本文關(guān)鍵詞：先天性巨結(jié)腸根治術(shù)后再次手術(shù)的原因分析及處理策略　出處：《廣西醫(yī)科大學(xué)》2016年碩士論文　論文類型：學(xué)位論文

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【摘要】：目的：通過對先天性巨結(jié)腸根治術(shù)后再次手術(shù)的原因進行分析,探討其處理策略,以提高手術(shù)療效。方法：回顧性分析廣西醫(yī)科大學(xué)第一附屬醫(yī)院小兒外科2005年1月至2015年10月期間我院收治的先天性巨結(jié)腸病例術(shù)后因各種原因再次手術(shù)病例共60例,其中首次在我院行巨結(jié)腸根治術(shù)有42例(42/416,10.1%),另外18例由外院轉(zhuǎn)入。本組男性56例,女性4例,首次手術(shù)年齡最小為1月,最大為12歲,其中1歲以下26例,1～3歲19例,3歲以上15例,平均年齡28.6個月,中位年齡12個月。本組病例行巨結(jié)腸根治術(shù)后再次經(jīng)歷1次手術(shù)有34例,2次手術(shù)有23例,3次及3次以上手術(shù)3例。統(tǒng)計并分析再次手術(shù)病例的原因,結(jié)合臨床分型、首次根治術(shù)式、再次手術(shù)方式的選擇、再次手術(shù)與既往手術(shù)病理結(jié)果等相關(guān)資料,進行統(tǒng)計學(xué)分析。結(jié)果：首次手術(shù)年齡與術(shù)后便秘復(fù)發(fā)關(guān)系無統(tǒng)計學(xué)意義(P0.05),首次手術(shù)年齡與術(shù)后吻合口漏關(guān)系有統(tǒng)計學(xué)意義(P0.05),年齡超過1歲患兒,術(shù)后發(fā)生吻合口漏率較年齡小于1歲患兒高。術(shù)前巨結(jié)腸臨床分型：短段型4例,常見型38例,長段型10例,全結(jié)腸型3例,結(jié)果顯示巨結(jié)腸術(shù)前臨床分型與再次手術(shù)關(guān)系無統(tǒng)計學(xué)意義(P0.05)。既往手術(shù)方式：經(jīng)肛門改良Swenson術(shù)32例,再次手術(shù)例數(shù)2例；Duhamel術(shù)43例,再次手術(shù)例數(shù)2例；改良Rehbein術(shù)50例,再次手術(shù)例數(shù)7例；經(jīng)肛門改良Soave術(shù)282例(單純肛門拖出74例,開腹輔助166例,腔鏡輔助42例),再次手術(shù)例數(shù)40例。9例病人外院轉(zhuǎn)入,首次根治手術(shù)方式不詳或不能確定,結(jié)果顯示首次巨結(jié)腸根治術(shù)與再次手術(shù)關(guān)系無統(tǒng)計學(xué)差異(P0.05)。再次手術(shù)的原因有：術(shù)后便秘復(fù)發(fā)28例(46.7%),其中誤診類緣病使手術(shù)中切除腸管范圍不足5例,病變腸管切除不全21例,吻合口狹窄及內(nèi)括約肌痙攣2例；吻合口漏20例(33.3%),其中有2例術(shù)后肛門吻合口回縮(3.3%)；術(shù)后粘連性腸梗阻10例(16.7%),其中有1例吻合口腸扭轉(zhuǎn)；術(shù)后切口愈合不良或裂開4例(6.7%)；術(shù)后盆腔膿腫2例(3.3%)；術(shù)后出血1例(1.7%)；副損傷性瘺3例(5%)：直腸尿道瘺1例(1.7%)、直腸陰道瘺1例(1.7%)、肛瘺1例(1.7%),其中有8例病人同時合并有2種或2種以上并發(fā)癥。28例術(shù)后便秘復(fù)發(fā)病例中,再次手術(shù)病理結(jié)果與首次病理結(jié)果相符有21例,有5例病例首次診斷巨結(jié)腸,再次手術(shù)術(shù)后病例診斷巨結(jié)腸類緣病,手術(shù)范圍切除不恰當有2例,術(shù)中切除了擴張段腸管,狹窄段未做切除。獲得隨訪例數(shù)48例(80%),失訪例數(shù)11例(18.3%),死亡1例(1.6%)。在訪病人中：41例病人均能自主排便,排便控制良好,大便次數(shù)1-3次/天,大便成形,偶有稀便,生長發(fā)育與同齡兒童無明顯差異；4例病人有少量肛周污糞,不影響日常生活；3例近期出院的病人間斷發(fā)生小腸結(jié)腸炎。結(jié)論：先天性巨結(jié)腸根治術(shù)后吻合口漏與手術(shù)年齡相關(guān),年齡越大,術(shù)后吻合口漏發(fā)生率會越高,其臨床分型、首次手術(shù)方式與再次手術(shù)率無明顯相關(guān)。對于吻合口漏及副損傷性瘺等圍手術(shù)期并發(fā)癥：保守治療無效時,強調(diào)當機立斷手術(shù)探查,特別是吻合口漏,應(yīng)果斷造瘺,充分引流。便秘復(fù)發(fā)強調(diào)術(shù)前全面了解既往診療過程,充分準備,必須了解吻合口及結(jié)腸形態(tài)功能做到術(shù)前診斷證據(jù)充分,強調(diào)以術(shù)前或術(shù)中病理檢查作為手術(shù)依據(jù)。再次根治術(shù)應(yīng)在可靠的病理診斷基礎(chǔ)上實施,尤其是便秘復(fù)發(fā)及既往造瘺術(shù)后的病例。盆腔的精準解剖是完成手術(shù)的關(guān)鍵。
[Abstract]:Objective: to analyze the cause of reoperation for congenital megacolon radical operation, to explore its treatment strategies, in order to improve the curative effect. Methods: retrospective analysis of the First Affiliated Hospital of Guangxi Medical University from January 2005 to October 2015 in pediatric surgery of congenital megacolon patients admitted to our hospital due to various reasons of reoperation in 60 cases, among them for the first time in our hospital 42 cases of Hirschsprung's disease (42/416,10.1%), the other 18 cases from outside the hospital into. 56 patients were male and 4 female patients, the youngest was the first operation in January, the maximum of 12 years, under the age of 1 in 26 cases, 19 cases of 1 ~ 3 years old, 3 years old in 15 cases, the average age of 28.6 months, the median age was 12 months. The patients underwent megacolon radical operation again after 1 operations in 34 cases, 2 surgeries in 23 cases, 3 cases were 3 times and 3 times more surgery. Statistics and analysis the cause of reoperation cases, according to the clinical Bed type for the first time, radical surgery again, the choice of surgical method, reoperation and previous surgical pathologic results and other relevant information, for statistical analysis. Results: the relationship between recurrent constipation first surgery and postoperative age had no statistical significance (P0.05) for the first time, age at surgery and postoperative anastomotic leakage was statistically significant relationship (P0.05) over 1 years of age, children, anastomotic leakage rate is less than 1 years of age in children with megacolon after surgery. Preoperative clinical classification: 4 cases of short segment type, common type in 38 cases, 10 cases of long segment type, 3 cases of total colonic type, showed megacolon preoperative clinical classification and surgery again the relationship was not statistically significant (P0.05). Methods: 32 cases with previous surgery anal modified Swenson procedure, 2 cases of reoperation cases; 43 cases of Duhamel patients, 2 cases of reoperation cases; 50 cases of modified Rehbein surgery, reoperation and 7 cases; 282 cases with modified Soave operation (simple anal anal 鎷栧嚭74渚，

本文編號：1387669