直线型切割吻合器在右半结肠切除术中22例的应用体会

目的探讨直线型切割吻合器在右半结肠切除术中的应用。方法结肠癌患者行右半结肠切除术时应用直线型切割缝合器(安得55)行侧侧吻合术为治疗组;应用常规回肠-结肠端端吻合术为对照组。统计两组间患者手术时间、术中出血量、吻合口瘘、肠梗阻及吻合口狭窄例数、肠功能恢复时间、术后12d内排便次数的差异。应用Ficher's精确概率检验及t检验比较两组数据。结果治疗组的手术时间、术中出血量、术后12d内排便次数较对照组明显减少(P0.05);而术后吻合口瘘、肠梗阻、吻合口狭窄、肠功能恢复时间治疗组虽有减少但两组无显著性差别(P0.05)。结论右半结肠切除中应用直线型切割缝合器行侧侧吻合术有较好的应用价值。     

腹腔镜直肠癌前切除双吻合器吻合术103例临床分析

目的探讨腹腔镜直肠癌前切除双吻合器吻合术的安全性、可行性及临床疗效。方法回顾性分析2009年1月至2015年12月103例中低位直肠癌施行腹腔镜直肠癌前切除双吻合器吻合术资料。其中男59例,女44例,年龄32~85岁,平均61.6岁。肿瘤距肛缘7~12 cm。术前评估T1N0M026例,T2-4N1-3M077例。从腹腔镜腹部手术时间、术中出血量、淋巴结清扫数目、术后肛门排气时间、术后住院时间,术后并发症发生率、术后排便功能等评价手术质量。采用门诊检查和电话方式进行随访,随访时间至2015年4月。结果本组103例手术经过顺利均获成功,平均检出淋巴结12枚以上,行预防性横结肠和回肠造瘘术12例,3个月后还纳造口。术后3~5 d肠蠕动恢复肛门排气,术后平均11 d出院。术后病理为T_1-T_2N_0M_015例,T_2-4N_(1-3)M_082例,T_2-4N_1-3M_16例。术后随访3~50个月,平均26个月,术后发生吻合口漏3例(2.9%),2例经结肠腹部临时造口,3个月后还纳愈合,1例保守治疗,1个月后愈合;吻合口狭窄2病例(1.9%),均经扩张狭窄解除。局部肿瘤复发4例(3.8%)。结论腹腔镜中低位直肠癌前切除双吻合器吻合术,是安全可靠,符合微创原则,临床疗效满意。     

应用直肠吻合器治疗成人先天性巨结肠症16例的体会

成人先天性巨结肠症的手术治疗方法较多。我院自１９８１年１月至１９９６年１０月，对成人先天性巨结肠症非手术治疗无效、又行根治性１期切除的１６例患者，采用直肠吻合器吻合方法治疗，临床效果满意，现报告如下。临床资料一、一般资料本组共１６例，男９例，女７例，...     

腹腔镜超低位直肠癌经肛拖出式双吻合器吻合术的临床应用

目的探讨腹腔镜超低位直肠癌经肛拖出式双吻合器吻合手术在实现腹壁切口最小化中的临床价值。方法回顾性分析1年来收治的腹腔镜下经肛门拖出式双吻合器吻合手术联合放化疗治疗的4例超低位直肠癌患者的临床资料。结果 4例患者无中转开腹,手术时间平均约150min,术中出血量约50～100ml,术后肠功能恢复时间48h,术后5～7d出院,术后无肠漏、大便失禁等并发症。病理类型：高分化腺癌2例,中分化腺癌2例。切除标本远端阴性切缘≥1cm,环周经病理检查未见癌细胞侵犯,淋巴结清扫6～12枚。DukesB期2例,C期2例。4例患者随访3～12个月,无种植性肿瘤转移和局部复发。结论腹腔镜超低位直肠癌经肛拖出式双吻合器吻合术拥有创伤小、出血少、恢复快的特点。同时也尽可能地避免或减少种植性转移和腹腔感染的发生概率。     

圆形吻合器在中低位直肠癌保肛术中应用233例临床经验

目的探讨圆形吻合器在中低位直肠癌应用的安全性和临床效果。方法对233例中低位直肠癌施行圆形吻合器吻合保肛术的临床资料进行分析。结果术后随访率86.3%（201/233）,中位随访时间60.1个月。术后发生吻合口瘘11例（4.7%）均发生在术后4～12d,4例保守治疗痊愈,7例采用横结肠造口,3～4个月后还纳。吻合口狭窄6例（2.6%）多发生在术后2～6个月,经扩肛持续均解除。术后局部复发率为5.9%（12/201）,复发时间为术后2～3年内。肝转移发生率为10.4%（21/201）,多发生在术后2～3年内。中位生存时间60.1个月。术后5年生存率67.0%。结论圆形吻合器在中低位直肠癌保肛术中应用操作快捷、吻合可靠、方便安全,疗效满意。     

吻合器痔上黏膜吻合术治疗中重度痔的临床应用

我院采用国产吻合器行痔上黏膜环行吻合术（PPH）治疗中重度痔52例，现总结报告如下。     

心形吻合术治疗先天性巨结肠症

目的 评价直肠肛管纵切、心形吻合术治疗先天性巨结肠症的手术疗效。方法 对１９９１年４月至２０００年４月间应用直肠肛管纵切、心形吻合术治疗先天性巨结肠症９８例的疗效与手术并发症进行分析。结果 ９８例患者中术后均未发生盆腔、腹腔及伤口感染，无吻合口狭窄。１例出现吻合口漏经修补痊愈。全部病例随访５个月至８年：便秘复发３例，经扩肛６个月后痊愈；偶有污粪１例；小肠结肠炎６例；术后并发症的总发生率为１１．２％。结论 直肠肛管纵切、心形吻合术治疗先天性巨结肠症，可提高手术效果并减少并发症。     

一期次全或全结肠切除吻合术治疗左半结肠癌急性梗阻19例报告

回顾性总结采取一期次全或全结肠切除吻合术治疗左半结肠癌并急性梗阻19例,其中结肠脾曲癌4例和降结肠癌5例行一期次全结肠切除回结肠吻合,乙状结肠癌10例行一期全结肠切除回直肠吻合,术后发生切口感染3例,无手术死亡,无吻合口漏,无严重腹泻,随访19例,除4例死于癌转移,2例死于内科疾病外,其余13例健在,认为只要病情允许,该术式是治疗左半结肠癌并急性梗阻,尤其是结肠明显扩张的有效措施。     

应用弯曲端端吻合器行直肠癌前切除吻合术临床疗效观察

利用弯曲端端吻合器（ＰＣＥＥＡ）行胃肠道吻合术在很多国家已较广泛地应用于临床,它对减少术后吻合口痊等并发症,以及使更多的低位直肠癌患者避免腹部结肠造口提供了帮助。作者自１９９４年３月起,对２０例直肠癌患者利用ＰＣＥＥＡ行直肠癌前切除吻合术。与对照组进行比较,表明此法可明显降低吻合口瘘发生率,缩短手术时间,减少术后平均住院时间。并复习有关文献对临床使用体会和并发症预防进行初步探讨。     

国产吻合器在156例进展期胃癌手术中的应用体会

目的探讨国产吻（缝）合器在进展期胃癌手术中的应用价值。方法总结2007年7月至2010年6月间收治的237例进展期胃癌手术患者资料,应用国产吻（缝）合器吻合156例患者为吻合器组,传统手工方法吻合81例患者为手工组,对其TNM分期、近期并发症的发生、围手术期的处理进行分析。经统计学分析两组患者具有可比性。结果吻合器组平均手术时间明显少于手工吻合组[（115±10.2）minvs.（195±24.6）min],差异有统计学意义,P〈0.05。吻合器组总并发症发生率为1.9%（3/156）,手工组总并发症发生率为6.2%（5/81）,吻合器组明显低于手工组,差异有统计学意义,P〈0.05。结论国产吻（缝）合器在进展期胃癌手术比手工手术吻合的时间短,并发症少、应用方便快捷、经济省时、安全可靠。     

经肛门I期先天性巨结肠根治术临床观察

目的 探讨经肛门I期先天性巨结肠根治术的治疗方法和临床效果。方法 对12例已证实为短段型或普通型先天性巨结肠患儿行经肛门I期先天性巨结肠根治术。年龄3月至5岁，平均1．8岁。结果 全组手术顺利，无死亡。术后1周左右出院，随访半年，术后有1例出现轻度排便困难，经保守治疗痊愈。有3例出现不同程度的污粪，3-6月后痊愈。无严重并发症，生长发育良好。结论 经肛门I期巨结肠根治术适用于患短段型或普通型先天性巨结肠症的婴幼儿，手术创伤小，不需开腹，合并症少、手术时间短，效果满意。     

New operative technique for Hirschsprung's disease

A new technique for definitive surgery in Hirschsprung's disease is described. After transection of the rectum at 2 cm above the peritoneal reflection, the distal rectum is incised laterally on both sides in a longitudinal direction half way to the anus. The mucosal lining of the anterior rectum is partially removed. The posterior portion of the rectum is divided into two flaps by sagittal incision up to the mucocutaneous junction of the anus, which are then reflected and everted through the anus. The proximal colon is then pulled through, exteriorizing 5 cm of ganglionic colon. The exteriorized colon is resected two weeks later. Nine cases were operated upon by this technique. The postoperative results were satisfactory in all cases.     

直肠拖出双吻合器保肛术治疗超低位直肠癌

目的 评价直肠拖出采用双吻合器技术实施保肛超低位直肠癌切除手术的疗效。方法1997年12月王2005年1月对38例超低位直肠癌，采用直肠拖出、双吻合器技术行保肛的手术切除。结果38例病人均成功地保留了有大便控制功能的肛门，术后发生吻合口瘘1例，随访中有2例局部复发。结论直肠拖出双吻合器保肛术是安全可行的。     

Contemporary practice patterns in the surgical management of Hirschsprung's disease

Background

Many options exist in the surgical management of Hirschsprung's disease (HD). To gain insight into contemporary management, we queried pediatric surgeons listed in the American Pediatric Surgical Association Directory on their management for the typical baby with HD.

Methods

Surveys were sent electronically to the surgeons concerning a typical newborn diagnosed with HD. Questions included the preferred approach, number of stages, anastomotic technique, length of muscular rectal cuff, point of initiation of the anorectal dissection, and length of colonic resection. Surgeons performing laparoscopy were asked about how the colonic biopsy was performed. Other questions included the type of leveling colostomy, level of residents, and criteria for performing a primary transanal pull-through. The maximum margin of error was calculated using a 95% confidence interval based on the response percentages for discrete variables.

Results

Surveys were sent to 719 surgeons with 270 responses. A minimally invasive approach is currently used by 80%, of which 42.3% favor laparoscopy and 37.7% prefer transanal dissection only. Only 5.4% of respondents prefer the Duhamel technique. A 1-stage approach is used by 85.6%. An average muscular cuff length of 2.4 cm (range, 0.5-6 cm) is reported. A divided muscular cuff is reported by 55%. On average, the anal anastomosis is 0.73 cm (range, 0-4.5 cm) above the top of the anal columns and 3.0 cm (0-12.5 cm) above the biopsy site on the ganglionic colon. Of the respondents using laparoscopy, 80.2% report using an intracorporeal colonic biopsy technique. Participation in a training program, either fellows and/or residents, is reported by 84.8% of respondents. The most common reason given for not performing a primary transanal pull-through is long segment disease (45.6%). Margin of error was no greater than 6% for any of the responses.

Conclusions

A minimally invasive approach with a 1-stage operation has become the most common strategy for the surgical management of the typical baby with HD. Opinions vary about the amount of colonic resection, length of the rectal cuff, and site of initiation of the anorectal dissection, and these represent potential points for future studies.     

Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children

Background

The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children.

Methods

Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children.

Results

The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders (P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3° ± 15.1° vs 84.7° ± 8.3° vs 79.0° ± 11.6°, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6° ± 15.9° vs 111.0° ± 14.3°, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 ± 8.2 vs >188 hours, P < .01; 6.3 ± 4.1 vs >60 hours, P < .01; 11.8 ± 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 ± 5.6 vs 28.1 ± 10.1 hours, P < .05; 12.2 ± 6.7 vs 9.8 ± 4.0 hours, P < .05).

Conclusions

The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the “neorectosigmoid”, an open and fixed anorectal angle, and ischemia of the pull-through segment.     

Duhamel手术治疗成人先天性巨结肠

目的　了解Ｄｕｈａｍｅｌ 手术治疗成人先天性巨结肠的效果,探讨其术后结直肠间隔的再手术处理。方法　回顾性分析５ 例经病理证实为成人先天性巨结肠患者行Ｄｕｈａｍｅｌ 手术治疗和长期随诊的结果。结果　３例排便情况良好;２ 例因结直肠间隔过长引起排便困难,应用侧侧吻合器（ＧＩＡｏｒ ＴＬＣ） 行结直肠间隔切开术,再手术后其排便功能良好。结论　Ｄｕｈａｍｅｌ 手术是治疗成人先天性巨结肠的有效方法;术后出现排便困难的原因之一是结直肠间隔过长,可应用侧侧吻合器（ＧＩＡｏｒ ＴＬＣ） 行结直肠间隔切开术处理。     

The versatility of the umbilical incision in the management of Hirschsprung's disease

Background/Purpose

The aim of this report is to describe how the umbilical incision provides a quick and safe alternative to laparoscopy or other abdominal incisions in the management of Hirschsprung's disease (HD).

Methods

An analysis of 24 patients with HD, who were treated using an umbilical incision as part of their operative management between 1999 and 2003, was performed.

Results

There were 18 boys and 6 girls (mean age at diagnosis: 16.5 ± 20.9 days). Twenty-one had rectosigmoid HD, and 3 had total colonic HD. Eighteen patients received a 1-stage transanal pull-through with transumbilical colonic biopsies at a mean age of 33.9 ± 25.3 days, and a mean weight of 3.8 ± 1.0 kg. Three patients with rectosigmoid disease had more complicated HD: 2 had a colostomy (1 enterocolitis, 1 extensive colonic dilatation), and 1 had an ileostomy (for perforated cecum). All subsequently underwent transanal pull-through. Three patients with total colonic HD had an ileostomy. All stomas were situated at the umbilicus. One of these patients subsequently underwent a Duhamel procedure via the umbilicus; 1 is still waiting; and 1 died of sepsis. Complications in this cohort included a seromuscular tear of the distal sigmoid at the level of the umbilical incision (1), infection at the umbilical incision requiring antibiotics (2), obstruction (1) and death (1 sepsis, 1 from Ondine's curse). The median time to start full feeds was 24 hours. For postoperative analgesia, 13 patients required acetaminophen only, and 9 patients received low-dose morphine. After a mean follow-up of 7.3 ± 9.7 months, there has been an excellent functional and cosmetic result in the 22 survivors.

Conclusions

The umbilical incision has all the benefits of a minimal access approach, but is less expensive and requires no specialized equipment or skill. The umbilical incision is an excellent, safe, and versatile alternative to laparoscopy for the treatment of patients with the full spectrum of HD.     

An improved staining technique for acetylcholinesterase activity using rubeanic acid in the diagnosis of Hirschsprung's disease

An improved staining technique for acetylcholinesterase (AChE) activity using rubeanic acid was used to make a clinical diagnosis in 54 children with constipation. Nineteen were thus confirmed to have Hirschsprung's disease. False positive or negative reactions were nil. The sites of AChE activities were in the form of black deposits and the contrast was sharp. This approach should find a wide application for the diagnosis of Hirschsprung's disease.     

Gastroschisis with Hirschsprung's disease: a therapeutic dilemma

The authors report a case of a neonate with gastroschisis, which, after repair, was further complicated by the diagnosis of Hirschsprung's disease. The authors discuss the diagnostic and management dilemmas posed by the coexistence of these two conditions for the clinician.     

一种新的手术方式——单纯经肛门手术治疗先天性巨结肠

目的 观察一期经肛门拖出术治疗先天性巨结肠患儿的经过及近期疗效。方法 6例年龄分别为15天、4、5、6、15个月及2岁的小儿接受了单纯经肛门治疗巨结肠的手术。诊断由术前钡灌肠及术中、术后的病理检查确定。2例并巨大粪石,麻醉下夹碎,温盐水灌洗清除。直肠粘膜自齿线上0.5cm起分离至腹膜返折处,移行段及乙状结肠上段经肛门内拖出,限制拖出的血管予电凝或结扎,将正常结肠与肛门齿线上粘膜吻合。结果 术后平均住院4天(2～7天),所有小儿每日有3～5次正常大便,无需药物及洗肠。结论 单纯经肛门直肠内手术的方式既安全又容易施行,而且术中对结肠系膜的游离范围最小。该法具有创伤少,术后恢复快,并发症少、住院时间短等优点,值得临床推广应用。