Langer J C, Minkes R K, Mazziotti M V, Skinner M A, Winthrop A L
Department of Surgery, Washington University School of Medicine, St Louis, MO, USA.
J Pediatr Surg. 1999 Jan;34(1):148-51; discussion 152. doi: 10.1016/s0022-3468(99)90246-4.
Many centers perform a one-stage pull-through procedure for Hirschsprung's disease (HD) diagnosed in infancy. The authors have developed a one-stage pullthrough procedure using a transanal approach that eliminates the need for intraabdominal dissection.
Nine children aged 3 weeks to 18 months with biopsy-proven HD underwent a transanal pull-through procedure over a 13-month period. A rectal mucosectomy was performed starting 0.5 cm proximal to the dentate line, and extending proximally to the level of the intraperitoneal rectum. In the first eight children, intraperitoneal position was confirmed with a laparoscope placed through a 3- to 5-mm port in the base of the umbilicus. The muscular sleeve was divided circumferentially to allow full-thickness mobilization of the rectosigmoid junction. Manual transanal traction permitted direct visualization and division of mesenteric vessels with transanal mobilization above the transition zone. Ganglion cells were confirmed by frozen section, and the bowel was transected. The rectal muscular cuff was divided longitudinally, and the anastomosis was completed. The laparoscope confirmed orientation and adequate hemostasis. In a ninth patient, the identical procedure was performed, but with the laparoscope used only for confirmation at the end of the procedure.
Operative time, including frozen sections, averaged 194 minutes (range, 169 to 250 minutes), and the average length of bowel resected was 12 cm (range, 7.5 to 22 cm). Four of the nine patients were discharged on postoperative day (POD) 1, four on POD 2, and one patient with Down's syndrome was discharged on POD 6. Median follow-up was 6 months (range, 3 to 14 months). One death occurred 2.5 months postoperatively secondary to sudden infant death syndrome. Complications included postoperative apnea spells (n = 1), mild enterocolitis (n = 2), constipation (n = 1), anastomotic stricture(n = 1), and muscularcuff narrowing (n = 1); each responded to nonoperative management. Stool output has ranged from four to eight per day.
A one-stage pull-through for HD can be performed successfully using a transanal approach without intraperitoneal dissection. This procedure is associated with excellent clinical results and permits early postoperative feeding, early hospital discharge, and no visible scars.
许多中心对婴儿期诊断出的先天性巨结肠（HD）采用一期拖出术。作者开发了一种经肛门入路的一期拖出术，无需进行腹腔内解剖。
9名年龄在3周龄至18个月的经活检证实为HD的儿童在13个月期间接受了经肛门拖出术。在齿状线近端0.5 cm处开始进行直肠黏膜切除术，并向近端延伸至腹膜内直肠水平。在前8名儿童中，通过脐部底部3至5 mm的端口插入腹腔镜来确认腹膜内位置。将肌鞘沿圆周方向切开，以使直肠乙状结肠交界处能够进行全层游离。经肛门手动牵引可直接观察并经肛门在过渡区上方游离时切断肠系膜血管。通过冰冻切片确认神经节细胞，然后切断肠管。纵向切开直肠肌袖，完成吻合。腹腔镜确认方位并确保充分止血。在第9例患者中，进行了相同的手术，但腹腔镜仅在手术结束时用于确认。
包括冰冻切片在内，手术时间平均为194分钟（范围为169至250分钟），平均切除肠管长度为12 cm（范围为7.5至22 cm）。9例患者中有4例在术后第1天出院，4例在术后第2天出院，1例唐氏综合征患者在术后第6天出院。中位随访时间为6个月（范围为3至14个月）。1例患者术后2.5个月因婴儿猝死综合征死亡。并发症包括术后呼吸暂停发作（n = 1）、轻度小肠结肠炎（n = 2）、便秘（n = 1）、吻合口狭窄（n = 1）和肌袖狭窄（n = 1）；均通过非手术治疗得到缓解。每日排便次数为4至8次。
采用经肛门入路且无需腹腔内解剖，可成功进行HD一期拖出术。该手术具有出色的临床效果，允许术后早期喂养、早期出院且无明显瘢痕。
