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Title: [Long-term efficacy analysis of laparoscopic-assisted anorectoplasty for high and middle imperforate anus].
Author: Yue M, Zhang D, Yang HY, Wang JX, Jiang Y, Guo F, Xie T, Zhang GF.
Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2019 Dec 25; 22(12):1177-1182. PubMed ID: 31874535.
Abstract:
Objective: To explore the long-term efficacy of laparoscopic-assisted anorectoplasty and conventional anorectoplasty in the treatment of children with high and middle anal atresia. Methods: A retrospective cohort study was used. Inclusion criteria: (1) children with high and middle anal atresia; (2) complicated with rectourethral or rectovesical fistula; (3) complete follow-up data. Exclusion criteria: (1) complicated with 21-trisomy; (2) cerebral palsy and other mentaldisabilities; (3) Currarino syndrome; (4) FG syndrome. Clinical data of 88 patients with middle and high anal atresia, who complicated with rectourethral fistula or rectovesical fistula, and underwent anoplasty at Department of Pediatric Surgery, the First Affiliated Hospital of Zhengzhou University from January 2009 to June 2014 were enrolled in the study and analyzed. There were 24 cases with middle atresia and 64 cases with high atresia. All the cases were divided into 2 groups based on the operative method: laparoscopic group (laparoscopic-assisted anorectoplasty, 49 cases), pena group (posterior sagittal anorectoplasty, 39 cases). The demographic features of two groups were comparable. There were no statistically significant differences in gender, age, body mass, classification of anomaly types and sacral ratio (all P>0.05). Student t test and Chi square tests were used to compare the surgical conditions (operative time, postoperative hospital stay and complications), anal function (Kelly score), constipation (Krickenbeck constipation score) and anorectal pressure. Results: Children of both groups all completed operation ssuccessfully. There were no statistically significant differences between laparoscopic group and pena group in the operative time [(120±31) minutes vs. (112±23) minutes, t=1.343, P=0.091] and postoperative hospital stay [(7.1±2.3) days vs. (10.7±3.3) days, t=6.021, P=1.000]. Complications were more common in the pena group [16.3% (8/49) vs. 35.9% (14/39), χ(2)=4.436, P=0.035]. The main complications in laparoscopic group were anal prolapse (8.2%, 4/49) and anal stenosis (6.2%, 3/49), while in pena group were anal stenosis (12.8%, 5/39) and perioperative perianal skin erosion (10.3%, 4/39). As for the anal function, the degree of feces, defecation control and sphincter contractility, the single scoring differences of Kelly scoring system were not statistically significant between the two groups, but the proportion of good function in the laparoscopic group was higher than that in the pena group [67.3% (8/49) vs. 38.5% (15/39), χ(2)=7.308, P=0.007]. Constipation occurred in 6 (12.2%) patients in the laparoscopic group, of whom 5 were improved by diet regulation and 1 required laxatives, while 9 (23.1%) patients developed constipation in the pena group, of whom 4 were improved by diet regulation and 5 required long-term laxatives. The difference of constipation ratio was not statistically significant (χ(2)=1.802, P=0.180). There were no cases of Krickenbeck constipation grade 3. Compared to the pena group, the laparoscopic group had higher anal resting pressure [(33.35±9.69) mmHg vs. (27.68±10.74) mmHg, t=2.599, P=0.011], higher dilating pressure [(9.00±5.61) mmHg vs.(6.51±3.24) mmHg, t=2.462, P=0.016], higher maximal squeeze pressure [(65.80±17.23) mmHg vs. (56.74±18.93) mmHg, t=2.389, P=0.019] and longer maximal contraction time [(21.16±5.02) seconds vs. (18.44±7.24) seconds, t=2.079, P=0.041]. The rectal resting pressure [(5.36±3.00) mmHg vs. (4.61±3.93) mmHg, t=1.015, P=0.312] was not statistically significantly different. Conclusions: Compared with posterior sagittal anorectoplasty, laparoscopic-assisted anorectoplasty in the treatment of high and middle anal atresia has better long-term efficacy with less perioperative complications. 目的： 探讨腹腔镜辅助肛门成形术与传统肛门成形术治疗中高位肛门闭锁患儿的远期疗效。 方法： 采用回顾性队列研究方法。病例纳入标准：（1）中高位肛门闭锁患儿；（2）合并直肠尿道瘘或直肠膀胱瘘；（3）随访资料完整。排除标准：（1）合并21-三体者；（2）脑瘫等智力障碍者；（3）Currarino综合征者；（4）FG综合征者。2009年1月至2014年6月期间，在郑州大学第一附属医院小儿外科行肛门成形术的88例合并直肠尿道瘘或直肠膀胱瘘的中高位肛门闭锁患儿临床病例资料纳入研究，其中中位闭锁24例，高位闭锁64例。根据手术方式的不同分为：腹腔镜组（腹腔镜辅助肛门成形术，49例）和pena组（经骶会阴矢状位切开肛门成形术，39例），两组患儿性别、年龄、体质量、肛门闭锁位置、骶骨比率以及一期成形的比例等基线资料的比较，差异均无统计学意义（均P>0.05）。采用t检验或χ(2)检验比较两组患儿的手术情况（手术时间、术后住院时间及并发症发生情况）以及术后36个月后患儿的肛门功能（Kelly评分）、便秘情况（Krickenbeck便秘分级）以及肛门直肠测压情况。 结果： 两组患儿均顺利完成手术。腹腔镜组和pena组手术时间和术后住院时间的比较，差异均无统计学意义[分别（120±31）min比（112±23）min，t=1.343，P=0.091；（7.1±2.3）d比（10.7±3.3）d，t=6.021，P=1.000]。与pena组比较，腹腔镜组术后总体并发症发生率较低[16.3%（8/49）比35.9%（14/39），χ(2)=4.436，P=0.035]，并以肛门脱垂（8.2%，4/49）和肛门狭窄为主（6.1%，3/49），而pena组以肛门狭窄（12.8%，5/39）和围手术期肛周皮肤糜烂（10.3%，4/39）为主。两组肛门功能情况的比较，污粪程度、排粪控制力及括约肌收缩力单项得分的差异均无统计学意义（均P>0.05），但总评分腹腔镜组肛门功能为优者的比例明显高于pena组[67.3%（33/49）比38.5%（15/39）]，差异有统计学意义（χ(2)=7.308，P=0.007）。腹腔镜组出现便秘6例（12.2%），5例可通过饮食调节改善，1例需服用缓泻剂；pena组出现便秘9例（23.1%），4例可通过饮食调节改善，5例需长期服用缓泻剂，两组患儿便秘发生率比较，差异无统计学意义（χ(2)=1.802，P=0.180）；两组均未出现饮食调节和服轻泻剂抵抗或无效的患儿（Krickenbeck便秘3级）。与pena组比较，腹腔镜组肛管静息压[（33.35±9.69）mmHg比（27.68±10.74）mmHg，t=2.599，P=0.011]、肛管舒张压[（9.00±5.61）mmHg比（6.51±3.24）mmHg，t=2.462，P=0.016]、肛管最大收缩压[（65.80±17.23）mmHg比（56.74±18.93）mmHg，t=2.389，P=0.019]及最长收缩时间[（21.16±5.02）s比（18.44±7.24）s，t=2.079，P=0.041]均较高，差异有统计学意义（均P<0.05）；但直肠静息压的比较，差异无统计学意义[（5.36±3.00）mmHg比（4.61±3.93）mmHg，t=1.015，P=0.312]。 结论： 与传统经骶会阴矢状位切开肛门成形术相比，腹腔镜辅助肛门成形术治疗肛门闭锁围手术期并发症明显减少，远期疗效更佳。.

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