3例小肠结肠炎,1例污粪,1例吻合口漏,经治疗后治愈。13例随访6~42个月,平均26个月,排便正常,无并发症发生。结论腹腔镜辅助下改良Swenson治疗婴幼儿巨结肠可行、有效。     

Laparoscopic-assisted transanal endorectal coloanal anastomosis for Hirschsprung's disease

BACKGROUND: There has been a recent trend in the use of laparoscopic-assisted one-stage pull-through in the management of Hirschsprung's disease (HD). We describe our initial experience using laparoscopy with a transanal coloanal anastomosis as described by Rintala and Lindhal for HD. METHODS: Six children with biopsy-confirmed HD underwent laparoscopic-assisted pull-through using Rintala's transanal endorectal coloanal anastomosis. The procedure was done through one 5-mm camera port and two 5-mm working ports. The transition zone was identified by seromuscular biopsies obtained laparoscopically. The sigmoid colon and proximal rectum were mobilized laparoscopically. A transanal endorectal mucosal dissection and a coloanal anastomosis were done, using an absorbable monofilament 5/0 polyglyconate suture. RESULTS: Six children aged 4 weeks to 36 months underwent this procedure laparoscopically. Two cases had to be converted to an open procedure as a result of dense pelvic adhesions. The entire mobilization of the bowel as well as biopsy confirmation of the transition zone was done laparoscopically in all 6 cases. The median operative time was 135 minutes (range, 120-240 minutes). All 6 children tolerated full enteral feeds after 48 hours and the median hospital stay was 7 days (range, 6-10 days). There were no early postoperative complications. Two cases developed mild enterocolitis that resolved with conservative management. The overall functional outcome was good in all cases with no soiling, stool incontinence, or constipation at a median follow-up period of 12 months (range, 4-27 months). CONCLUSION: Laparoscopic-assisted pull-through, apart from being cosmetically superior, permits obtaining biopsies as well as an adequate mobilization of the bowel. The transanal endorectal coloanal anastomosis technique is simple and easy to perform, with a minimal dissection which causes less damage to the internal sphincter and pelvic nerves.     

Primary laparoscopic endorectal colon pull-through for Hirschsprung's disease: early results of 61 cases

OBJECTIVE: To report early results after a one-stage laparoscopic endorectal colon pull-through for Hirschsprung's disease (HD). METHODS: Between January 2002 and June 2004, 61 patients underwent primary laparoscopic-assisted endorectal colon pull-through procedure for HD. Ages ranged from 21 days to 36 months. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was performed according to Georgeson's technique. We left a short rectal seromuscular sleeve 2 cm from the dentate line. RESULTS: The aganglionic segment was located in the rectum in 33 patients, in the sigmoid colon in 27 patients and in the left colon in one patient. The median operating time was 140 minutes. There were no operative complications or deaths. No conversion was required. There was minimal blood loss during surgery. Clear fluids were given 12 hours after surgery and milk was given on the 2nd day. In one patient, small intestinal perforation occurred 3 days after surgery and required ileostomy. The median hospital stay was 6 days, excluding one patient with intestinal perforation. Spontaneous defaecation occurred in all patients before discharge. CONCLUSION: One-stage laparoscopic-assisted colon pull-through is a safe and effective procedure for HD.     

1岁以上儿童巨结肠经肛门结肠拖出术

目的:介绍1岁以上儿童先天性巨结肠经肛门结肠拖出术(改良Soave法)的方法及体会。方法:23例年龄1～12岁患儿,经肛门剥离直肠黏膜管至腹膜返折水平,横断肌鞘进入腹腔。直肠肌鞘沿后正中线切开。游离病变结肠拖出肛门,一期切除吻合18例,二期切除5例。结果:初期1例结肠拖出困难加做腹部小切口,其余均经肛门完成手术。切除结肠长度15～70cm,平均30cm。1例早期并发全结肠脱出肛门,再手术复位,23例均痊愈出院。术后随访3～32个月,早期大便均有不同程度的增多,1～3个月后逐渐恢复。结论:经肛门结肠拖出术指征可适当放宽,只要掌握正确的手术方法,多数患儿可单纯经肛门完成手术。其方法简单,创伤小,不需剖腹。     

经肛门Soave根治术与开腹根治术治疗先天性巨结肠疗效比较

目的:对比经肛门Soave根治术与开腹巨结肠根治术对小儿先天性巨结肠的疗效。方法:回顾分析1991年1月—2011年12月252例先天性巨结肠患儿病历资料,其中开腹手术组121例,经肛门手术组131例。对比分析两组的手术时间、住院天数、术中出血、术后并发症、切口长度、肛门功能情况以及生活质量等。结果:与开腹手术相比,经肛门手术组手术时间短,术中出血量少,术后下床活动时间和进食时间短,术后切口感染、小肠结肠炎、腹腔感染等并发症发生率低,差异均有统计学意义(P0.05)。2年随访,经肛门手术组的术后远期并发症如肠梗阻、排尿功能异常、术后复发等比开腹组少,远期恢复情况及生活质量比开腹组好,差异有统计学意义(P0.05)。结论:与开腹手术相比较,经肛门Soave巨结肠根治术治疗小儿先天性巨结肠手术时间短、切口美观、住院时间短、术后并发症少、肛门功能恢复好、生活质量好。     

内括约肌部分切除在经肛门Soave巨结肠根治术中的应用

目的探讨内括约肌部分切除对经肛门Soave巨结肠根治手术疗效的影响。方法前瞻性人组2003-2012年间广东省东莞市人民医院收治的153例先天性巨结肠患儿,均予以经肛门Soave巨结肠根治术治疗。按简单单双号法将患儿分为部分切除组（77例）和单纯切开组（76例）,分别于术中进行内括约肌部分切除或仅单纯切开直肠后壁肌鞘。比较两组患儿术后并发症及排粪控制功能的差异。结果部分切除组患儿较单纯切开组术后直肠肌鞘内感染[1．3％（1／77）比11．8％（9／76）,P〈0．05]、小肠结肠炎[2．6％（2／77）比13．2％（10／76）,P〈0．05]、吻合口狭窄[3．9％（3／77）比22．4％（17／76）,P〈0．01]及腹胀[10．4％（8／77）比25．0％（19／76）,P〈0．05]的发生率均明显降低。两组术后1年排粪控制功能比较差异无统计学意义（Kelly评分：5．1±0．5比5．2±0．6,P〉0．05）。结论与单纯切开直肠后壁肌鞘相比,内括约肌部分切除能明显降低经肛门Soave巨结肠根治术后直肠肌鞘内感染、腹胀、吻合口狭窄和小肠结肠炎的发生率,同时并不会加重术后远期排粪控制功能的损害。     

Clinical outcome in children after transanal 1-stage endorectal pull-through operation for Hirschsprung disease

Background/Purpose

Recently, the transanal 1-stage pull-through operation has been widely used in Hirschsprung disease (HD), and it is obviously superior to traditional approach in early term for its noninversion. However, the procedure is relatively so new that it makes assessment of the functional outcome and stooling patterns difficult. The aim of this study was to evaluate the clinical outcomes of the transanal 1-stage endorectal pull-through operation in the management of rectosigmoid HD.

Methods

Fifty-eight children (39 boys and 19 girls) aged 12 months to 13 years (mean, 2 years) who underwent transanal 1-stage endorectal pull-through operation for HD were followed up from 6 to 24 months. Clinical outcome was assessed by interviews and questionnaires. All patients had an aganglionic segment confined to the rectosigmoid area which was confirmed by the preoperative barium enema and postoperative pathological examination.

Results

Forty-six patients had satisfactory results without complications. In all the children, the mean stool times were 1 to 2 per day; only 4 had mean stool times of 8 to 10 per day. Postoperative soiling was present in 9, constipation in 5, and HD-associated enterocolitis in 3. There were no incontinence, cuff infection, anastomotic leak, and mortality in any of the patients. In the 12 symptomatic patients, there were 4 children with length of aganglionic segment less than 30 cm, and 8 had 30 cm or more. In the 46 asymptomatic patients, 42 had length of aganglionic segment less than 30 cm, and 4 had 30 cm or more. There was a significant difference between the group with less than 30 cm and the group with 30 cm or more of aganglionic segment. For statistical analysis, the Fisher exact test showed P < .05.

Conclusions

The transanal 1-stage endorectal pull-through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. A gradual recovery could be noted in the stooling patterns along with the time after surgery. The younger the patient operated on and the shorter the aganglionic segment, the lower do the stooling disorders occur and the faster does the stooling function recover.     

免气腹腹腔镜新生儿巨结肠根治术的临床体会

目的:总结免气腹腹腔镜新生儿巨结肠根治术的应用优势。方法:回顾分析2005年至今为41例新生儿行巨结肠根治术的临床资料,患者根椐手术方式分为3组,2005年7月至2008年12月12例行单纯经肛门Soave术(单纯组),2009年1月至2011年2月行气腹腹腔镜辅助下经肛门Soave术16例(气腹组),2011年3月至今行免气腹腹腔镜辅助下经肛门Soave术13例(免气腹组),对比分析3组手术结果。结果:腹腔镜手术均获成功,无一例中转开腹。单纯组中4例加用腹腔镜辅助完成手术。3组患儿术中出血量、术后肛门排气时间、住院时间差异无统计学意义,无一例发生吻合口漏。单纯组手术时间明显长于其他两组,差异有统计学意义(P<0.05);单纯组、免气腹组拔管时间明显短于气腹组,术后患儿清醒快,差异有统计学意义(P<0.05)。单纯组、免气腹组患儿血液动力学指标在不同时段有波动,但差异无统计学意义(P>0.05)。气腹组患儿术中、术后血液动力学指标波动较明显,差异有统计学意义(P<0.05)。患儿均于术后第20天开始扩肛,每天一次,连续3个月,无一例发生肛门狭窄。术后随访4～28个月,气腹组与免气腹组患儿于术后4～6个月肛门排便基本正常;术后24个月,单纯组中尚有3例患儿有污粪现象。结论:免气腹腹腔镜辅助新生儿巨结肠根治术安全可行、操作简便、微创美容、经济实用,避免了腹内高压对血流动力学参数的影响,值得临床推广。     

腹腔镜辅助经肛门直肠内拖出术治疗小儿先天性巨结肠165例中长期随访报告

目的总结腹腔镜辅助经肛门直肠内拖出术（laparoscopic-assisted transanal endorectal pull-through,LATEP）治疗先天性巨结肠（Hirschsprung’s disease,HD）的中长期随访疗效。方法回顾性分析2000年1月～2010年1月我中心单个手术小组完成的随访资料完整的165例LATEP。术前行钡剂灌肠、直肠肛门测压和直肠黏膜活检确诊。LATEP应用3个trocar;腹腔探查找到移行和扩张的肠段;多处浆肌层活检确定诊断和病变肠段范围;腹腔镜辅助彻底游离巨结肠,经肛门直肠内拖出彻底切除,近端与肛门吻合。临床问卷式调查随访患儿肛门功能评分、生长发育和生活质量评分。结果术后7 d吻合口感染1例。165例随访10个月～9年,（60.2±2.0）月,其中〈1年1例,1～3年15例,〉3～5年50例,〉5年99例。采用李正等肛门功能临床评分标准评定：术后3个月、1年和3年肛门排便优良率分别为59.4%（98/165）、92.1%（151/164）和97.3%（145/149）。术后3个月、1年和3年肛门静息压力依次为（20.2±6.4）、（23.8±10.4）、（26.8±9.0）mm Hg,与同年龄组20例儿童志愿者肛门静息压力（27.9±9.6）mm Hg比较,术后3个月肛门静息压力明显降低（t=-4.781,P=0.000）,术后1、3年肛门静息压力与对照组比较无明显差异性（t=-1.677,P=0.095;t=0.509,P=0.611）。术后1年146例（89.0%）患儿钡剂结肠造影示结肠扩张和痉挛段消失,肛管直肠角正常。患儿均生长发育正常。结论 LATEP是一种安全、有效、更为全面的治疗HD手术方式,术后肠功能恢复快,中长期随访肛门功能和生活质量良好。     

Surgical Management of Recto-Sigmoid Hirschsprung’s Disease

Introduction : Over the years, the surgical management of recto-sigmoid Hirschsprung’s disease (HD) has evolved radically and at present a single stage transanal pull-through can be done in suitable cases, which obviates the need for multiple surgeries.

Aim : The aim of this paper was to evaluate the role of transanal pull-through in the management of recto-sigmoid HD in our institution.

Material and Methods : A retrospective analysis (between January 2003 and December 2009) was carried out on all cases of Hirschsprung’s reporting to unity of pediatric surgery of Tunis Children’s Hospital that were managed by transanal pull-through as a definitive treatment. All selected patients including neonates had an aganglionic segment confined to the rectosigmoid area, confirmed by preoperative barium enema and postoperative histology. Twenty-six children (86%) had their operation done without construction of prior colostomy.

Results : Transanal pull-through was performed in 31 children. Mean operating time was 150 minutes (range 64 to 300 minutes). No patients required laparotomy because all patients including neonates had an aganglionic segment confined to the rectosigmoid area. Blood loss ranged between 20 to 56 ml without blood replacement. Since all children were given an epidural caudal block, the requirement of analgesia in these cases was minimal. Postoperative complications included perianal excoriation in 7 out of 31 patients lasting from 3 weeks to 6 months. Complete anorectal continence was noted in 21 of 31 (67%) children in follow up of 3–5 years.

Conclusions : Transanal endorectal pull-through procedure for the management of rectosigmoid HD is now a well-established and preferred approach. Parental satisfaction is immense due to the lack of scars on the abdomen. As regards the continence, a long-term follow-up is necessary to appreciate better the functional results of this surgery.