Pediatric Surgical Centre of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
J Pediatr Surg. 2010 Jul;45(7):1505-8. doi: 10.1016/j.jpedsurg.2010.02.042.
BACKGROUND/PURPOSE: Usually, anorectal malformations (ARM) are treated in 2 or 3 stages for fear of disturbed wound healing and subsequent damage to the anal sphincter complex. The aim of this study was to assess the feasibility, safety, advantages, and follow-up of an anterior or posterior sagittal anorectoplasty in low-type ARM (rectoperineal or rectovestibular), performed without colostomy.
Prospective collection of data regarding demographics, VACTERL (Vertebral-, Anal-, Cardiac-, Tracheo-Esophageal-, Renal-, Limb malformations) screening, perioperative measurements, surgeons, and complications.
In 35 consecutive children (13 boys, 22 girls), repair of a low-type ARM was performed without colostomy. There were 13 boys and 10 girls with a rectoperineal and 12 girls with a rectovestibular fistula. The median age at operation was 4 months (range, 0-73 months); 34% being performed in the newborn period. Seventeen children had one or more other congenital anomaly. Preoperatively, all patients had rectal washouts with oral and rectal neomycin, and perioperative antibiotics, either 24 h (prophylaxis) or for 2 to 5 days. An anterior or posterior sagittal anorectoplasty was performed. Postoperatively, 9 children had no enteral feeding and total parenteral nutrition (TPN). All children had postoperative anal dilatations according to the Peña scheme. Two children (both with rectoperineal fistula) had a wound abscess; in the first child (with renal insufficiency), a colostomy was performed and in the other child a successful correction of the anoplasty was done. In 7 children (4 rectoperineal, 3 rectovestibular fistulae), the anus eventually healed after minor wound dehiscence. There was 1 anal stricture, after a median follow up of 14 months (range, 1-84 mo). After therapeutic antibiotics (2-5 days), 11% (2/18) had some degree of wound infection, versus 41% (7/17) after either no antibiotics or after prophylactic antibiotics (24 hours). Patients with TPN did not seem to profit with regard to wound healing and one patient experienced a central line related sepsis. At last follow-up, 12 children needed regular laxatives and/or enemas. Anal dilatations were well accepted above 6 months, and a trend was seen towards less need for laxatives when dilatations were continued longer.
Repair of a low-type ARM without colostomy, with therapeutic antibiotics, and followed by a long period of postoperative anal dilatations has low morbidity and good outcome, which does not seem to be improved with TPN.
背景/目的：通常情况下，为了避免伤口愈合受到干扰以及随后对肛门括约肌复合体造成损害，会分 2 到 3 期治疗肛肠畸形（ARM）。本研究旨在评估低型 ARM（直肠会阴型或直肠前庭型）行无需造口术的前路或后路矢状肛直肠成形术的可行性、安全性、优势和随访情况。
前瞻性收集有关人口统计学、VACTERL（脊柱、肛门、心脏、气管食管、肾脏、肢体畸形）筛查、围手术期测量、外科医生和并发症的数据。
在 35 例连续的 ARM 患儿（13 名男孩，22 名女孩）中，无需造口术修复低型 ARM。其中 13 例为直肠会阴瘘，10 例为直肠前庭瘘，12 例为直肠阴道瘘。手术时的中位年龄为 4 个月（范围，0-73 个月）；34%的患儿在新生儿期进行手术。17 例患儿存在 1 种或多种其他先天性异常。术前，所有患儿均接受直肠冲洗和口服及直肠新霉素治疗，并接受围手术期抗生素治疗，24 小时（预防）或 2-5 天。行前路或后路矢状肛直肠成形术。术后，9 例患儿无肠内喂养，采用全肠外营养（TPN）。所有患儿均根据 Peña 方案进行术后肛门扩张。2 例患儿（均为直肠会阴瘘）发生伤口脓肿；第一例患儿（合并肾功能不全）行造口术，另一例患儿成功矫正了肛门成形术。7 例患儿（4 例为直肠会阴瘘，3 例为直肠前庭瘘）术后轻微伤口裂开后肛门最终愈合。1 例出现肛门狭窄，中位随访时间为 14 个月（范围，1-84 个月）。在接受治疗性抗生素（2-5 天）后，11%（2/18）出现一定程度的伤口感染，而在未使用抗生素或预防性使用抗生素（24 小时）后，这一比例为 41%（7/17）。接受 TPN 的患儿在伤口愈合方面似乎没有受益，1 例患儿发生与中心静脉置管相关的败血症。末次随访时，12 例患儿需要定期使用泻药和/或灌肠。6 个月以上患儿对肛门扩张的接受度良好，且当延长肛门扩张时间时，使用泻药的需求似乎减少。
无需造口术、使用治疗性抗生素，并在术后长期进行肛门扩张治疗低型 ARM 的方法具有较低的发病率和良好的结局，而 TPN 的应用似乎并不能改善其结果。
