基于倾向性评分匹配的末端直肠三厘米切除对中高位肛门直肠畸形患儿中期预后的影响研究

Resection of distal 3 cm rectal pouch for high-and-intermediate anorectal malformation:medium-term outcomes from a propensity score matching analysis

目的采用基于倾向性评分的科研设计,探讨切除直肠末端3 cm对于先天性肛门直肠畸形(anorectal malformations,ARMs)患儿中期预后的影响。方法回顾性分析2010年1月至2018年12月在首都儿科研究所普通(新生儿)外科接受腹腔镜下肛门成形术治疗的171例中高位ARMs患儿临床资料。根据术中是否切除直肠末端3 cm肠管,分为切除组(120例)和对照组(51例)。采用倾向性评分对两组患儿基本资料进行1∶1匹配,得到术前临床资料(年龄、体重、分型、造瘘方式、合并畸形)差异无统计学意义的两组(每组各46例),比较两组患儿术后并发症及排便功能(排便功能采取Krickenbeck评分进行评估)。结果行倾向性评分匹配后,切除组和对照组手术时间、术后住院时间及术后并发症发生率比较,差异均无统计学意义(P>0.05);对照组1例术后发生直肠回缩,1例随访过程中出现巨直肠。所有患儿中位随访时间5.5年,两组自主控便及污便发生率比较,差异均无统计学意义(P>0.05),但切除组便秘发生率显著低于对照组,差异有统计学意义(37.0%比69.6%,P=0.014)。结论切除ARMs患儿直肠远端3 cm可以降低术后便秘的发生率,不会增加污便发生风险。远端肠管过多保留是导致肛门直肠畸形患儿术后便秘的原因之一,可能与肠壁纤维化残留有关。

Objective To evaluate the medium-term outcomes of resecting distal 3 cm of rectal pouch in children with congenital anorectal malformations(ARMs).Methods From January 2010 to December 2018,the relevant clinical data were retrospectively reviewed for 171 children with high-and-intermediate ARMs undergoing laparoscopic-assisted anorectoplasty.Based upon whether or not distal 3 cm rectal pouch was resected,they were divided into two groups of resection(n=120)and control(n=51).Baseline characteristics of two groups were matched with a ratio of 1∶1 using propensity score matching.No statistically significant difference existed in preoperative clinical data.Forty-six cases were included for each group and medium-term outcomes were compared between two groups.Results After propensity score matching,no statistically significant differences existed in operative duration,postoperative hospitalization stay or postoperative complication rate between resection and control groups(P>0.05).However,postoperative rectal retraction(n=1)and megarectosigmoid(n=1)during follow-ups in control group.The median follow-up period for both groups was 5.5 years and defecation function was evaluated by Krickenbeck scores.No significant inter-group difference existed in voluntary bowel movement or stool soiling.However,resection group exhibited a significantly a lower constipation rate than control group(47.0%vs.69.6%,P=0.014).Conclusions The constipation rate in ARM with distal 3cm resection is significantly lower without any increment of soiling.Excessive preservation of rectal pouch is one of the contributing factors to postoperative constipation in ARM children.It may be associated with residual fibrosis of rectal pouch.