前矢状入路肛门成形术治疗肛门闭锁直肠前庭瘘的疗效评价

Evaluation of anterior sagittal anoplasty for anorectal malformation with rectovestibular fistula

目的评价前矢状入路肛门成形术治疗肛门闭锁直肠前庭瘘的临床疗效。方法肛门闭锁直肠前庭瘘患儿25例,年龄3个月至1岁,术前全部行钡灌肠造影和MRI检查。所有患儿行前矢状入路肛门成形术,其中5例同时行巨直肠切除术。术后6个月行肛管内超声、肛肠测压,并进行肛门功能评价。选择同期30例6～9个月因腹胀就诊的婴儿作为对照组。结果术前钡灌肠造影显示9例合并直肠扩张,MRI显示2例合并脊髓栓系。术后2例切口浅层裂开,6例存在直肠黏膜外翻,6例出现便秘。肛管内超声显示11例肛门括约肌轻度受损,14例括约肌完整。与对照组比较,患儿组术后肛管静息压(cmH_2O)(32. 18±10. 86 vs. 52. 94±15. 20)及肛管高压区长度(cm)(1. 22±0. 30 vs. 1. 59±0. 41)均降低,差异有统计学意义(P <0. 001)。6例便秘组患儿与肛门功能正常组的19例患儿比较,括约肌评分(1. 00±1. 27 vs. 0. 95±1. 27)、肛管高压区长度(1. 28±0. 42 vs. 1. 24±0. 29)及肛管静息压(cmH_2O)(34. 25±16. 39 cmH_2O,31. 52±8. 99 cmH_2O)无明显差别。2例便秘合并直肠扩张的患儿二次行巨直肠切除术,术后排便功能正常。结论肛门闭锁直肠前庭瘘行一期前矢状入路肛门成形术仍存在一定的并发症。术前合并直肠扩张是导致排便障碍的重要原因,合并直肠扩张的患儿行肛门成形术的同时可考虑切除扩张直肠。

Objective To evaluate the clinical efficacies of anterior sagittal anoplasty for anorectal malformation with rectovestibular fistula.Methods A total of 25 patients with rectovestibular fistula aged from 3 months to 1 year were recruited.Barium enema and magnetic resonance imaging(MRI)were performed pre-operation.Anterior sagittal anoplasty was performed in all of them.And megarectum was resected in 5 patients simultaneously.Anal endosonography(AES),anorectal manometry and anal function were evaluated at 6 months post-operation.The control group included 30 infants aged 3-9 months with abdominal distention.Results Before operation,barium enema indicated megarectum in 9 cases and MRI hinted at tethered spinal cord in 2 cases.After operation,there were superficial dehiscence(n=2),rectal prolapse(n=6)and constipation(n=6).AES indicated minor damaged anal sphincter(n=11)and intact anal sphincter(n=14).The anal resting pressure and the length of anal high pressure zone(32.18±10.86 cmH 2O,1.22±0.30 cm)decreased in patients as compared with controls(52.94±15.20 cmH 2O,1.59±0.41 cm respectively).For 6 constipated cases,no difference existed in anal sphincter score,length of anal high pressure zone and anal resting pressure(1.00±1.27,1.28±0.42cm,34.2±16.39 cmH 2O)as compared with 19 cases with normal anal function(0.95±1.27,1.24±0.29 cm,31.52±8.99 cmH 2O).Two constipated cases regained normal defecation function after resecting dilated rectums.Conclusion Primary anterior sagittal anoplasty has some complications for anorectal malformation with rectovestibular fistula.Megarectum is a major cause of postoperative constipation.Enlarged rectun should be resected simultaneously during anoplasy.