先天性无肛并直肠尿道瘘的腹腔镜辅助治疗效果评估
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摘要
目的探讨腹腔镜辅助治疗无肛尿道瘘治疗效果及并发症。方法回顾性分析本院2010年5月至2018年3月采用腹腔镜辅助治疗先天性无肛并直肠尿道瘘男性患儿93例临床资料。所有病例在腹腔镜辅助下游离直肠至瘘管颈部,膀胱颈部瘘和前列腺部瘘采用腹腔内结扎直肠尿道瘘管,尿道球部瘘经会阴部扩大盆底隧道导入丝线于会阴部结扎。切断瘘管后直肠盲端自盆底隧道拖出与会阴皮肤切口缝合形成肛门。结果所有患儿顺利完成手术,无中转开腹病例,手术时间98～205(136±32) min,术中出血量2～5 mL。术后6～24 h开始进食,导尿管留置7～10 d。术后均获随访,随访时间3个月至5年,依据kelly评分随访患儿肛门功能1年以上,优61例(5～6分),良26例(3～4分),差6例(0～2分),肛门功能较满意。结论腹腔镜辅助肛门成形对于治疗无肛直肠尿道瘘是安全可行的,能准确辨别盆底肌群中心,有效保护横纹肌复合体,有助于建立排便功能,是值得选择的治疗方式。
Objective To evaluate the therapeutic effect of laparoscopic-assisted treatment for repairing anorectal malformations with urethral fistula and investigate the postoperative complications. Methods We performed a retrospective analysis of the data of 93 children with imperforate anus and urethral fistula undergoing staged laparoscopic-assisted treatment in our hospital between May, 2010 and March, 2018. All the patients underwent laparoscopic surgery to free the rectum to the level of the fistula neck, followed by ligation of the rectobladder fistula and rectoprostate fistula in the abdominal cavity, or by peritoneal ligation of the urethral bulb fistula through peritoneal extension of the pelvic floor tunnel. The blind end of the posterior rectum was pulled out from the pelvic floor tunnel and sutured with the perineal skin incision to form the anus. Results The operations were successfully completed in all the patients without conversion to open surgeries. The operative time ranged from 98 to 205 min(136±32 min), and the intraoperative blood loss was 2-5 mL. The patients started to eat in 6 to 24 h after the operation, and the catheter was retained for 7 to 10 d. The patients were followed up for 3 months to 5 years. Follow-up assessment of the anal function based on the Kelly scores at 1 year showed excellent function in 61 cases(5-6 points), good function in 26 cases(3-4 points), and poor function in 6 cases(0-2 points). Conclusion Laparoscopic-assisted anorectoplasty is safe and feasible for treatment of anorectal malformations with urethral fistula. This surgical approach can accurately identify the center of pelvic floor muscle group, protect the striated muscle complex, and facilitate defecation.
Objective To evaluate the therapeutic effect of laparoscopic-assisted treatment for repairing anorectal malformations with urethral fistula and investigate the postoperative complications. Methods We performed a retrospective analysis of the data of 93 children with imperforate anus and urethral fistula undergoing staged laparoscopic-assisted treatment in our hospital between May, 2010 and March, 2018. All the patients underwent laparoscopic surgery to free the rectum to the level of the fistula neck, followed by ligation of the rectobladder fistula and rectoprostate fistula in the abdominal cavity, or by peritoneal ligation of the urethral bulb fistula through peritoneal extension of the pelvic floor tunnel. The blind end of the posterior rectum was pulled out from the pelvic floor tunnel and sutured with the perineal skin incision to form the anus. Results The operations were successfully completed in all the patients without conversion to open surgeries. The operative time ranged from 98 to 205 min(136±32 min), and the intraoperative blood loss was 2-5 mL. The patients started to eat in 6 to 24 h after the operation, and the catheter was retained for 7 to 10 d. The patients were followed up for 3 months to 5 years. Follow-up assessment of the anal function based on the Kelly scores at 1 year showed excellent function in 61 cases(5-6 points), good function in 26 cases(3-4 points), and poor function in 6 cases(0-2 points). Conclusion Laparoscopic-assisted anorectoplasty is safe and feasible for treatment of anorectal malformations with urethral fistula. This surgical approach can accurately identify the center of pelvic floor muscle group, protect the striated muscle complex, and facilitate defecation.
引文
[1] GEORGESON K E, INGE T H, ALBANESE C T. Laparoscopically assisted anorectal pull-through for high imperforate anus—a new technique[J]. J Pediatr Surg, 2000, 35(6): 927-930. DOI: 10.1053/jpsu.2000.6925.
[2] 李龙, 余奇志, 黄柳明, 等. 腹腔镜高位肛门闭锁一期成形术4例报告[J]. 中国微创外科杂志, 2003, 3(3): 199-201. LI L, YU Q Z, HUANG L M, et al. Primary laparoscopically assisted anorectal pull-through for high imperforate anus: A report of 4 cases[J]. Chin J Minim Inva Surg, 2003, 3(3): 199-201.
[3] 肖辉, 陈龙, 刘树立, 等. 腹腔镜辅助肛门成形术与后矢状入路肛门成形术治疗中高位肛门直肠畸形的疗效对比[J]. 中华胃肠外科杂志, 2018, 21(1): 68-72. XIAO H, CHEN L, LIU S L, et al. Comparison of laparoscopic-assisted anorectoplasty and posterior sagittal anorectoplasty for high and intermediate anorectal malformations[J]. Chin J Gastrointest Surg, 2018, 21(1): 68-72.
[4] RAMASUNDARAM M, SUNDARAM J, AGARWAL P, et al. Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis[J]. J Minim Access Surg, 2017, 13(4): 265-268. DOI: 10.4103/jmas.JMAS_254_16.
[5] SHAWYER A C, LIVINGSTON M H, COOK D J, et al. Laparoscopic versus open repair of recto-bladderneck and recto-prostatic anorectal malformations: a systematic review and meta-analysis[J]. Pediatr Surg Int, 2015, 31(1): 17-30. DOI: 10.1007/s00383-014-3626-3.
[6] AMANOLLAHI O, KETABCHIAN S. One-stage vs. three-stage repair in anorectal malformation with rectovestibular fistula[J]. African J Paediatric Surg, 2016, 13(1): 20. DOI: 10.4103/0189-6725.181702.
[7] LIEM N T, QUYNH T A. Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: an easier and more physiologic approach[J]. J Pediatr Surg, 2013, 48(6): 1450-1453. DOI: 10.1016/j.jpedsurg.2013.03.007.
[8] CHUNG P H Y, WONG K K Y, TAM P K H. Management of anorectal malformations in the era of laparoscopy[J]. Surg Prac, 2014, 18(2): 94-97. DOI: 10.1111/1744-1633.12059.
[9] RUGGERI G, DESTRO F, RANDI B, et al. Laparoscopic-assisted anorectal pull-through for high imperforate anus: 14 years experience in a single center[J]. J Laparoendosc Adv Surg Tech A, 2016, 26(5): 404-408. DOI: 10.1089/lap.2015.0408.
[10] BISCHOFF A, PE?A A, LEVITT M A. Laparoscopic-assisted PSARP-the advantages of combining both techniques for the treatment of anorectal malformations with recto-bladderneck or high prostatic fistulas[J]. J Pediatr Surg, 2013, 48(2): 367-371. DOI: 10.1016/j.jpedsurg.2012.11.019.
[11] KRICKHAHN A, PETERSEN C, URE B. Transvesical resection of a mucocele after laparoscopically assisted anorectal pull-through for imperforate anus with rectobulbar urethral fistula[J]. J Pediatric Surgery, 2011, 46(1): e29-e31.
[12] BAILEZ M M, CUENCA E S, DI BENEDETTO V, et al. Laparoscopic treatment of rectovaginal fistulas. Feasibility, technical details, and functional results of a rare anorectal malformation[J]. J Pediatr Surg, 2010, 45(9): 1837-1842. DOI: 10.1016/j.jpedsurg.2010.02.064.
[13] AL-HOZAIM O, AL-MAARY J, ALQAHTANI A, et al. Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting[J]. J Pediatr Surg, 2010, 45(7): 1500-1504. DOI: 10.1016/j.jpedsurg.2009.12.001.
[14] WATAYO H, KANEYAMA K, ICHIJO C, et al. Is intraoperative anal endosonography necessary during laparoscopy-assisted anorectoplasty for high/intermediate type imperforate anus[J]. J Laparoendosc Adv Surg Tech A, 2008, 18(1): 123-126. DOI: 10.1089/lap.2007.0134.
[15] WONG K K, WU X, CHAN I H, et al. Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus[J]. J Pediatr Surg, 2011, 46(12): 2313-2315. DOI: 10.1016/j.jpedsurg.2011.09.021.
[16] JUNG S M, LEE S K, SEO J M. Experience with laparoscopic-assisted anorectal pull-through in 25 males with anorectal malformation and rectourethral or rectovesical fistulae: postoperative complications and functional results[J]. J Pediatr Surg, 2013, 48(3): 591-596. DOI: 10.1016/j.jpedsurg.2012.08.001.
[17] CHALOVICH J M. Regulation of striated muscle contraction: a discussion[J]. J Muscle Res Cell Motil, 2002, 23(4): 353-361.
[18] ALBANESE C T, JENNINGS R W, LOPOO J B, et al. One-stage correction of high imperforate anus in the male neonate[J]. J Pediatr Surg, 1999, 34(5): 834-836. DOI: 10.1016/s0022-3468(99)90382-2.
[19] 刁美, 李龙, 叶茂, 等. 新生儿一期经脐单切口腹腔镜肛门成形术22例分析[J]. 中华小儿外科杂志, 2017, 38(9): 653-659. DOI: 10.3760/cma.j.issn.0253-3006.2017.09.003. DIAO M, LI L, YE M, et al. One-stage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula[J]. Chin J Pediatr Surg, 2017, 38(9): 653-659. DOI: 10.3760/cma.j.issn.0253-3006.2017.09.003.
[2] 李龙, 余奇志, 黄柳明, 等. 腹腔镜高位肛门闭锁一期成形术4例报告[J]. 中国微创外科杂志, 2003, 3(3): 199-201. LI L, YU Q Z, HUANG L M, et al. Primary laparoscopically assisted anorectal pull-through for high imperforate anus: A report of 4 cases[J]. Chin J Minim Inva Surg, 2003, 3(3): 199-201.
[3] 肖辉, 陈龙, 刘树立, 等. 腹腔镜辅助肛门成形术与后矢状入路肛门成形术治疗中高位肛门直肠畸形的疗效对比[J]. 中华胃肠外科杂志, 2018, 21(1): 68-72. XIAO H, CHEN L, LIU S L, et al. Comparison of laparoscopic-assisted anorectoplasty and posterior sagittal anorectoplasty for high and intermediate anorectal malformations[J]. Chin J Gastrointest Surg, 2018, 21(1): 68-72.
[4] RAMASUNDARAM M, SUNDARAM J, AGARWAL P, et al. Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis[J]. J Minim Access Surg, 2017, 13(4): 265-268. DOI: 10.4103/jmas.JMAS_254_16.
[5] SHAWYER A C, LIVINGSTON M H, COOK D J, et al. Laparoscopic versus open repair of recto-bladderneck and recto-prostatic anorectal malformations: a systematic review and meta-analysis[J]. Pediatr Surg Int, 2015, 31(1): 17-30. DOI: 10.1007/s00383-014-3626-3.
[6] AMANOLLAHI O, KETABCHIAN S. One-stage vs. three-stage repair in anorectal malformation with rectovestibular fistula[J]. African J Paediatric Surg, 2016, 13(1): 20. DOI: 10.4103/0189-6725.181702.
[7] LIEM N T, QUYNH T A. Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: an easier and more physiologic approach[J]. J Pediatr Surg, 2013, 48(6): 1450-1453. DOI: 10.1016/j.jpedsurg.2013.03.007.
[8] CHUNG P H Y, WONG K K Y, TAM P K H. Management of anorectal malformations in the era of laparoscopy[J]. Surg Prac, 2014, 18(2): 94-97. DOI: 10.1111/1744-1633.12059.
[9] RUGGERI G, DESTRO F, RANDI B, et al. Laparoscopic-assisted anorectal pull-through for high imperforate anus: 14 years experience in a single center[J]. J Laparoendosc Adv Surg Tech A, 2016, 26(5): 404-408. DOI: 10.1089/lap.2015.0408.
[10] BISCHOFF A, PE?A A, LEVITT M A. Laparoscopic-assisted PSARP-the advantages of combining both techniques for the treatment of anorectal malformations with recto-bladderneck or high prostatic fistulas[J]. J Pediatr Surg, 2013, 48(2): 367-371. DOI: 10.1016/j.jpedsurg.2012.11.019.
[11] KRICKHAHN A, PETERSEN C, URE B. Transvesical resection of a mucocele after laparoscopically assisted anorectal pull-through for imperforate anus with rectobulbar urethral fistula[J]. J Pediatric Surgery, 2011, 46(1): e29-e31.
[12] BAILEZ M M, CUENCA E S, DI BENEDETTO V, et al. Laparoscopic treatment of rectovaginal fistulas. Feasibility, technical details, and functional results of a rare anorectal malformation[J]. J Pediatr Surg, 2010, 45(9): 1837-1842. DOI: 10.1016/j.jpedsurg.2010.02.064.
[13] AL-HOZAIM O, AL-MAARY J, ALQAHTANI A, et al. Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting[J]. J Pediatr Surg, 2010, 45(7): 1500-1504. DOI: 10.1016/j.jpedsurg.2009.12.001.
[14] WATAYO H, KANEYAMA K, ICHIJO C, et al. Is intraoperative anal endosonography necessary during laparoscopy-assisted anorectoplasty for high/intermediate type imperforate anus[J]. J Laparoendosc Adv Surg Tech A, 2008, 18(1): 123-126. DOI: 10.1089/lap.2007.0134.
[15] WONG K K, WU X, CHAN I H, et al. Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus[J]. J Pediatr Surg, 2011, 46(12): 2313-2315. DOI: 10.1016/j.jpedsurg.2011.09.021.
[16] JUNG S M, LEE S K, SEO J M. Experience with laparoscopic-assisted anorectal pull-through in 25 males with anorectal malformation and rectourethral or rectovesical fistulae: postoperative complications and functional results[J]. J Pediatr Surg, 2013, 48(3): 591-596. DOI: 10.1016/j.jpedsurg.2012.08.001.
[17] CHALOVICH J M. Regulation of striated muscle contraction: a discussion[J]. J Muscle Res Cell Motil, 2002, 23(4): 353-361.
[18] ALBANESE C T, JENNINGS R W, LOPOO J B, et al. One-stage correction of high imperforate anus in the male neonate[J]. J Pediatr Surg, 1999, 34(5): 834-836. DOI: 10.1016/s0022-3468(99)90382-2.
[19] 刁美, 李龙, 叶茂, 等. 新生儿一期经脐单切口腹腔镜肛门成形术22例分析[J]. 中华小儿外科杂志, 2017, 38(9): 653-659. DOI: 10.3760/cma.j.issn.0253-3006.2017.09.003. DIAO M, LI L, YE M, et al. One-stage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula[J]. Chin J Pediatr Surg, 2017, 38(9): 653-659. DOI: 10.3760/cma.j.issn.0253-3006.2017.09.003.