腹腔镜辅助 Duhamel 结肠次全切除术治疗肠神经元发育不良症

摘要

目的总结腹腔镜辅助 Duhamel 结肠次全切除术治疗肠神经元发育不良症 B 型（IND —B）的操作技巧，探讨其临床疗效。方法2010年至2014年，我们收治29例 IND — B 型患儿，经规范的保守治疗仍存在顽固型便秘，延迟拍片提示钡剂残留位于脾曲以近的结肠。均接受腹腔镜辅助 Du-hamel 结肠次全切除术，平均手术年龄为5岁2个月。手术操作按照 Smith 方法有改进：将腹腔镜下腹腔内直肠的离断改为经直肠后壁切口肛门外直肠离断。结果所有病例均在腹腔镜下顺利完成手术，平均手术时间为180 min，术中无并发症。术后发生小肠结肠炎1例，便血1例，均经保守治疗好转。均获随访，平均随访时间31个月，无吻合口狭窄、污粪发生。术后第2周排便频率为每日3～18次，第4周排便频率为每日6～10次，术后平均3．5个月，排便次数达到正常。1例术后需持续扩肛3个月。无一例出现便秘复发、大便失禁。结论腹腔镜辅助 Duhamel 结肠次全切除术治疗 IND — B 患儿安全有效，操作简便，创伤小，术后排便次数少，需扩肛的患儿少。%Objective To describe our technique about modified laparoscopic Duhamel procedure with subtotal colectomy for intestinal neuronal dysplasia type B(IND—B)and evaluate the clinical outcomes.Meth-ods 29 children with IND—B underwent a modified laparoscopic Duhamel procedure with subtotal colectomy, whose bowel symptoms such as chronic constipation persisted after conservative treatment between 2010 and 2014.Barium stagnation over 24 hours was located in the proximal segment to the tranverse colon.Mean age at operation was 5 years and 2 months.The procedure was according to Smith,but had some improvements.The main improvement was that the distal dissected rectum was extracorporeally divided through the transverse inci-sion which was made in the posterior rectum wall,using Endo-GIA for short rectal stump,not divided in the ab-dominal.Results The operation was completed laparoscopically for all patients.The average operation time was 180 min.No intraoperative complications occurred.Postoperative enterocolitis and chronic bleeding occurred in two cases separately,and both of them recovered by treated conservatively.No anastomotic leakage or related complications were observed.Mean follow-up period was 31 months.Defecation frequency within two weeks was 3 ~18 times per day,6 ~10 times per day within four weeks.Timespan to obtain normal frequency was 3.5 months.1 patients needed routine daily dilatation for 3 months.The clinical results were good,with no stool in-continence or constipation. Conclusions Laparoscopic colectomy with modified Duhamel procedure for IND—B is safe and feasible.It is easy to operate with smaller abdominal scarring,fewer complications,quicker recovery of the fecal frequency,and fewer patients require dilatation.