远端乙状结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的疗效评价

Evaluation on Effects of Two-staged Laparoscopically Assisted Proximal Colon Pull-through Anorectoplasty After Distal Sigmoidostomy in Patients with Congenital Anorectal Malformations

目的探讨远端结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的术后疗效。方法将我院2008年10月~2014年10月10例新生儿期在外院行远端结肠造瘘术的中高位肛门闭锁患儿,二期在我院行腹腔镜辅助肛门成形术设为A组,10例合并直肠尿道瘘,2例合并双侧输尿管膀胱返流,术中游离远端结肠,合并尿道瘘者于瘘管颈部缝扎后离断直肠尿道瘘管,远端结肠下托至肛门口有张力,将远端结肠切除行近端结肠拖出成形肛门。选择2008年6月~2014年6月20例中高位肛门闭锁行经典三期手术（造瘘-腹腔镜辅助下直肠拖出肛门成形术-关瘘）设为B组作为对照,比较2组术后肛肠测压指标,术后1年肛周肌群厚度和Kelly评分。结果 A组随访12~60个月,（35±6）个月;B组随访15~60个月,（46±4）个月。2组肛门直肠组织的形态无明显差异。A、B组肛管静息压分别为（25.85±3.68）、（26.93±4.54）mm Hg,无统计学差异（t=-0.651,P=0.520）;A组最大收缩压（35.90±8.44）、B组（41.14±9.60）mm Hg,无统计学差异（t=-1.464,P=0.154）;2组肛管持续收缩长度分别为（12.53±0.75）、（12.67±0.78）mm,无统计学差异（t=-0.469,P=0.643）;2组直肠内超声观察肛门外括约肌、耻骨直肠肌的厚度分别为（1.93±0.36）、（2.12±0.43）mm,无统计学差异（t=-1.200,P=0.240）;2组肛门排便功能的Kelly评分比较无显著统计学差异（Z=-0.334,P=0.738）。结论远端结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的疗效与经典三期手术相仿,而且方便患儿护理、缩短疗程,可以作为中高位肛门闭锁的手术选择。

Objective To discuss the feasibility and outcomes of two-staged laparoscopically assisted anorectal pull-through anorectoplasty （LAARP） after distal sigmoidostomy in patients with congenital anorectal malformation （ARMs）. Methods Between October 2008 and October 2014, 10 ARMs children with distal colostomy history （group A） underwent two-staged LAARP at this center. There were 10 cases accompanying urethrorectal fistula and 2 cases accompanying bilateral vesicoureteral reflux. In the operation, the distal colon was dissociated and the fistula neck was suture ligated and then dissected. After testing the tension when pulling the distal colon to the anus, the proximal colon pull-through anorectoplasty was carried out. During the same period, 20 cases （ group B） including 16 males and 4 females with ARMs underwent classical three-staged anoreetoplasty （ eolostomy - laparoscopieally assisted colon pull-through anorectoplasty - colostomy closure）. Their clinical data were retrospectively analyzed to evaluate the feasibility and results of two-staged pull-through anoreetoplasty. Results There was no significant difference between the two groups in anorectal morphology. The anorectal manometry after surgery showed the rest pressure was （25.85 ±3.68 ）mm Hg in the group A and （26.93 ±4.54） mm Hg in the group B, without statistical difference （ t = - 0. 651, P = 0. 520）. The maximum high pressure was （35.90±8.44） mm Hgin the group A and （41.14±9.60） mm Hgin the group B, without statistical difference （t= -1.464, P= 0. 154）. The length of high pressure was （12.53 ±0.75） mm in the group A and （ 12.67 ±0.78） mm in the group B, without statistical difference （t = - 0. 469, P = 0. 643）. The thickness of sphincter under ultrasonography was （ 1.93 ±0.36） mm in the group A and （2.12 ± 0.43） mm in the group B, without statistical difference （t = - 1. 200, P = 0. 240）. The Kelly scores between the two groups were not significantly different （ Z = - 0. 334, P = 0. 738 ）. Conclusions Two-staged LAARP after distal colostomy for ARMs obtains effects comparable of three-staged treatment. It also has advantages of convenient nursing and short treatment course.