先天性巨结肠经肛门Ⅰ期根治术后便秘的再手术探讨

Repeat Soave procedure for failed transanal pull-through in Hirschsprung's disease

目的分析经肛门SoaveⅠ期拖出根治术治疗先天性巨结肠后便秘的病例,探讨其原因、再手术的指征和方法。方法2000年来经肛门SoaveⅠ期拖出根治术治疗先天性巨结肠术后发生便秘的患儿17例;分为2组。保守治疗组共4例,占23.5%;手术组13例,占76.5%;手术组又分为开腹和再次经肛门直接拖出手术治疗2组;其中开腹手术组4例,经肛门直接拖出治疗9例。对手术时间、合并症、术后便失禁、便秘的情况进行分析随访。结果保守治疗组有3例经洗肠、排便训练及年龄增加便秘情况由1次/2～4 d,转为1次/1～2 d,无合并症;1例治疗2年因反复肠炎,顽固性便秘转手术治疗。经肛门再次直接拖出治疗10例和腹部小切口辅助经肛门拖出治疗4例,无手术并发症。患儿术后1个月随访时:排便2～6次/d,半年时:排便1～3次/d;术后2年随访排便:1～2次/d,无肛门狭窄。仅1例偶有污裤。结论经肛门SoaveⅠ期拖出时,因视野小、拖出困难,容易遗留无神经节细胞的结肠,是术后便秘的主要原因。经肛门SoaveⅠ期拖出根治术具有腹腔干扰少和粘连少的优点,因此再次手术时,仍可采用此方法。有腹腔肠粘连的患儿可腹部切口辅助下经肛门SoaveⅠ期直接拖出治疗。

Objective To review our experience for children with recurrent constipation after transanal one-stage pull-through for Hirschsprung＇s disease （HD）. Methods There were 17 cases suffered from constipation after transanal pull-through procedure for liD, Four cases underwent conservative therapy, and the other 13 cases underwent reoperation （transand or laparotomic Soave pullthrough）. The operating time, bleeding, complications, and Junctional results were analyzed in these patients. Results Three cases recovered after conservative treatment, and the other one underwent operation because of recurrent constipation and enterocolitis. There were no operative complications, enterocolitis, stricture or cuff narrowing in transanal approach and Soave pull-through group.Aftter 6 months,all children had 1 ～ 3 bowel movements per day. Only one patient presented dirty pants. Conclusions The preservation of aganglional segment after one-stage pull-through procedure is the main cause for the recurrent constipation. Reoperation through transanal approach can get satisfactory results for these patients.