Xu Weili,Li Suolin,Sun Chi,et al.Single-site laparoscopic-assisted Martin-Duhamel procedure in the treatment of total colonic aganglionosis with stage Ⅰ stoma and evaluation of postoperative defecation function[J].Journal of Clinical Pediatric Surgery,2020,19(01):31-35.[doi:10.3969/j.issn.1671-6353.2020.01.006]
经Ⅰ期造瘘口单部位腹腔镜辅助Martin-Duhamel术在全结肠型巨结肠症治疗中的应用
- Title:
- Single-site laparoscopic-assisted Martin-Duhamel procedure in the treatment of total colonic aganglionosis with stage Ⅰ stoma and evaluation of postoperative defecation function
- 关键词:
- Hirschsprung病; 腹腔镜检查; 外科手术; 排便功能; 儿童
- Keywords:
- Hirschsprung Disease; Laparoscopy; Surgical Procedures; Operative; Defecation Function; Child
- 分类号:
- R726;R574;R574.62
- 摘要:
- 目的 探讨经Ⅰ期造瘘口单部位腹腔镜辅助Martin-Duhamel术在先天性全结肠型巨结肠症患儿治疗中的应用价值，并对患儿术后排便功能进行评价。方法 回顾性分析2014年6月至2017年6月间河北医科大学第二医院小儿外科收治的15例先天性全结肠型巨结肠症患儿的诊治及术后随访资料，其中男11例，女4例，月龄（5.11±2.67）个月，所有患儿Ⅰ期行回肠末端造瘘术，Ⅱ期行腹腔镜辅助Martin-Duhamel手术。术后随访2年，采用李正肛门功能临床评分法进行排便功能评分。定期肛管直肠测压，记录和比较患儿排便频率、性状及近远期并发症情况。结果 15例均顺利完成手术，无中转开腹和死亡病例。手术时间（184.43±30.46）min，出血量（27.57±10.63）mL，肠功能恢复时间（3.29±0.91）d，术后住院时间（7.86±1.77）d。术后1~3个月排便频率为8~20次/日，术后6~9个月排便频率为4~8次/日，术后1~2年排便频率为2~4次/日（接近正常水平）。术后3个月和术后6个月排便评分无显著性差异（P=0.115），术后6个月和术后1年排便评分有显著性差异（P=0.040），术后1年和术后2年排便评分无显著性差异（P=0.542）。肛管直肠测压从术后6个月开始逐渐恢复至正常范围，与术前比较有显著性差异（肛管反射舒张压P=0.027；肛管静息压P=0.010；直肠静息压P=0.034）。术后6个月内因排便次数多致肛周湿疹、皮肤破溃6例，予以造口粉、氧化锌或芦荟软膏涂抹后恢复；小肠结肠炎1例，经保守治疗后缓解；无便秘等其他并发症发生。结论 经Ⅰ期造瘘口单部位腹腔镜辅助Martin-Duhamel术治疗全结肠型巨结肠症患儿安全可行；排便功能可在术后6个月至1年逐渐恢复至接近正常儿童的水平。
- Abstract:
- Objective To explore the value of single-site laparoscopic-assisted Martin-Duhamel procedure in the treatment of children with total colonic aganglionosis with stage Ⅰ stoma and evaluate their postoperative defecation functions.Methods A retrospective analysis was performed for the data of diagnosis,treatment and postoperative follow-ups of 15 hospitalized cases of total colonic aganglionosis with stage I stoma from June 2014 to June 2017.There were 11 boys and 4 girls with an average age of (5.11±2.67) months.All of them underwent stage Ⅰ terminal ileostomy and stage Ⅱ laparoscopic assisted Martin-Duhamel operation.They were postoperatively followed up and defecation scores were assessed for 2 years.Anorectal pressures were measured regularly and frequency,characteristics of defecation and complications recorded and compared. Results All 15 laparoscopic-assisted Martin-Duhamel procedures were performed successfully.There was neither mortality nor conversion into laparotomy.The operative duration was (184.43±30.46) min,the bleeding volume (27.57±10.63) milliliters,the recovery time of intestinal function (3.29±0.91) days and the postoperative hospital stay (7.86±1.77) days.During postoperative follow-ups,the results showed 8 to 20 times of defecation per day at 1 to 3 months,4 to 8 times of defecation per day at 6 to 9 months and 2 to 4 times of defecation per day at 1 to 2 years.No significant postoperative differences existed in defecation scores between 3 and 6 months (P=0.115) or 1 and 2 years (P=0.542).However,significant postoperative differences existed between 6 months and 1 year (P=0.040).The postoperative measurements of anorectal pressure gradually normalized at 6 months.And it was significantly different from that of preoperation (anal reflex diastolic pressure,P=0.027; anal canal resting pressure,P=0.010; rectal resting pressure,P=0.034).Six cases of perianal eczema and skin erosion were caused by frequent defecation at 6 months.One case of enterocolitis was relieved after conservative measures.No constipation occurred.Conclusion Single-site laparoscopic-assisted Martin-Duhamel procedure is both safe and feasible in the treatment of total colonic aganglionosis with stage I stoma.The postoperative function of defecation gradually normalizes at 6 months to 1 year.
参考文献/References:
1 李索林,张永婷,费川.肠造口术后单切口腹腔镜辅助巨结肠根治术(Duhamel术)[J].临床小儿外科杂志,2015,14(2):148-151.DOI:10.3969/j.issn.1671-6353.2015.02.020. Li SL,Zhang YT,Fei C.Single-incision laproscopic assisted radical procedure (Duhamel) for Hirschsprung’s disease after colostomy[J].J Clin Ped Sur,2015,14(2):148-151.DOI:10.3969/j.issn.1671-6353.2015.02.020.
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 Endoscopy,Branch of Pediatric Surgery,Chinese Medical Association:Guideline for laparoscopic pull-through for Hirschsprung’s disease (2017 edition)[J].Chin J Pediatr Surg,2017,38(4):247-254.DOI:10.3760/cma.j.issn.0253-3006.2017.04.002.
3 王维林.小儿排便障碍性疾病的诊断与治疗(第2版)[M].北京:人民卫生出版社,2014:191. Wang WL.Diagnosis and treatment of pediatric defecation disorders (2nd Edition)[M].Beijing:People’s Medical Publishing House,2014:191.
4 Shen C,Song Z,Zheng S,et al.A comparison of the effectiveness of Soave and Martin procedures for the treatment of total colonic aganglionosis[J].J Pediatr Surg,2009,44(12):2355-2358.DOI:10.1016/j.jpedsurg.2009.07.056.
5 Urla C,Lieber J,Obermayr F,et al.Surgical treatment of children with total colonic aganglionosis:functional and metabolic long-term outcome[J].BMC Surg,2018,18(1):58.DOI:10.1186/s12893-018-0383-6.
6 李颀,张震,姜茜,等.内括约肌部分切除、回肠肛管吻合术治疗全结肠型巨结肠的中期功能研究[J].中华小儿外科杂志,2018,39(6):428-433.DOI:10.3760/cma.j.issn.0253-3006.2018.06.006. Li Q,Zhang Z,Jiang Q,et al.Mid-term outcomes of transanal rectal mucosectomy & partial internal anal sphincterectomy,proctocolectomy and ileoanal anastomosis for total colonic aganglionosis[J].Chin J Pediatr Surg,2018,39(6):428-433.DOI:10.3760/cma.j.issn.0253-3006.2018.06.006.
7 Miyano G,Ochi T,Lane GJ,et al.Factors affected by surgical technique when treating total colonic aganglionosis:laparoscopy-assisted versus open surgery[J].Pediatr Surg Int,2013,29(4):349-352.DOI:10.1007/s00383-012-3247-7.
8 Miyano G,Nakamura H,Seo S,et al.Laparoscopy-assisted Duhamel-Z anastomosis for total colonic aganglionosis:outcome assessed by fecal continence evaluation[J].J Laparoendosc Adv Surg Tech A,2017,27(3):302-305.DOI:10.1089/lap.2016.0216.
9 Zhang X,Cao GQ,Tang ST,et al.Laparoscopic-assisted Duhamel procedure with ex-anal rectal transaction for total colonicaganglionosis[J].J Pediatr Surg,2018,53(3):531-536.DOI:10.1016/j.jpedsurg.2017.06.009.
10 李世宪,张宏伟,刘丰丽,等.直线切割吻合器在全结肠型巨结肠根治术中的应用[J].临床小儿外科杂志,2015,14(4):281-283.DOI:10.3969/j.issn.1671-6353.2015.04.008. Li SX,Zhang HW,Liu FL,et al.Application value of linear cutting stapler in the treatment of total Hirschsprung’s disease[J].J Clin Ped Sur,2015,14(4):281-283.DOI:10.3969/j.issn.1671-6353.2015.04.008.
11 钟微,余家康,夏慧敏,等.全结肠型巨结肠患儿术后远期疗效及营养状况评估[J].中华胃肠外科杂志,2012,15(5):480-483.DOI:10.3760/cma.j.issn.1671-0274.2012.05.020. Zhong W,Yu JK,Xia HM,et al.Long-term outcomes and nutrition evaluation in children with total colonic aganglionosis[J].Chinese Journal of Gastrointestinal Surgery,2012,15(5):480-483.DOI:10.3760/cma.j.issn.1671-0274.2012.05.020.
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备注/Memo
收稿日期:2019-11-22。
基金项目:河北省重点研发计划健康医疗与生物医药专项项目（编号：18277747D）
通讯作者:徐伟立,Email:drxwl99@126.com