先天性巨结肠Soave术后大便失禁的评价和治疗

目的 对先天性巨结肠Soave术后大便失禁进行评价和治疗.方法 先天性巨结肠Soave术后大便失禁患儿24例,男14例,女10例,年龄6～13岁,肛门功能临床评价为良19例,差5例.全部患儿行肛门直肠测压,并与18例肛门功能正常的Soave术后儿童比较.所有患儿在医院接受生物反馈训练2周后自行在家中行盆底肌收缩训练.结果 肛管静息压、收缩压、直肠初感觉分别为(18.9±6.2)mmHg、(179.9±17.8)mmHg、(45.4±9.4)ml,与18例对照组儿童相比[分别为(44.5±11.1)mmHg、(177.7±15.9)mmHg、(50.0±10.1)ml],静息压明显下降,收缩压、直肠感觉无明显变化.3例不配合治疗,21例1年后除5例未能坚持外,其余16例获得良好的肛门控制,肛管静息压、肛管收缩压、直肠初感觉分别为(35.4±8.7)mmHg、(195.3±15.0)mmHg、(45.9±8.4)ml.肛管静息压和收缩压均升高.结论 内括约肌损伤可能是先天性巨结肠Soave术后大便失禁的原因之一,对此盆底肌训练可取得满意的治疗效果.

Abstract：

Objective To evaluate the efficacy of pelvic floor muscle exercise for the treatment of fecal incontinence after Soave procedure for Hirschsprung's disease. Methods Twenty four patients who had Soave procedure for Hirschsprung's disease and presented fecal incontinence after surgery were recruited in this study. They were 14 males and 10 females, aged from 6 to 13 years old. Eighteen children who had normal defecation after Soave procedure were selected as controls. All the subjects had manometry to measure resting anal canal pressure, squeeze pressure, and rectal sensation.All the patients had two weeks biofeedback therapy during their stay in hospital. After being discharged, they were taught and prescribed to do pelvic floor muscle exercise at home. Results Of the children with fecal incontinence, the resting anal canal pressure, squeeze pressure and rectal sensation were ( 18. 9 ± 6. 2 ) mmHg, ( 179. 9 ± 17. 8) mmHg, (45. 4 ± 9. 4) ml, respectively. Compared with the controls, the resting anal canal pressure was lower [(18. 9±6. 2) mmHg vs (44. 5 ± 11.1) mmHg].But no difference of squeeze pressure and rectal sensation was found between the 2 groups [(179. 9 ±17. 8)mmHg vs (177. 7 ± 15. 9) mmHg, (45.4 ± 9. 4)ml vs (50. 0 ± 10. 1)ml]. Three patients dropped out of the therapy. Five patients stopped the exercise after the first year. The other 21 who kept exercise improved their defecation function. Their resting anal canal pressure, squeeze pressure and rectal sensation were (35. 4 ± 8. 7)mmHg, (195. 3 ± 15.0)mmHg and (45. 9 ± 8. 4)ml, respectively. Conclusions The dysfunction of internal anal sphincter might be the main cause for fecal incontinence after Soave procedure. Pelvic floor muscle training is helpful to improve the defecation function of the patients.     

阑尾原位造口可控性顺行灌肠的临床评价

Objective To evaluate the clinical results of antegrade continence enema via appendi-costomy in situ to treat neurogenic faecal incontinence. Methods 13 patients with tethered cord syn-drome complaeated neurogenic faecal incontinence were performed appendicostomy in situ with intus-susception valve between June 1998 and December 1999 (male 9, female 4, age 6～13 years). After operation,enema were performed via stoma. Results All patients were followed up 2 to 6 years later. All stomas are continent of faeces and flatus. Stoma stricture developed in 2 patients, and atresia in an-other 2 patients. Anus function were increased in 11 patients. Conclusions Antegrade continence ene-ma via appendicostomy in situ is a effective method to treat neurogenic faecal incontinence. It can devel-oped life quality of patients.     

神经源性大便失禁患儿提肛肌的病理学改变及临床意义

目的：对神经源性大便失禁患儿的提肛肌进行病理学观察，为临床治疗提供病理学依据。方法：取22例神经源性大便失禁患儿的提肛肌标本，男15例，女7例，平均8．2岁。另取8例排便正常儿童的提肛肌作为对照，男5例，女3例，平均8岁。采用免疫组化染色(SY、NF200和MBP)进行观察分析。结果：对照组所有提肛肌标本NF-200和MBP均强阳性反应(染色强度 ～ )，SY染色深且数目多。神经源性大便失禁患儿组，SY染色浅，小且数目少，NF-200和MBP染色强度均较弱(-～ )，与正常对照组比较明显减少，但脊髓脊膜膨出术后组和隐性脊柱裂患儿组之间SY、NF-200和MBP指标无明显差异。结论：提肛肌神经支配异常是造成提肛肌功能不全的病因。为临床上采用盆底功能锻炼、生物反馈和手术等方法恢复提肛肌肌肉功能来治疗神经源性大便失禁提供了病理学依据。     

排便障碍性疾病的生物反馈治疗

生物反馈治疗(biofeedback therapy)用于排便功能障碍疾病的辅助治疗，目前在提高远期生活质量方面已得到肯定，但治疗方法尚未统一.2001年9月至2003年3月我院收治36例患儿，均进行生物反馈治疗，疗效满意。     

介绍一种治疗逼尿肌无反射神经原性膀胱的手术方法

逼尿肌无反射神经原性膀胱,临床上并非少见,但处理甚为棘手。我院采用去粘膜肠管平滑肌加固逼尿肌术治疗4例,获得良效,现报告如下.临床资料4例患者中男3例,女1例,年龄4     

小儿术后大便失禁的理疗与康复

我们对1985～1993年时行肛门外括约肌重建术的18例患儿(行神经压榨股薄肌转移肛门外括约肌重建术11例,臀大肌瓣转移肛门括约肌重建术7例,男10例,女8例;年龄2～15岁)术后随访1～9年,发现坚持康复训练者7例,其排便功能均在半年内恢复,而训练不佳的11例中仅4例在1年内恢复排便功能。     

阑尾原位造口可控性顺行灌肠的临床评价

Objective To evaluate the clinical results of antegrade continence enema via appendi-costomy in situ to treat neurogenic faecal incontinence. Methods 13 patients with tethered cord syn-drome complaeated neurogenic faecal incontinence were performed appendicostomy in situ with intus-susception valve between June 1998 and December 1999 (male 9, female 4, age 6～13 years). After operation,enema were performed via stoma. Results All patients were followed up 2 to 6 years later. All stomas are continent of faeces and flatus. Stoma stricture developed in 2 patients, and atresia in an-other 2 patients. Anus function were increased in 11 patients. Conclusions Antegrade continence ene-ma via appendicostomy in situ is a effective method to treat neurogenic faecal incontinence. It can devel-oped life quality of patients.     

经尿道电切治疗有症状的前列腺囊

目的介绍一种治疗前列腺囊的微创方法—尿道镜下电切扩大前列腺囊开口。方法自2003年2月至2005年10月我们共收治9例有并发症的前列腺囊患儿,平均年龄7.4岁(4～20岁)。术前6例尿道造影证实。9例患儿均行尿道镜检查 电切术。前列腺囊开口明显者,直接将电刀插入开口,切除开口周围组织,扩大开口;开口不明显者,先用环形电灼头在精阜正中电灼胀大的精阜,显露出前列腺囊开口后,再电灼扩大开口。手术完成后,置双腔导尿管4～7d。结果平均手术时间35min(20～45min);平均住院时间5d(4～7d)。平均随访2年2个月(6个月～3年1个月)。7例患儿经1次电切,2例患儿经2次电切,临床症状消失,排尿恢复正常。结论对表现有临床症状的病例主张积极的手术干预,尿道镜下电灼去顶、扩大囊肿开口,是一种简单、安全有效的治疗方法。     

肠浆肌层膀胱扩大术治疗神经原性膀胱的临床应用

目的报告逼尿肌切开双层肠浆肌层膀胱扩大术治疗神经原性膀胱的临床应用.方法1986～1999年间治疗脊髓发育不良所致的反射亢进性神经原性膀胱52例(年龄4～18岁),通过随访比较手术前后临床表现和尿流动力学检查,评价其疗效.结果 43例随访3个月～13年,平均6.7年.术前均表现为尿失禁;术后均无粘液尿、电解质失衡、代谢紊乱、尿路结石等,24例(55.8%)能完全自主排尿,15例(34.9%)配合CIC可达到不失禁,有效率达到90.7%(39/43).39例手术前后行尿流动力学检查,其术前膀胱容量为(159±78)ml,膀胱容量差为(-145±67)ml,充盈期末逼尿肌压为(6.5±2.6)kPa;术后分别改变为(346±86)ml、(12±52)ml、(2.1±1.5)kPa.均较术前有显著改善(P<0.01),已达到或接近其正常范围.结论逼尿肌切开双层浆肌层膀胱扩大术是一种较理想的膀胱扩大术和反射亢进性神经性膀胱的有效疗法.     

脊髓发育不良患儿尿路功能的早期评价和处理

目的探讨早期评价和干预治疗对脊髓发育不良所致的神经原性膀胱患儿上尿路和膀胱功能的影响。方法回顾性分析1997-2003年收治的脊髓发育不良，尿流动力学显示存在膀胱高压和／或逼尿肌括约肌不协调的75例年龄在1岁以内神经原性膀胱患儿，其中30例从发现高危因素后即开始应用间歇导尿和抗胆碱能药物治疗的患儿作为研究组，随访数年，记录上尿路功能、膀胱功能及手术干预情况，与其余没有进行间歇导尿和抗胆碱能药物治疗的患儿（对照组）进行比较。结果平均随访时间6．6年（3．6～9．8年），研究组共30例患儿，在随访期间2例出现上尿路持续性扩张，2例膀胱输尿管反流，3例膀胱顺应性差，最终5例行膀胱扩大术；对照组除去7例失访，38例中18例上尿路扩张，15例膀胱输尿管反流，23例膀胱顺应性下降，26例行膀胱扩大术，上尿路损害和最终需行膀胱扩大术的病例研究组明显低于对照组。结论脊髓发育不良所致的神经原性膀胱，病理损害是逐渐加重的，如早期进行尿流动力学评价，针对高危因素早期预防性治疗对保护肾脏和膀胱功能，控制尿失禁，减少膀胱扩大术，被证实是有效的。