中高位肛门闭锁末端肠壁异常与患儿术后排便功能的关系

Association between abnormalities of the distal rectal pouch and postoperative bowel function in high or intermediate anal atresia

目的本研究通过对中高位肛门闭锁末端肠壁病理学研究及系统地评价患儿术后排便功能，探讨末端3tin发育异常肠管切除的必要性。方法2008年1月至2012年12月期间在首都儿科研究所附属儿童医院手术治疗的中高位肛门闭锁患儿60例，根据术中是否切除末端3cm肠管分为切除组（36例）和对照组（24例），比较两组患儿的术后排便功能。将切除组的切除标本进行常规HE染色和免疫组化检查，对比距盲端2cm和3cm两处肠壁组织的形态差异。结果60例患儿均手术成功，术后均接受随访，中位随访时间为4．5年。以Kfickenbeck标准评价，切除组术后严重便秘发生率低于对照组（3％比21％，Х^2=5．216，P〈0．05）。两组的自主排便和污便评分值相比差异均无统计学意义（均P〉0．05）。距盲端2cm处肠管均有不同程度的纤维结缔组织增生，肌层发育异常，肠壁神经丛数目明显少于距盲端3cm处（1．6±0．9比5．6±1．8，t=11．715，P〈0．01），并且发育差，丛内神经节细胞量少。结论距盲端2cm处及远端肠管的肠壁存在病理学异常，对末端3cm肠管切除有利于中高位肛门闭锁患儿术后长期排便功能的恢复。

Objective To evaluate wall histological abnormalities 2 to 3 cm to the end in high or intermediate anal atresia in order to identify features that explain postoperative bowel dysfunctions. Methods Sixty anal atresia patients treated in the Capital Pediatric Institution between January 2008 and December 2012 were recruited in our study. 36 patients were resected the terminal anal segment （3 cm）. Compared with those 24 cases who were not. Resected samples were fixed for HE and immuno-histochemical stainings. Clinical data including sacral ratio （SR）, age at operation, gender, bowel function were evaluated. Results There was no significant difference in patients＇ SR value, gender and age at operation between resected group and control group. The median follow-up period was 4. 5 years. The rates of voluntary bowel movement, soiling （grade 1, 2, 3 ） were similar in both groups, however, the rates of severe constipation in resection group was significantly lower that in control group （3 % vs. 21% , P 〈 0.05 ）. In the bowel wall of distal 2 cm anrectal canal, the connective tissue was found to be irregular and abnormally represented. Muscle coat was abnormal in all cases, showing the dysplasia circular and longitudinal layers. The number of enteric nervous system was significant fewer in distal 2cm anrectal canal than that in distal 3 cm （1. 6 ±0.9vs. 5.6 ±1.8,t=11.715, P〈0.01）. Conclusions Resection of terminal 3 cm at least of the atresia anal canal benefits postoperative bowel defecation function.