经尾路巨直肠及乙状结肠切除术在治疗肛门成形术后顽固性便秘中的应用

目的 探讨经尾路行巨直肠及乙状结肠切除术治疗肛门成形术后顽固性便秘的可行性。方法 患儿6例，年龄2～18岁，均为先天性肛门闭锁行会阴肛门成形术后合并顽固性便秘和充盈性大便失禁。钡灌肠示：直肠及乙状结肠高度扩张，蠕动差。6例患儿均经尾路切除直肠及远端乙状结肠，同时行肛门成形术。结果 平均手术时间205min(125min～265min)，切除扩张肠管长度23．3cm(10cm～40cm)。术后2月～4月后，6例患儿均可控制排便：12月～30月随访结果示：患儿便秘均消失。6例中4例患1度污便，另2例2度污便，无其他术后并发症。结论 尾路切除巨直肠及乙状结肠是治疗无肛术后顽固性便秘的有效方法。     

经肛门乙直肠切除术治疗儿童直肠脱垂

直肠脱垂（rectal prolapse，RP）在儿童中并不少见，但仅少部分患儿需接受手术治疗，常用的手术方式有数十种，各种术式的疗效不尽相同，其中经腹直肠悬吊固定术的疗效肯定，术后复发率也低，但手术对机体的创伤较大。为减少手术创伤，寻找新的行之有效的手术路径，受经肛门SoaveI期拖出根治术治疗儿童先天性巨结肠症的启发，我科成功地为2例直肠脱垂患儿实施了经肛门乙直肠切除术（transanal rectosigmoidectomy，TAR），取得了满意疗效，现将初步的经验总结报告如下。     

儿童腹腔镜下巨结肠根治、结直肠钉合吻合术的应用

目的评价腹腔镜辅助下结直肠切除、结直肠钉合吻合术治疗儿童先天性巨结肠的疗效。方法2010年2月至2012年2月我们对12例4—14岁常见型先天性巨结肠患儿,采取腹腔镜辅助下病变肠段游离经肛门拖出切除（改良Swenson手术）、结直肠采用吻合器完成钉合吻合术,统计手术时间、出血量、住院时间、住院期间排便情况和近期并发症。结果12例患儿均在腹腔镜辅助下顺利完成改良Swenson手术、结直肠钉合吻合术,手术时间1．5～2．0h;术中出血3～5mL;无术中并发症及术后伤口感染。2例术后出现排便时肛门疼痛;2例出现吻合口瘘,1例保守治疗30d瘘口愈合;1例行横结肠造瘘,术后4个月出现结直肠吻合口狭窄,经肛门纵行切开横行缝合后扩肛缓解;1例出现肠炎症状给予对症治疗痊愈。7例获随访患儿均无污粪、便秘情况存在,每日排便1～3次。所有患儿小便正常。结论腹腔镜辅助巨结肠根治、结直肠吻合器钉合方法可行,手术时间明显缩短,出血少,创伤小,术后恢复快,短期随访疗效满意,适合儿童巨结肠手术,但婴幼儿不适合此法。     

腹腔镜下肛门成形术治疗直肠肛门畸形的并发症分析

目的 探讨腹腔镜下肛门成形术治疗直肠肛门畸形的并发症的产生原因和应对方法.方法 总结分析本中心2010年1月至2015年12月共腹腔镜手术治疗的直肠肛门畸形92例,全部为男性患儿,其中直肠膀胱颈瘘23例,直肠前列腺球部瘘35例,直肠尿道瘘34例.全部患儿均行横结肠造瘘或乙状结肠造瘘的分期手术.术后平均随访时间2.5年(4个月～5年),统计术后并发症和肛门排便情况,其中31例患儿随访大于3年.结果 术后直肠回缩11例,有1例再次手术缝合,另10例保守治疗.术后直肠黏膜外翻7例,均为早期病例,有4例再次手术切除局部外翻黏膜,有3例游离拖出结肠切除部分后再次肛门成形.腹腔残余感染4例,均经抗感染后好转.在已随访3年以上的31例患儿中术后排便失禁3例,其中有1例患儿由于严重瘢痕狭窄予扩肛治疗,另外有2例患儿伴发脊髓栓系.结论 虽然手术并发症难以完全避免,但注意围术期处理和手术技巧,能减少术后并发症的发生.     

经肛门结肠拖出根治小儿乙状结肠冗长症

目的总结经肛门结肠拖出根治小儿乙状结肠冗长症的手术过程、疗效及短期随访。方法我院2000～2005年经该术式治疗小儿乙状结肠冗长症19例，乙状结肠冗长症有典型的便秘症状，钡灌肠显示19例乙状结肠比正常对照组平均长25cm；直肠肛管测压显示直肠肛管松弛反射存在，呈“W”型特殊波型；组织化学检查无乙酰胆碱酯酶阳性的副交感神经纤维。结果19例经肛门拖出切除结肠肠管20～52cm，平均切除结肠肠管28cm。均于术后2～3d开始进食，术后1个月随访每日排便6～8次，其中15例行钡灌肠检查未见结肠扩张，24h无钡剂潴留。6个月随访（17例）每日排便1～3次，无污粪。结论经肛门结肠拖出根治小儿乙状结肠冗长症手术安全有效，具有创伤小、操作简单、近期疗效良好的特点。     

经骶直肠肌层悬吊治疗儿童完全性直肠脱垂

经骶直肠肌层悬吊治疗儿童完全性直肠脱垂杜育达，陈桂荣，张海玉１９９０年以来收治３例直肠完全性脱垂，均采取经骶直肠肌层悬吊术治疗，报告如下。例１：男，８岁。病史４年。每次排便均有直肠脱垂，脱出长度逐渐加重，最长可达５ｃｍ。肛门松弛，收缩力差。经骶直肠肌...     

经肛门手术治疗小儿先天性巨结肠症15例治疗体会

目的探讨小儿先天性巨结肠症肛门手术治疗的适应证、方法、疗效和随访结果。方法采用经肛门直肠肌鞘内病变黏膜切除，保留直肠肌鞘6cm左右，沿结肠壁处理肠系膜血管，结肠拖出并在齿状线以上吻合。结果手术时间平均75min(50～100min)，均于术后48h内进食，平均术后住院6天，随访2～18个月，患儿排便情况1～5次／d，无明显大便失禁和肛门狭窄(术后坚持扩肛6个月)。结论本术式简单，效果好，并发症少。     

新生儿骶尾部畸胎瘤术后肛门直肠功能随访

目的评估新生儿骶尾部畸胎瘤术后的肛门直肠功能。方法对2008年2月至2014年1月在南京医科大学附属儿童医院新生儿外科手术治疗的新生儿骶尾部畸胎瘤患儿进行肛门直肠功能随访。记录资料包括:入院时年龄、症状和体征、手术方式、Altman分型和组织病理学分类。依据Krickenbeck分类法评估肛门直肠功能:有无自主排便、粪污等级和便秘等级。结果共计92例患儿(男/女=21/71)纳入本次研究,平均入院年龄(18.5±6.6)d(1~25 d),Altman分型Ⅰ型57例(62.0%),Ⅱ型25例(27.1%),Ⅲ型10例(10.9%)。全部患者均手术切除肿瘤及尾骨。依据Krickenbeck分类法共28例(30.4%)患儿存在肛门直肠功能障碍,其中21例(22.8%)便秘(Ⅰ型13例,Ⅱ型6例,Ⅲ型2例),7例(7.6%)污粪(Ⅰ型4例,Ⅱ型2例,Ⅲ型1例)。不同性别、组织病理学分类、手术方式患儿术后肛门直肠功能障碍的发生率存在差异,但差异无统计学意义(χ~2=3.795,P=0.051;χ~2=3.341,P=0.188;χ~2=1.737,P=0.187)。Ⅰ型、Ⅱ型和Ⅲ型患儿肛门直肠功能障碍发生率无统计学差异(χ~2=0.040,P=0.980)。Ⅱ型和Ⅲ型患儿术后出现肛门直肠功能障碍和未发生肛门直肠功能障碍者肿瘤大小比较,差异有统计学意义(t=4.003,P=0.025;t=2.796,P=0.017)。结论新生儿骶尾部畸胎瘤患儿术后可能并发肛门直肠功能障碍,其中便秘最常见,小部分患儿存在污粪。     

经肛门Soave巨结肠根治术后肛门功能与直肠肛管测压的研究

目的探讨经肛门Soave巨结肠根治术后患儿直肠肛管测压改变及排便控制情况。方法63例经肛门Soave巨结肠根治术患儿,术后平均随访3年(6个月～4.5年),对患儿大便控制能力、便秘发生情况及肛门直肠测压结果进行评价。结果获访47例,大便控制优15例,良26例,差6例。2例患儿有持续性便秘,8例曾出现肠炎。肛门直肠测压检查2例恢复直肠肛管抑制反射。47例随访患者的直肠静息压与正常对照组无显著性差别(P>0.05),但6例大便控制差的患者肛管高压区长度较正常对照组下降(P<0.05)。结论应用经肛门Soave巨结肠根治术治疗小儿巨结肠,术后可获得较好的排便控制功能。少数病例排便功能障碍可能与内括约肌功能受损有关,直肠肛管测压是重要的评估依据之一。     

肛门闭锁术后再手术的原因及对策CSCD

目的 分析肛门闭锁术后再手术的原因,探讨如何避免及处理手术相关并发症。方法 回顾性分析2009年12月至2015年1月25例肛门闭锁行肛门成形术后再手术患儿的临床资料。其中,男23例,女2例;年龄12 d～9岁;合并大便失禁8例,存在大小便失禁2例。6例直肠黏膜脱垂患儿行脱垂直肠切除,1例同时行肛门重建术;12例巨直肠患儿中11例行巨直肠切除术,其中1例同时行Malone手术,1例同时行脱垂直肠切除和Malone手术,1例同时行尿道憩室切除和Malone手术,另外1例仅行Malone手术;2例直肠尿道瘘行经会阴瘘修补术;1例前置肛门行肛门重建术;2例骶尾部直肠切口瘘行肠造瘘术;1例肛周炎性肉芽肿行肉芽肿切除术;1例粘连性肠梗阻行肠粘连松解术。大便失禁者术前、术后行肛门功能评分并行配对t检验。结果 患儿平均术后3.48 d开始无渣饮食,平均术后住院时间6.76 d。术后出现切口感染1例。随访6个月～3年,除2例患儿仍存在排便功能障碍,余患儿无大小便功能障碍及远期并发症发生。大便失禁者术后肛门功能评分（7.75分）明显高于术前（4.20分）,差异有统计学意义（t＝－8.631,P〈0.01）。结论 首次手术合理的手术方案、术中精细操作可以减少术后并发症,降低再手术的发生率。直肠脱垂和巨直肠是肛门闭锁术后再手术的主原因;再次手术根据具体情况综合评估制定合理的手术方案可获得良好疗效。     

Mucosal plication in the treatment of partial rectal prolapse

A technique used for the treatment of 34 patients with partial rectal prolapse [20 children (mean age 4.2 ± 1.4 years), 10 women, and 4 men (mean age 44.6 years)] is presented. The prolapsed mucosa protruded outside the anus in 26 patients and was inside the rectal neck in 8. Mucosal plication was performed; the prolapsed mucosa was reefed by multiple vertical pursestring sutures. Associated hemorrhoids and anal fissures were also corrected. The patients were followed up for a mean of 31.6 months. No straining at stool or recurrence of the mucosal prolapse occurred. The technique is simple, cost-effective, had no complications, and was performed on an outpatient basis.     

Ⅰ期经肛门巨结肠根治术15例报告

目的 报告一种新型I期肛门巨结肠根治术及期手术效果。方法 15例经组织学检查诊断为直肠乙状结肠型巨结肠患儿均行I期经肛门巨结肠根治术,方法为在直肠后壁齿状线上1cm、前壁齿状线上2－3cm切开直肠粘膜,向近端游离达腹腔水平后,切除腹膜外直肠肌鞘至肛提肌水平,残留肌鞘后壁“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 平均手术时间145min(95-250min）,平均出血45ml。无术中和术后并发症。随访1－4个月所有患儿排便2－6次／d,无污粪。结论 I期经肛门巨结肠根治术安全有效,远期效果有待随访。     

Outcome of submucosal injection of different sclerosing materials for rectal prolapse in children

Parasitic infestations, mainly enterobiasis and amoebiasis, and poor toilet training practices are commonly associated with rectal prolapse in developing countries. Injection sclerotherapy is one of the commonly used modalities for treating partial rectal prolapse in children. Various materials are available for such injection, but each has its advantages and complications. Comparing different materials used in the treatment of such pathology form the basis of this study trying to define the best material with the least complications. Data records of 130 children with partial rectal prolapse referred to the Department of Pediatric Surgery at Al Galaa Teaching Hospital, Cairo, over a 3-year period were analyzed. Their ages ranged from 6 months to 12 years (mean 6.14 years ±3.4). Forty-five patients (35%) responded to conservative treatment, and 85 patients (65%) required injection sclerotherapy and were divided into three groups: Group 1 (35 patients) was injected with 98% ethyl alcohol, group 2 (22 patients) was injected with phenol in almond oil 5%, and group 3 (28 patients) was injected with Deflux (Q-Med, Uppsala, Sweden). The follow-up period ranged from 2 months to 3 years; clinical data and all complications were recorded. Submucosal injection of the three sclerosing materials showed no mortality in this series, but in group 1, seven had recurrence on short-term follow-up that required reinjection, and long-term follow-up in this group showed a recurrence rate of 11% (four patients), plus two patients had mucosal sloughing and one girl developed a rectovaginal fistula. Group 2 showed abscess formation and mucosal sloughing in four patients (18%), and two developed perianal fistula. Group 3 showed immediate postoperative prolapse in two cases that ameliorated spontaneously. No patients had mucosal ulceration or abscess formation, and long-term follow-up showed no recurrence. Deflux had the lowest complication rate with no recurrence on long-term follow-up. Phenol in almond oil 5% injection should not be used for treating such conditions because of its high complication rate. Alcohol is commercially cheap and available and should be considered an alternative for Deflux.     

Abdominal posterior rectopexy with an omental pedicle for intractable rectal prolapse: a modified technique

Introduction  Rectal prolapse is a relatively common paediatric surgical condition. It has a number of benign aetiologies. Management is usually centred on regulating bowel habits. Surgery is considered after the failure of medical treatment. Numerous surgical techniques have been described with a spectrum of results. Materials and methods  We adopted a limited abdominal approach to achieve a posterior rectopexy using an omental pedicle in intractable cases. This technique has not been performed in children previously. Results  From 2005 to 2008 we have applied this technique on five patients with recurrent rectal prolapse which had failed to respond to medical treatment, injection sclerotherapy or perianal cercalage. One patient had solitary rectal ulcer syndrome, and was initially treated with a defunctioning colostomy, had a concomitant sigmoidectomy performed at the time of rectopexy. None of the patients had cystic fibrosis. There were three females and two males, with a mean age of 9.6 years (4.7–14.0). No operative complications were encountered. The mean hospital stay was 5.4 days (3–8). None of the patients experienced recurrence at a mean of 2.1 years (0.2–2.8) follow up. The cosmetic result was regarded as satisfactory by all patients. Conclusion  This early experience with abdominal posterior rectopexy using an omental pedicle graft is encouraging. This technique does not involve the use of synthetic material and hence the risk of infection is low.     

Ⅰ期改良Pe(n)a术治疗新生儿中高位先天性肛门直肠畸形

目的 探讨Ⅰ期改良Pe(n)a术治疗新生儿中高位先天性肛门直肠畸形的临床可行性及有效性.方法对48例先天性肛门直肠畸形的新生儿行Ⅰ期Pe(n)a术,其中31例进行2个月至4年4个月随访,对临床及随访资料进行回顾性分析.结果术后1例因肺部感染加重出现呼吸循环衰竭死亡,2例切口部分裂开,余恢复良好.31例坚持随访2个月至4年4个月,3例便秘,3例稀便时污粪,1例用力时污粪,2例直肠黏膜脱垂,1例切口感染,1例肛门狭窄(未坚持扩肛所致).无完全大便失禁、瘘管复发、尿潴留等并发症出现.17例中高位肛门直肠畸形术后行肛门直肠测压检查,有3例存在RAIR.结论Ⅰ期Pe(n)a术治疗先天性肛门直肠畸形,术后肛门功能良好,早中期疗效满意,Ⅰ期Pe(n)a术是一种创伤小、花费少、美观、简洁的手术方式.

Abstract：

Objective The aim of this study was to examine the feasibility, safety, cost- effectiveness , and medium-term outcome of one-stage repair of intermediate and high imperforate anus in the newborn. Methods This is a retrospective review of forty eight consecutive newborns who underwent one-stage anorectoplasty during the newborn period at the children's hospital of Chongqing medical University between January 2006 and March 2010. Thirty one of 48 patients were followed-up for 2 months to 4 years 4 months, followed-up data on the retrospective analysis. Results Forty-five patients had excellent results. One case died of respiratory and circulatory failure, the other two suffered from part incision dehiscence. Twelve of Thirty-one of the 48 cases has been followed-up for 2 months to 4 years and 6 months. No fecal incontinence,fistula recurrence,urinary retention has been observed. 3 cases has had constipation, 4 patients has soiled his diapers between bowel movements, 2 cases has had rectal mucosa prolapse, 1 patient has had wound infection, 1 patient has had stricture of anus without dilating of the anus. 17 cases underwent Anorectal manometry,only 4 exist RAIR. Conclusions Complete 1-stage repair using the Pe(n)a to treat high-type and intermediate-type anorectal malformations can be offered the same results as the traditional Pe(n)a. Also.it is safe and feasible.     

Ⅰ期改良Pe(n)a术治疗新生儿中高位先天性肛门直肠畸形

目的 探讨Ⅰ期改良Pe(n)a术治疗新生儿中高位先天性肛门直肠畸形的临床可行性及有效性.方法对48例先天性肛门直肠畸形的新生儿行Ⅰ期Pe(n)a术,其中31例进行2个月至4年4个月随访,对临床及随访资料进行回顾性分析.结果术后1例因肺部感染加重出现呼吸循环衰竭死亡,2例切口部分裂开,余恢复良好.31例坚持随访2个月至4年4个月,3例便秘,3例稀便时污粪,1例用力时污粪,2例直肠黏膜脱垂,1例切口感染,1例肛门狭窄(未坚持扩肛所致).无完全大便失禁、瘘管复发、尿潴留等并发症出现.17例中高位肛门直肠畸形术后行肛门直肠测压检查,有3例存在RAIR.结论Ⅰ期Pe(n)a术治疗先天性肛门直肠畸形,术后肛门功能良好,早中期疗效满意,Ⅰ期Pe(n)a术是一种创伤小、花费少、美观、简洁的手术方式.     

Dynamic defecography in the diagnosis of paediatric rectal prolapse and related disorders

Background and aim

Paediatric rectal prolapse (RP) is rarely a diagnostic problem and resolves often spontaneously. We studied whether the assessment of recurrent RP (RP), postoperative relapsed RP (RRP) or anorectal discomfort without RP (ARD) benefits from dynamic defecography (DD) and describe DD findings in relation with outcome.

Patients and methods

Fifteen patients (7 males), median age of 10 (range 3.7–15) years, underwent 19 DD with a synchronic small bowel contrast study. Indications for DD were RP (n = 11), RD (n = 3) and RRP (n = 1). Three patients had solitary rectal ulcer and one juvenile rectal polyps (n = 1). Three patients underwent a total of four postoperative DD because of suspected relapse.

Results

In 11 patients with a clinically diagnosed prolapse DD displayed a simple prolapse (n = 3), prolapse with enterocele (n = 1), prolapse with small bowel interposition (n = 1), rectal intussusception with anterior rectocele (n = 1) and rectal intussusception (n = 1) and no pathology (n = 4) (37 %). In four patients with ARD DD displayed rectal prolapse originating from sigmoid intussusception (n = 1), enterocele (n = 1) and anterior rectocele (n = 1) and no pathology in one. Median follow-up was 8.1(range 3.0–44) months. Ten patients underwent surgery. Three patients with RP underwent simple laparoscopic rectopexy, five with RP or RD with enterocele or anterior rectocele had rectopexy with anterior peritoneoplasty and two (RP n = 1, RRP n = 1) with sigmoid intussusception had sigmoid resection with rectopexy. Two symptomatic patients (RP, negative DD) are scheduled for rectopexy. Three patients PPRP (n = 2) RD (n = 1) had spontaneous cure. Postoperative DD confirmed relapsed RP in one patient.

Conclusion

In patients, RP and associated disorders’ DD can disclose significant pathology (enterocele, rectocele or sigmoid intussusception) and thereby guide surgical treatment, and should be included in the pre-treatment assessment.     

结肠次全切除术治疗巨结肠同源病23例

目的探讨小儿巨结肠同源病(HAD)的诊断和治疗方法。方法回顾性分析23例巨结肠同源病的病例资料,男8例,女15例,年龄5个月～16岁,其中5个月～3岁4例,3～16岁19例。患儿均以便秘、腹胀为主诉,术前常规行钡灌肠、直肠肛管测压检查。其中11例行直肠粘膜活检术;5例因肠梗阻行结肠造瘘术;3例为先天性巨结肠术后复发便秘。结果全部病例均行腹会阴Soave法结肠次全切除术。23例中,钡剂灌肠均未见明显狭窄段、移行段,24h延迟拍片提示钡剂滞留;部分病例有结肠扩张和结肠冗长表现;直肠肛管测压均有抑制反射,11例直肠粘膜活检AchE阴性。23例术后病理诊断与术前诊断一致。术后均有不同程度腹泻,1例出现伤口裂开,2例直肠粘膜脱垂,2例粘连性肠梗阻;无吻合口瘘、肌鞘感染等并发症。结论腹会阴Soave法结肠次全切除术是治疗HAD较为彻底的术式。     

Three-flap anoplasty for imperforate anus: results for primary procedure or for redoes.

Three-flap anoplasty was first described in 1987 by Yazbeck for the treatment of rectal prolapse after pull-through operations for imperforate anus, and in 1992 in a case of anterior perineal approach. It is intended to reproduce the normal anatomy of a sensitive anal canal. The purpose of this study is to evaluate 14 children (9 boys and 5 girls) operated for imperforate anus. METHOD: Eleven children had an intermediate or high imperforate anus and 3 had a low imperforate anus. Nine were operated for the first time with a three-flap anoplasty (GrA), and 5 were reoperated with this technique because of fecal incontinence and/or rectal prolapse (GrB). Seven patients had associated malformations: one Hirschsprung's disease, one cloacal defect with renal insufficiency, three complex caudal malformations with tethered cord, one Down syndrome, and two psychological and psychomotor troubles. The patients (average age = 6 years) have been evaluated every year since 1997, with a questionnaire based on a clinical score validated with 30 healthy children, used as a control group. Ten anal manometries were carried out. RESULTS: In 1998, the GrA score was 16.1 (control = 22.5) and the GrB score was 11.5 (p = 0.25). In 1999, GrA and GrB score were approximately the same. The score of those without associated anomalies was 19.6 whereas the score of the children with other malformations or anomalies was 10 (p = 0.02). Anal manometry is almost normal in patients with low or intermediate imperforate anus (rectoanal relaxation reflex for 10 cm H2O, and basal resting pressure more than 40 cm H2O). Even though anal manometry is subnormal in patients with Down syndrome or psychomotor troubles, the clinical score remains low (score = 10). In cases of complex caudal malformations or high imperforate anus, the results of anal manometry and clinical score are bad (score 9.7). CONCLUSION: The three-flap anoplasty can be carried out in newborns without colostomy and often represents the only possible surgical approach to avoid a laparotomy. This plasty, proposed secondarily to correct a defect of continence, can be performed without colostomy, with satisfactory results.