Li Long,Zhou Yan,Wang Changlin,et al.Anatomic observations on anorectal musculatures of normal and anorectal malformations in neonates[J].Journal of Clinical Pediatric Surgery,2020,19(10):872-877.[doi:10.3969/j.issn.1671-6353.2020.10.003]
肛门直肠畸形患儿肛周肌肉改变的研究
- Title:
- Anatomic observations on anorectal musculatures of normal and anorectal malformations in neonates
- 分类号:
- R726.2;R657.1;R322.7+4
- 摘要:
- 目的 对比正常新生儿和肛门直肠畸形（anorectal malformations，ARMs）患儿的肛周肌肉解剖，了解其异常改变，探讨其对手术方案改进的意义。方法 对33例死于非ARMs相关疾病的新生儿和13例ARMs患儿（高位8例，中位5例）的骨盆进行解剖。通过对纵肌管、耻骨直肠肌等组织进行观察、测量，对各组测量结果进行对比分析。结果 正常新生儿肛周肌肉由内向外可分为三个管状结构：内括约肌管、纵肌管（由直肠纵肌和盆底纵肌组成）和横肌管。ARMs患儿内括约肌管缺如，纵肌管仅由盆底纵肌构成，呈闭合状态，分为盆腔和会阴两个部分。盆腔部纵肌管向前上方移位，会阴部纵肌管中心没有直肠通过，两侧会阴部纵肌相互融合形成闭合的肌管，向下延伸，形成肛穴。肛穴代表了会阴部肛周肌肉的中心。经测量，在正中矢状面，高、中位ARMs患儿和正常新生儿纵肌管后壁的平均长度分别为（2.66±0.31）cm、（2.34±0.54）cm和（1.80±0.29）cm，高位ARMs患儿的纵肌管后壁长度长于正常新生儿（P<0.05），中位ARMs患儿与高位ARMs患儿及正常新生儿的纵肌管后壁长度无明显差异（P>0.05）；高、中位ARMs患儿和正常新生儿会阴部纵肌管的平均长度分别为（2.08±0.51）cm、（1.24±0.15）cm和（1.02±0.25）cm，高位ARMs患儿的会阴部纵肌管长度长于正常新生儿及中位ARMs患儿（P<0.05），正常新生儿与中位ARMs患儿的会阴部纵肌管长度无差异（P>0.05）；高、中位ARMs患儿和正常新生儿耻骨直肠肌的平均长度分别为（1.49±0.40）cm、（2.13±0.25）cm和（2.29±0.22）cm，高位ARMs患儿的耻骨直肠肌长度短于正常新生儿及中位ARMs患儿（P<0.05），正常新生儿与中位ARMs患儿的耻骨直肠肌长度无差异（P>0.05）。结论 新生儿肛周肌肉由内括约肌，纵肌和横肌三个管状系统组成，高、中位ARMs患儿的内括约肌管缺如，纵肌管和横肌管有发育异常改变，闭合的纵肌管可为术中辨别重建直肠拖出的中心位置提供解剖学基础。
- Abstract:
- Objective To compare anorectal musclulatures in normal neonates and anorectal malformations (ARMs) to evaluate its role in bowel control mechanism.Methods Pelvis of 33 neonates dead from ARM-unrelated diseases and 13 neonates with anorectal malformations (8 high,5 intermediate) were dissected and analyzed.The morphologies of longitudinal muscle tube (LMT) and puborectalis were measured and the results of each group were compared.Results Normal anorectal musculature was divided into three muscular groups of internal sphincter tube (IAST),LMT and transverse muscle tube (TMT).In ARMs,LMT was divided into pelvic and perineal LMTs.The former became narrowed and dislocated anteriorly adjacent to posterior urethra in high ARMs and rectal pouch in intermediate ARMs.The latter,below bulbar urethra to anal dimple,was fused to a column both in high and intermediate ARMs.Columnar perineal LMT coursed downwards and then split,penetrated superficial part of EAS and terminated at the deep aspect of skin for forming anal dimple,representing the center of perineal LMT from perineal aspect.In middle sagittal plane,the lengths of LMT were significantly longer in high ARMs than that in neonates (2.66±0.31 vs.1.80±0.29 cm,P<0.05).The length of LMT in intermediate ARMs showed no significant difference from that in high ARMs and neonates (P>0.05).The lengths of perineal LMT were significantly longer in high ARMs than that in neonates and intermediate ARMs (2.08±0.51 vs.1.02±0.25 and 1.24±0.15 cm,P<0.05).The length of perineal LMT in neonates showed no significant difference from that in intermediate ARMs (P>0.05).The lengths of puborectalis were significantly shorter in high ARMs than that in neonates and intermediate ARMs (1.49±0.40 vs.2.29±0.22 and 2.13±0.25 cm,P<0.05).The length of puborectalis in neonates showed no significant difference from that in intermediate ARMs (P>0.05).Conclusion Columnar perineal and narrowed pelvic LMTs may be identified by laparoscopic and perineal approaches and offer anatomical evidence of the center where neorectum is pulled through.
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备注/Memo
收稿日期:2019-09-20。
基金项目:北京市医院管理中心儿科学科协同发展中心专项经费资助（编号：XTZD20180302）；北京市属医学科研院所公盖发展改革试点项目（编号：京医研2019—11）
通讯作者:王常林,Email:wangcl@sj-hospital.org