發(fā)布時間：2018-02-14 15:51

  本文關鍵詞： B型腸神經(jīng)元發(fā)育異常(IND) 腹腔鏡輔助結(jié)腸切除 巨結(jié)腸根治術 排便功能　出處：《山東大學》2017年碩士論文　論文類型：學位論文

【摘要】：背景目的:腸神經(jīng)元性發(fā)育異常(Intestinal neuronal dysplasia,IND)是以遠端腸管神經(jīng)節(jié)細胞質(zhì)量、數(shù)量異常為特征的常見消化道發(fā)育畸形,臨床表現(xiàn)酷似先天性巨結(jié)腸(HD)[1]。IND分為A型和B型,臨床以B型為主,A型罕見[2]。IND-B可先行保守治療,保守治療無效或效果欠佳的患兒需行病變腸管切除。本研究從多項手術指標及效果等方面進行比較腹腔鏡輔助結(jié)腸切除術與巨結(jié)腸根治術,以指導臨床治療方式的選擇。從而為臨床上治療IND-B提供更好參考依據(jù)。研究方法:回顧性研究自2009—2014年山東大學第二醫(yī)院小兒外科收治并獲得隨訪的81例經(jīng)術后病理確定診斷為單純IND-B型患兒,其中42例采取巨結(jié)腸根治術,39例采取腹腔鏡輔助結(jié)腸切除手術。術前均行肛門直腸測壓、鋇灌腸及24小時X線片復查。術后待患兒排氣后方可飲水,肛管保留2天,廣譜抗生素應用3天,術后3周醫(yī)師指導患兒家長開始擴肛,持續(xù)擴肛半年至吻合口平整柔軟為止。1.比較兩種術式手術時間、術中出血量、術后腸道蠕動恢復所需時間、住院時間及各種圍手術期并發(fā)癥等。2.客觀排便功能檢測:所有手術患兒術后3個月、6個月均復查肛門直腸測壓,檢測直腸靜息壓(RRP)、肛管靜息壓(ARP)及直腸肛門抑制反射(RAIR)等指標;術后6個月、1年復查鋇灌腸,檢測結(jié)直腸運動功能。3.主觀排便功能檢測:根據(jù)Reding評分標準[3],對巨結(jié)腸根治術與腹腔鏡輔助結(jié)腸切除術后不同時間排便控制功能進行評分分級。結(jié)果:1.腹腔鏡輔助結(jié)腸切除術手術時間少于巨結(jié)腸根治術(P0.01),腹腔鏡手術術中出血明顯少于巨結(jié)腸根治術(P0.05);腹腔鏡輔助結(jié)腸切除術的手術費用明顯高于巨結(jié)腸根治術(P0.01),但兩者住院總費用沒有統(tǒng)計學差異(P0.05);腹腔鏡手術腸蠕動恢復時間少于巨結(jié)腸根治術(P0.05),兩種術式留置肛管時間相比無顯著性差異(P0.05),兩組術后住院時間具有統(tǒng)計學差異(P0.05)。腹腔鏡輔助結(jié)腸切除術后2例患兒出現(xiàn)臍部感染、1例患兒出現(xiàn)吻合口部分裂開,1例患兒出現(xiàn)小腸結(jié)腸炎,經(jīng)保守抗感染治療后均獲得痊愈(12.8%);巨結(jié)腸根治術12例患兒(28.57%)出現(xiàn)并發(fā)癥,3例患兒刀口感染、3例患兒吻合口部分裂開、2例患兒小腸結(jié)腸炎經(jīng)保守治療痊愈,1例患兒吻合口瘺伴腹膜炎再次手術行結(jié)腸造瘺,4例患兒出現(xiàn)腸梗阻,2例經(jīng)理療好轉(zhuǎn),2例保守治療無效后再次手術行腸粘連松解術。2.術前兩組患兒的直腸靜息壓和肛管靜息壓均明顯高于正常,直腸順應性明顯下降,腹腔鏡輔助結(jié)腸切除術前直腸肛門抑制反射(RAIR)消失或不典型25例,巨結(jié)腸根治術前直腸肛門抑制反射(RAIR)消失或不典型例26例。術后3個月直腸靜息壓、肛管靜息壓仍高于正常但明顯低于術前(P0.05),直腸順應性無明顯改變,兩組直腸肛管抑制反射均消失;術后6個月,兩種術式患兒術后的直腸測壓均無明顯差異,直腸順應性較術前明顯變大。兩組術前鋇灌腸24小時后均有鋇劑存留,腹腔鏡輔助結(jié)腸切除術前鋇灌腸典型巨結(jié)腸表現(xiàn)10例,巨結(jié)腸根治術前典型巨結(jié)腸表現(xiàn)10例;術后6個月復查鋇灌腸示兩組患兒結(jié)直腸內(nèi)均無鋇劑存留;術后1年復查,腹腔鏡輔助結(jié)腸切除術無鋇劑存留,巨結(jié)腸根治術后2例24小時后鋇劑存留。3.術后1個月兩組均有肛周污糞,腹腔鏡輔助結(jié)腸切除術手術組Reding評分高于巨結(jié)腸根治術(P0.05);術后1～3個月兩組患兒污糞較前減輕;術后3-6個月腹腔鏡輔助結(jié)腸切除手術組7例污糞,巨結(jié)腸根治術組5例存在污糞,2例排便需開塞露輔助;術后1年,腹腔鏡輔助結(jié)腸切除手術組2例污糞,巨結(jié)腸根治術組3例污糞、2例便秘復發(fā)。結(jié)論:1.與巨結(jié)腸根治術相比,腹腔鏡輔助結(jié)腸切除術可減少手術時間及術中出血,且術后并發(fā)癥少,術后住院時間相應縮短,雖然手術費用明星提高,但總的住院費用并無明顯差異。2.IND-B不同于先天性巨結(jié)腸(HD),直腸肛門抑制反射(RAIR)消失并不能作為診斷IND-B的依據(jù)。3.腹腔鏡輔助結(jié)腸切除術后短期內(nèi)主觀和客觀排便情況優(yōu)于巨結(jié)腸根治術。
[Abstract]:Background and objective: intestinal neuronal dysplasia (Intestinal neuronal, dysplasia, IND) is the quality of the distal intestinal ganglion cells, the number of abnormal characteristics of common digestive tract malformation. The clinical manifestations mimicking congenital megacolon (HD) [1].IND is divided into A type and B type, the bed is dominated by B type, A type rare [2].IND-B may be conservative treatment, conservative treatment is invalid or poor effect of children for lesions of bowel resection. This study comparing laparoscopic assisted colectomy with Hirschsprung's disease from a number of index of operation and effect, to guide the clinical treatment options for clinical treatment of IND-B. In order to provide better reference for the research methods.: a retrospective study from 2009 to 2014 the second hospital of Shandong University from pediatric surgery and followed up 81 cases of pathologically confirmed the diagnosis of herpes type IND-B patients, including 42 cases with giant. Intestinal resection, 39 cases by laparoscopy assisted colon surgery. All patients underwent preoperative anorectal manometry, barium enema and 24 hours after operation. X-ray examination for children with exhaust before drinking, anal canal 2 days, broad-spectrum antibiotics for 3 days, 3 weeks after surgery doctors to help parents of children with anal start, continued to expand half a year to anal anastomotic smooth and soft.1. comparison of two kinds of surgical operation time, intraoperative blood loss, postoperative intestinal peristalsis recovery time, hospitalization time and perioperative complications were.2. objective defecation function detection: 3 months after operation, all patients were reexamined 6 months, anorectal manometry, detection of rectal resting pressure (RRP), anal resting pressure (ARP) and rectoanal inhibitory reflex (RAIR) and other indicators; 6 months after surgery, 1 years barium enema examination, detection of colorectal motor function.3. subjective bowel function detection: according to the Reding standard for evaluation of [3], the root of Hirschsprung's disease Treatment of surgery and laparoscopic assisted colectomy after different time of defecation control function score. Results: 1. laparoscopic assisted colectomy surgery for Hirschsprung's disease (less than P0.01), the intraoperative bleeding was less than radical macrosigmoid operation (P0.05); the operation cost of laparoscopic assisted colectomy was significantly higher than that of Hirschsprung's disease radical resection (P0.01), but the total cost of hospitalization was not statistically significant (P0.05); laparoscopic surgery recovery time of intestinal peristalsis less than Hirschsprung's disease (P0.05), two kinds of operation time retention anal compared no significant difference (P0.05), two groups of postoperative hospitalization time had statistical differences (P0.05) laparoscopic. Assisted colectomy after 2 cases of umbilical infection, 1 cases of anastomotic partial dehiscence, 1 cases of enterocolitis after conservative anti infection treatment were cured (12.8%); megacolon Radical resection in 12 cases (28.57%) had complications, 3 cases of incision infection, 3 cases of anastomotic part dehiscence, 2 cases of enterocolitis cured by conservative treatment, 1 cases of anastomotic fistula with peritonitis surgery colostomy, 4 cases of intestinal obstruction, 2 cases of physical therapy improved, 2 conservative treatment had no reoperation after underwent enterolysis before.2. two groups of children with rectal resting pressure and anal resting pressure was significantly higher than that of normal, rectal compliance decreased, laparoscopic assisted colectomy before the rectoanal inhibitory reflex (RAIR) disappeared or atypical 25 cases of Hirschsprung's disease before rectum anal inhibitory reflex (RAIR) disappeared or atypical cases in 26 cases. 3 months postoperative rectal resting pressure, anal resting pressure is still higher than normal but was significantly lower than that before operation (P0.05), rectal compliance had no obvious change, two groups of rectoanal inhibitory reflex disappeared after operation; 6 months, there were no significant difference between the two kinds of surgical postoperative patients with rectal manometry, rectal compliance significantly larger. Two groups of preoperative barium enema after 24 hours of barium retention, laparoscopic assisted colectomy before barium enema typical manifestations of 10 cases of megacolon, Hirschsprung's disease before. Megacolon manifestation in 10 cases; 6 months after the treatment in two groups of children with colorectal barium enema were not barium retention; review 1 years after surgery, laparoscopic assisted colectomy without barium retention, radical macrosigmoid operation in 2 cases after 24 hours after barium retention after.3. 1 months in two groups have crissum soiling, laparoscopy assisted colectomy surgery group Reding was higher than that of Hirschsprung's disease (P0.05); 1~3 months after surgery, two groups of children with fecal pollution decreased; 3-6 months after surgery, laparoscopic assisted colectomy group 7 cases of fecal pollution, Hirschsprung's disease group 5 cases with fecal pollution, 2 cases of bowel to glycerine With assistance; 1 years after surgery assisted laparoscopic resection of colon surgery group 2 cases of fecal pollution, Hirschsprung's disease group and 3 cases of soiling, 2 cases of recurrent constipation. Conclusion: 1. compared with radical macrosigmoid operation, laparoscopic assisted colectomy can reduce bleeding and operation time, and fewer postoperative complications. Postoperative hospitalization time shortened, while the cost of surgery but no star increase, the cost of hospitalization was significantly difference in total.2.IND-B different from Hirschsprung's disease (HD), rectoanal inhibitory reflex (RAIR) disappeared and cannot be used as a diagnosis of IND-B.3. laparoscopic colon resection in a short period of time after the subjective and objective defecation is better than that of the giant radical resection of colon.

【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R726.5

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