Yang Zhonghua,Wang Dabin,Liu Dan,et al.Comprehensive assessments of defecation functions in anorectal malformation children with postoperative constipation[J].Journal of Clinical Pediatric Surgery,2020,19(01):18-25.[doi:10.3969/j.issn.1671-6353.2020.01.004]
先天性肛门直肠畸形术后合并便秘患儿排便功能评定及病因探讨
- Title:
- Comprehensive assessments of defecation functions in anorectal malformation children with postoperative constipation
- 分类号:
- R726;R574.63;R574.62
- 摘要:
- 目的 便秘是先天性肛门直肠畸形（anorectal malformation，ARM）术后常见的并发症，其病理改变复杂，病因尚不清楚。本研究利用多种客观检查方法对ARM术后便秘患儿肛门直肠功能和神经功能进行评定，并对其病因进行探讨。方法 利用同位素排便造影、直肠肛管测压、肌电图和肛门括约肌神经电生理等方法对49例ARM患儿和31例正常儿童的排便功能进行全面、系统和动态的评价，49例ARM患儿根据畸形位置分为中低位组和高位组，每组再根据是否发生便秘分出两个亚组，并对上述测量指标进行统计分析。结果 同位素排便造影结果显示，ARM术后便秘组半排时间[中低位：（13.45±8.35）s；高位：（20.59±4.26）s]与术后无便秘组[中低位：（4.69±6.86）s；高位：（7.66±6.38）s]相比明显延长，ARM术后便秘组排空率[中低位：（29.35±14.84）s；高位：（33.00±9.04）s]与术后无便秘组[中低位：（61.70±23.01）s；高位：（60.31±30.38）s]相比明显降低，差异具有统计学意义（P<0.05）。直肠肛管测压检测结果显示，直肠感觉阈在所有ARM组中均明显高于正常组（P<0.05），ARM便秘组[中低位：（53.57±9.45）mL；高位：（57.50±9.14）mL]高于ARM无便秘组[中低位：（46.32±14.61）mL；高位：（47.27±8.76）mL]。ARM便秘组感觉收缩时间[中低位：（2.79±0.39）s；高位：（3.51±1.93）s]明显长于ARM无便秘组[中低位：（1.97±0.67）s；高位：（2.11±0.43）s]，差异具有统计学意义（P<0.05）。肌电图结果显示，反映排便动力的痉挛指数在术后合并便秘组均明显高于未合并便秘组。神经电生理结果显示会阴-肛门反射潜伏期在ARM患儿组均明显延长，其中ARM合并便秘组[中低位：（66.04±16.20）ms；高位：（70.41±17.91）ms]延长更加明显，与ARM无便秘组[中低位：（38.51±16.92）ms；高位：（49.91±9.45）ms]相比存在统计学差异（P<0.05）。结论 ARM术后便秘患儿直肠感觉功能和排便动力存在明显异常，其严重程度与支配盆底肌肉的神经功能异常有关。治疗前应进行详细、系统的肛门直肠和神经功能的客观检查，明确排便功能障碍的具体病因和病理改变。
- Abstract:
- Objective Constipation is one of the most common postoperative complications in anorectal malformation (ARM) children.Since the pathological changes are rather complicated,its etiology has remained elusive.In this study,various kinds of examinations were utilized for assessing objectively anorectal and nervous functions of ARM children with postoperative constipation and exploring the possible etiologies. Methods With the objectives of assessing fecal functions comprehensively,systematically and dynamically and examining the pathological alterations,anal functions of postoperative 49 ARM children and 31 normal controls were evaluated by isotopic defecography,anorectal manometry,electromyogram and anal sphincter neuroelectrophysiologiy. Results Isotopic defecography showed that,as compared with ARM counterparts without postoperative constipation,half-defecating time prolonged,rectal evacuation rate decreased and residual rate increased significantly in ARM children with postoperative constipation.The results of rectal manometry indicated that rectal sensitivity threshold was higher in ARM group than that in normal group and higher in ARM children with postoperative constipation than that in those without.Rectal compliance was significantly worse in ARM group with postoperative constipation than that in those without.Rectal sensation-contraction time was delayed significantly in ARM group while it was longer in ARM group with postoperative constipation than that in those without.Both resting and contracting anal vector volumes significantly decreased in patient group.However,no difference existed between children with postoperative constipation and those without.Anal myoelectrography implied that myoelectric amplitude significantly decreased in high-type ARM children and changes of myoelectric amplitude were not associated with whether or not ARM children were complicated with postoperative constipation.Spasm parameters indicated that defecation dynamics increased significantly in children with postoperative constipation than those without.Neuroelectrophysiologiy hinted that pubendo-anal reflex latency,spinal-anal reflex latency and central conduct time of reflex arc were delayed in ARM children.These parameters significantly increased in ARMs children with postoperative constipation than those without and normal group. Conclusion There are significant abnormalities of rectal sensory function and defecation dynamics in ARM children with postoperative constipation.And severity of abnormality is correlated with nervous dysfunction of innervating pelvic muscles.Therefore functional pre-treatment tests should be performed for evaluating anal functions of postoperative ARM children comprehensively and systematically.It helps to ascertain its etiologies and detect the pathological changes of defecation dysfunctions.
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备注/Memo
收稿日期:2019-07-02。
基金项目:国家自然科学基金（编号：81800453，81270436，81671503）
通讯作者:王维林,Email:wangwl@sj-hospital.org;袁正伟,Email:yuanzw@hotmail.com