Teeraratkul Sumate
Pediatric Surgery Unit, Department of Surgery, Ramathibodi Hospital, Mahidol University, Rajathavi, Bangkok, Thailand.
J Pediatr Surg. 2003 Feb;38(2):184-7. doi: 10.1053/jpsu.2003.50039.
This report presents the technique and results of transanal one-stage endorectal pull-through procedure in children with rectosigmoid lesions from Hirschsprung's disease.
Eight children aged one month to 6 years with frozen section biopsy-proven Hirschsprung's disease underwent transanal one-stage endorectal pull-through procedures during a 12-month period. A rectosigmoid transitional zone was suggested by contrast enema in 7 patients; rectal manometry was done to confirm the diagnosis in one patient. Preoperative colonic irrigation to evacuate feces out of the dilated colon was done in the hospital. Bowel preparation was the same as conventional colorectal surgery. Full-thickness rectal biopsy at 1 to 2 cm above the dentate line was submitted for pathologic diagnosis. A rectal mucosectomy dissection was started 0.5 cm proximal to the dentate lines and was extended into the intraperitoneal rectum. The muscular sleeve was divided circumferentialy at 3 to 4 cm proximal to the dentate line, exposing the intraperitoneal rectum and allowing full-thickness mobilization of the rectosigmoid colon out of the anus. Aganglionic colon segment was resected, and the normal colon was pull down to anastomose with the distal end of anorectal mucosa.
Operating time, including taking frozen sections, ranged from 110 to 180 minutes. The length of bowel resections ranged from 9 to 25 cm. The length of hospital stay depended on the amount of fecal impaction in the colon. Older children with substantial fecal impaction required 2 weeks of preoperative saline enema. One infant needed 3 days for bowel preparation, the same as for conventional colorectal surgery. The hospital stay ranged from 6 to 7 days in children younger than 2 years and 10 to 28 days in older children. There were no intraoperative or postoperative complications related to the pull-through procedure. One case of colitis occurred in the 6-year-old child, which required rectal tube decompression one week after the operation. Seven patients passed stool within 24 hours after surgery. All patients had normal bowel movements within 3 weeks. There was no rectal cuff stricture or enterocolitis during one year of follow-up.
Transanal one-stage endorectal pull-through operations for rectosigmoid lesions from Hirschsprung's disease can be performed successfully in all ages of children with good results, avoiding transabdominal exploration. The early postoperative enterocolitis in the older children might occur and should be treated urgently. The partial coloanal anastomosis obstruction found in older children could be treated by placing a rectal tube into the anus to decompress the dilated pull-through colon. The limitation of this approach is that retroperitoneal fixation of the descending colon could not be dissected by the transanal route.
本报告介绍了经肛门一期直肠内拖出术治疗患有乙状结肠直肠型先天性巨结肠症患儿的技术及结果。
在12个月期间，8例年龄从1个月至6岁、经冰冻切片活检证实为先天性巨结肠症的患儿接受了经肛门一期直肠内拖出术。7例患者经钡剂灌肠提示存在乙状结肠直肠移行区；1例患者进行了直肠测压以确诊。术前在医院进行结肠灌洗以清除扩张结肠内的粪便。肠道准备与传统结直肠手术相同。在齿状线以上1至2厘米处取全层直肠活检送病理诊断。在齿状线近端0.5厘米处开始进行直肠黏膜切除术，并延伸至腹膜内直肠。在齿状线近端3至4厘米处环形切断肌鞘，暴露腹膜内直肠，使乙状结肠直肠能够全层从肛门拖出。切除无神经节的结肠段，将正常结肠下拉与肛管黏膜远端吻合。
手术时间（包括取冰冻切片）为110至180分钟。肠切除长度为9至25厘米。住院时间取决于结肠内粪便嵌塞的程度。年龄较大且有大量粪便嵌塞的患儿术前需要2周的生理盐水灌肠。1例婴儿肠道准备需要3天，与传统结直肠手术相同。2岁以下患儿住院时间为6至7天，年龄较大患儿为10至28天。没有与拖出术相关的术中或术后并发症。1例6岁患儿术后发生结肠炎，术后1周需要肛管减压。7例患者术后24小时内排便。所有患者在3周内排便正常。随访1年期间未出现直肠袖口狭窄或小肠结肠炎。
经肛门一期直肠内拖出术治疗乙状结肠直肠型先天性巨结肠症可成功应用于各年龄段患儿，效果良好，避免了经腹探查。年龄较大患儿术后早期可能发生小肠结肠炎，应紧急处理。年龄较大患儿出现的部分结肠肛管吻合口梗阻可通过经肛门放置肛管对扩张的拖出结肠进行减压治疗。该方法的局限性在于经肛门途径无法游离降结肠的腹膜后固定。
