高分辨率肛门直肠测压在先天性肛门直肠畸形术后患儿排便功能评估中的应用
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摘要
目的分析先天性肛门直肠畸形术后患儿高分辨率肛门直肠测压数据,总结相关特征,探讨其作为先天性肛门直肠畸形患儿术后排便功能评估的依据。方法选取2014-2017年在重庆医科大学附属儿童医院胃肠新生儿外科治疗的先天性肛门直肠畸形患儿77例,女性13例,男性64例,其中直肠盲端距肛隐窝的距离<1.5 cm(低位)32例,≥1.5 cm(中高位)45例;术后6个月至1年排便功能Kelly评分:3～6分(功能优良)的72例,0～2分(功能差)的5例。72例排便功能优良的患儿分为低位组(32例)与中高位组(40例);45例中高位患儿又分为排便功能优良组(40例)和功能差组(5例)。分析各组患儿高分辨率肛门直肠测压检查结果(平均静息压、最大静息压、肛管有效长度、直肠肛门抑制反射)。三维图像分析患儿肛门直肠压力。结果 72例排便功能优良的低位组与中高位组患儿的平均静息压(38.00±12.33 vs 32.27±11.86 mmHg)、最大静息压(42.65±14.23 vs 36.67±12.10 mmHg)、肛管有效长度(2.43±0.30 vs 2.18±0.33 cm)差异有统计学意义(P<0.05),两组直肠肛门抑制反射的恢复率分别为90.63%及17.50%,差异也有统计学意义(P<0.05);45例中高位患儿中,与排便功能优良组比较,排便功能差组平均静息压(26.08±2.36 mmHg)、最大静息压(29.96±2.55 mmHg)更低,两组间差异有统计学意义(P<0.05);通过三维图像分析,功能差组在三维图像上存在低压带或压力缺失带,其中4例低压带在后壁,1例低压带在前壁。结论低位肛门直肠畸形患儿平均静息压、最大静息压、肛管有效长度及直肠肛门抑制反射恢复率较中高位肛门直肠畸形高,可通过三维图像判断肛门括约肌功能,高分辨率肛门直肠测压可作为先天性肛门直肠畸形术后评估患儿排便功能的依据之一。
Objective To assess the application of high-resolution anorectal manometry(HRAM) for evaluating postoperative defecation function in children following surgical repair of congenital anorectal malformations(ARMs). Methods A total of 77 children undergoing surgeries for ARMs in our hospital. from 2014 to 2017 were enrolled in this study. The patients' postoperative defecation function was evaluated based on Kelly scores at 6 to 12 months after the surgeries. The results of HRAM for measuring the resting and maximum pressures, effective length of the anal canal, and rectoanal inhibitory reflex recovery were compared among the patients with different positions of ARM and with different postoperative defecation functions. Of the 77 children included, 32 were found to have low ARM(with a distance <1.5 cm between the blind rectal pouch and the anal crypt) and 45 had high ARM(≥1.5 cm); 72 of the children had good postoperative defecation function(Kelly score of 3-6) and 5 had poor defecation function(Kelly score of 0-2). Results We compared the HRAM findings between the 32 children having low ARM and the 40 children with high ARM in the 72 children with good postoperative defecation function, and the results showed significantly higher mean resting pressure(38.00±12.33 vs 32.27±11.86 mmHg) and maximum resting pressure(42.65±14.23 vs 36.67±12.10 mmHg), a longer effective length of the anal canal(2.43±0.30 vs 2.18±0.33 cm), and a higher recovery rate of rectoanal inhibitory reflex(90.63% vs 17.50%) in the former children(all P<0.05). In the 45 children with high ARMs, the children with poor defecation function had a significantly mean higher resting pressure than those with good defecation function(32.27±11.86 vs 26.08±2.36 mmHg, P<0.05) and had also a higher maximum resting pressure(36.67±12.10 vs 29.96±2.55 mmHg, P<0.05). Three-dimensional image analysis highlighted the presence of a low pressure band or a pressure loss zone in the images in the children with poor postoperative defecation function. Conclusion Children with low ARMs have significantly higher mean resting pressure and maximum resting pressure, a longer effective anal canal length, and a higher rectoanal inhibitory reflex recovery rate than those with high ARMs. The anal sphincter function can be evaluated based on the three-dimensional images, and HRAM can be used for assessing postoperative defecation function in children with ARMs.
Objective To assess the application of high-resolution anorectal manometry(HRAM) for evaluating postoperative defecation function in children following surgical repair of congenital anorectal malformations(ARMs). Methods A total of 77 children undergoing surgeries for ARMs in our hospital. from 2014 to 2017 were enrolled in this study. The patients' postoperative defecation function was evaluated based on Kelly scores at 6 to 12 months after the surgeries. The results of HRAM for measuring the resting and maximum pressures, effective length of the anal canal, and rectoanal inhibitory reflex recovery were compared among the patients with different positions of ARM and with different postoperative defecation functions. Of the 77 children included, 32 were found to have low ARM(with a distance <1.5 cm between the blind rectal pouch and the anal crypt) and 45 had high ARM(≥1.5 cm); 72 of the children had good postoperative defecation function(Kelly score of 3-6) and 5 had poor defecation function(Kelly score of 0-2). Results We compared the HRAM findings between the 32 children having low ARM and the 40 children with high ARM in the 72 children with good postoperative defecation function, and the results showed significantly higher mean resting pressure(38.00±12.33 vs 32.27±11.86 mmHg) and maximum resting pressure(42.65±14.23 vs 36.67±12.10 mmHg), a longer effective length of the anal canal(2.43±0.30 vs 2.18±0.33 cm), and a higher recovery rate of rectoanal inhibitory reflex(90.63% vs 17.50%) in the former children(all P<0.05). In the 45 children with high ARMs, the children with poor defecation function had a significantly mean higher resting pressure than those with good defecation function(32.27±11.86 vs 26.08±2.36 mmHg, P<0.05) and had also a higher maximum resting pressure(36.67±12.10 vs 29.96±2.55 mmHg, P<0.05). Three-dimensional image analysis highlighted the presence of a low pressure band or a pressure loss zone in the images in the children with poor postoperative defecation function. Conclusion Children with low ARMs have significantly higher mean resting pressure and maximum resting pressure, a longer effective anal canal length, and a higher rectoanal inhibitory reflex recovery rate than those with high ARMs. The anal sphincter function can be evaluated based on the three-dimensional images, and HRAM can be used for assessing postoperative defecation function in children with ARMs.
引文
[1] KELLY J H.The clinical and radiological assessment of anal continence in childhood[J].Aust N Z J Surg,1972,42(1):62-63.
[2] PE?A A,GUARDINO K,TOVILLA J M,et al.Bowel management for fecal incontinence in patients with anorectal malformations[J].J Pediatr Surg,1998,33(1):133-137.
[3] PE?A A,HONG A.Advances in the management of anorectal malformations[J].Am J Surg,2000,180(5):370-376.
[4] 张雅楠,陈永卫,郭卫红,等.先天性肛门闭锁前庭瘘前矢状入路肛门成型术及其改良术式术后排便功能随访[J].中华小儿外科杂志,2015,36(6):416-419.DOI:10.3760/cma.j.issn.0253-3006.2015.06.005.ZHANG Y N ,CHEN Y W,GUO W H,et al.Follow-ups of anterior sagittal anorectoplasty and its modified operation in the treatment of congenital anorectal malformations with vestibular fistula[J].Chin J Pediatr Surg,2015,36(6):416-419.DOI:10.3760/cma.j.issn.0253-3006.2015.06.005.
[5] 吴永隆,陈思远,陈秀兰,等.男性先天性中高位肛门直肠畸形术后排便功能评估及其影响因素[J].第三军医大学学报,2015,37(21):2151-2155.DOI:10.16016/j.1000-5404.201503166.WU Y L,CHEN S Y,CHEN X L,et al.Bowel function and its influencing factors for male children with high and intermediate anorectal malformation after surgical treatment[J].J Third Mil Med Univ,2015,37(21):2151-2155.DOI:10.16016/j.1000-5404.201503166.
[6] 高威,李静,刘翔,等.先天性肛门直肠畸形的临床特征及预后研究[J].安徽医科大学学报,2018,53(2):316-318.DOI:10.19405/j.cnki.issn1000-1492.2018.02.034.GAO W,LI J,LIU X,et al.Clinical features and prognosis of congenital anorectal malformations [J].Acta Univ Med Anhui,2018,53(2):316-318.DOI:10.19405/j.cnki.issn1000-1492.2018.02.034.
[7] KUMAR S,RAMADAN S,GUPTA V,et al.Manometric tests of anorectal function in 90 healthy children:A clinical study from Kuwait[J].J Pediatr Surg,2009,44(9):1786-1790.DOI:10.1016/j.jpedsurg.2009.01.008.
[8] KUMAR S,AL RAMADAN S,GUPTA V,et al.Use of anorectal manometry for evaluation of postoperative results of patients with anorectal malformation:A study from Kuwait[J].J Pediatr Surg,2010,45(9):1843-1848.DOI:10.1016/j.jpedsurg.2010.04.012.
[9] CALDARO T,ROMEO E,DE ANGELIS P,et al.Three-dimensional endoanal ultrasound and anorectal manometry in children with anorectal malformations:new discoveries[J].J Pediatr Surg,2012,47(5):956-963.DOI:10.1016/j.jpedsurg.2012.01.051.
[10] PFEFFERKORNM D,CROFFIE J M,CORKINS M R,et al.Impact of sedation and anesthesia on the rectoanal inhibitory reflex in children[J].J Pediatr Gastroenterol Nutr,2004,38(3):324-327.
[11] NYAMD C.The current understanding of continence and defecation[J].Singapore Med J,1998,39(3):132-136.
[12] DOOLIN E J,BLACK C T,DONALDSON J S,et al.Rectal manometry,computed tomography,and functional results of anal atresia surgery[J].J Pediatr Surg,1993,28(2):195-198.
[13] RINTALA R J,LINDAHL H.Is normal bowel function possible after repair of intermediate and high anorectal malformations?[J].J Pediatr Surg,1995,30(3):491-494.
[14] EMBLEM R,DISETH T,MORKRID L.Anorectal anomalies:anorectal manometric function and analendosonography in relation to functional outcome[J].Pediatr Surg Int,1997,12(7):516-519.DOI:10.1007/BF01258715.
[15] SAIGUSA N,BELIN B M,CHOI H J,et al.Recovery of the rectoanal inhibitory reflex after restorative proctocolectomy:does it correlate with nocturnal continence?[J].Dis Colon Rectum,2003,46(2):168-172.DOI:10.1097/01.DCR.0000049345.21202.99.
[2] PE?A A,GUARDINO K,TOVILLA J M,et al.Bowel management for fecal incontinence in patients with anorectal malformations[J].J Pediatr Surg,1998,33(1):133-137.
[3] PE?A A,HONG A.Advances in the management of anorectal malformations[J].Am J Surg,2000,180(5):370-376.
[4] 张雅楠,陈永卫,郭卫红,等.先天性肛门闭锁前庭瘘前矢状入路肛门成型术及其改良术式术后排便功能随访[J].中华小儿外科杂志,2015,36(6):416-419.DOI:10.3760/cma.j.issn.0253-3006.2015.06.005.ZHANG Y N ,CHEN Y W,GUO W H,et al.Follow-ups of anterior sagittal anorectoplasty and its modified operation in the treatment of congenital anorectal malformations with vestibular fistula[J].Chin J Pediatr Surg,2015,36(6):416-419.DOI:10.3760/cma.j.issn.0253-3006.2015.06.005.
[5] 吴永隆,陈思远,陈秀兰,等.男性先天性中高位肛门直肠畸形术后排便功能评估及其影响因素[J].第三军医大学学报,2015,37(21):2151-2155.DOI:10.16016/j.1000-5404.201503166.WU Y L,CHEN S Y,CHEN X L,et al.Bowel function and its influencing factors for male children with high and intermediate anorectal malformation after surgical treatment[J].J Third Mil Med Univ,2015,37(21):2151-2155.DOI:10.16016/j.1000-5404.201503166.
[6] 高威,李静,刘翔,等.先天性肛门直肠畸形的临床特征及预后研究[J].安徽医科大学学报,2018,53(2):316-318.DOI:10.19405/j.cnki.issn1000-1492.2018.02.034.GAO W,LI J,LIU X,et al.Clinical features and prognosis of congenital anorectal malformations [J].Acta Univ Med Anhui,2018,53(2):316-318.DOI:10.19405/j.cnki.issn1000-1492.2018.02.034.
[7] KUMAR S,RAMADAN S,GUPTA V,et al.Manometric tests of anorectal function in 90 healthy children:A clinical study from Kuwait[J].J Pediatr Surg,2009,44(9):1786-1790.DOI:10.1016/j.jpedsurg.2009.01.008.
[8] KUMAR S,AL RAMADAN S,GUPTA V,et al.Use of anorectal manometry for evaluation of postoperative results of patients with anorectal malformation:A study from Kuwait[J].J Pediatr Surg,2010,45(9):1843-1848.DOI:10.1016/j.jpedsurg.2010.04.012.
[9] CALDARO T,ROMEO E,DE ANGELIS P,et al.Three-dimensional endoanal ultrasound and anorectal manometry in children with anorectal malformations:new discoveries[J].J Pediatr Surg,2012,47(5):956-963.DOI:10.1016/j.jpedsurg.2012.01.051.
[10] PFEFFERKORNM D,CROFFIE J M,CORKINS M R,et al.Impact of sedation and anesthesia on the rectoanal inhibitory reflex in children[J].J Pediatr Gastroenterol Nutr,2004,38(3):324-327.
[11] NYAMD C.The current understanding of continence and defecation[J].Singapore Med J,1998,39(3):132-136.
[12] DOOLIN E J,BLACK C T,DONALDSON J S,et al.Rectal manometry,computed tomography,and functional results of anal atresia surgery[J].J Pediatr Surg,1993,28(2):195-198.
[13] RINTALA R J,LINDAHL H.Is normal bowel function possible after repair of intermediate and high anorectal malformations?[J].J Pediatr Surg,1995,30(3):491-494.
[14] EMBLEM R,DISETH T,MORKRID L.Anorectal anomalies:anorectal manometric function and analendosonography in relation to functional outcome[J].Pediatr Surg Int,1997,12(7):516-519.DOI:10.1007/BF01258715.
[15] SAIGUSA N,BELIN B M,CHOI H J,et al.Recovery of the rectoanal inhibitory reflex after restorative proctocolectomy:does it correlate with nocturnal continence?[J].Dis Colon Rectum,2003,46(2):168-172.DOI:10.1097/01.DCR.0000049345.21202.99.