经肛门行改良Swenson巨结肠根治术疗效分析

目的 对7年来所做的143例手术做一总结回顾.方法 143例经钡剂灌肠、直肠测压或直肠活检确诊.患儿取截石位,经肛门插入一把卵圆钳,于耻骨结节(腹膜返折)上方钳住直肠壁下牵将直肠套叠翻出,在翻出的直肠内壁处缝合牵引线两圈,于两圈线间全层切断直肠.远端后壁全层游离,并背切至齿状线上0.5～1.0 cm,前壁游离至齿状线上方2.5～3.5 cm,近端边下牵边游离,切除病变肠管.近远端行双层吻合,吻合口呈心形.结果 平均手术时间70 min,平均出血量10 ml,无中转开腹,术后不需扩肛,术后1个月平均排便2～3次/d,术后3个月平均排便1～2次/d.1例因术中背切远端直肠后壁过于靠近齿状线,术后出现轻度便失禁,经再次缝合内括约肌痊愈;1例术后5 d出现吻合口后壁撕裂、血便,经保守治疗痊愈;4例发生小肠结肠炎,保守治疗痊愈.1例术后复发,经再手术治愈.结论 经肛门巨结肠根治结直肠全层吻合术安全、可靠、操作简便、术后效果好.

Experience of modified Swenson operation for Hirschsprung's disease

Objective To introduce the experience of modified Swenson operation by transanal pull- through for 143 patients with Hirschsprung's disease in the past 7 years. Methods All patients were diagnosed by barium enema, anorectal manometry or biopsy before operations. Patients were anesthetized and placed in lithotomy position. Then the rectum was pulled out into intussusception above the peritoneal reflection. Fine silk suture was performed circumferentially for traction of the distal end. Another circumferential suture was performed at 0. 5-1.0 cm above the original one and used for traction for the proximal intestines. The full-thick rectal wall was truncated between the above-mentioned two circumferential sutures with cautery. The proximal intestines were pulled down and the mesenteric vessels were controlled with the electrocautery until normal intestines appeared (ganglion cells were determined by intraoperative rapid frozen section). The distal end was dissected anteriorly 2.5-3.5 cm above the dentate line. The posterior rectal wall was split longitudinally and dissected till 0. 5-1.0 cm above the dentate line. The affected segment was resected. An oblique anastomosis was made. Results The mean operating time was 70 min and mean intraoperative bleeding was 10 ml. Postoperative rectal dilation was not necessary. Ninety-eight patients were followed-up. All these patients had 2-3 bowel movements per day 1 month postoperatively. There were 7 patients presented complications, one had postoperative incontinence for the closer incision of distal rectal wall from dentate line; one had laceration of posterior stoma and bloody stools, who was cured by conservative treatment; 4 patients who had postoperative enterocolitis were cured conservatively; one relapsed after operation, who was cured by a reoperation. Conclusions Transanal one-stage pull-through procedure for Hirschsprung's disease by modified Swenson operation is an easy adaptation to a well-established technique, which is safe, reliable, convenient and well prognosis.