腹腔镜辅助与开腹Soave术治疗小儿先天性巨结肠的疗效分析

目的:探讨腹腔镜辅助Soave术治疗小儿长段型及不能单纯经肛门Soave手术治疗的常见型先天性巨结肠的有效性与安全性。方法:回顾分析62例先天性巨结肠患儿的临床资料,患儿分别行腹腔镜辅助Soave手术(腹腔镜组,n=30)与传统开腹Soave手术(开腹组,n=32)。结果:两组手术时间、单种并发症发生率差异无统计学意义(P0.05);腹腔镜组术中出血量、术后首次排气排便时间、住院时间、术后并发症总发生率优于开腹组(P0.05),腹腔镜组住院费用偏高(P0.05)。结论:腹腔镜辅助Soave手术治疗长段型及不能单纯经肛门Soave手术治疗的常见型先天性巨结肠是安全、有效的。对于常见型巨结肠,可先行经肛门Soave术,必要时选择腹腔镜辅助。     

腹腔镜辅助经肛门Soave拖出术治疗先天性巨结肠症及同类性疾病

目的 探讨腹腔镜辅助经肛门Soave手术治疗先天性巨结肠症及同类性疾病的可行性和效果.方法 2010年3月至2011年12月,对31例先天性巨结肠症及同类性疾病的患儿实施腹腔镜辅助经肛门Soave手术,作者改进这种技术,在经脐或经肛门腹腔镜监视下联合直肠肌鞘入路游离左半结肠或全部结肠,然后拖出体外完成直肠乙状结肠或次全结肠切除术. 结果 本组31例患儿均顺利完成手术,16例行直肠乙状结肠切除,15例次全结肠切除术,平均手术时间(117 ±13) min,切除肠段35 ～ 80 cm,术中估计出血5～20 ml,1例因小肠梗阻开腹探查.随访无吻合口狭窄和便秘复发,仅1例出现小肠结肠炎.结论 经脐或经肛门腹腔镜辅助Soave手术治疗先天性巨结肠及同类性疾病安全、有效,手术创伤更小.     

腹腔镜辅助下改良Soave术治疗先天性巨结肠20例

先天性巨结肠是一种常见的小儿先天肠道发育不良,以肠道局部神经节细胞缺失为特征,主要表现为新生儿肠道梗阻,胎粪排出延迟,婴幼儿便秘等,在消化道先天畸形中仅次于肛门直肠畸形,位于第二位.我院于2006年开始采用经肛门改良Soave巨结肠根治术治疗婴幼儿先天性巨结肠,但对于年长儿、长段型需配合开腹方可完成.我院2008年1月-2010年12月对20例先天性巨结肠采用腹腔镜辅助下改良Soave术治疗,客服了传统手术不足,现报道如下.     

微创手术与经肛门Soave术治疗先天性巨结肠的临床效果、并发症及生活质量分析

目的:分析微创手术与经肛门Soave术治疗先天性巨结肠的效果、并发症及生活质量。方法:回顾分析2015年9月至2017年1月60例先天性巨结肠患儿的临床资料,分为对照组(经肛门Soave术)与观察组(腹腔镜辅助Soave术),每组30例,对比两组手术效果、并发症及生活质量。结果:观察组术中出血量、肛门解剖时间及住院时间、肛门功能评分均优于对照组(P<0.05);观察组术后并发症总发生率(6.67%)低于对照组(30.00%),差异有统计学意义(P<0.05)。术后1个月,观察组躯体、情绪、社会、角色及整体生活评分均优于对照组(P<0.05)。结论:腹腔镜辅助Soave术治疗先天性巨结肠效果显著,可降低术后并发症发生率,改善肛门排便功能及生活质量。     

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。     

先天性巨结肠微创手术的研究进展

1886年丹麦医生HaraldHirschsprung在柏林儿科学会上首先报道先天性巨结肠(Hirschsprung’sdisease,HP),随后的100多年里,人们对先天性巨结肠的病因、病理、遗传基因、诊断、治疗等进行了越来越深入的研究。先天性巨结肠手术的发展在历史上历经了很多种手术方式,包括Swenson,Duhanmel,Rehbein,Soave等,各有其特点,效果也各异。新近开展的腹腔镜辅助下巨结肠根治术和经肛门Soave手术代表了小儿外科手术向微创发展的趋势。本文对先天性巨结肠微创手术的进展做一综述。　　一、腹腔镜辅助下巨结肠根治术随着对儿童先天性巨结肠的进一步认识…     

经肛门Soave先天性巨结肠根治术的护理

自2001年9月～2005年9月我院共采用经肛门Soave先天性巨结肠根治术162例。该手术方式一改传统的开腹先天性巨结肠根治术，全部操作在肛门处完成，避免了术后肠粘连、切口感染等并发症的发生，治疗效果满意。现将162例巨结肠根治术的护理介绍如下。     

经肛门先天性巨结肠根治术围手术期的护理

先天性巨结肠是小儿外科常见的先天性胃肠道发育畸形,发生率为0．2‰～0．5‰,男女之比为3～4：1．治疗方法主要是手术治疗,传统手术方式是经腹巨结肠根治术。1998年De La Torre首创经肛门Soave术,治疗小儿先天性巨结肠,取得满意的效果。该术式手术时间短、操作简单、患者反应轻、术后恢复快、并发症少、腹部无疤痕等优点。     

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。     

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.     

腹腔镜辅助与单纯经肛门手术行一期Soave拖出术治疗先天性巨结肠的对比研究

目的:探讨腹腔镜手术行一期经肛门Soave拖出术的优点及常规腹腔镜探查的必要性。方法:回顾分析110例巨结肠患者行经肛门Soave拖出术的临床资料。分为两组:常规腹腔镜辅助经肛门Soave组(LTS,n=73),单纯经肛门并选择性应用腹腔镜手术组(TS,n=37)。分析两组手术过程,比较肠蠕动恢复时间、手术时间、并发症及近期排便情况。结果:TS组中3例因拖出结肠移行段不明确选择性应用腹腔镜,3例长段型巨结肠单纯经肛门游离系膜困难用腹腔镜游离系膜和脾曲。两组患者年龄、性别、移行区位置、小肠结肠炎、肛门狭窄、吻合口并发症、肠蠕动恢复时间、手术时间等无显著差异。LTS组肛门部解剖时间51～71min,平均61min,明显短于TS组;手术费用LTS组比TS组平均高约2 000元。LTS组2例患儿因吻合口瘘行肠造瘘术。TS组5例患者需再次手术,1例吻合口瘘行肠造瘘,1例肠扭转,1例肛门回缩、狭窄,2例便秘复发。术后随访3个月～8年,平均4年6个月,两组近期排便功能相似。结论:单纯经肛门Soave术能完成多数短段型和常见型巨结肠的诊治,费用低于腹腔镜Soave手术,近期排便功能良好,不需常规应用腹腔镜。但当拖出困难、疑为长段型时则应使用。腹腔镜辅助Soave术是更全面的技术,适于不同类型的患者。     

Transanal mucosectomy in the treatment of Hirschsprung's disease

BACKGROUND/PURPOSE: Transanal mucosectomy of the aganglionic segment of colon is a critical step in minimally invasive surgery for Hirschsprung's disease. The purpose of this study was to examine the outcome of patients undergoing transanal mucosectomy. METHODS: From January 1979 to November 1998, 26 patients (ages 25 days to 17 years) underwent transanal mucosectomy for Hirschsprung's disease. Seventeen (65%) had partial transanal mucosectomy (PTM; 1979 to 1998) and 9 (35%) complete transanal mucosectomy (CTM; 1995 to 1998). In PTM, a 2- to 3-cm mucosal dissection was begun 1 cm above the dentate line in conjunction with transabdominal endorectal dissection (modified Soave). In CTM, the entire mucosal dissection was performed transanally as part of a laparoscopically assisted Soave procedure. Results were obtained by chart review and personal communication. Patients were assessed clinically for continence where age appropriate (>3 years) and for development of constipation, postoperative enterocolitis, and anal stricture. RESULTS: One of 16 (6.2%) of the PTM group was incontinent versus none (4 patients) in the CTM group. Five of 17 (29.4%) of the PTM group were constipated versus 4 of 9 (44.4%) in the CTM group (t test, P = not significant). Postoperative enterocolitis developed in 4 of 17 (23.5%) of the PTM group versus 6 of 9 (66.6%) in the CTM group (t test, P<.05). Three of 6 (50%) of the CTM group versus none in the PTM group required hospitalization for bowel rest, rectal washouts, and antibiotics. All patients were well at the time of the report. Anal stricture was not seen in either group. CONCLUSIONS: Constipation and postoperative enterocolitis are a significant feature of transanal mucosectomy for Hirschsprung's disease deserving close surveillance, especially in patients in whom the entire mucosal dissection was performed transanally. Continence appears to be satisfactorily preserved from these preliminary results.     

One-stage transanal Soave pullthrough for Hirschsprung disease: a multicenter experience with 141 children

BACKGROUND: The surgical management of Hirschsprung's disease (HD) has evolved from the original 3-stage approach to the recent introduction of minimal-access single-stage techniques. We reviewed the early results of the transanal Soave pullthrough from 6 of the original centers to use it. METHODS: The clinical course of all children with HD undergoing a 1-stage transanal Soave pullthrough between 1995 and 2002 were reviewed. Children with a preliminary stoma or total colonic disease were excluded. RESULTS: There were 141 patients. Mean time between diagnosis and surgery was 32 days, and mean age at surgery was 146 days. Sixty-six (47%) underwent surgery in the first month of life. Forty-seven (33%) had the pathologic transition zone documented laparoscopically or through a small umbilical incision before beginning the anal dissection. Mean blood loss was 16 mL, and no patients required transfusion. Mean time to full feeding was 36 hours, mean postoperative hospital stay was 3.4 days, and 87 patients (62%) required only acetaminophen for pain. Early postoperative complications included perianal excoriation (11%), enterocolitis (6%), and stricture (4%). One patient died of congenital cardiac disease. Mean follow-up was 20 months; 81% had normal bowel function for age, 18% had minor problems, and 1% had major problems. Two patients required a second operation (twisted pullthrough, and residual aganglionosis). One patient developed postoperative adhesive bowel obstruction. CONCLUSION: To date, this report represents the largest series of patients undergoing the 1-stage transanal Soave pullthrough. This approach is safe, permits early feeding, causes minimal pain, facilitates early discharge, and presents a low rate of complications.     

经脐单一腹腔镜监视下联合经肛门拖出次全结肠切除术治疗先天性长段巨结肠

目的探讨经脐单一腹腔镜监视下联合经肛门直肠内拖出次全结肠切除术治疗长段型先天性巨结肠及其类缘性疾病的可行性和效果。方法 2010年3~12月,对6例长段型先天性巨结肠及其类缘病的病儿实施经脐单一腹腔镜监视下联合经肛门直肠肌鞘入路游离全部结肠,然后拖出体外完成次全结肠切除术。结果全部病儿均顺利完成手术,手术时间188±18 min（155~225 min）;切除肠段70~90 cm,术中估计出血10~20 ml。无术中并发症。1例术后6天因小肠梗阻开腹探查。大便次数由术后近期的每天5~15次降至2个月后的3~5次,随访2~10个月,平均6个月,无大便失禁或便秘复发,复查肛管直肠测压反应接近正常。结论经脐单一腹腔镜联合经肛门拖出次全结肠切除术安全、可行,使手术创伤更小,无腹部可见的手术瘢痕,达到经自然腔道内镜手术（NOTES）的美观效果。     

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。     

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。     

One-stage Soave pull-through for Hirschsprung's disease: a comparison of the transanal and open approaches

PURPOSE: The authors reviewed their experience using the transanal Soave technique, to determine (1) if it offers any advantages over the standard open approach and (2) whether routine laparoscopic visualization is necessary. METHODS: The case reports of 37 consecutive children less than 3 years old undergoing Soave pull-through were reviewed. Patients were excluded from analysis if they had total colon disease or had a previous colostomy. The patients were divided into 3 groups: open Soave (OS, n = 13), transanal Soave with routine laparoscopic visualization (LVS, n = 9), and transanal Soave with selective laparoscopy or minilaparotomy (TAS, n = 15). Cost was calculated based on hospital stay, operating room time, and use of laparoscopic equipment. RESULTS: In the TAS group, suspicion of a longer segment led to the selective use of laparoscopy with or without biopsy in 2 children, and the use of a small umbilical incision for mobilization of the splenic flexure in 2. There were no differences among groups with respect to age, weight, gender, transition zone, operating time, blood loss, intraoperative complications, enterocolitis, or stricture or cuff narrowing. Hospital stay was significantly longer in the OS group (median, 7 days; range, 3 to 47) than the LVS (median, 1; range 1 to 6) or TAS (median, 1, range, 1 to 3) groups. Cost (in thousands of dollars) was also higher in the OS group (median, 6.9; range, 3.9-25.7) than the LVS (median, 3.9; range, 3.6 to 6.4) or TAS (median, 3.4; range, 2.2 to 9.4) groups. Repeat surgery was necessary for 4 OS patients: 2 adhesive small bowel obstructions (1 of whom died), 1 twisted pull-through, and 1 recurrent aganglionosis. Three TAS patients required repeat surgery: 1 twisted pull-through, 1 anastomotic leak, and 1 cuff narrowing. CONCLUSIONS: These data suggest that the transanal pull-through is associated with a significantly shorter hospital stay and lower cost than the open approach, without an increased risk of complications. Because there is no intraabdominal dissection, there probably is a lower incidence of adhesive bowel obstruction. Routine laparoscopic visualization or minilaparotomy is not necessary but should be used in children who are at higher risk for long segment disease.     

Pseudomembranous colitis following resection for Hirschsprung's disease.

Enterocolitis is the most common cause of significant morbidity and death in Hirschsprung's disease. Although most cases respond to nasogastric decompression, antibiotics, and colonic evacuation, some children have an unusually fulminant or protracted clinical course. Four cases are reported of pseudomembranous colitis (PMC) that developed 1 to 18 months (mean, 8 months) after definitive surgery for Hirschsprung's disease (Soave endorectal pull-though, 2; Duhamel procedure, 2). While all children presented with fever, abdominal distention, and diarrhea, indistinguishable from typical Hirschsprung's enterocolitis, the clinical course was fulminant in two cases, both of whom died of septic shock. Postmortem examination in both showed extensive colonic pseudomembranes despite identification of Clostridium difficile toxin and subsequent vancomycin therapy (initiated late in the clinical course). Two children in the series had protracted hospitalizations and eventually required diverting enterostomy despite recognition of C difficile toxin and treatment with enteral vancomycin, in one child necessitating multiple courses of antibiotic therapy. Awareness of the virulence of PMC associated with Hirschsprung's disease (even after definitive resection) should prompt submission of stool specimens from any child who presents with enterocolitis for both C difficile culture and toxin levels. On the basis of our experience it is our policy to initiate a prompt course of vancomycin by rectal lavage or nasogastric tube in all children with Hirschsprung's enterocolitis, pending culture results, in view of the significant morbidity and mortality exemplified by cases in this review.