内镜下离断直肠尿道瘘黏膜预防先天性肛门闭锁术后尿道并发症

目的探讨小婴儿在先天性肛门闭锁二期手术中,在直肠腔内应用胃镜离断直肠尿道瘘交界部黏膜及黏膜下层的作用。方法收集2020年1月至2020年5月在首都儿科研究所附属儿童医院普通外科因先天性肛门闭锁伴直肠尿道瘘行二期肛门成形术8例患儿的病例资料。所有患儿均为先天性肛门闭锁伴直肠尿道瘘已行一期结肠造瘘术后。均为男性患儿,平均手术年龄为3.9个月,手术年龄范围为2.8~6.3个月;平均体重为7.5 kg,体重范围为5.9~9.0 kg;造瘘口位于右上腹1例,脐上中腹部3例,左上腹2例,左下腹2例。因为本研究患儿年龄较小,肠腔细小、薄弱,故应用成人的普通电子胃镜在结肠、直肠内操作。在二期肛门成形术中,均在胃镜下尝试离断直肠尿道瘘交界部黏膜及黏膜下层组织,在胃镜离断黏膜后,再行腹腔镜辅助肛门成形术。结果8例患儿,1例经胃镜多次尝试仍未能到达直肠末端而放弃胃镜下黏膜离断术。1例因术中呼吸循环不稳定,仅在胃镜下完成交接部黏膜离断术,而未连续完成腹腔镜下肛门成形术,5 d后在腹腔镜下完成肛门成形术。其余6例均完成胃镜下瘘口交界部黏膜及黏膜下离断术,并同期行腹腔镜下肛门成形术。二期术后两周行尿道造影复查未见尿道狭窄和尿道憩室。结论运用胃镜在直肠腔内游离直肠尿道瘘交界部黏膜及黏膜下组织的操作方法是可行、有效的,是目前比较准确和全新的辅助直肠末端离断的方法,也是胃镜和腹腔镜联合手术完成肛门成形术的有益尝试。

Endoscopic dissection of rectourethral fistula mucosa to prevent postoperative urethral complications in congenital anal atresia

Objective To explore the role of gastroscopy in dividing mucosa and submucosa at the junction of rectourethral fistula in infants undergoing two-stage surgery for congenital anal atresia.Methods From January 2020 to May 2020,clinical data were collected from 8 boys undergoing two-stage anoplasty for congenital anal atresia with rectourethral fistula after primary colostomy.They had an average operative age of 3.9(2.8-6.3)months and an average body weight of 7.5(5.9-9.0)kg;stoma was located in right upper quadrant(n=1),supraumbilical middle abdomen(n=3),left upper quadrant(n=2)and left lower quadrant(n=2).Because of a young age with intestinal lumen which was small and fragile,common electronic gastroscope for adults was applied for colon and rectum.Mucosa and submucosal tissue were transected at the junction of rectourethral fistula under gastroscopy.The laparoscopic-assisted anoplasty was followed.Results Among them,1 case failed to reach rectal end after multiple attempts.In another case of intraoperative respiratory and circulatory instability,only gastroscopic mucosal transection of junction was completed while laparoscopic anoplasty remained incompleted until 5 days later.The remainders completed gastroscopic mucosal and submucosal dissection at fistula junction with simultaneous laparoscopic anoplasty.Urethrography was performed 2 weeks after a second stage without urethral stricture or diverticulum.Conclusions Gastroscope is both feasible and effective for separating mucosa and submucosal tissue at the junction of rectourethral fistula in rectal cavity.As an accurate and brand-new approach for assisting rectal end transaction,it is also a useful attempt to complete anoplasty by combining gastroscope and laparoscopy.