Cheng Tianran,Ma Ya,Li Qi.Conservative managements of anastomotic leak under ultrasonic monitoring for Hirschsprung’s disease in infants[J].Journal of Clinical Pediatric Surgery,2024,(09):825-829.[doi:10.3760/cma.j.cn101785-202209044-005]
超声监测下保守治疗婴儿先天性巨结肠根治术后吻合口漏的初步探索
- Title:
- Conservative managements of anastomotic leak under ultrasonic monitoring for Hirschsprung’s disease in infants
- Keywords:
- Hirschsprung Disease; Postoperative Complications; Anastomotic Leak; Conservative Treatment; Treatment Outcome; Infant
- 摘要:
- 目的 总结分析超声监测下保守治疗1岁以内婴儿先天性巨结肠根治术后吻合口漏伴局部脓肿的相关经验。方法 回顾性分析2020年1月至2021年12月在首都儿科研究所普通外科行巨结肠根治术,并采用保守方法治疗的巨结肠根治术后吻合口漏伴局部脓肿患儿临床资料。保守治疗方法包括超声监测下采用局部麻醉下肛门扩张、脓肿外口置管引流、全身和局部抗感染以及留置肛管。收集患儿基本情况、发生吻合口漏的时间和部位以及治疗结果等,并评估患儿预后。结果 共4例患儿纳入研究,男1例、女3例,手术年龄3~11个月,常见型2例、长段型1例、全结肠型1例。分别于术后7、15、21、50 d发现吻合口漏。吻合口漏外口均位于吻合口后壁6点处,均存在向上延伸至骶前的脓肿。经保守治疗后3例愈合,愈合时间为保守治疗后34、48、72 d;1例转肠造瘘术治愈。患儿肛门功能评估均可,无一例严重吻合口狭窄及窦道形成。结论 1岁以内婴儿先天性巨结肠根治术后吻合口漏伴局部脓肿可以尝试超声监测下保守治疗,其中局部抗感染和保持引流通畅是保守治疗的关键,如保守治疗无效应及时手术干预。
- Abstract:
- Objective To summarize and share our institutional experience in the conservative managements of anastomotic leak in infants under ultrasonic monitoring for Hirschsprung’s disease (HD) over the last two years. Methods From January 2020 to December 2021,a HD child underwent pull-through and conservative treatment was offered for anastomotic leak.Under ultrasound monitoring,anal dilatation,catheter drainage,systemic and local anti-infection and placing anal tube under local anesthesia and sedation were performed.The outcomes were summarized. Results There were 3 girls and 1 boy.The causes were recto-sigmoid segment HD (n=2),long segment HD (n=1) and total colonic aganglionosis (n=1).Operative age was (3-11) month.Anastomosis leak occurred at Day 7/15/21/50 post-operation.All external openings were located at 6 o’clock point with presacral abscess.Three cases healed at Day 34/48/72 and 1 child underwent enterostomy.Function was satisfactory without stricture or sinus tract formation. Conclusions HD with postoperative anastomotic leak and local abscess formation may be managed conservatively under ultrasonic monitoring.Non-responsive cases should be operated as soon as possible.
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[2] 中华医学会小儿外科学分会内镜外科学组.腹腔镜先天性巨结肠症手术操作指南(2017版)[J].中华小儿外科杂志,2017,38(4):247-254.DOI:10.3760/cma.j.issn.0253-3006.2017.04.002. Section of Laparoendoscopy,Branch of Pediatric Surgery,Chinese Medical Association:Guideline for Laparoscopic Pull-through for Hirschsprung’s Disease (Edition 2017)[J].Chin J Pediatr Surg,2017,38(4):247-254.DOI:10.3760/cma.j.issn.0253-3006.2017.04.002.
[3] Holschneider AM,Puri P.Hirschsprung’s disease and allied disorders[M].3rd ed.Berlin:Springer,2008:115.
[4] Lu CG,Hou GJ,Liu CY,et al.Single-stage transanal endorectal pull-through procedure for correction of Hirschsprung disease in neonates and nonneonates:A multicenter study[J].J Pediatr Surg,2017,52(7):1102-1107.DOI:10.1016/j.jpedsurg.2017.01.061.
[5] Chi SQ,Guo JL,Zhang X,et al.Resuturing without enterostomy for the treatment of early-stage anastomotic leaks after laparoscopic soave procedure in Hirschsprung’s disease[J].J Laparoendosc Adv Surg Tech A,2020,30(12):1295-1300.DOI:10.1089/lap.2020.0640.
[6] Engum SA,Grosfeld JL.Long-term results of treatment of Hirs-chsprung’s disease[J].Semin Pediatr Surg,2004,13(4):273-285.DOI:10.1053/j.sempedsurg.2004.10.015.
[7] Pratap A,Gupta DK,Shakya VC,et al.Analysis of problems,complications,avoidance and management with transanal pull-through for Hirschsprung disease[J].J Pediatr Surg,2007,42(11):1869-1876.DOI:10.1016/j.jpedsurg.2007.07.017.
[8] 彭春辉,陈亚军,张廷冲,等.先天性巨结肠症术后早期有症状吻合口漏的治疗与转归[J].中华小儿外科杂志,2018,39(12):895-899.DOI:10.3760/cma.j.issn.0253-3006.2018.12.004. Peng CH,Chen YJ,Zhang TC,et al.Treatments and outcomes of early symptomatic anastomotic leakage after pull-through procedure for Hirschsprung’s disease[J].Chin J Pediatr Surg,2018,39(12):895-899.DOI:10.3760/cma.j.issn.0253-3006.2018.12.004.
[9] Pini-Prato A,Mattioli G,Giunta C,et al.Redo surgery in Hirschsprung disease:what did we learn? Unicentric experience on 70 patients[J].J Pediatr Surg,2010,45(4):747-754.DOI:10.1016/j.jpedsurg.2009.08.001.
[10] Li Q,Zhang Z,Xiao P,et al.Surgical approach and functional outcome of redo pull-through for postoperative complications in Hirschsprung’s disease[J].Pediatr Surg Int,2021,37(10):1401-1407.DOI:10.1007/s00383-021-04965-4.
[11] 李颀,张震,肖萍,等.再次手术治疗先天性巨结肠初次根治术后中远期并发症的临床研究[J].中华小儿外科杂志,2021,42(7):639-645.DOI:10.3760/cma.j.cn421158-20200309-00153. Li Q,Zhang Z,Xiao P,et al.Redo pull-through for late postoperative complications of Hirschsprung’s disease[J].Chin J Pediatr Surg,2021,42(7):639-645.DOI:10.3760/cma.j.cn421158-20200309-00153.
[12] 马亚,李颀,张震,等.超声对先天性巨结肠术后并发症的诊断价值[J].中国医学影像学杂志,2021,29(1):60-64.DOI:10.3969/j.issn.1005-5185.2021.01.015. Ma Y,Li Q,Zhang Z,et al.Diagnostic value of ultrasonography for postoperative complications of Hirschsprung disease[J].Chin J Med Imaging,2021,29(1):60-64.DOI:10.3969/j.issn.1005-5185.2021.01.015.
[13] Ma Y,Jiang Q,Zhang ZJ,et al.Diagnosis of Hirschsprung disease by hydrocolonic sonography in children[J].Eur Radiol,2022,32(3):2089-2098.DOI:10.1007/s00330-021-08287-w.
[14] Peng CH,Chen YJ,Pang WB,et al.STROBE-anastomotic leakage after pull-through procedure for Hirschsprung disease[J].Medicine (Baltimore),2018,97(46):e13140.DOI:10.1097/MD.0000000000013140.
[15] Podevin G,Lardy H,Azzis O,et al.Technical problems and complications of a transanal pull-through for Hirschsprung’s disease[J].Eur J Pediatr Surg,2006,16(2):104-108.DOI:10.1055/s-2006-923995.
[16] Dingemans A,van der Steeg H,Rassouli-Kirchmeier R,et al.Redo pull-through surgery in Hirschsprung disease:Short-term clinical outcome[J].J Pediatr Surg,2017,52(9):1446-1450.DOI:10.1016/j.jpedsurg.2016.09.059.
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备注/Memo
收稿日期:2022-9-23。
基金项目:北京市属医院科研培育项目(PX2020054)
通讯作者:李颀,Email:35036091@qq.com