直肠黏膜剥离盲袋肌鞘内拖出术治疗先天性高位肛门闭锁

Rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch in the treatment of congenital high anal atresia in the newborn

目的探讨直肠黏膜剥离盲袋肌鞘内拖出术在新生儿先天性高位肛门闭锁患儿的临床应用价值。方法回顾性分析2001年1月至2010年12月间在江苏省徐州市儿童医院接受手术治疗的232例高位肛门闭锁新生患儿的临床资料，其中168例行前矢状人路直肠黏膜剥离盲袋肌鞘内拖出术（肌鞘内拖出组），64例行经典Pena手术（Pena手术组，分为结肠造口、肛门成形和关瘘三期手术）。术后进行门诊随访，采用Kellv评分评估术后肛门功能，通过排粪造影评估肛门直肠形态，并予以肛门直肠测压。结果术后2年，肌鞘内拖出组和Pena手术组分别有126例（75．0％）和54例（84．4％）患儿能良好控粪，差异无统计学意义（P〉0．05）。但肌鞘内拖出组便秘发生率明显低于Pena手术组[8．3％（14／168）比21．9％（14／64），P〈0．05]。排粪造影结果显示，两组患儿肛直肠角、肛管长度、骶直间距及直肠最大直径的差异均无统计学意义（均P〉0．05）。肛管直肠测压结果显示．两组患儿肛管高压区长度、肛管静息压、肛管最大收缩压、直肠感知阈值及直肠最大容量阈值的差异均无统计学意义（均P〉0．05）。结论直肠黏膜剥离盲袋肌鞘内拖出术治疗先天性高位肛门闭锁可于新生儿期一期完成手术，其疗效与经典Pena手术相当，可避免多次手术，从而减少患儿痛苦及其家人经济负担，且术后便秘发生率更低，值得临床推广应用。

Objective To explore the value of rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch in the treatment of congenital high anal atresia in the newborn. Methods Clinical data of 232 newborns diagnosed as congenital high anal atresia undergoing operation from January 2001 to December 2010 were retrospectively analyzed. Among these patients, 168 underwent rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch through the previous of sagittal approach （intrathecal pull-through group）, and 64 cases underwent the Pena procedure （Pena group）. Patients were followed up for two years. Kelly score was used to estimate postoperative anorectal function. Defecography was used to examine the morphology of anorectum. Rectal pressure was measured as well. Results Two years after operation, Kelly score revealed that 126（75.0%） cases in the intrathecal pull-through group and 54 cases （84.4%） in the Pena group had good control defecation （P〉0.05）, while constipation rate was significantly lower in intrathecal pull-through group [8.3% （14/168） vs. 21.9% （14/64）, P〈0.05]. Postoperative barium defecography showed that defecation rectum maximum diameter was （2.2±0.3） cm in intrathecal pull-through group and （2.3±0.8） cm in the Pena group （P〉0.05）. Anorectal manometry showed rectal maximum capacity threshold value was （91.4±15.2） ml in the intrathecal pull-through group and （95.1±08.6） ml in the Pena group（P〉0.05）. There were no significant differences in defecography, anal bowel function and anorectal manometry between thetwo groups postoperatively （all P〉0.05）. Conclusions Rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch through the former sagittal can be completed with one-stage operation in newborn for the treatment of congenital high anal atresia, the efficacy of which is similar to the classic Pena operation. This procedure can avoid other operations, ameliorate the pains of newborns, decrease the burden of family, and has lower constipation rate, therefore it is a valid surgical option.