臀大肌瓣转移术治疗肛门直肠畸形术后排便功能障碍

Gluteus maximus flap transplantation for anrectal dysfunction after anorectal malformation operation

目的评价臀大肌瓣转移肛提肌加强术治疗肛门直肠畸形术后排便功能障碍的恢复情况。方法选择28例先天性肛门闭锁术后排便功能障碍的患儿，年龄4～14岁，男19例，女9例，单纯肛提肌功能不良的18例，肛提肌和肛门外括约肌功能均不良的10例，全部行臀大肌瓣转移肛提肌加强术，术前均行盆底肌MRI、钡灌肠及臀大肌肌电图检查，手术前后均行结肠传输试验、肛门直肠测压和排便功能评分。术后对患儿进行6～48个月的随访，平均24个月。结果28例手术患儿中26例获得随访，术前臀大肌肌电图均显示臀大肌功能良好，钡灌肠显示直肠无扩张，结肠传输试验表现为出口梗阻，盆底肌MRI见28例患儿肛提肌发育薄弱或不对称，排便功能评分结果示28例患儿均差。肛管静息压手术前后分别为（16．77±4．25）mmHg和（18．67±4．48）mmHg、肛管最大收缩压在手术前后分别为（61．05±14．37）mmHg和（72．12±16．76）mmHg，差异均无统计学意义（P〉0．05），术后单纯肛提肌功能不良的排便功能评分达优6例，良10例，肛提肌和肛门外括约肌功能均不良的排便功能评分优0例，良2例，差8例。优良率占69．23％。结论对于肛提肌功能不全所导致的排便功能障碍，行臀大肌瓣转移肛提肌加强术可改善排便功能，部分括约肌功能不良的患儿术后可能失禁不能改善或者加重，需要进一步的手术或训练治疗。

Objective To evaluate the effect of gluteus maximus flap transplantation to reinforce levator ani for the anorectal dysfunction after previous anorectal malformation operation. Methods Twenty eight children aged 4-14 years old, including 19 boys and 9 girls, were enrolled in this study. All the children suffered from anorectal dysfunction after previous operations for congenital anal atresire Among them, 18 patients had levator ani muscle dysfunction, while the other 10 had levator ani muscle and anal sphincter dysfunction. All subjects received examinations including pelvic floor MR, barium enema and gluteus maximus electromyography. All patients underwent gluteus maximus flap transplantation to reinforce levator ani. Colonic transit testing, anorectal pressure and defecation score were also studied to evaluate the surgical efficacy. The patients were followed up for 4-48 months, with an average of 24 months. Results Twenty six patients were followed up after surgery. Before surgery, gluteus maximus electromyography and barium enema revealed normal muscle function and bowel movement. Colonic transit testing showed outlet obstruction. Pelvic floor MR revealed levator ani muscle complex was poorly developed and asymmetric. All 28 patients＇ defecation function was scored as poor before operation. After surgery, 69. 23% patients achieved excellent and good defecation function. Among the patients with levator ani muscle dysfunction, 6 patients＇ defecation were scored excellent and 10 were good. However, among the patients with levator ani muscle and anal sphincter dysfunction, 2 patients＇ defecation function was scored good while the other 8 were poor. Conclusions Gluteus maximus flap transplantation to reinforce levator ani is safe and effective to treat anorectal dysfunction in patients with previous anorectal malformation operation.