CAJ | 학술논문

目的对先天性巨结肠同源病的手术处理方式做探讨.方法 2008年1月至2010年12月45例巨结肠同源病行根治术,平均年龄(35.5±5)个月,其中节细胞减少症(HG)33例(有既往手术史4例,12.1％),肠神经元发育不良症(IND) 12例(有既往手术史4例,33.33％).所有患儿均在术后1、3、6及12个月进行随访,记录患儿术后排便功能并与术前结果相比较.结果 HG组33例中17例(52％)经开腹手术,16例(48％)腹腔镜辅助或经肛门拖出术.结肠切除范围:左半切除28例(84.8％),次全切除5例(15.2％);12例IND组全部经开腹手术,结肠左半切除4例(33.3％),次全切除8例(66.7％).术后随访:所有患儿便秘症状消失,无手术死亡及严重并发症发生.不同术式组中均有少数患儿持续存在污粪现象,1年期随访经肛门手术显著高于开腹手术(P＜0.05).出现术后污粪患儿施行肛管直肠测压术前肛管静息压(66.5±11.67) mmHg,术后3个月为(52.17±0.31)mmHg较术前明显下降,但至术后6个月～1年后测压为(58±5.7)mmHg,与术前相比均无显著差异.结论同源病的手术应根据不同病理类型和临床情况选择手术方式:原发性HG病变可采用直接经肛门拖出或腹腔镜辅助游离术.既往曾经肛门直肠手术或年长、晚期患儿应采取保留肛管直肠括约肌形态和功能完整性的术式.IND患儿均需行根治性次全切除术,不主张采用简单的经肛门拖出术式而应采用盆腔内的低位吻合术式.经肛门或腹腔镜辅助经肛门拖出术式组1年期随访时污粪率要高于非拖出术组,左半切或次全切方式对术后是否污粪无影响.
목적 대선천성거결장동원병적수술처리방식주탐토.방법 2008년1월지2010년12월45례거결장동원병행근치술,평균년령(35.5±5)개월,기중절세포감소증(HG)33례(유기왕수술사4례,12.1％),장신경원발육불량증(IND) 12례(유기왕수술사4례,33.33％).소유환인균재술후1、3、6급12개월진행수방,기록환인술후배편공능병여술전결과상비교.결과 HG조33례중17례(52％)경개복수술,16례(48％)복강경보조혹경항문타출술.결장절제범위:좌반절제28례(84.8％),차전절제5례(15.2％);12례IND조전부경개복수술,결장좌반절제4례(33.3％),차전절제8례(66.7％).술후수방:소유환인편비증상소실,무수술사망급엄중병발증발생.불동술식조중균유소수환인지속존재오분현상,1년기수방경항문수술현저고우개복수술(P＜0.05).출현술후오분환인시행항관직장측압술전항관정식압(66.5±11.67) mmHg,술후3개월위(52.17±0.31)mmHg교술전명현하강,단지술후6개월～1년후측압위(58±5.7)mmHg,여술전상비균무현저차이.결론 동원병적수술응근거불동병리류형화림상정황선택수술방식:원발성HG병변가채용직접경항문타출혹복강경보조유리술.기왕증경항문직장수술혹년장、만기환인응채취보류항관직장괄약기형태화공능완정성적술식.IND환인균수행근치성차전절제술,불주장채용간단적경항문타출술식이응채용분강내적저위문합술식.경항문혹복강경보조경항문타출술식조1년기수방시오분솔요고우비타출술조,좌반절혹차전절방식대술후시부오분무영향.
Objective To determine operative procedures for Hirschsprung's disease allied diseases (HAD) in children. Methods From Jun. 2008 to Dec. 2010, 45 consecutive patients with an average ages of 35.5 ± 5 months underwent radical surgery for HAD in one surgical group, including 33 hypoganglionosis (HG) and 12 intestinal neuronal dysplasia (IND). All patients have been followed up at 1, 3, 6 and 12 months after surgery. Defecation function were studied and compared with that before surgery, Results Among the 33 HG patients, 17 patients (52％) underwent open surgery, the other 16 (48％) underwent transanal or laparoscopic-assisted pull-through surgery including left colectomy on 28 (84.8％) and subtotal colectomy on 5 (15.2％). All IND patients underwent oPen surgery, and left colectomy were performed on 4(33.3％) and subtotal colectomy on 8 (66.7％). Constipation disappeared in all patients during follow-up after surgery. No death and severe complication was noted. The incidence of soiling was significantly higher in patients with transanal pull-through procedure than that patients underwent open surgery 1 year after surgery (P＜0.05). Anorectal manometry for the patients with soiling showed the parameter of manometry was decreased markedly at the 3rd month after surgery is compared with preoperative manometry(52.17 ± 0.31 )mmHg vs. (66.5 ± 11.67)mmHg. However, manometry at 6th or 12th postoperative month is(58 ± 5.7)mmHg was not different with preoperative manometry. Conclusions The choice of operative procedures for HAD should be based on different pathological types and clinical conditions. Primary HG lesions can be removed directly by a simple transanal pull-through or laparoscopic-assisted surgery. For HG patients with previous anorectal surgery or in older children, the surgical procedures of saving the anorectal sphincter morphology and function should be chosen. For IND children, radical subtotal colectomy and low level anastomosis within pelvic should be performed. It was not advocated using a simple transanal pull-through procedure for IND children. The rate of soiling in transanal pull-through group was higher than that in open surgery group 1 year after surgery. Neither left nor subtotal colectomy was associated with the incidence of postoperative soiling.