CAJ | 학술논문

目的报道一组既往巨结肠根治术失败而再手术的病例,对失败的原因作出探讨.方法 3年间本科单一手术组187例巨结肠根治术病例;其中既往手术失败而行二次以上手术者42例,占22.46％,既往手术次数在3～9次之间,平均3.5次.合并有心脏、泌尿、生殖等系统严重畸形以及先天性愚型者5例(11.9％).所有患儿入院时均行组化、测压及钡灌检查,对未造瘘的手术失败患儿同时行结肠传输实验.术后病理样本HE染色病检以及免疫组化染色检查.结果全部187例患儿按术后病理诊断分组:同源病(HAD)组78例,因既往手术失败再手术者22例(28.21％).节细胞减少症(HG) 46例,再手术者8例(17.39％);IND 32例,再手术14例(43.75％),失败原因均为残留病变导致复发.先天性巨结肠(HD)组109例,因既往手术失败再手术20例(15.6％),失败原因:病变段肠管残留14例;肠管扭曲、回缩、吻合口瘘等6例.结论临床所谓的巨结肠症实际上是包括无神经节细胞症(HD)、肠神经元发育不良症(IND)、神经节细胞减少症(HG)等一大类肠道神经系统病变.术前临床症状结合各种检查做出准确的诊断并准确判断肠管病变的范围十分重要.诊断及病变范围估计错误而误选手术方式并导致病变残余是手术失败的重要原因.
목적 보도일조기왕거결장근치술실패이재수술적병례,대실패적원인작출탐토.방법 3년간본과단일수술조187례거결장근치술병례;기중기왕수술실패이행이차이상수술자42례,점22.46％,기왕수술차수재3～9차지간,평균3.5차.합병유심장、비뇨、생식등계통엄중기형이급선천성우형자5례(11.9％).소유환인입원시균행조화、측압급패관검사,대미조루적수술실패환인동시행결장전수실험.술후병리양본HE염색병검이급면역조화염색검사.결과 전부187례환인안술후병리진단분조:동원병(HAD)조78례,인기왕수술실패재수술자22례(28.21％).절세포감소증(HG) 46례,재수술자8례(17.39％);IND 32례,재수술14례(43.75％),실패원인균위잔류병변도치복발.선천성거결장(HD)조109례,인기왕수술실패재수술20례(15.6％),실패원인:병변단장관잔류14례;장관뉴곡、회축、문합구루등6례.결론 림상소위적거결장증실제상시포괄무신경절세포증(HD)、장신경원발육불량증(IND)、신경절세포감소증(HG)등일대류장도신경계통병변.술전림상증상결합각충검사주출준학적진단병준학판단장관병변적범위십분중요.진단급병변범위고계착오이오선수술방식병도치병변잔여시수술실패적중요원인.
Objective To report a group of failed and reoperated megacolon radical surgical cases and discuss the causes of failure.Methods A total of 187 patients underwent megacolon radical surgery during the past 3 years in a single group.Among them,42 cases (22.46％％) were operated more than twice due to failed previous surgery.The average number of previous surgery was 3.5 (3 9) times.Five patients (11.9％) had cardiac,urinary,reproductive system abnormalities or Down's syndrome.All received anorectal manometry,acetylcholinesterase (AChE) histochemical staining of rectal suction biopsy and preoperative barium enema.Those without enterostomy underwent colon transmission test for checking colon motility.Pathological diagnosis was based on the examination of specimens with hematoxylin & eosin and immunohistochemical staining.Results All of them were grouped according to pathological diagnosis.The Hirschsprung's allied disorders (HAD) group had 78 cases.And reoperation was performed due to failed previous surgery (n=22,28.21％).This group also included 46 cases of hypoganglionosis (HG) with reoperation in 8 cases (17.39％); 32 patients of intestinal neuronal dysplasia (IND) with reoperation in 14 cases (43.75％),excessive residual colonic lesion was cause of failure in this group; Hirschsprung's disease (HD) group had 109 cases and reoperation was performed due to failed previous surgery (n=20,15.6％).Residual colonic lesion led to surgery failure (n=14) and bowel twisting,retraction and anastomotic leakage (n=6).Conclusions Clinically megacolon is composed of intestinal dysganglionosis (IDs),aganglionosis (HD),intestinal neuronal dysplasia (IND),hypoganglionosis (HG) and other enteric nervous system lesions.Clinical symptoms plus pertinent examinations for making an accurate diagnosis and determining lesion distribution are quite important.Incorrect evaluations for types and range of intestinal dysganglionosis lesion result in wrong surgical approaches.And this is an important reason for surgical failure.