改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症

Modified Laparoscopic Duhamel Subtotal Colectomy for Extended Hirschsprung's Disease

目的探讨改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症（Hirschsprung disease,HD）的并发症和疗效。方法回顾分析2010年3月~2014年1月12例长段型HD资料,男7例,女5例,中位年龄8月（5月~6岁）。其中移行区位于降结肠近端8例,横结肠2例,结肠肝曲1例,升结肠1例。7例行结肠造瘘。手术主要改良之处：经肛门齿状线上方直肠后壁切口将结肠拖出至肛门外,用Endo-GIA肛门外切断并封闭,保留直肠残端4~5 cm。然后结合Deloyer技术将升结肠拖下与原直肠后壁端侧吻合,再将Endo-GIA切缝器两肢分别放入原直肠和新直肠,切开两段肠管间隔并行侧侧吻合。观察术中术后并发症及排便功能。结果 12例均在腹腔镜辅助下完成次全结肠切除升结肠Duhamel拖出术,平均手术时间170 min（125~240 min）,未出现术中并发症,无吻合口漏。4例诉肛周疼痛,1例术后5天便血,保守治疗治愈。大便频率2周以内4~15次/天,恢复到正常排便频率（1~2次/天）时间平均3.5月（2.2~5个月）。平均随访时间32个月（3~46个月）,2例术后小肠结肠炎,1例早期有便秘症状,均保守治疗治愈。无闸门综合征和粪石发生,无大便失禁。结论改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型HD安全有效,排便频率恢复正常快。肛门外处理直肠盲端简单可靠,腹壁创伤小。

Objective To discuss the efficacy of modified laparoscopic Duhamel subtotal colectomy for extended Hirschsprung＇s disease（ HD）. Methods Between March 2010 and January 2014,12 children（ male,7 cases; female,5 cases）with extended HD underwent a modified laparoscopic Duhamel subtotal colectomy. The median age at operation was 8 months old（ 5months- 6 years）. The level of the transition zone was in the proximal descending colon in 8 cases,the transverse colon in 2 cases,the hepatic flexure of the colon in 1 case,and the ascending colon in 1 case,respectively. Seven children received a colostomy. During the operation,extracorporeal low rectal transection was performed by using Endo-GIA through the incision in the posterior rectum above the dentate line,with short rectal stump 4- 5 cm in length. Then the ascending colon was pulled down to perform an end-to-side anastomosis with the rectum by using the Deloyer artifice. Finally,a side-to-side anastomosis was conducted between the rectum and reconstructed rectum by using Endo-GIA. Intra- and post-operative complications and bowel functional outcomes were evaluated.Results The operation was completed laparoscopically in all the patients. The mean operating time was 170 min（ 125- 240 min）.No intraoperative complications were observed. No leakage was observed. Defecation frequency within two weeks was 4- 15 times per day. Timespan to obtain normal frequency（ 1- 2 times per day） was 3. 5 months（ 2. 2- 5 months）. The mean follow-up period was 32months（ 3- 46 months）. The enterocolitis occurred postoperatively in 2 cases,1 of which showed episodes of constipation during the early follow-up period,and they were all responded to conservative treatment. All achieved normal defecation without incontinence and gate syndrome. Conclusions Modified laparoscopic Duhamel subtotal colectomy for extended HD has quick recovery and good bowel functions. Extracorporeal rectal transection using Endo-GIA was easy to perform and credible,with less damage to the abdominal wall.