Aggarwal Satish Kumar, Yadav Sunil, Goel Deepak, Sengar Mamta
Department of Pediatric Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India.
J Pediatr Surg. 2002 Aug;37(8):1156-9. doi: 10.1053/jpsu.2002.34462.
BACKGROUND/PURPOSE: In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and retained aganglionosis after a previous operation. Duhamel or Swenson method is used commonly for redo operations. The pelvic dissection may be difficult, especially in Swenson's type of operation, because of fibrosis resulting from previous surgery or its complications. To overcome this, the authors used a combined abdominal and posterior sagittal approach to perform redo pull-through of Swenson's type in 4 children.
Four boys (2.5 to 12 years) underwent redo pull-through for failed endorectal pull through (n = 2), persistent symptoms after 2 myectomies (n = 1) and late anastomotic disruption after Swenson's PT (n = 1). Abdominal dissection was done first to mobilize colon and resect aganglionic segment as far as the mid pelvis. The mobilized ganglionic colon was tacked to the pelvic rectal stump, hemostasis checked, and the abdomen closed. The lower pelvic dissection was done through the posterior sagittal route, under direct vision. The remainder of diseased rectum was excised, and the pull-through colon was retrieved and anastomosed to the anal stump. No covering colostomy was done.
A rectocutaneous fistula developed in one patient, which healed spontaneously. All patients had increased stool frequency in the early postoperative period but improved with time. All patients have attained normal voluntary bowel actions, but one child has infrequent minor soiling. There was no anastomotic narrowing in any case.
Posterior sagittal approach is a useful alternative in difficult redo pull-through surgery. It offers excellent exposure, precise dissection, and direct anastomosis. There are minimal chances of complications, and continence is retained.
背景/目的：在先天性巨结肠症（HD）中，再次拖出术（PT）适用于吻合口并发症以及先前手术后残留的无神经节细胞症。再次手术通常采用杜哈梅尔或斯文森术式。盆腔解剖可能会很困难，尤其是在斯文森术式中，因为先前手术或其并发症导致的纤维化。为克服这一问题，作者采用经腹联合后矢状入路，为4例患儿实施了斯文森式再次拖出术。
4名男孩（年龄2.5至12岁）接受了再次拖出术，原因分别为经直肠拖出术失败（n = 2）、两次肌切除术（n = 1）后仍有持续症状以及斯文森PT术后晚期吻合口破裂（n = 1）。首先进行腹部解剖，游离结肠并切除无神经节段直至中盆腔。将游离的有神经节结肠固定于盆腔直肠残端，检查止血情况后关闭腹部。通过后矢状入路在直视下进行下盆腔解剖。切除剩余病变直肠，将拖出的结肠取出并与肛门残端吻合。未行保护性结肠造口术。
1例患者出现直肠皮肤瘘，自行愈合。所有患者术后早期排便次数均增加，但随时间推移有所改善。所有患者均已实现正常自主排便，但1名儿童偶尔有轻微便污。所有病例均未出现吻合口狭窄。
后矢状入路是困难的再次拖出手术的一种有用替代方法。它提供了良好的暴露、精确的解剖和直接吻合。并发症几率极小，且保留了控便能力。
