腹腔镜下改良Swenson法治疗小儿先天性巨结肠症

目的介绍腹腔镜下改良Swenson法治疗先天性巨结肠症的经验和体会.方法应用改良Swenson法治疗先天性巨结肠症100例,短段型21例,常见型72例,长段型7例,年龄8个月～7岁,平均年龄1.5岁.脐部和左右下腹放置内径0.5 cm的0°或30°腹腔镜和操作钳,设定CO2压力8～12 mmHg,取结肠浆肌层组织做病理诊断,紧贴肠管处理需要切除的结肠系膜血管,达齿状线上0.5～1 cm水平后经直肠肛门内翻拖出切除,结肠直肠全层心形斜形吻合.结果手术时间80～170 min,平均110 min.术中出血量不足10 ml.全部病例治愈,无一例死亡,皮下气肿5例,尿潴留6例,全部病例随访6～18个月,术后结肠炎5例,污粪2例,吻合口狭窄1例,迟发吻合口漏1例.结论腹腔镜下改良Swenson法治疗先天性巨结肠症创伤小,方法简单,具有改良Swenson法的优点,是一种值得推广的手术方法.     

腹腔镜下应用超声刀行婴幼儿巨结肠根治术20例

目的 总结腹腔镜下应用超声刀治疗婴幼儿巨结肠根治术的价值。方法2003年2月-2006年1月，20例婴幼儿巨结肠在全身麻醉下行腹腔镜切除术，CO2人工气腹压力为10—12mmHg。腹部置3个trocar，腹腔镜直视下应用超声刀紧贴结肠壁将痉挛段、移行段和扩张段肠管肠系膜切断，环形切开盆底腹膜反折。会阴部采用改良Soave术，在肛管后壁齿状线上0．5cm处环形切开直肠黏膜并游离直肠黏膜呈管状，切断直肠侧韧带，打开盆底腹膜反折，进人腹腔，将游离的病变段结肠拖出，切除病变段结肠，其近端结肠与肛管齿状线切缘吻合。结果20例均顺利完成手术，手术时间120．210min．平均132min。切除病变段结肠肠管长度20-55cm，平均35cm。术中出血量5-20ml，平均14ml，均未输血。术后发生小肠结肠炎2例。20例随访3-36个月，平均12．5月，无并发症发生，排便控制在1-2次／d。结论腹腔镜下应用超声刀行婴幼儿巨结肠根治术具有创伤小、出血少、操作简便、安全可靠、术后恢复快、并发症少等优点。     

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…     

改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症

目的探讨改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症(Hirschsprung disease,HD)的并发症和疗效。方法回顾分析2010年3月~2014年1月12例长段型HD资料,男7例,女5例,中位年龄8月(5月~6岁)。其中移行区位于降结肠近端8例,横结肠2例,结肠肝曲1例,升结肠1例。7例行结肠造瘘。手术主要改良之处:经肛门齿状线上方直肠后壁切口将结肠拖出至肛门外,用Endo-GIA肛门外切断并封闭,保留直肠残端4~5 cm。然后结合Deloyer技术将升结肠拖下与原直肠后壁端侧吻合,再将Endo-GIA切缝器两肢分别放入原直肠和新直肠,切开两段肠管间隔并行侧侧吻合。观察术中术后并发症及排便功能。结果 12例均在腹腔镜辅助下完成次全结肠切除升结肠Duhamel拖出术,平均手术时间170 min(125~240 min),未出现术中并发症,无吻合口漏。4例诉肛周疼痛,1例术后5天便血,保守治疗治愈。大便频率2周以内4~15次/天,恢复到正常排便频率(1~2次/天)时间平均3.5月(2.2~5个月)。平均随访时间32个月(3~46个月),2例术后小肠结肠炎,1例早期有便秘症状,均保守治疗治愈。无闸门综合征和粪石发生,无大便失禁。结论改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型HD安全有效,排便频率恢复正常快。肛门外处理直肠盲端简单可靠,腹壁创伤小。     

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。     

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。     

完全腹腔镜下直肠癌全直肠系膜切除根治术29例报告

目的探讨四孔法完全腹腔镜下完成全直肠系膜切除(total mesorectal excision,TME)、直肠拖出低位或超低位行结肠-直肠、结肠-肛管吻合治疗直肠癌的可行性。方法2008年4月~2009年5月,按TME原则,四孔法完全腹腔镜下对29例低位直肠癌实施低位或超低位结肠-直肠、结肠-肛管吻合术,全系膜游离后拖出肛门外切除并手工吻合或吻合器吻合。结果29例均完全在腹腔镜下完成,无辅助切口,保肛率100%。手术时间150~310min,平均185min。术中出血20~120ml,平均50ml。术后2~3d恢复胃肠功能并下床活动,住院时间12~35d,平均15d。术后28例应用止痛剂。1例直肠阴道瘘。29例随访3~13个月,平均8个月,未发现穿刺口种植和局部复发。结论四孔法完全腹腔镜下行TME低位或超低位结肠-直肠、结肠-肛管吻合术治疗直肠癌安全可行,具有创伤小、出血少、保肛率高、术后疼痛轻、恢复快等优点。     

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。     

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。     

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。     

内括约肌、直肠肌层切开术在巨结肠治疗中的作用分析

目的探讨肛门内括约肌和直肠末端肌层切开手术在先天性巨结肠及其类缘病治疗中的作用。方法选择1995年9月至2010年7月我院及协作医院收治的先天性巨结肠及先天性巨结肠类缘病100例,其中采用Swenson术式50例,Du—hamel术式50例,对两种术式疗效作分析、比较。结果Duhamel术式均一次成功,首次治愈率100％,而Swenson术式组中26例一次成功,8例直肠保留端神经节细胞缺如;16例直肠保留端神经节细胞减少、未成熟等（巨结肠类缘病）,术后巨结肠症状复发,行二次手术,首次治愈率仅52％。两种术式首次治愈率对比差异具有统计学意义（Pd0．05）。结论对于病变累及直肠末端的巨结肠及其类缘病的治疗,肛门内括约肌和直肠末端肌层的切开,起着重要作用,可提高手术治愈率。     

Zwanzig Jahre diagnostisches Hirschsprung-Kompetenzzentrum in Basel

Background

The experience gained by the Basel Hirschsprung Competence Center over 20 years is presented.

Materials and Methods

A total of 19,365 rectal mucosal biopsies were investigated in the 20 years between 1987 and 2006. All biopsies of rectal mucosa originated from 6,615 children aged between 1 week and 4 years. Biopsies were collected in teaching hospitals all over Germany and transported on dry ice by Intercity Courier Service. Serial sections of frozen tissue were made using a cryostat. Enzyme histochemical staining was performed.

Results

A total of 935 cases of Hirschsprung’s disease (14%) were observed (769 cases of classical Hirschsprung’s disease, 68 total colon aganglionosis, 98 ultrashort rectum aganglionosis). Total colon aganglionosis was found in 1.0% and the frequency of ultrashort Hirschsprung’ disease was 1.4%. The quality of the histological results was confirmed by a second independent investigator. There were neither false positive nor false negative diagnoses. Enzyme histochemical staining results were readable within 2 h. Acetylcholinesterase, which is significantly increased in Hirschsprung’s disease, was used for nerve fiber staining. Succinic and lacticdehydrogenases and nitric oxide synthase served as confirmatory proof of aganglionosis (elective nerve cell staining of the submucous plexus).

Conclusion

Among 100 children with chronic constipation an average of 12 children were diagnosed with Hirschsprung’s disease. Of these 2% showed total colon aganglionosis or ultrashort Hirschsprung’s disease. Enzyme histochemical diagnosis of Hirschsprung’s disease proved 100% reliable and time saving.     

Adult Hirschsprung’s disease in Jamaica: operative treatment and outcome

Aim This study reviewed the operative management and outcome of patients with adult Hirschsprung’s disease treated at the University Hospital of the West Indies, Mona, Jamaica. Method The case notes for 11 patients with adult Hirschsprung's disease, treated operatively between January 1986 and December 2007, were reviewed and data on preoperative diagnosis, operative procedures and postoperative complications were retrieved. Results Diagnosis was by open rectal biopsy in nine patients and by rectal suction biopsy in two patients. The time taken for preoperative bowel preparation ranged from 10 to 35 days, and colostomy was required in three patients to facilitate bowel cleansing. The Soave and Swenson procedures were used in six and five patients, respectively, leading to anastomotic stricture in one patient treated using the Soave procedure and to leakage in two patients treated using the Swenson procedure. All procedures took longer than 300 min, and 300–800 ml of blood or plasma was transfused. Conclusion Therapeutic procedures for adult Hirschsprung's disease may result in life‐threatening anastamotic complications. A protective colostomy is recommended when Swenson’s procedure is used.     

三个月内婴儿巨结肠症腹腔镜Soave改良根治术探讨

目的:总结腹腔镜Soave改良根治术治疗3个月内婴儿巨结肠症的临床经验。方法:为45例巨结肠患儿施行腹腔镜Soave改良根治术并对术后发生并发症的21例进行分析。结果:45例均治愈出院,术后随访3个月至4年,患儿生长发育良好,食欲及大小便正常,无污粪。结论:腹腔镜下巨结肠Soave改良根治术对婴儿打击小,创伤轻,手术风险低,安全系数高,手术效果好。在腹腔镜辅助下可将巨结肠患儿的手术年龄提前至新生儿和小婴儿期,早期治愈有利于患儿身心健康及发育。     

Case report of a skip segment Hirschsprung’s disease: A real phenomenon

Introduction and importanceHirschsprung’s disease is a congenital anomaly that results from an incomplete craniocaudal migration and maturation of intestinal ganglion progenitor cells leading to distal intestinal aganglionosis. Skip segment Hirschsprung’s disease is an extremely rare phenomenon. We report a case involving only the small bowel with confirmed colonic ganglionosis.Case presentationA case report of a 14-month-old with a skipped segment involving the distal 50 cm of the small bowel associated with colonic ganglionosis is presented. A current review of the literature is discussed.Clinical discussionOur patient had persistent obstructive symptoms despite undergoing a technically good, ganglionic pull-through operation at an outside institution. A laparoscopic-assisted pull-through might have documented a small bowel wall diameter discrepancy.ConclusionAlthough rare, skip segment Hirschsprung’s disease is a real phenomenon that paediatric surgeons should be aware of and could involve small and large bowels.     

腹腔镜下改良Soave巨结肠根治术的临床疗效分析

目的:对比分析腹腔镜下改良Soave巨结肠根治术与Ikeda术治疗婴幼儿先天性巨结肠症的临床疗效。方法:为60例先天性巨结肠症患儿分别行腹腔镜下改良Soave巨结肠根治术与传统Ikeda术,对比两组患儿术前及术后4 h、8 h、12 h、24 h的平均动脉压(MAP)、心率(HR)、血氧饱和度(SpO2),术后疼痛评分,切口愈合情况,采用Kelly评分标准观察中远期手术效果。结果:两组手术均获成功,腹腔镜组术后各时点MAP、HR和疼痛评分均低于Ikeda组,且术后切口愈合良好,并发症少。结论:腹腔镜下改良Soave巨结肠根治术具有患儿创伤轻、疤痕小、术后康复快、并发症少等优点,安全可靠,充分体现了微创手术的优越性,值得推广应用。     

Clinical features’ diagnostics and treatment of Hirschsprung’s disease in adults

Aim Hirschsprung’s disease first diagnosed in adulthood is symptomatic from early childhood in most cases. However, the condition is frequently masked when constipation is managed effectively by enemas and aperients. One third of the patients will experience progressive symptoms or complications, requiring urgent surgical intervention. Method Ninety patients with adult Hirschsprung’s disease were observed by a combination of investigations: barium enema, anorectal physiology, estimation of acetylcholinesterase activity and a 60 mm full‐thickness strip biopsy. The latter two modalities were performed in selected patients where there was diagnostic uncertainty. Single‐staged resections, mostly modified Duhamel procedures, were performed in patients who were stable and fit, and with only a limited degree of megacolon present, and no other complications. Otherwise patients were temporarily defunctioned prior to staged resection. All patients underwent surgical treatment. Long‐term functional outcomes were expressed as good, satisfactory or poor. Results Median age was 24.5 years, range 14–47 years, and 72.2% were men. Almost three quarters (73.3%) of the patients had symptoms dating from early childhood. Barium enema was diagnostic in 84.3%, and 36.2% had a positive, but weak rectoanal inhibitory reflex. Acetylcholinesterase staining was positive in 85.7%, but full‐thickness strip biopsy was positive in 100% of equivocal cases. A separate cadaveric study of unaffected individuals determined the true length of the normal physiological hypoganglionic zone, mean 24.4 mm and range 7.5–50 mm. Supra‐anal short segment Hirschprung’s disease was found in 5.6% patients, rectal involvement in 54.4%, rectosigmoid in 38.9% and total aganglionosis of the colon in 1.1%. Resection of the aganglionic zone and proximally dilated colon was performed as a single‐staged procedure in 67.8%. Staged surgery was carried out in 32.2%. A modified Duhamel procedure was performed in 91.2% of cases. A good or satisfactory functional outcome was achieved in 96.7%. Long‐term functional outcome after resection depends on the degree of preoperative megacolon present. Megacolon limited to the sigmoid colon was associated with a good outcome in 89.7%, but in only 66.7% with more proximal dilatation (P < 0.05). Conclusion Occasionally, Hirschsprung’s disease presents in adulthood, with ongoing symptoms from early childhood or with the development of functional obstruction, faecal impaction and megacolon in later life. Diagnosis often requires multimodal investigation. A 60 mm full‐thickness strip biopsy confirms aganglionosis in 100%. A modified Duhamel procedure is the operation of choice.     

腹腔镜Soave术治疗婴儿先天性巨结肠症的临床疗效

目的探讨腹腔镜Soave术治疗婴儿先天性巨结肠症的临床疗效。方法回顾性分析2005年6月至2012年6月江苏省徐州市儿童医院采用腹腔镜Soave术治疗368例先天性巨结肠症患儿的临床资料。368例患儿均采用3个0．5cm Trocar,经腹腔镜游离拖出结肠及分离结扎系膜,经肛门剥离直肠黏膜5～7cm,将腹腔镜下游离的病变结肠从直肠肌鞘内拖出。采用门诊随访,术后1、3、6、12个月了解患儿排便次数,有无污粪及肛门狭窄等,随访时间截至2013年6月。结果2例患儿中转开腹,其余366例顺利完成腹腔镜Soave术,手术时间为（1004-20）min,术中出血量为（5．4±1．5）mL,术后无切口感染,术后住院时间为（7．34±1．5）d,术后应用抗生素时间为（3．5±1．6）d,输液时间为（3．8±1．4）d。全部患儿术后获得随访,平均随访时间为4．5年（1．0～8．0年）。随访期间发生小肠结肠炎11例、便秘7例、肛门狭窄5例、污粪4例,均经保守及对症治疗后好转。结论腹腔镜Soave巨结肠根治术适用于治疗年龄〈2个月的婴儿先天性巨结肠症;该手术创伤小,瘢痕小,恢复快,外表美观,术后并发症少,有一定的优越性。     

腹腔镜Soave术及Swenson术治疗短段型先天性巨结肠对控便功能的影响

目的探讨腹腔镜Soave术（LS）与改良腹腔镜Swenson术（MLSw）治疗短段型先天性巨结肠（HD）患儿的效果及对控便功能的影响。 方法回顾性分析2012年1月至2017年12月西安市儿童医院手术治疗的短段型HD患儿90例，其中LS治疗45例（LS组），另外45例采用MLSw治疗（MLSw组）。对比两组患儿的围手术期指标，术后1年时检测患儿的肛肠压，Heikkinen评分法评价其控便功能。 结果MLSw组的手术时间、术中出血量、术后进食时间、住院时间均少于LS组（t=6.718、15.583、2.183、3.343，均P<0.05）。术后1年时，MLSw组的肛管静息压、肛管高压带长度、最大收缩压、感觉阈值均低于LS组，排便次数、大便性状、污粪、需要治疗及Heikkinen总分均高于LS组，差异有统计学意义（P<0.05）。MLSw组术后并发症发生率为6.67%（3/45），显著低于LS组的22.22%（10/45），差异有统计学意义（χ²=4.406，P=0.036）。 结论MLSw治疗短段型HD患儿的效果优于LS，患者术后并发症发生率更低，控便功能更好。