改良腹腔镜辅助 Duhamel 结肠次全切除术治疗长段型先天性巨结肠症

摘要

目的：探讨改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症（ Hirschsprung disease ，HD）的并发症和疗效。方法回顾分析2010年3月～2014年1月12例长段型HD资料，男7例，女5例，中位年龄8月（5月～6岁）。其中移行区位于降结肠近端8例，横结肠2例，结肠肝曲1例，升结肠1例。7例行结肠造瘘。手术主要改良之处：经肛门齿状线上方直肠后壁切口将结肠拖出至肛门外，用Endo－GIA肛门外切断并封闭，保留直肠残端4～5 cm。然后结合Deloyer技术将升结肠拖下与原直肠后壁端侧吻合，再将Endo－GIA切缝器两肢分别放入原直肠和新直肠，切开两段肠管间隔并行侧侧吻合。观察术中术后并发症及排便功能。结果12例均在腹腔镜辅助下完成次全结肠切除升结肠Duhamel拖出术，平均手术时间170 min（125～240 min），未出现术中并发症，无吻合口漏。4例诉肛周疼痛，1例术后5天便血，保守治疗治愈。大便频率2周以内4～15次／天，恢复到正常排便频率（1～2次／天）时间平均3．5月（2．2～5个月）。平均随访时间32个月（3～46个月），2例术后小肠结肠炎，1例早期有便秘症状，均保守治疗治愈。无闸门综合征和粪石发生，无大便失禁。结论改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型HD安全有效，排便频率恢复正常快。肛门外处理直肠盲端简单可靠，腹壁创伤小。%Objective To discuss the efficacy of modified laparoscopic Duhamel subtotal colectomy for extended Hirschsprung’s disease (HD). Methods Between March 2010 and January 2014, 12 children (male, 7 cases;female, 5 cases) with extended HD underwent a modified laparoscopic Duhamel subtotal colectomy .The median age at operation was 8 months old ( 5 months-6 years).The level of the transition zone was in the proximal descending colon in 8 cases, the transverse colon in 2 cases, the hepatic flexure of the colon in 1 case, and the ascending colon in 1 case, respectively.Seven children received a colostomy .During the operation , extracorporeal low rectal transection was performed by using Endo-GIA through the incision in the posterior rectum above the dentate line, with short rectal stump 4 -5 cm in length.Then the ascending colon was pulled down to perform an end-to-side anastomosis with the rectum by using the Deloyer artifice .Finally, a side-to-side anastomosis was conducted between the rectum and reconstructed rectum by using Endo-GIA.Intra-and post-operative complications and bowel functional outcomes were evaluated . Results The operation was completed laparoscopically in all the patients .The mean operating time was 170 min (125-240 min). No intraoperative complications were observed .No leakage was observed .Defecation frequency within two weeks was 4-15 times per day.Timespan to obtain normal frequency (1-2 times per day) was 3.5 months (2.2-5 months).The mean follow-up period was 32 months (3-46 months).The enterocolitis occurred postoperatively in 2 cases, 1 of which showed episodes of constipation during the early follow-up period , and they were all responded to conservative treatment .All achieved normal defecation without incontinence and gate syndrome . Conclusions Modified laparoscopic Duhamel subtotal colectomy for extended HD has quick recovery and good bowel functions .Extracorporeal rectal transection using Endo-GIA was easy to perform and credible , with less damage to the abdominal wall .