【摘要】：目的:探討經(jīng)肛門逐層梯度切除直腸肌鞘治療嬰幼兒先天性巨結(jié)腸的療效。方法:回顧性分析遵義醫(yī)學院附屬醫(yī)院小兒普胸泌外科2010年1月~2016年12月明確診斷并行逐層梯度切除直腸肌鞘的改良Soave術(shù)治療嬰幼兒巨結(jié)腸共77例,年齡2天-3歲,其中常見型45例,長段型24例,短段型3例,全結(jié)腸型5例,由于短段型和全結(jié)腸型病例數(shù)較少未納入研究范疇。隨訪69例,死亡2例(均于家中因腹脹、高熱死亡,考慮小腸結(jié)腸炎),5例失訪,隨訪資料完整有62例,男患46例,女患16例(男:女=2.9:1),手術(shù)年齡17天~3歲,一期根治術(shù)48例,普通型39例,長段型9例,其中腹腔鏡輔助35例,單純經(jīng)肛手術(shù)8例,腹會陰術(shù)5例;新生兒期造瘺二期根治14例,二期根治手術(shù)在造瘺術(shù)后6月-9月,普通型1例,長段型13例,其中腹腔鏡輔助12例,腹會陰術(shù)2例。隨訪時間1月-6年,根據(jù)病變范圍(普通型和長段型)和隨訪時間進行分組(A組:術(shù)后1-6月,B組:術(shù)后6月-2年,C組:術(shù)后2年-6年);隨訪內(nèi)容:(1)術(shù)后并發(fā)癥(肛周皮炎、腸梗阻、小腸結(jié)腸炎、吻合口狹窄、污糞、大便失禁、便秘復(fù)發(fā));(2)排便功能評估:主觀指標應(yīng)用Heikkinen評分,客觀指標采用直腸肛門測壓以及鋇灌腸檢查。結(jié)果:62例患兒中發(fā)生術(shù)后并發(fā)癥20例(肛周皮炎13例,腸梗阻3例,小腸結(jié)腸炎12例,吻合口狹窄4例,污糞11例,大便失禁3例,便秘復(fù)發(fā)6例),發(fā)生率為32.3%,其中普通型8例,長段型12例,兩組比較有統(tǒng)計學差異(P0.05);術(shù)后排便功能優(yōu)良率:術(shù)后1-6月普通型80%,長段型59.1%,術(shù)后6月-2年普通型89.7%,長段型68.8%,術(shù)后2年-6年普通型94.7%,長段型81.3%,三個時間段普通型和長段型比較,P0.05,均有統(tǒng)計學意義;三組患兒排便功能總的優(yōu)良率:A組71.0%,B組83.6%,C組90.7%,A組與B組、C組比較均有統(tǒng)計學意義(P0.05)。術(shù)后6月行肛門直腸測壓檢查46例,普通型32例,長段型14例,RAIR恢復(fù)19例,其中普通型14例,長段型5例,兩組比較無統(tǒng)計學意義(P0.05);普通型肛管靜息壓較長段型高,兩組比較有差異(P0.05)。術(shù)后6月復(fù)查鋇劑灌腸50例,普通型33例,長段型17例,結(jié)果顯示:拖下結(jié)腸形態(tài)正常,未見明顯狹窄段和擴張段,24h復(fù)查鋇劑排空26例(普通型19例,長段型7例),未排空24例(普通型14例,長段型10例)。結(jié)論:1.經(jīng)肛門逐層梯度切除直腸肌鞘的改良Soave術(shù)治療嬰幼兒先天性巨結(jié)腸可獲得較好的排便功能;2.普通型巨結(jié)腸術(shù)后排便功能優(yōu)良率明顯優(yōu)于長段型巨結(jié)腸,病變范圍越長,術(shù)后排便功能恢復(fù)越慢,長段型巨結(jié)腸患兒隨著術(shù)后時間延長絕大多數(shù)可獲得較好的效果。
[Abstract]:Objective: to investigate the effect of transanal gradient resection of rectal muscle sheath in the treatment of congenital Hirschsprung's disease (Hirschsprung's disease) in infants. Methods: a retrospective analysis of 77 cases of Hirschsprung's disease in infants, aged 2 days, was performed in 77 cases of Hirschsprung's disease (n = 77, age 2 days), who were treated with modified Soave procedure combined with graded resection of rectum muscle sheath from January 2010 to December 2016 in the Department of General Thoracic surgery in affiliated Hospital of Zunyi Medical College. Among them, there were 45 cases of common type, 24 cases of long segment type, 3 cases of short segment type and 5 cases of total colonic type. 69 cases were followed up, 2 cases died (all died of abdominal distension, high fever, considering enterocolitis) in 5 cases. The follow-up data were complete in 62 cases, 46 males and 16 females (male: female 2.9: 1). The age of operation was 17 days and 3 years old, and 48 patients underwent one stage radical operation. There were 39 cases of common type, 9 cases of long segment type, 35 cases of laparoscope assisted operation, 8 cases of simple transanal operation, 5 cases of abdominal perineum operation, 14 cases of second stage radical operation of neonatal fistula, 1 case of common type of secondary radical operation from 6 months to 9 months after operation. There were 13 cases of long segment type, of which 12 cases were laparoscopically assisted, 2 cases were abdominal perineum operation. The patients were followed up for 1 month to 6 years, according to the range of lesions (common type and long segment type) and follow-up time (group A: 1-6 months after operation: group B: 6 months to 2 years after operation: group C: 2 years to 6 years after operation), and follow up: (1) postoperative complications (perianal dermatitis, 2 years and 6 years after operation), (1) postoperative complications (perianal dermatitis), Bowel obstruction, enterocolitis, anastomotic stricture, feces, fecal incontinence, constipation recurrence (); (_ 2) were evaluated: Heikkinen score was used as subjective index, rectal and anal manometry and barium enema were used as objective index. Results postoperative complications occurred in 20 cases (13 cases of perianal dermatitis, 3 cases of intestinal obstruction, 12 cases of enterocolitis, 4 cases of anastomotic stenosis, 11 cases of feces, 3 cases of fecal incontinence). The incidence of constipation was 32.3%, including 8 cases of common type, 12 cases of long segment type, 6 cases of constipation recurrence. There was significant difference between the two groups (P0.05), the excellent and good rate of postoperative defecation function: normal type 80%, long segment 59.1%, common type 89.778, long segment 68.8%, common type 94.7 7, long segment 81.3%, common type 81.3% after operation 1 to 6 months after operation. The comparison of long segment type (P0.05) was statistically significant. The total excellent and good rate of defecation function in group A was 71.0% and 83.6% in group B was significantly higher than that in group A (P 0.05). Six months after operation, 46 cases of anorectal manometry, 32 cases of common type, 19 cases of long segment type, 14 cases of common type, 5 cases of long segment type, had no significant difference between the two groups (P0.05), the rest pressure of common anal canal was higher than that of long segment type. There was a difference between the two groups (P0.05). Six months after operation, 50 cases of barium enema, 33 cases of common type and 17 cases of long segment type were reexamined. The results showed that the shape of dragging down colon was normal, 26 cases of barium emptying were found in 24 hours without obvious stenosis and dilated segment (19 cases of common type). There were 7 cases of long segment type and 24 cases of non-emptying (14 cases of common type and 10 cases of long segment type). Conclusion 1. The improved Soave procedure for the treatment of congenital Hirschsprung's disease can obtain better defecation function in the treatment of infants with Hirschsprung's disease (Hirschsprung's disease). The excellent and good rate of defecation function in general Hirschsprung's colon was obviously better than that in long Hirschsprung's colon. The longer the lesion range, the slower the postoperative defecation function was recovered. Most of the children with long Hirschsprung's colon could get better results with the extension of postoperative time.
【學位授予單位】：遵義醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R726.5

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