心形吻合术治疗先天性巨结肠的远期效果

目的 总结心形吻合术治疗巨结肠的经验。方法 回顾11年来心形吻合术治疗巨结肠的疗效,技术操作及改进,并发症的发生率和防治。结果 193例手术患者得到随访者152例,早期术后并发症15例,其中尿潴留2例,肠炎10例,吻合口狭窄1例,肠梗阻2例。晚期并发症22例,其中肠梗阻2例,便秘5例,切口疝2例,肠炎6例,7例偶有污粪,无盆腔、腹腔伤口感染、肛门失禁和死亡。结论 心形吻合术能明显减少术后并发症,提高疗效。     

直肠肛管纵切心型吻合术治疗先天性巨结肠远期疗效观察

目的 评定经直肠肛管纵切心型吻合术式治疗5年以上先天性巨结肠68例疗效。方法 随访收集1992至1996年间采用心型吻合术式根治的先天性巨结肠68例的临床资料。男40例,女28例,手术时年龄<6个月22例(32％),其中新生儿10例(15％),6个月～3岁27例(40％),>3岁19例(28％);常见型46例(67％),长段型10例(15％),短段型12例(18％)。本组患儿均来院复查。通过①临床观察排便功能检查:每日排便次数、性状、有无便意、便秘、失禁及污粪,是否使用泻药,是否影响日常群体生活等。同时常规做肛诊检查。②客观排便功能测定:钡灌肠造影检查、直肠肛门测压。结果 肛门功能异常者13例(19％),主观检查以污粪为多7例(10％),其中术后6年以上1例(1.4％),4～6年6例(8.8％),便秘2例(3％),失禁4例(6％);钡灌肠造影检查:肛管直肠角68例均在正常范围,钡剂外溢7例(10％),24 h钡剂潴留2例(3％)。直肠肛门测压:直肠肛管抑制反射阳性36例(52.94％),肛管直肠压差和肛管高压区长度均低于正常参考值。结论 直肠肛管纵切心型吻合术适用于各年龄组及各种类型的巨结肠,其远期肛门直肠功能受无神经节细胞肠管长度影响,但症状随年龄增长而逐渐改善,可望通过生物反馈训练加快功能恢复。     

先天性巨结肠症直肠肛管纵切心形吻合术12例报告

对12例先天性巨结肠患儿采用腹内不断结肠经直肠内套出结肠,直肠肛管纵切,结肠直肠前高后低心形吻合不用夹具的手术方法。患儿平均住院30d,吻合口狭窄1例,1月后作狭窄部切开;1例发生尿潴留,3个月后恢复,2例肛门污粪,全组钡灌肠复查结肠无狭窄及扩张,肛门排便功能正常,直肠肛管纵切心形吻合术根治先天性巨结肠症,不造成腹腔感染,不用夹具,术后肛门排便功能恢复快,并发症少。     

腹腔镜心形吻合术治疗先天性巨结肠与开腹手术比较

目的比较腹腔镜辅助下背侧纵切心形吻合术(LHSC)与开腹手术治疗先天性巨结肠的术后并发症和排便功能.方法1999年8月～2003年11月,57例患儿进行了LHSC,54例获随访,平均随访时间是2.8年(6个月～4.8年),主要观察手术时间、并发症、排便功能及费用并与1999年8月之前的48例开腹手术进行对比.结果手术时间腹腔镜组为(168±59)min,明显长于开腹手术组(138±43)min,(f=2.903,P=0.005);腹腔镜组住院总费用为(12 030±1 050)元,明显高于开腹手术组(10 500±1 500)元(t=6.019,P=0.000);2种手术方式的术后并发症统计学上差异无明显性(χ2=2.86,P=0.091);伤口感染和肠粘连肠梗阻的发生率腹腔镜组较少,而尿潴留的发生率比开腹组高.腹腔镜组直肠肛管反射恢复率55.6%,直肠肛管角为83.4°±10.4°,排便功能异常发生率为11.1%,便秘和污粪各占50%,与开腹组相近.肛管直肠压差与肛管高压区长度两组无明显差异性(t=-0.979,P=0.334;t=-0.234,P=0.816).结论LHSC是治疗先天性巨结肠安全、有效的手术方法,术后恢复快,并发症少,排便功能与开腹手术相同.     

改良Soave术治疗新生儿和婴儿先天性巨结肠

目的评价经肛门改良Soave术式治疗新生儿和婴儿先天性巨结肠的手术效果。方法 17例经组织学确诊为短段型及部分常见型先天性巨结肠患儿行经肛门改良Soave巨结肠根治术。在直肠后壁齿状线上1cm、直肠前壁齿状线上2～3 cm呈斜面切开直肠黏膜,向近端游离直肠黏膜管进入腹腔,切除腹膜外直肠肌鞘达肛提肌水平,残留肌鞘后壁做“V”形切除,游离近端结肠,拖出正常结肠与肛门斜行吻合。结果本组平均手术时间(160±45)min,术中平均出血(45±35)ml, 无术中并发症。术后未发现小肠结肠炎、吻合口漏、肛周感染及吻合口狭窄等并发症。随访4个月- 3年,所有患儿排便成形,无便秘、无污粪。结论经肛门改良Soave术式治疗新生儿和婴儿先天性巨结肠安全有效。     

肛门直肠畸形合并先天性巨结肠

目的：探讨先天肛门直肠畸形（ＡＲＭ）合并先天性巨结肠（ＨＤ）的临床特点和诊治方法。方法：回顾性分析总结本院２０年来ＡＲＭ３２６例，ＨＤ３２０例，其中两种并存有３例，３例均经手术病理证实诊断，结论：ＡＲＭ作结肠造瘘术后，排便不畅应及时作结肠活检，随访ＡＲＭ术后患儿有腹胀，便秘，应进一步作钡灌肠和直肠粘膜乙酰胆碱酯酶检查，确诊后按巨结肠处理。     

经肛门结肠拖出加内括约肌部分切除治疗先天性巨结肠

目的探讨经肛门结肠拖出同时肛门内括约肌部分切除治疗先天性巨结肠的临床效果。方法自2001年7月-2003年8月采用该手术方法共治疗先天性巨结肠72例。对27例患者手术前、后行肛门直肠测压,按Reding评分法评估术后肛门功能。结果术前静息压(38±8) mm Hg,术后静息压(22±6)mm Hg,对照组静息压(23±4)mm Hg,手术后较手术前静息压明显降低,两者之间差异有统计学意义(P<0．01)。但手术前、后均无肛门直肠反射。随访48例,肛门功能优31例,良15例,差2例。结论经肛门结肠拖出同时内括约肌部分切除治疗先天性巨结肠创伤小,可解除直肠肛管高压,近期排便效果良好,生活质量提高。     

先天性巨结肠122例根治术疗效观察

目的：总结先天性巨结肠根治术的治疗经验。方法：本组１２２例。其中直肠肛管后壁纵切－心形吻合术４８例，随访４２例；对照组７４例（其中Ｄｕｈａｍｅｌ－Ｇｒｏｂ法４２例，得到随访的３８例；Ｓｗｅｎｓｏｎ－Ｇｒｏｂ法３２例，随访３０例）。结果：直肠肛管后壁纵切－心形吻合术远期并发症７．１４％，治愈率９２．８６％，对照组Ｄｕｈａｍｅｌ－Ｇｒｏｂ法术的并发症１５．９％，治愈率８４．１％。Ｓｗｅｎｓｏｎ－Ｇｒｏ     

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。     

Z shaped primary colorectal anastomosis using the GIA autosuture for Hirschsprung's disease

The Duhamel operation for Hirschsprung's disease has won wide acceptance throughout the world. However, this procedure is not without difficulties, and the usual technique of employing various crushing clamps for division of the colo-rectal septum is inelegant, inconvenient and uncertain. This paper presents an operative technique with particular reference to the use of the GIA autosuture surgical stapling instrument in the Z shaped primary colorectal side-to-side anastomosis for Hirschsprung's disease advocated by Ikeda. This is a single and primary procedure, and makes the postoperative care easier and more comfortable for the patients. Experiences with twenty-five patients are reported.     

Posterior longitudinal split osteotomy for femoral component extraction in revision total hip arthroplasty

We present a technique of single posterior longitudinal split osteotomy. This technique allows the expansion of the proximal femur and easier extraction of uncemented femoral components. Since 1998 we have performed this osteotomy in 12 revision total hip arthroplasties in 11 patients who had either stable fibrous ingrowth or a small amount of bony ingrowth. All were revised to a cemented Exeter stem (Stryker Benoist Gerard, Caen, France). No patient required conversion from a longitudinal split to an extended trochanteric osteotomy. At mean follow-up of 48 months, there were significant improvements in both pain and function. There were no complications due to this technique. Mean in-cement taper engagement (subsidence) was 1.1 mm (range, 0-2 mm). Femoral impaction grafting did not adversely affect the cement mantle or increase in-cement taper engagement. With appropriate patient selection, this is a simple, reliable, and extensile technique to assist in the extraction of uncemented ongrowth femoral components whether hydroxyapatite-coated or not.     

Posterior cloaca—further experience and guidelines for the treatment of an unusual anorectal malformation

Introduction

The term posterior cloaca refers to a malformation in which the urethra and vagina are fused, forming a urogenital sinus that deviates posteriorly to open in the anterior rectal wall or immediately anterior to the anus.

Methods

A retrospective review of 411 patients diagnosed with cloaca was performed to identify the ones with a posterior cloaca. Special emphasis was placed on anatomy, diagnosis, associated anomalies, and outcome in terms of urinary and fecal continence. Surgical treatment was a total urogenital mobilization with a transrectal approach.

Results

Twenty-nine patients were diagnosed with a posterior cloaca. Of these, 15 had a single orifice at the normal location of the anus with the urogenital sinus opening in the anterior rectal wall. Fourteen had the urogenital sinus opening immediately anterior to the normally located anal opening (2 orifices), which we considered a posterior cloaca variant. Nineteen patients (65%) had hydrocolpos. Twenty-seven patients (93%) had associated urologic anomalies, 12 patients (41%) had gynecologic anomalies, and vertebral malformations occurred in 41% of cases. Other anomalies included gastrointestinal (7 patients), cardiac (5), and tethered cord (2). Late diagnosis occurred in 2 patients. Twenty patients were available for long-term follow-up: 17 are fecally continent, 3 are fecally incontinent, 11 are urinary continent, 5 are dry with intermittent catheterization, and 4 have dribble urine.

Conclusion

The most important characteristic of the posterior cloaca is the high frequency of a normal anus, which differentiates this malformation from the classic cloaca. Often, many associated malformations are present and therefore should be suspected and diagnosed. The main goal during the operation should be to not mobilize the anus and thereby preserve the anal canal. A total urogenital mobilization, transperineally or with a transanorectal approach, is ideal for the repair.     

Anterior resection combined with anorectal myectomy in the treatment of Hirschsprung's disease.

During the period October 1974 to November 1977, six children with Hirschsprung's disease have undergone anorectal myectomy followed by anterior resection. The procedure was carried out in a group of older children who presented late, where the aganglionic segment was thought to be confined to the rectum alone. In these cases, when the initial myectomy specimen revealed total aganglionosis and serial biopsies revealed that the aganglionic segment extended beyond the reach of myectomy, it was decided to carry out anterior resection. The rationale, methods, and results are discussed. It is suggested that this type of procedure is most suitable to those older patients who are diagnosed late, with disease located in the rectum.     

直肠中下段癌经腹肛门切除后经肛门结肠直肠粘膜吻合术

目的为探讨直肠中下段癌保留肛门临床最佳治疗术式。方法对1993年～1997年收治28例中下段直肠癌经腹肛门切除后经肛门行结肠直肠粘膜吻合术。结果随访6～52个月,平均29个月。无手术死亡率,无吻合口漏和吻合口狭窄发生。仅1例于术后19个月局部癌复发(3.6%),余27例现仍无瘤生存。术后8～12周时排便控制良好,次数为2～3次/日,18周时肛门排便功能基本恢复正常,排便次数为1～2次/日。结论合理选择手术适应症,既要避免腹壁结肠造口,又要保证手术的彻底性,在提高患者生活质量的同时,还要注重远期效果。     

心外管道全腔静脉肺动脉吻合术治疗复杂性先天性心脏病

目的 评价心外管道全腔静脉肺动脉吻合术(TCPA)治疗复杂先天性心脏病的临床应用价值。方法 1998年6月～2002年7月，26例先天性心脏病复杂畸形的患者接受了心外管道TCPA，包括单心室伴完全型大动脉转位16例，三尖瓣下移畸形2例，右心室双出口伴大动脉转位3例，三尖瓣闭锁伴右心室发育不良5例。19例在全身麻醉低温体外循环下手术，7例在非体外循环下手术。结果 无手术死亡，全部患者治愈出院。术后随访1～47个月，无晚期死亡。所有患者症状消失，无静脉压明显升高现象，超声心动图检查示心外管道血流通畅，无血栓形成，心电图检查示无严重的心律失常，血氧饱和度0．93～0．96，心功能均达Ⅰ～Ⅱ级。结论 心外管道TCPA是一种较为简单的手术方式，易于掌握；术后疗效满意，优于其他术式。     

肛肠动力性疾病的诊治进展

肛肠动力学是近年来胃肠动力学发展中的一个重要分支。它以静力学和动力学及肌电为主的方法来研究结肠、直肠、肛管(包括盆底)的各种运动方式，从而对排便生理及有关肛肠疾病的病理生理学进行研究。肛肠动力性疾病主要表现为肛肠动力异常所致的便秘、腹泻、肛门失禁，并常伴随腹痛、腹胀、肛门坠胀不适等。这类疾病不像恶性肿瘤直接对病人生命构成威胁，其病因病理复杂，诊断困难，临床医师重视不够。流行病学调查显示发病率呈上升趋势，约占人群的10％～15％，因此必须给予高度重视。