经脐部造口在先天性巨结肠症分期手术中的应用

Application of transumbilical enterostomy during staged pull-through for Hirschsprung's disease

目的评估经脐部肠造口术(transumbilical enterostomy,TUE)及二期腹腔镜辅助拖出术治疗先天性巨结肠症(Hirschsprung's disease,HSCR)的安全性、疗效和美容效果。方法回顾性分析2014年2月至2019年2月华中科技大学同济医学院附属协和医院小儿外科收治的58例HSCR并行肠造口患儿的临床资料。其中,男41例,女17例;包括13例常见型HSCR合并重度小肠结肠炎或结肠扩张、27例长段型HSCR和18例全结肠无神经节细胞症(total colonic aganglionosis,TCA)。患儿行肠造口年龄为(5.7±2.4)个月;按手术方式不同,分为TUE组(27例)和常规腹部肠造口术(conventional abdominal enterostomy,CAE)组(31例)。常见型和移行区位于降结肠下段的长段型HSCR患儿行腹腔镜Soave手术,移行区位于降结肠上段需行大部分结肠切除的长段型HSCR和TCA患儿行腹腔镜Duhamel手术。对比分析两组患儿一般情况、并发症和术后1年腹部外观。结果两组间肠造口术的手术时间、失血量、住院时间和住院费用差异均无统计学意义(P均>0.05)。TUE组术后出现造口黏膜脱垂2例(7.41%)、造口部位局部伤口感染1例(3.70%)、造口周围皮炎4例(14.81%),CAE组出现造口黏膜脱垂2例(6.45%)、造口部位局部伤口感染2例(6.45%)、造口周围皮炎8例(25.81%),两组上述参数比较,差异均无统计学意义(P均>0.05)。TUE组术后未出现肠梗阻,CAE组有1例。TUE和CAE组分别发现3例(11.11%)和4例(12.90%)小肠结肠炎,但组间比较,差异无统计学意义(P>0.05),且患儿均经保守治疗好转。TUE组的二期腹腔镜手术时间为(143.0±27.1)min,短于CAE组的(158.9±29.4)min,组间比较,差异有统计学意义(P<0.05)。TUE组瘢痕评分为(6.51±0.86)分,优于CAE组的(14.12±1.29)分,组间比较,差异有统计学意义(P<0.05)。结论经脐部肠造口术在HSCR中应用安全、有效,且分期腹腔镜手术达到了与一期腹腔镜手术相似的腹壁美容效果。

Objective To explore the safety,efficacy and cosmetic outcomes of transumbilical enterostomy(TUE)and two-stage laparoscopic-assisted pull-through for Hirschsprung's disease(HSCR).Methods From February 2014 to February 2019,58 HSCR children(41 boys,17 girls)undergoing enterostomy were reviewed,including rectosigmoid HSCR of severe enterocolitis or dilated colon(n=13),long-segment HSCR(n=27)and with total colonic aganglionosis(TCA,n=18).Enterostomy was performed at a mean age of(5.7±2.4)months.TUE(n=27)and conventional abdominal enterostomy(CAE,n=31)were performed.Short segment HSCR underwent laparoscopic Soave procedure while long segment HSCR or TCA laparoscopic Duhamel procedure.Demographics,complications and cosmetic outcomes were evaluated.Results No significant inter-group differences existed in operation time of TUE,blood loss,length of stay or hospital costs(P>0.05).Two cases in TUE group and 2 in CAE group developed stomal mucosal prolapse(7.41%vs.6.45%,P>0.05).There was wound infection at stoma in 1 case in TUE group and 2 cases in CAE group(3.70%vs.6.45%,P>0.05).Dermatitis around stoma occurred in 4 patients in TUE group and 8 in CAE group(14.81%vs.25.81%,P>0.05).There was one case of obstruction in CAE group and none in TUE group.Enterocolitis occurred in 3 and 4 children in TUE and CAE groups respectively(11.11%vs.12.90%,P>0.05)and both responded well to conservative measures.Operative duration for two-stage laparoscopic procedure was significantly shorter in TUE group than that in CAE group(143.0±27.1 vs.158.9±29.4 min,P<0.05).The cosmetic outcomes using scar score was significantly better in TUE group than that in CAE group(6.51±0.86 vs.14.12±1.29,P<0.05).Conclusions Transumbilical enterostomy is both safe and effective for HSCR.And staged laparoscopy-assisted pull-through achieves cosmetic outcomes similar to primary laparoscopic pull-through.