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。

One-stage Soave pull-through operation for Hirschsprung's disease:a comparison of the laparoscopic-assisted and simple transanal approaches

Objective:To compare the effects of the laparoscopy-assisted transanal endorectal pull-through operation and the transanal Soave technique without laparoscopy,and determine whether the laparoscopy-assisted procedure offers more advantages than the transanal Soave approach.Methods:We reviewed the data of 110 children with Hirschsprung's disease undergoing Soave pull-through approach.The patients were divided into 2 groups:transanal Soave with routine laparoscopic visualization(LTS,n=73),and transanal soave with selective laparoscopy(TS,n= 37).The surgical procedures,time of passing feces or flatus and operation,complications,early defecation functions,and cost of laparoscopic equipments were analyzed.Results:In the TS group,laparoscopy was used in 3 children because of indetermination of the level of the transition zone,and in 3 children for mobilization of the splenic flexure because of longer segment HD.There were no differences between two groups in age,gender,location of transition zone,severity of enterocolitis,anal stenosis,anastomotic complications,time of passing flatus and total operation,but the anal dissection time was significantly shorter in the LTS group(the mean was 61 minutes;range from 51 to 71) than the TS(the mean was 3 hours;range from 2.25 to 3.5).The cost(RMB) was higher in the LTS group(2 000 yuan) than the TS by using laparoscopic equipments(ultrasonic scalpel and Trocars),two LTS patients underwent repeat surgery because of anastomotic leak and 5 TS patients required repeat surgery including 1 case of anastomotic leak,1 case of twisted pull-through,1 case of anal shrinking and narrowing and 2 case of recurrent constipation.There were no difference about early defecation functions in 4 following up years(3 months to 8 years).Conclusions:Although the transanal pull-through cost lower than the laparoscopic approach,without a significantly increased risk of complications,routine laparoscopic visualization should be used in children suffering long segment diseases and a part of rectosigmoid diseases.And the laparoscopy-assisted transanal pull-through operation is a much more versatile technique.