基于"肛肠平衡"原则治疗先天性巨结肠患儿术后肠功能不良的研究

Treatment of postoperative intestinal dysfunction in children with Hirschsprung's disease based upon the principle of"anorectal balance"

目的分析基于"肛肠平衡"原则治疗先天性巨结肠(Hirschsprung disease,HD)患儿术后肠功能不良的临床疗效。方法收集2019年7月至2021年7月在华中科技大学同济医学院附属同济医院小儿外科由单一治疗组收治的30例HD术后肠功能不良患儿的相关资料。其中,男19例,女11例,平均年龄为2.4岁;临床症状包括腹胀21例,便秘28例和肠炎23例。患儿既往治疗HD的手术方式为结肠次全切除术(25例)和全结肠切除术(5例)。所有患儿先进行肛门内括约肌肉毒杆菌毒素注射术(2 U/kg);3~6个月后对仍出现症状的患儿再次施行注射术;对接受肉毒杆菌毒素注射术≥2次,但反复出现肠功能不良的患儿施行肛门内括约肌肌条切除术。术后常规进行直肠肛管测压检查,并记录患儿腹胀、排便情况。结果所有患儿接受肉毒杆菌毒素注射术后,排便次数较术前增加,(1.1±0.6)次比(5.4±1.1)次;肛门静息压较术前降低,(62.1±9.1)mmHg比(27.3±5.4)mmHg(1 mmHg=0.133 kPa);便秘、腹胀、肠炎症状较术前改善,差异均具有统计学意义(P<0.01)。12例患儿接受再次肉毒杆菌毒素注射术后,排便次数增加,(1.2±0.7)次比(4.7±1.2)次;肛门静息压降低,(49.2±6.3)mmHg比(23.4±4.4)mmHg;临床症状再次缓解,差异均具有统计学意义(P<0.05)。11例患儿接受肛门内括约肌肌条切除术,术后排便次数增加,(0.9±0.1)次比(5.7±1.6)次;肛门静息压降低,(51.4±3.7)mmHg比(17.2±3.2)mmHg;临床症状较术前明显改善,差异均具有统计学意义(P<0.01)。结论基于"肛肠平衡"原则,采用肉毒杆菌毒素注射术和肛门内括约肌肌条切除术,可有效降低肛门静息压,缓解患儿术后肠功能不良症状,具有较好的临床疗效。

Objective To explore the clinical efficacy of treating postoperative intestinal dysfunction in children with Hirschsprung's disease based upon the principle of"anorectal balance".Methods The relevant clinical data were retrospectively reviewed for 30 children on monotherapy with intestinal dysfunction after Hirschsprung's disease surgery from July 2019 to July 2021.There were 19 boys and 11 girls with an average age of 2.4 years.Clinical symptoms included abdominal distension(n=21),constipation(n=28)and enteritis(n=23).Previous surgical approaches were subtotal colectomy(n=25)and total colectomy(n=5).All children received an initial injection of botulinum toxin injection(2 U/kg)in internal anal sphincter.At Month 3 to 6,injection was provided again for symptomatic children;muscle strip resection of internal anal sphincter was performed for children receiving injection≥twice and recurrent intestinal dysfunction.Postoperative anorectal manometry was routinely performed and abdominal distension and defecation recorded.Results After an injection of botulinum toxin,the frequency of defecation spiked(1.1±0.6)vs.(5.4±1.1),anal resting pressure dropped(62.1±9.1)mmHg vs.(27.3±5.4)mmHg,the symptoms of constipation,abdominal distension and enteritis improved and the differences were statistically significant(P<0.01);After another injection of botulinum toxin,frequency of defecation spiked(1.2±0.7)vs.(4.7±1.2),anal resting pressure dropped(49.2±6.3)mmHg vs.(23.4±4.4)mmHg and clinical symptoms were relieved in 12 children.And the differences were statistically significant(P<0.05).After internal anal sphincterectomy,frequency of defecation spiked(0.9±0.1)vs.(5.7±1.6),anal resting pressure dropped(51.4±3.7)mmHg vs.(17.2±3.2)mmHg and the symptoms of constipation,abdominal distension and enterocolitis improved markedly in 11 children.And the differences were statistically significant(P<0.01).Conclusions Based upon the principle of"anorectal balance",use of botulinum toxin injection and muscle strip resection of internal anal sphincter can effectively lower anal resting pressure and relieve the symptoms of postoperative intestinal dysfunction in children with an excellent clinical efficacy.