可控性Malone顺行灌肠在神经性肛肠功能障碍患儿的应用评价

Evaluation of Malone antegrade continence enema in patients with neurogenic bowel dysfunction

目的 利用盆底肌电生理检测、肛门直肠测压及结肠传输试验对脊髓栓系综合征患儿肛肠功能的病理生理特点进行分析,并对行可控性Malone顺行灌肠（malone antegrade continence enema,MACE）患儿的临床疗效进行评价.方法 2005年5月至2013年8月对278例确诊为神经源性肛肠功能障碍（neurogenic bowel dysfunction,NBD）的患儿（男142例,女136例;年龄3～16岁,平均年龄8.8岁）行盆底肌电生理和肛门直肠测压检查.其中,35例（男21例,女14例;年龄3～16岁,平均年龄7.8岁）行结肠传输试验,并与20例健康儿童（男14例,女6例;年龄4～14岁,平均年龄8.2岁）进行对比;51例（男28例,女23例;手术年龄4～16岁,平均年龄9.3岁）行MACE,对手术前后的肛门功能进行量化评分.结果 患儿组肛门外括约肌和肛提肌动作电位波幅分别为（704.0±9.3）mv和（786.0±11.9）mv较对照组（356.0±7.3）my和（378.0±6.3）my明显增高,差异有统计学意义（P＜0.05）.患儿组肛门外括约肌和肛提肌动作电位时限分别为（7.6±2.8）ms和（8.9±3.9）ms,较对照组（4.8±1.3）ms和（5.0±1.4）ms明显延长,差异有统计学意义（P＜0.05）.患儿组阴部神经运动传导波幅为（0.5±0.3）mv,较对照组（1.7±0.2）mv明显降低;潜伏期为（2.6±0.4）ms,较对照组（1.8±0.3）ms明显延长,差异均有统计学意义（P＜0.05）.患儿组肛管静息压和肛管最大自主收缩压分别为（33.4±14.1）mmHg和（78.0±46.8）mmHg,较对照组（65.3±5.6）mmHg和（161.7±28.0）mmHg明显降低,差异有统计学意义（P＜0.05）;初次排便感觉阈值为（69.1±37.0）ml,较对照组（42.5±15.2）ml明显增高,差异有统计学意义（P＜0.05）.患儿组全结肠传输时间为（72.6±6.6）h,较对照组（40.4±7.4）h明显延长,差异有统计学意义（P＜0.05）.患儿组左半结肠传输时间为（20.9±4.2）h,乙状结肠传输时间为（32.8±5.2）h,与对照组（9.3±4.3）h和（19.6±6.7）h比较,均明显延长,差异均有统计学意义（P＜0.05）.MACE术后患儿的Rintala评分为15.7±1.4较术前5.4±2.8明显提高,差异有统计学意义（P＜0.05）.结论 NBD患儿同时存在排便和控便障碍,MACE能显著提高患儿的生活质量.

Objective To analyze the pathophysiological characteristics of neurogenic bowel dysfunction （NBD） by electrophysiological study of pelvic floor musculature,anorectal manometry and colonic transit study and evaluate the clinical efficacy of Malone antegrade continence enema （MACE）.Methods A total of 278 NBD patients received an electrophysiological study of pelvic floor musculature and anorectal manometry from May 2005 to August 2013.Meanwhile,35 patients underwent colonic transit study and another 20 healthy children were selected as controls.Fifty-one patients underwent MACE.And the preoperative and postoperative anal functions were compared.Results The action potential amplitude of external anal sphincter and levator ani muscle in NBD group （704.0 ± 9.3,786.0 ± 11.9 mv） increased significantly versus control group （356.0 ± 7.3,378.0 ±6.3 mv）and the difference had statistical significance （P＜0.05）; The action potential time limit of external anal sphincter and levator ani muscle in NBD group （7.6 ± 2.8,8.9 ± 3.9 ms） was significantly prolonged versus control group （4.8 ± 1.3,5.0 ± 1.4 ms） and the difference had statistical significance（P＜0.05）; Pudendal nerve motor conduction amplitude in NBD patients was significantly lower than that in control group [（0.5 ± 0.3） vs （1.7 ± 0.2） mv].And latent period in NBD patients was significantly prolonged versus control group [（2.6 ± 0.4） vs （1.8 ± 0.3 ms）].And the differences had statistical significance （P＜0.05）.The anal resting pressure and anal largest squeeze pressure （33.4 ± 14.1,78.0 ± 46.8 mmHg） declined significantly and the first defecation sensory threshold （69.1 ± 37.0 ml）increased significantly in NBD patients versus control group （65.3 ± 5.6 mmHg,161.7 ± 28.0 mmHg,42.5 ± 15.2 ml）and the difference had statistical significance（P ＜0.05）.The total colonic transit time（72.6 ± 6.6 h）became significantly prolonged in NBD patients,especially for left-half colon （20.9 ± 4.2 h） and sigmoid colon （32.8 ± 5.2 h） versus control group （40.4 ± 7.4,9.3 ± 4.3,19.6 ± 6.7 h）and the difference had statistical significance（P＜0.05）.The clinical postoperative scores （15.7 ± 1.4） obviously improved versus preoperation （5.4 ± 2.8） and the difference had statistical significance （P ＜ 0.05）.Conclusions NBD patients have defecation and continence dysfunction.And MACE may significantly improve their quality of life.