Rintala R J, Lindahl H G
Children's Hospital, University of Helsinki, Finland.
J Pediatr Surg. 1999 Feb;34(2):334-7. doi: 10.1016/s0022-3468(99)90203-8.
BACKGROUND/PURPOSE: It is unclear which surgical method offers best long-term functional results in patients with high anorectal anomalies. The purpose of this study was to compare the long-term outcome of sacroperineal-sacroabdominoperineal pull-through (SP-SAP) to that of posterior sagittal anorectoplasty (PSARP).
Only boys with high anorectal anomalies (rectourethral fistula) were included in the study to get fully comparable patient groups. From 1975 to 1987, 36 consecutive patients underwent anorectal reconstruction: 19 had SP-SAP (1975 to 1983) and 17 PSARP (12 with internal sphincter-sparing technique, 1983 to 1987). The late bowel function (age at follow up, SP-SAP, 19 years; range, 15 to 22; PSARP, 13 years; range, 10 to 19) was evaluated by clinical interview and examination, and anorectal manometry.
Six (35%) of the PSARP patients and one (5%) of the SP-SAP patients (P < .04) were always clean without any adjunctive measures. Three PSARP patients and two SP-SAP patients stayed clean with daily enemas. In the PSARP patients with soiling, the median frequency of soiling episodes in a month was four (range, 1 to 16), in the SP-SAP patients, 20 (range, 2 to 28, P < .001). None of the SP-SAP patients but 8 of 17 of the PSARP patients had constipation requiring diet or oral medication. Two PSARP patients and four SP-SAP patients had occasional faecal accidents. The median daily bowel movements in the PSARP group was one (range, one to four) and in the SP-SAP group, three (range, one to five, P < .001). The PSARP patients had significantly higher anorectal resting and squeeze pressures and voluntary sphincter force (cm/H2O, PSARP: mean resting, 47+/-9; mean squeeze, 106+/-29; mean voluntary sphincter force, 60+/-22; SP/SAP: mean resting, 27+/-10; mean squeeze, 68+/-22; mean voluntary sphincter force, 41+/-17; P < .01). Thirteen (76%) of the 17 PSARP patients and none of SP-SAP patients had positive rectoanal reflex indicating functional internal sphincter.
In boys with high anorectal anomalies, PSARP clearly is superior to sacroperineal and sacroabdominoperineal pull-through in terms of long-term bowel function and faecal continence.
背景/目的：目前尚不清楚哪种手术方法能为高位肛门直肠畸形患者带来最佳的长期功能结果。本研究的目的是比较骶会阴 - 骶腹会阴拖出术（SP - SAP）与后矢状入路肛门直肠成形术（PSARP）的长期疗效。
本研究仅纳入患有高位肛门直肠畸形（直肠尿道瘘）的男孩，以获得完全可比的患者组。1975年至1987年，连续36例患者接受了肛门直肠重建手术：19例接受了SP - SAP手术（1975年至1983年），17例接受了PSARP手术（12例采用保留内括约肌技术，1983年至1987年）。通过临床访谈、检查及肛门直肠测压评估晚期肠道功能（随访时年龄，SP - SAP组为19岁；范围15至22岁；PSARP组为13岁；范围10至19岁）。
PSARP组中有6例（35%）患者和SP - SAP组中有1例（5%）患者在无需任何辅助措施的情况下始终保持清洁（P <.04）。3例PSARP患者和2例SP - SAP患者通过每日灌肠保持清洁。在有粪便污染的PSARP患者中，每月粪便污染发作的中位数频率为4次（范围1至16次），在SP - SAP患者中为20次（范围2至28次，P <.001）。SP - SAP组患者均无便秘情况，而PSARP组17例患者中有8例需要通过饮食或口服药物治疗便秘。2例PSARP患者和4例SP - SAP患者偶尔发生粪便失禁。PSARP组每日排便次数中位数为1次（范围1至4次），SP - SAP组为3次（范围1至5次，P <.001）。PSARP组患者的肛门直肠静息压、收缩压和自主括约肌力量显著更高（厘米水柱，PSARP：平均静息压，47±9；平均收缩压，106±29；平均自主括约肌力量，60±22；SP/SAP：平均静息压，27±10；平均收缩压，68±22；平均自主括约肌力量，41±17；P <.01）。17例PSARP患者中有13例（76%）存在直肠肛门反射阳性，提示内括约肌功能正常，而SP - SAP组患者均无此情况。
对于患有高位肛门直肠畸形的男孩，就长期肠道功能和粪便失禁情况而言，PSARP明显优于骶会阴和骶腹会阴拖出术。
