一期腹腔镜辅助肛门成形术治疗先天性肛门闭锁伴直肠阴道瘘的可行性探讨

Feasibility of one-stage laparoscopic-assisted anorectoplasty for congenital anal atresia with rectovaginal fistula

目的总结肛门闭锁伴直肠阴道瘘(rectovaginal fistula,RVF)的诊断、治疗经验,探讨一期腹腔镜辅助肛门成形术(laparoscopy-assisted anorectoplasty,LAARP)治疗RVF的可行性。方法回顾性分析2013年3月至2022年2月在广东省妇幼保健院接受肛门成形术的9例RVF患儿的临床资料,9例RVF患儿接受肛门成形术的中位年龄为107 d,范围在4~223 d;手术时患儿的中位体重为5.6 kg,范围在2.8~7.9 kg。9例患儿中6例接受分期手术,肛门成形时2例行后矢状入路肛门成形术(posterior sagittal anorectoplasty,PSARP),4例行LAARP。另3例接受一期手术,1例行PSARP时无法找到瘘管中转LAARP,2例直接行LAARP。总结患儿的术后短期并发症,随访至患儿3岁时,使用Krickenbeck评分系统评估患儿的排便功能。结果所有患儿均顺利完成手术。2例分期PSARP患儿术后出现切口黏膜脱垂并行切除术治疗,疗效满意;1例行一期LAARP治疗的患儿术后出现尿潴留,短期留置导尿后症状消失;其余患儿均未出现伤口感染、裂开、回缩和脱垂等并发症。1例患儿随访时未满3岁未行排便功能评估;其余8例随访至3岁时,只有1例无法自主控制排便,且存在污粪情况;自主排便能力正常的7例患儿中2例存在便秘(用大便软化剂症状可缓解),2例存在污粪(偶尔出现)。结论RVF是肛门直肠畸形的一种罕见亚型,需通过仔细的体格检查和多种影像学检查并最终手术探查准确诊断。一期LAARP治疗RVF安全可行,术后无重大并发症发生,短期疗效好。

Objective To explore the diagnoses,managements and clinical outcomes of rectovaginal fistula(RVF)and to determine the feasibility and technical know-how of one-stage laparoscopy-assisted anorectoplasty(LAARP).Methods From March 2013 to February 2022,the relevant clinical data were retrospectively reviewed for 9 RVF children undergoing anorectoplasty.Median operative age was 107(4-223)days and median body weight 5.6(2.8-7.9)kg.Six of them underwent staged procedures of primary surgery(n=3),posterior sagittal anorectoplasty(PSARP,n=2)and LAARP(n=4).One child was been converted into LAARP during PSARP due to a failure of locating fistula while LAARP(n=2)was performed directly.Immediate postoperative complications was followed up for 3 years.And defecation function was tracked by Krickenbeck’s scoring system.Results All operations were completed smoothly.Two children of staged PSARP developed mucosal prolapsed and it was resected with a satisfactory efficacy.One case of primary LAARP had a postoperative onset of urinary retention and the symptoms disappeared after short-term tubing.None of the remainders developed wound infection,dehiscence,deflation or prolapse.One child aged under 3 years was too young for assessing defecation function.Among the remainders,only one child failed to control defecation and had soiling during 3-year follow-ups.Among 7 children of normal voluntary defecation,there were constipation(n=2)and soiling(n=2).Conclusions As a rare subtype of anorectal malformation,RVF requires careful physical examinations,multiple imaging examinations and final intraoperative explorations.Primary LAARP is both safe and feasible for RVF.Without major postoperative complications,it yields excellent short-term outcomes.