Rintala R J
Children's Hospital, University of Helsinki, Helsinki, Finland.
Eur J Pediatr Surg. 2003 Jun;13(3):181-6. doi: 10.1055/s-2003-41264.
A totally transanal operation for classic Hirschsprung's disease has become increasingly popular during the last few years. The procedure leaves no scars, is associated with less postoperative pain and discomfort and shortens hospital stay. The most commonly used technique for transanal pull-through is long endorectal dissection leaving a long muscular cuff, which is usually split posteriorly. We present our preliminary results following transanal endorectal operations with a short unsplit muscular cuff.
Twenty-six patients underwent short-cuff transanal endorectal operation for Hirschsprung's disease between years 2000 and 2002. Patients' hospital records were analysed retrospectively. The collected data included age at operation, associated conditions, hospital stay and time to full enteral feeding, occurrence of pre- and postoperative enterocolitis and preoperative stoma, operative complications, need for postoperative anal dilatations, postoperative perianal skin problems and preliminary data on bowel function.
The median age at operation was 1 month (range 0 - 60 months), 13 patients were operated on in the neonatal period. Four patients had Down's syndrome, 1 had cartilage-hair hypoplasia and one Ondine's syndrome. Five patients had preoperative enterocolitis. Four patients had undergone levelling stoma formation for unremitting constipation or enterocolitis. The proximal ganglionic stoma was concomitantly pulled-through and anastomosed to the anus in all 4 patients with a stoma. One patient with aganglionosis extending to the proximal sigmoid required additional laparoscopic colonic mobilisation. Complications related to surgery did not occur in the present series. Median postoperative hospital stay was 3 days (range 2 - 21 days) and median time to full enteral feeding was 3 days (range 1 - 14). Six patients required anal dilatations, two of those for a period of 3 weeks. The median follow-up time was 6 months (range 1 - 22 months). Fourteen patients had perianal skin rash, which usually resolved within 6 weeks. Postoperative enterocolitis requiring hospitalisation occurred in 1 patient, another patient had mild symptoms suggesting enterocolitis; these responded to oral antibiotic treatment. Early postoperative bowel function was characterised by frequent bowel movements in most patients. This usually resolved within a few months; of the 15 patients with a follow-up of longer than 6 months only 2 have more than 3 bowel movements per day. At the last follow-up frank soiling occurred in 1 patient with Down's syndrome, one patient requires oral laxatives for constipation.
Transanal endorectal pull-through with a short cuff is a safe operation with a low incidence of operative and postoperative complications. Hospital stay and time to full enteral feeds is significantly shorter than after conventional procedures; this is associated with lower hospital costs. Long-term functional outcome is unclear but short-term function is very similar to that after procedures where transanal mucosectomy is combined with open rectosigmoid dissection.
在过去几年中，经典型先天性巨结肠的经肛门全直肠系膜切除术越来越受欢迎。该手术不留疤痕，术后疼痛和不适较少，且缩短了住院时间。最常用的经肛门拖出术技术是长段直肠内剥离，保留长肌袖，通常在后方劈开。我们展示了采用短肌袖且未劈开的经肛门直肠内手术的初步结果。
2000年至2002年间，26例患者因先天性巨结肠接受了短肌袖经肛门直肠内手术。对患者的医院记录进行回顾性分析。收集的数据包括手术年龄、相关疾病、住院时间和完全肠内喂养时间、术前和术后小肠结肠炎的发生情况及术前造口情况、手术并发症、术后肛门扩张的需求、术后肛周皮肤问题以及肠道功能的初步数据。
手术时的中位年龄为1个月（范围0 - 60个月），13例患者在新生儿期接受手术。4例患者患有唐氏综合征，1例患有软骨毛发发育不全，1例患有翁丁氏综合征。5例患者有术前小肠结肠炎。4例患者因持续性便秘或小肠结肠炎行结肠造口术。所有4例有造口的患者，其近端神经节造口均同时拖出并与肛门吻合。1例神经节缺如延伸至乙状结肠近端的患者需要额外的腹腔镜结肠游离术。本系列未发生与手术相关的并发症。术后中位住院时间为3天（范围2 - 21天），完全肠内喂养的中位时间为3天（范围1 - 14天）。6例患者需要肛门扩张，其中2例持续3周。中位随访时间为6个月（范围1 - 22个月）。14例患者有肛周皮疹，通常在6周内消退。1例患者发生需要住院治疗的术后小肠结肠炎，另1例患者有提示小肠结肠炎的轻微症状，经口服抗生素治疗后缓解。大多数患者术后早期肠道功能的特点是排便频繁。这通常在几个月内缓解；在15例随访时间超过6个月的患者中，只有2例每天排便超过3次。在最后一次随访时，1例唐氏综合征患者出现明显的便污，1例患者因便秘需要口服泻药。
短肌袖经肛门直肠内拖出术是一种安全的手术，手术及术后并发症发生率低。住院时间和完全肠内喂养时间明显短于传统手术；这与较低的住院费用相关。长期功能结果尚不清楚，但短期功能与经肛门黏膜切除术联合开放直肠乙状结肠剥离术的术后功能非常相似。
