新生儿期一期肛门成形术治疗中位肛门直肠畸形疗效评价

Functional evaluations of neonates with intermediate anorectal malformations after primary anoplasty

目的总结中位肛门直肠畸形患儿行新生儿期一期肛门成形术与分期肛门成形术的远期排便功能及肛门直肠测压结果,评估新生儿期一期肛门成形术治疗中位肛门直肠畸形的临床疗效。方法回顾性收集2006年1月至2019年8月上海交通大学医学院附属新华医院小儿外科收治的132例中位肛门直肠畸形患儿临床资料,手术方式均为改良后矢状入路肛门成形术(mini-Peña),按照手术时期分为两组,A组为新生儿期接受一期肛门成形术的患儿,共22例;B组为接受传统三期肛门成形术的患儿,共110例。两组最远随访至术后15年。评估两组临床情况以及远期排便功能、并发症情况。术后排便功能评估采用Rintala评分,结果分为优、良、中、差四个等级。肛门直肠测压包括肛门静息压、肛门长度、内括约肌静息压及长度、外括约肌静息压及长度、直肠肛门抑制反射(rectoanal inhibitory reflex,RAIR)等。结果两组患儿性别比例、出生体重差异均无统计学意义(P>0.05)。单次肛门成形术后住院时间比较,A组长于B组[(17.1±3.9)d比(10.4±3.4)d,P<0.05];总住院时间及总手术时间比较,A组均明显短于B组,分别为(19.6±5.5)d比(37.5±10.7)d、(128.9±29.0)min比(287.9±61.2)min,差异均有统计学意义(P<0.05)。两组肛门长度以及内、外括约肌长度差异均无统计学意义(P>0.05);A组肛门静息压、内括约肌静息压及外括约肌静息压均高于B组,分别为(53.8±15.5)mmHg比(36.7±10.4)mmHg、(53.5±15.1)mmHg比(34.6±8.7)mmHg、(45.7±16.9)mmHg比(33.9±11.8)mmHg,差异均有统计学意义(P<0.05)。A组肛门直肠抑制反射引出率明显高于B组(66.7%比0%,P<0.05),其他肛门直肠测压数据差异无统计学意义(P>0.05)。两组Rintala评分优良率差异无统计学意义(83.3%比88.0%,P>0.05)。两组术后便秘、污粪的发生率以及术后并发症的发生率比较,差异均无统计学意义(P>0.05),分别为25.0%比28.0%、16.7%比16.0%、33.3%比50.7%。结论中位肛门直肠畸形行新生儿期一期肛门成形术可以获得良好的肛门控便能力。早期一期肛门成形术可避免造瘘以及造瘘关闭手术的创伤。

Objective To evaluate the clinical efficacy and prognosis of neonatal primary anoplasty through a retrospective comparison of the results of defecation function and anorectal manometry after one-stage anoplasty.Methods From January 2006 to August 2019,a total of 132 children with intermediate anorectal malformation were recruited as study subjects.All of them underwent modified posterior sagittal anorectoplasty(mini-Peña).According to operative period,they were divided into two groups.Group 1 included 22 children diagnosed with intermediate anorectal malformation during neonatal period undergoing primary anoplasty.And group 2 had 110 children undergoing traditional staged anoplasty.Both groups were followed up for 15 years to evaluate long-term defecation functions and complications.During follow-ups,Rintala score was employed for evaluating postoperative defecation function and the grades were excellent,good,moderate and poor.All cases were examined by anorectal manometry,including anal resting pressure,anal length,internal sphincter resting pressure and length,external sphincter resting pressure and length and rectoanal inhibitory reflex(RAIR),etc.Results No significant inter-group differences in gender ratio or birth weight(P>0.05).Duration of postoperative hospital stay was longer in group 1 than that in group 2[(17.1±3.9)vs.(10.4±3.4)d,P<0.05].Hospital stay and operative duration were markedly shorter in group 1 than those in group 2[(19.6±5.5)vs.(37.5±10.7)days;(128.9±29.0)vs.(287.9±61.2)min,P<0.05].No significant inter-group difference existed in anal length or internal/external sphincter length(P>0.05).Anal resting pressure,internal sphincter resting pressure and external sphincter resting pressure of group 1 were higher than those in group 2[(53.8±15.5)vs.(36.7±10.4)mmHg;(53.5±15.1)vs.(34.6±8.7)mmHg;(45.7±16.9)vs.(33.9±11.8)mmHg,P<0.05].Extraction rate of rectal inhibitory reflex was significantly higher in group 1 than that in group 2(66.7%vs.0%,P<0.05).No significant statistical difference existed in other anorectal pressures(P>0.05).Rintala score of two groups showed no obvious difference in rate of excellent/good(83.3%vs.88.0%,P>0.05).(83.3%vs.88.0%,P>0.05).No significant inter-group differences existed in the incidence of constipation,soiling or postoperative complications(25%vs.28.0%;16.7%vs.16.0%;33.3%vs.50.7%,P>0.05).Conclusion Neonates with intermediate anorectal malformations undergoing one-stage anoplasty can also have good postoperative stool control ability.Early one-stage anoplasty may avoid operative wound and closure of stoma.