经肛门及腹腔镜辅助Swenson-like术治疗短段型先天性巨结肠中的手术体会和中长期疗效随访

Transanal versus laparoscopic Swenson-like full-thickness pull-through for short-segment Hirschsprung disease:surgical experience and mid-term outcomes

目的评价Swenson-like术治疗短段型先天性巨结肠的效果,并比较其与Soave术的治疗效果及中长期预后差异。方法回顾性分析自2012年1月至2020年12月于上海交通大学医学院附属新华医院治疗的272例短段型先天性巨结肠患儿,患儿根据手术方式及手术入路分组,接受腹腔镜辅助Swenson-like术为A组(57例)、接受腹腔镜辅助Soave术为B组(55例)、接受经肛门Swenson-like术为C组(81例)、接受经肛门Soave术为D组(79例)。比较A组与B组患儿、C组与D组患儿临床资料,比较术后短期并发症情况、各组患儿肠功能随访及泌尿系统相关并发症情况。组间比较采用t检验、卡方检验或Mann-WhitneyU检验。结果A组与B组患儿、C组与D组患儿性别、年龄、术后吻合口瘘发生率差异无统计学意义。A组患儿手术时间为(184.1±52.5)min,低于B组的(256.2±74.8)min(P<0.001);C组患儿手术时间为(116.1±36.7)min,低于D组的(161.7±36.2)min(P<0.001),Swenson-like术较Soave术的手术时间更短。术后272例患儿中位随访时间为33.1个月,范围在6.0~121.8个月;末次随访时中位年龄为45.6个月,范围在8.9~224.3个月。随访过程中40例(14.7%,40/272)患儿失访,剔除失访病例后,剩余232例患儿一般临床资料差异无统计学意义。剔除失访病例后A组与B组患儿、C组与D组患儿在术后便秘及先天性巨结肠相关性小肠结肠炎(Hirchsprung-associated enterocolitis,HAEC)的发生率上差异无统计学意义。剔除失访病例后A组患儿每年发生HAEC的次数为(0.3±0.7)次,低于B组的(1.1±1.9)次,差异有统计学意义(P=0.007);C组患儿每年发生HAEC的次数为(0.3±0.6)次,低于D组的(0.7±1.8)次,差异有统计学意义(P=0.046)。评估117例年满4岁患儿的污粪、Rintala评分及泌尿系统症状,其中A组Rintala评分为(15.2±3.9)分,高于B组患儿的(13.9±4.8)分,差异有统计学意义(P=0.029),C组Rintala评分为(15.9±1.4)分,高于D组患儿的(14.2±4.2)分,差异有统计学意义(P=0.030);而术后污粪及泌尿系统症状发生率差异无统计学意义。结论采取经肛门及腹腔镜Swenson-like术治疗先天性巨结肠是安全有效的,与Soave术相比可明显缩短手术时间并降低术后HAEC发生频率,且不影响术后长期排便功能及泌尿系统功能。

Objective To summarize the outcomes of Swenson-like pull-through for treating short-segment Hirschsprung's disease(HSCR)and compare its effectiveness and mid-term prognosis with that of Soave pull-through.Methods From January 2012 to December 2020,retrospective analysis was conducted for 272 children with congenital short-segment HSCR.Based upon surgical approaches,they were assigned into four groups:Group A(n=57)underwent laparoscopic Swenson-like pull-through,Group B(n=55)laparoscopic Soave pull-through,Group C(n=81)transanal Swenson-like pull-through and Group D(n=79)transanal Soave pull-through.Clinical profiles,postoperative short-term complications,bowel function and urinary system-related complications were recorded for assessing postoperative outcomes.And t,chi-square and Mann-Whitney U tests were performed for group comparisons.Results No statistically significant differences existed in gender,age or the incidence of short-term postoperative complications between Group A/B or Group C/D.Operative duration was shorter in Group A than that in Group B[(184.1±52.5)vs(256.2±74.8)min,P<0.001]and in Group C than that in Group D[(116.1±36.7)vs(161.7±36.2)min,P<0.001].Median follow-up duration was 33.1(6.0-121.8)months and median age at the last follow-up 45.6(8.9-224.3)months.Forty patients(14.7%,40/272)became lost to follow-ups.After excluding these cases,no significant differences existed in general profiles among the remaining 232 children.After excluding lost cases,no statistically significant difference existed in the incidence of constipation or Hirschsprung-associated enterocolitis(HAEC)between Group A/B or Group C/D.However,annual incidence of HAEC was significantly lower in Group A than Group B[(0.3±0.7)vs(1.1±1.9)times/year,P=0.007]and similarly in Group C than Group D[(0.3±0.6)vs(0.7±1.8)times/year,P=0.046].For 117 patients aged over 48 months during follow-ups.Rintala score and urinary symptoms were evaluated.Rintala score was significantly higher in Group A than that in Group B[(15.2±3.9)vs(13.9±4.8),P=0.029]and in Group C(15.9±1.4)than Group D(14.2±4.2)(P=0.030).However,no statistically significant differences existed in the incidence of postoperative soiling or urinary symptoms.Conclusions Transanal and laparoscopic Swenson-like pull-throughs are both safe and effective for congenital HSCR.As compared with Soave procedure,it significantly shortens operative duration and lowers the frequency of postoperative HAEC without affecting bowel and urinary functions.