Wester T, Rintala R J
Children's Hospital, University of Helsinki, Helsinki, Finland.
J Pediatr Surg. 2004 Feb;39(2):157-60; discussion 157-60. doi: 10.1016/j.jpedsurg.2003.10.007.
BACKGROUND/PURPOSE: Transanal pull-through has been advocated recently for classic Hirschsprung's disease. The procedure leaves no scars, is associated with less postoperative pain and discomfort, and shortens hospital stay. Long-term functional outcome of patients having transanal pull-through is unclear, but short-term function is reported to be very similar to that after open or laparoscopic procedures. One-stage neonatal repair of Hirschsprung's disease has been suggested to be associated with less cost and demand of resources without jeopardizing functional outcome. The aim of this study was to ascertain the feasibility and safety of transanal pull-through in the neonatal period.
Case notes of 40 consecutive patients who had undergone transanal endorectal pull-through for Hirschsprung's disease between January 2000 and February 2003 were reviewed. The patients were divided in to 3 groups: patients with neonatal primary pull-through (group I, 15 patients), patients operated on beyond the neonatal period (group II, 11 patients), and patients with a previous colostomy (group III, 14 patients). All colostomies except one were taken down and pulled through concomitantly with the transanal procedure. The case notes were evaluated for hospital stay, time to full oral feedings, operative and postoperative complications, need for postoperative dilatations, and occurrence of postoperative enterocolitis.
There was no difference in median hospital stay (group I, 5 days; group II, 4; group III, 5) and median time to full oral feedings (group I, 4 days; group II, 2; group III, 3) between groups. Two patients (group III) had immediate postoperative prolapse of the pulled-through colon that was reduced without further sequels; 1 (group III) had infection of the stoma closure wound. Perianal skin rash that usually resolved within 6 weeks occurred more often in neonatal patients (group I, 10 of 15; group II: 4 of 11; group III: 8 of 14). Anastomotic dilatation regimen was required more often in neonatal cases (group I, 6 of 15; group II, 1 of 11; group III, 2 of 14). Enterocolitis requiring hospital care occurred in 2 patients (group I), 5 further patients (group II, 1; group III, 4) were treated as outpatients for symptoms suggesting mild enterocolitis or bacterial overgrowth. The median follow-up was 6 months.
Transanal endorectal pull-through in neonatal patients is as feasible and safe as in older children or in those with a levelling colostomy. However, temporary postoperative skin rash occurs more frequently in neonatal patients, and postoperative dilatations are required more often than in older children.
背景/目的：近期有人主张采用经肛门拖出术治疗典型的先天性巨结肠症。该手术不留疤痕，术后疼痛和不适较少，且缩短了住院时间。经肛门拖出术患者的长期功能结局尚不清楚，但据报道其短期功能与开放手术或腹腔镜手术术后的功能非常相似。有人提出，先天性巨结肠症的一期新生儿修复术成本较低且资源需求较少，同时不影响功能结局。本研究的目的是确定新生儿期经肛门拖出术的可行性和安全性。
回顾了2000年1月至2003年2月期间连续40例因先天性巨结肠症接受经肛门直肠拖出术患者的病历。患者分为3组：新生儿期初次拖出术患者（I组，15例）、新生儿期后接受手术的患者（II组，11例）和既往有结肠造口术的患者（III组，14例）。除1例结肠造口术外，其余所有结肠造口术均在经肛门手术的同时还纳并拖出。对病历进行评估，记录住院时间、完全经口喂养时间、手术及术后并发症、术后扩张需求以及术后小肠结肠炎的发生情况。
各组之间的中位住院时间（I组，5天；II组，4天；III组，5天）和完全经口喂养的中位时间（I组，4天；II组，2天；III组，3天）无差异。2例患者（III组）术后出现拖出结肠立即脱垂，复位后无进一步后遗症；1例患者（III组）造口关闭伤口感染。肛周皮疹通常在6周内消退，在新生儿患者中更常见（I组，15例中有10例；II组，11例中有4例；III组，14例中有8例）。新生儿病例更常需要吻合口扩张治疗（I组，15例中有6例；II组，11例中有1例；III组，14例中有2例）。2例患者（I组）发生需要住院治疗的小肠结肠炎，另有5例患者（II组1例；III组4例）因提示轻度小肠结肠炎或细菌过度生长的症状作为门诊患者接受治疗。中位随访时间为6个月。
新生儿患者经肛门直肠拖出术与大龄儿童或有结肠造口术的患者一样可行且安全。然而，新生儿患者术后短暂性皮疹的发生率更高，且术后扩张的需求比大龄儿童更频繁。
