先天性巨结肠手术后患儿远期生活质量的研究
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摘要
目的：先天性巨结肠(Hirschsprung's disease, HD)是一种严重危害婴幼儿健康的先天性畸形,其发病率很高。由于新生儿HD保守治疗两年生存率极低,常通过手术治疗来挽救患儿的生命,但受治疗年龄、病变肠段范围、手术方法、随访时间等因素的影响,手术后远期仍存在手术并发症多和排便习惯与控制不良的问题,影响患儿的生长发育和心理健康,降低生活质量。本课题对所获得随访病例采用临床主观指标,结合直肠肛管测压客观检查方法,对HD术后患儿的生活质量、排便功能和生长发育进行评价,以期通过了解先天性巨结肠术后患儿的生活质量及其影响因素,为采取针对性康复干预措施提供依据。
方法：2008年7月至2010年2月在山东省立医院复诊的先天性巨结肠根治术患儿73例,均详细填写随访一览表,行腹部查体、肛门指诊、肛管直肠测压。采用白玉作等编制的小儿肛门直肠术后生活质量评分标准,评价患儿生活质量；采用Heikkinen排便功能临床评分标准,评价患儿排便功能；采用WHO推荐NCHS-CDC-WHO(美国国家卫生统计中心-美国疾病控制中心-世界卫生组织)生长发育参考标准,评价患儿生长发育；研究一般资料、排便功能、肛管直肠测压结果、生长发育与生活质量的关系。建立数据库,应用SAS软件进行统计分析。
结果：
1.HD术后患儿生活质量评价：优49例(67.12%)、良19例(26.03%)、差5例(6.85%)。不同HD病变范围的患儿生活质量差异有统计学意义,等级相关分析显示,病变范围与生活质量成正相关关系。
2.患儿排便功能评价及其与生活质量的关系：优33例(45.21%),无任何排便功能障碍；良32例(43.84%),有较轻的排便异常；一般7例(9.59%),有明显的排便功能异常；差1例(1.37%),排便功能严重障碍或完全失禁。排便功能评分与生活质量评分成正相关关系,HD术后患儿的肛管直肠压力变化也影响着生活质量的变化,等级相关分析显示,肛管静息压与生活质量也成正相关关系。逐步回归分析显示,排便功能与肛管静息压对生活质量有显著影响,排便功能对生活质量影响最大,排便功能障碍程度可作为生活质量水平的预测变量。
3.患儿生长发育评价及其与生活质量的关系：生长发育正常57例(78.08%)、轻度营养不良8例(10.96%)、中度营养不良8例(10.96%)。不同的患儿生活质量差异有统计学意义,等级相关分析显示,生长发育状况与生活质量成正相关关系。
结论：
1.先天性巨结肠手术后,有部分患儿生活质量不同程度受损,尤其是病变范围为长段型和全结肠型的患儿。
2.HD术后部分患儿存在不同程度的排便功能障碍。排便功能障碍对生活质量产生影响最大,障碍程度对生活质量水平具有预测作用；肛管直肠测压中测量肛管静息压有重要的意义,肛管静息压的恢复从侧面反映了生活质量的提高。医院、家庭、社会应该积极采取干预措施,减少排便功能障碍等不良因素对生活质量的影响。
3.患儿的发育状况大多数良好,但也存在因营养状况差、发育不良而影响生活质量的状况。所以应长期监测患儿生长发育,给予针对性的营养治疗,改变其生活状态,提高生活质量。
Objective:Hirschsprung's disease is a sort of congenital malformations that threaten the health of children seriously. The disease has a high morbidity. After conservative treatments, neonatal with HD has an extremely low two-year survival rate, their lives have to be saved by surgical operation. But due to variations of age at operation, their ages, the length of aganglionosis colon, the types of operations and time of follow-up, the long-term postoperative effect is remained ascribed to complications and poor bowel evacuation habit. That will affect children's growth, development and mental health, and decrease their quality of life. This study evaluated the quality of life, defecation function, growth and development in children with HD through clinical subjective indexes and anorectal manometry postoperatively, so as to understand the status of quality of life and its affecting factors in children with HD after operation, and provide evidence for taking some measures to improve their quality of life.
Methods:73 cases that underwent operations for HD in the Department of Pediatric Surgery in Shandong Provincial Hospital were followed up. The study was undertaken from July 2008 to February 2010. And the clinical manifestations were recorded using the standard questionnaires in detail. Abdominal examination, anorectal manometry and anal examinations were applied. The standard quality of life scoring systems developed by Bai Yu-zuo was used to evaluate the quality of life. The Heikkinen standard qualitative clinical scoring systems were used to evaluate the defecation function. And the NCHS-CDC-WHO child growth standards were used to evaluate the growth and development. We further explored the relationship between the age of follow-up, the length of aganglionosis colon, defecation function, the results of anorectal manometry, growth and development and quality of life. S AS software was used in statistical analysis.
Results:
1. In 73 cases,49 (67.12%) of them were in excellent quality of life,19 (26.03%) in good,5 (6.85%) in poor. The differences of quality of life had statistical significance depending on the length of aganglionosis colon. Spearman's rank correlation analysis showed that the length of aganglionosis colon was correlated positively to the quality oflife.
2. In 73 cases,33 (45.21%) of them were excellent in postoperative defecation function, and with normal bowel habit; 32 (43.84%) were good, and with minor abnormal bowel habit; 7 (9.59%) were fair, and with marked abnormal bowel habit; and 1 (1.37%) was poor and with serious abnormal bowel habit or defecation incontinence. The defecation function was correlated positively to the quality of life. There was statistical significance in postoperative anal rest pressure among different quality of life classes, and Spearman's rank correlation analysis showed that the postoperative anal rest pressure was correlated positively to the quality of life. Stepwise regression analysis indicated that both defecation function and anal rest pressure could predict the quality oflife level in children with HD, and the defecation dysfunction was the most important predictor of the quality oflife.
3. In 73 cases,57 (78.08%) of them were in normal growth and development,8 (10.96%) in mild malnutrition,8 (10.96%) in moderate malnutrition. The differences of quality of life had statistical significance in children with different growth and development level. And Spearman's rank correlation analysis showed that the growth and development was correlated positively to the quality oflife.
Conclusions:
1.Some children with HD had some extent of quality of life deterioration after operation, especially in long and whole segment of aganglionosis colon.
2.Some children with HD had some extent of defecation dysfunction after operation. The defecation dysfunction was the most important predictor of their quality of life. Anorectal manometry was also essential to predict the quality of life in children with HD, the recovery of anal rest pressure reflected the improvement of quality of life. Hospitals, families and society should take some positive measures to reduce the influence of harmful factors on quality of life such as defecation function.
3. Most children with HD developed good, but some still had bad nutrition and development, which affected their quality of life badly. So we should take long-term growth condition monitoring, provide nutrition therapy to change their growth and development, further to improve their quality of life.
方法：2008年7月至2010年2月在山东省立医院复诊的先天性巨结肠根治术患儿73例,均详细填写随访一览表,行腹部查体、肛门指诊、肛管直肠测压。采用白玉作等编制的小儿肛门直肠术后生活质量评分标准,评价患儿生活质量；采用Heikkinen排便功能临床评分标准,评价患儿排便功能；采用WHO推荐NCHS-CDC-WHO(美国国家卫生统计中心-美国疾病控制中心-世界卫生组织)生长发育参考标准,评价患儿生长发育；研究一般资料、排便功能、肛管直肠测压结果、生长发育与生活质量的关系。建立数据库,应用SAS软件进行统计分析。
结果：
1.HD术后患儿生活质量评价：优49例(67.12%)、良19例(26.03%)、差5例(6.85%)。不同HD病变范围的患儿生活质量差异有统计学意义,等级相关分析显示,病变范围与生活质量成正相关关系。
2.患儿排便功能评价及其与生活质量的关系：优33例(45.21%),无任何排便功能障碍；良32例(43.84%),有较轻的排便异常；一般7例(9.59%),有明显的排便功能异常；差1例(1.37%),排便功能严重障碍或完全失禁。排便功能评分与生活质量评分成正相关关系,HD术后患儿的肛管直肠压力变化也影响着生活质量的变化,等级相关分析显示,肛管静息压与生活质量也成正相关关系。逐步回归分析显示,排便功能与肛管静息压对生活质量有显著影响,排便功能对生活质量影响最大,排便功能障碍程度可作为生活质量水平的预测变量。
3.患儿生长发育评价及其与生活质量的关系：生长发育正常57例(78.08%)、轻度营养不良8例(10.96%)、中度营养不良8例(10.96%)。不同的患儿生活质量差异有统计学意义,等级相关分析显示,生长发育状况与生活质量成正相关关系。
结论：
1.先天性巨结肠手术后,有部分患儿生活质量不同程度受损,尤其是病变范围为长段型和全结肠型的患儿。
2.HD术后部分患儿存在不同程度的排便功能障碍。排便功能障碍对生活质量产生影响最大,障碍程度对生活质量水平具有预测作用；肛管直肠测压中测量肛管静息压有重要的意义,肛管静息压的恢复从侧面反映了生活质量的提高。医院、家庭、社会应该积极采取干预措施,减少排便功能障碍等不良因素对生活质量的影响。
3.患儿的发育状况大多数良好,但也存在因营养状况差、发育不良而影响生活质量的状况。所以应长期监测患儿生长发育,给予针对性的营养治疗,改变其生活状态,提高生活质量。
Objective:Hirschsprung's disease is a sort of congenital malformations that threaten the health of children seriously. The disease has a high morbidity. After conservative treatments, neonatal with HD has an extremely low two-year survival rate, their lives have to be saved by surgical operation. But due to variations of age at operation, their ages, the length of aganglionosis colon, the types of operations and time of follow-up, the long-term postoperative effect is remained ascribed to complications and poor bowel evacuation habit. That will affect children's growth, development and mental health, and decrease their quality of life. This study evaluated the quality of life, defecation function, growth and development in children with HD through clinical subjective indexes and anorectal manometry postoperatively, so as to understand the status of quality of life and its affecting factors in children with HD after operation, and provide evidence for taking some measures to improve their quality of life.
Methods:73 cases that underwent operations for HD in the Department of Pediatric Surgery in Shandong Provincial Hospital were followed up. The study was undertaken from July 2008 to February 2010. And the clinical manifestations were recorded using the standard questionnaires in detail. Abdominal examination, anorectal manometry and anal examinations were applied. The standard quality of life scoring systems developed by Bai Yu-zuo was used to evaluate the quality of life. The Heikkinen standard qualitative clinical scoring systems were used to evaluate the defecation function. And the NCHS-CDC-WHO child growth standards were used to evaluate the growth and development. We further explored the relationship between the age of follow-up, the length of aganglionosis colon, defecation function, the results of anorectal manometry, growth and development and quality of life. S AS software was used in statistical analysis.
Results:
1. In 73 cases,49 (67.12%) of them were in excellent quality of life,19 (26.03%) in good,5 (6.85%) in poor. The differences of quality of life had statistical significance depending on the length of aganglionosis colon. Spearman's rank correlation analysis showed that the length of aganglionosis colon was correlated positively to the quality oflife.
2. In 73 cases,33 (45.21%) of them were excellent in postoperative defecation function, and with normal bowel habit; 32 (43.84%) were good, and with minor abnormal bowel habit; 7 (9.59%) were fair, and with marked abnormal bowel habit; and 1 (1.37%) was poor and with serious abnormal bowel habit or defecation incontinence. The defecation function was correlated positively to the quality of life. There was statistical significance in postoperative anal rest pressure among different quality of life classes, and Spearman's rank correlation analysis showed that the postoperative anal rest pressure was correlated positively to the quality of life. Stepwise regression analysis indicated that both defecation function and anal rest pressure could predict the quality oflife level in children with HD, and the defecation dysfunction was the most important predictor of the quality oflife.
3. In 73 cases,57 (78.08%) of them were in normal growth and development,8 (10.96%) in mild malnutrition,8 (10.96%) in moderate malnutrition. The differences of quality of life had statistical significance in children with different growth and development level. And Spearman's rank correlation analysis showed that the growth and development was correlated positively to the quality oflife.
Conclusions:
1.Some children with HD had some extent of quality of life deterioration after operation, especially in long and whole segment of aganglionosis colon.
2.Some children with HD had some extent of defecation dysfunction after operation. The defecation dysfunction was the most important predictor of their quality of life. Anorectal manometry was also essential to predict the quality of life in children with HD, the recovery of anal rest pressure reflected the improvement of quality of life. Hospitals, families and society should take some positive measures to reduce the influence of harmful factors on quality of life such as defecation function.
3. Most children with HD developed good, but some still had bad nutrition and development, which affected their quality of life badly. So we should take long-term growth condition monitoring, provide nutrition therapy to change their growth and development, further to improve their quality of life.
引文
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