先天性巨结肠症术后早期有症状吻合口漏的治疗与转归

Treatment and prognosis of early symptomatic anastomotic leakage after pull-through procedure for Hirschsprung's disease

目的探讨先天性巨结肠症(Hirschsprung’s disease,HSCR)术后早期有症状吻合口漏的治疗及转归。方法回顾性分析2006年1月至2017年12月收治的15例HSCR术后早期有症状的吻合口漏或其并发症患儿的临床资料。其中,男13例,女2例。结果吻合口漏发生时间为术后(6.8±4.7) d。在当地行肠造瘘8例;在我院行肠造瘘7例,其中5例同时行吻合口再缝合,再缝合与出现症状的中位间隔时间为4 d(1~29 d)。4例患儿(80.0%)行肠造瘘、吻合口再缝合后,吻合口漏治愈;余11例出现了并发症。其中,单纯骶前窦道2例,单纯高位吻合口狭窄5例,骶前窦道同时伴高位吻合口狭窄4例。单纯骶前窦道2例,曾行窦道清除及吻合口再缝合,均失败。此11例患儿均行再次拖出手术-经腹经肛门Soave手术,两次拖出手术的中位间隔时间为1.5年(7个月至7年)。再次拖出手术后,有1例单纯骶前窦道患儿(1/15,6.7%)未愈,仍有肠造瘘。随访14例已关瘘患儿排便情况,随访时间为(61.7±30.9)个月。4例患儿(4/14,28.6%)有不同程度的污粪,均出现在再次拖出手术后。结论早期肠造瘘同时吻合口再缝合可有效治疗HSCR术后吻合口漏。吻合口漏可导致吻合口狭窄、骶前窦道,而经腹经肛门Soave手术可安全有效地治疗这些并发症。

Objective To explore the treatment and prognosis of early symptomatic anastomotic leakage after pull-through procedure for Hirschsprung’s disease. Methods A retrospective analysis was performed for 15 patients with early symptomatic anastomotic leakage or its secondary complications after a pull-through procedure between January 2006 and December 2017 at our hospital. Medical records were reviewed for 13 boys and 2 girls. Results The mean postoperative time of symptom onset of anastomotic leakage was (6.8±4.7) days. Eight patients underwent ostomy creation procedure at local hospitals. In the other 7 patients, ostomy was constructed and anastomotic dehiscences were resutured in 5/7 patients within the same operation. The median time between onset of symptoms and resuturing was 4 (1-29) days. After primary operation, 4 patients (4/5, 80.0%) with ostomy and anastomotic resutruing were cured. There were presacral sinus (n=2), high anastomotic stricture (n=5) and presacral sinus with high anastomotic stricture (n=4). Excision and reanastomosis failed in 2 patients with presacral sinus alone. Eleven patients with stricture or sinus underwent redo pull-through-transanal Soave procedure with laparotomy. The median interval between two pull-through procedures was 1.5 years(7 months to 7 years). After redo pull-through, one patient (1/15, 6.7%) with unhealed presacral sinus underwent another ostomy. Fourteen patients were followed up for a mean period of (61.7±30.9) months. Four patients (4/14, 28.6%) with redo pull-through had varying degrees of soiling. Conclusions Early ostomy and reanastomosis are effective for patients with anastomotic leakage. For anastomotic leakage, the sequelae of anastomotic stricture and presacral sinus may be successfully treated with transanal Soave procedure with laparotomy.