Cincinnati Children's Hospital Colorectal Center, Cincinnati, OH, USA.
Cincinnati Children's Hospital Colorectal Center, Cincinnati, OH, USA.
J Pediatr Surg. 2024 Jan;59(1):86-90. doi: 10.1016/j.jpedsurg.2023.09.024. Epub 2023 Sep 22.
A proximal resection margin greater than 5 cm from the intra-operative histologically determined transition zone has been deemed necessary to minimize the risk of transition zone pull-through. This extended resection may require the sacrifice of vascular supply and even further bowel resection. The impact of extended proximal resection margin on post-operative complications and functional outcomes is unclear.
A retrospective chart review of patients who underwent primary pull-through for Hirschsprung disease at a single institution between January 2008 and December 2022 was performed. An adequate proximal margin was defined by a circumferential normally ganglionated ring and absence of hypertrophic nerves. The extended margin was defined as the total length of proximal colon with normal ganglion cells and without hypertrophic nerves. Fecal incontinence severity was assessed with the Pediatric Fecal Incontinence Severity Score (PFISS).
Eighty seven patients met criteria for inclusion. Median age at primary pull-through was 17 days (IQR 10-92 days), 55% (n = 48) of patients had an extended proximal margin (EPM) ≤ 5 cm, and 45% (n = 39) had an EPM > 5 cm. An EPM ≤5 cm was not associated with increased rates of Hirschsprung associated enterocolitis (≤5 cm 43%, >5 cm 39%, P = 0.701), diversion post pull-through (≤5 cm 10%, >5 cm 5%, P = 0.367) or reoperation for transition zone pull-through (≤5 cm 3%, >5 cm 0%, P = 0.112). EPM ≤5 cm had more frequent involuntary daytime bowel movements (P = 0.041) and more frequent voluntary bowel movements (P = 0.035). There were no differences in other measures of fecal incontinence severity.
Shorter proximal extended margins beyond the adequate ganglionated margin do not significantly impact post-operative complication rates and have an unclear effect on fecal incontinence.
Case Control.
Level III.
为了最大限度地降低移行区拉通的风险，术中病理确定的移行区近端切缘距离应大于 5cm。这种广泛的切除可能需要牺牲血管供应，甚至需要进一步进行肠切除。目前尚不清楚延长近端切缘对术后并发症和功能结果的影响。
对 2008 年 1 月至 2022 年 12 月在单家机构接受原发性拉通术治疗先天性巨结肠症的患者进行回顾性图表审查。适当的近端切缘定义为环形正常神经节段和无肥大神经。扩展切缘定义为具有正常神经节细胞且无肥大神经的近端结肠总长度。粪便失禁严重程度采用儿科粪便失禁严重程度评分（PFISS）进行评估。
87 例患者符合纳入标准。初次拉通的中位年龄为 17 天（IQR 10-92 天），55%（n=48）的患者近端有扩展切缘（EPM）≤5cm，45%（n=39）的患者近端有 EPM＞5cm。EPM≤5cm 与更高的先天性巨结肠相关结肠炎发生率无关（≤5cm 43%，＞5cm 39%，P=0.701），拉通后分流术（≤5cm 10%，＞5cm 5%，P=0.367）或因移行区拉通而再次手术（≤5cm 3%，＞5cm 0%，P=0.112）。EPM≤5cm 的患者日间非自愿性排便更频繁（P=0.041），自愿性排便更频繁（P=0.035）。粪便失禁严重程度的其他指标没有差异。
超出适当神经节段的近端延长切缘较短不会显著影响术后并发症发生率，对粪便失禁的影响也不清楚。
病例对照。
III 级。
