肠套叠是急症。多发生于婴幼儿,有突然发作的腹痛,间歇性发作。婴儿可表现为阵发性剧烈哭闹。其他变现不完全相同,如有的婴儿呕吐,呕吐物为黄绿色胆汁样或胃内容物。如有的婴儿大便时可混有血液或黏液,颜色呈红栗色或果酱色或果冻样等等。有时患儿家长可触及患儿腹部包块。若延误就诊,孩子可能变得虚弱,可能出现发热,甚至休克。 目前,婴幼儿肠套叠病因尚未知,通常认为与病毒、细菌感染有关,也有认为与添加辅食有关。 发病年龄多在3个月至5岁之间。还有些肠道发育畸形的年龄大的儿童也会发生肠套叠。 现在肠套叠的确诊较合适的检查是腹部彩超, 彩超下肠套叠包块横切面呈“同心圆”表现,纵切面呈“套筒样”或“套袖样”表现。 就诊时间早,套叠头部不紧的话,行空气灌肠可复位。影像学透视下可发现“杯口样”表现。套块大的,病史长的,空气灌肠复位困难的应手术治疗。 若怀疑婴幼儿肠套叠时可就近医院检查腹部彩超。或者及时到儿外科就诊以免延误病情。
Infantilehypertrophicpyloricstenosis(IHPS)isaconditionaffectingyounginfants,inwhichtheantropyloricportionofthestomachbecomesabnormallythickenedandmanifestsasobstructiontogastricemptying.Typically,infantswithIHPSareclinicallynormalatbirth;duringthefirstfewweeksofpostnatallife,theydevelopnonbiliousforcefulvomitingdescribedas“projectile.”Gastricoutletobstructionleadstoemaciationand,ifleftuntreated,mayresultindeath.Surgicaltreatmentiscurative.Theclinicaldiagnosishingesonpalpationofthethickenedpylorus,or“olive.”Abdominalpalpationisaccuratebutnotalwayssuccessful,dependingonfactorssuchastheexperienceoftheexaminer,thepresenceofgastricdistention,andacalminfant.Palpationrequiresacalminfantwithrelaxedabdominalmusculature,whichisadifficultaccomplishmentinthesehungrybabies.Sedationofinfantshasbeensuggestedtofacilitatetheexamination. IHPSisfamiliartomostpediatricpractitionersandisthemostcommonconditionrequiringsurgeryininfants.Theoperationproceduredividesthehypertrophiedmuscle,leavingtheintactmucosabulgingthroughtheincision,andwhetherperformedviaabdominalincisionoratlaparoscop,remainsthestandardofsurgicaltreatmenttoday. Infantilehypertrophicpyloricstenosiscausesgastricoutletobstructionbecauseofanatomicalchangesaroundthepyloriccanal.Themostimportantchangeisabnormalthickeningofthecircularmusclethatisoftenassociatedwithredundantpyloricmucosa.Theincidencerangesfrom1to8per1000livebirthsandmalesaremorecommonlyaffectedthanfemales(ratio4:1).TheetiologyremainsunclearbutcasesclusterwithinfamiliesandassociationshavebeenreportedwithavarietyofcongenitaldisordersincludingHirschsprungdiseaseandesophagealatresia.Thetypicalsymptomisrecurrentvomitingthatdevelops2-10weeksafterbirthandisoftenassociatedwithfailuretothriveanddehydration.Thepylorichypertrophyisfeltclassicallyasanolive-shapedmassinthemiddleupperpartorrightupperquadrantoftheinfant'sabdomen.Atleast70%ofinfantshaveanepigastricmass(‘olive’)andsomehavevisibleperistalticwaves.Thediagnosisisusuallyconfirmedbyanabdominalultrasoundstudythatshowsa‘donut’signwiththickeningofthecircularmuscletogreaterthan3mm.Bariumstudieswillalsoshowgastricoutletobstructionbutcanbedifficultinyounginfantsandshouldbeprecededbygastricaspiration.DefinitivetherapyisaRamstedtpyloromyotomythatincludesalongitudinalincisionthroughthehypertrophiedmuscledowntothesubmucosa.Almostallinfantshaveanexcellentshortandlonger-termoutcome. Theclinicalpresentationvarieswiththelengthofsymptoms.Theinfantpresentswitharecentonsetofforcefulnonbiliousvomiting,typicallydescribedas“projectile.”Theemesisconsistsofgastriccontents,whichmaybecomebloodtingedwithprotractedvomiting,likelyrelatedtogastritis.Initiallyintermittent,thefrequencyofvomitingincreasestofollowallfeedings.Sincethechildisunabletoachieveadequatenutrition,heorsheexhibitsavoraciousappetitedespitedistentionofthestomach.Starvationcanexacerbatediminishedhepaticglucoronyltransferaseactivity,andindirecthyperbilirubinemiamaybeseenin1%~2%ofaffectedinfants.Vomitingofgastriccontentsleadstodepletionofsodium,potassium,andhydrochloricacid,whichresultsinhypochloremicalkalosisandsodiumandpotassiumdeficits.Renalmechanismsdesignedtomaintainintravascularvolumeconservesodiumattheexpenseofhydrogenions,leadingtoparadoxicalaciduria.Weightlossmaybeextensive,andtheinfantmaybebelowbirthweightatthetimeofpresentationtotheradiologist. Weightlossanddehydrationcoupledwithaninsatiableappetiteleadtoacharacteristicfacies,withafurrowedbrow,wrinkledappearance,andprominentsuckingpads,resemblinganoldmancryinginconsolablyandgnawingathisorherfist.Inemaciatedinfants,thedistendedstomachmaybeidentifiableinthehypochondrium,withactiveperistalticactivityvisiblethroughthethinabdominalwall.
便秘是常见疾病,无论成人或儿童,在一生中均会不同时期不同程度的出现,据统计便秘在成人占2-10%,儿童大约占5%。首先,食物通过消化道的时间与年龄有关,进食后,小肠会出现移动性运动复合波,将食物大约以每小时5cm向回肠末端推进,而后小肠内容物经过盲肠后进入结肠,结肠主要通过集团运动将肠内容物向远端推送,残渣进入直肠壶腹部后刺激局部感觉神经反射从而引起便意。这种按时规律的排泄一方面可以减轻肠管淤滞及细菌过度生长,另一方面可以减轻肠管负担及毒素过多吸收。临床中常见的便秘主要有以下几种可能,其中包括功能性、器质性、药物性等等。(1)肠管器质性病变,如肿瘤、炎症、发育畸形甚至也包括异物或寄生虫损伤等。(2)直肠肛门病变:肛门狭窄、肛裂、肛瘘、直肠内脱垂、痔疮、直肠前膨出、耻骨直肠肌肥厚、盆底病等。(3) 内分泌及代谢疾病:甲减、甲状旁腺疾病、糖尿病、氨基酸代谢异常等。(4)神经系统疾病:中枢性脑部疾病、脊髓损伤、周围神经病变等。其他方面等等。针对新生儿及儿童出现便秘主要注意以下两种肠管器质性病变:一是先天性巨结肠症:其主要特征为出生后90%以上不排胎便或排出延迟,且顽固性便秘加重,腹胀明显,可见肠型及蠕动波。钡灌肠可见狭窄及扩张段,24小时复查平片见钡剂残留。直肠测压检查无内括约肌松弛反射,直肠粘膜组化AchE呈阳性反应+~~+++,病理狭窄段无神经节细胞存在。二是巨结肠同源病(或有称类缘病)便秘症状可出现较晚,多数在数月或半年之后,腹胀不著,便秘逐渐加重,有时有短期缓解期,钡灌肠狭窄段低或不明显,扩张段长短不一,测压可出现非典型的松弛反射,组化检查据取材深浅表现(+~-)病理检查可有神经节细胞,然而其细胞数量及质量异常其特点(1)巨大神经丛、神经节细胞增多(每个节内多于7个细胞)(2)乙酰胆碱酶活性升高(3)可见异常孤立的神经节细胞(4)A型肌间神经丛交感神经不全或未发育。关于治疗方面,Scharle认为早期发现诊断后90%手术后可治愈。其中也有认为多数超短段型及部分同源病可保守治疗6个月。手术方面一般认为根治手术要求切除全部病变肠管,否则易复发。有国外学者报道复发者多数为同源病,常见型巨结肠治愈效果较好。(未完)
一、Pena手术方法 Pena术是目前分期治疗高中位肛门闭锁的首选术式,分三期,结肠造瘘-肛门形成-造瘘口关闭。高位先天性肛门闭锁的患儿,术中估计直肠拖出不致游离乙状结肠困难,均采用乙状结肠近端或与降结肠交界处造瘘,取左下腹经麦氏点的弧形切口入腹,游离结肠于腹壁行双口造瘘术。术后2-3个月行肛门成形术。肛门成形术后2周即给予扩肛治疗。肛门愈合后远端瘘口适当灌大便无不适后择期关瘘。Pena肛门成形术即后矢状入路肛门直肠成形术理论基础为直肠肛门畸形局部解剖特点:肛门外括约肌是控制排便的主要肌群,该肌肉在接近正常肛门附近彼此融合形成外括约肌复合体中的一个组成部分。此肌与外括约肌深部肌群围绕直肠形成顶环。 依据如下:(1)直肠肛门畸形患儿包括中高位无肛,均可有发育良好的肛门外括约肌;(2)直肠后方一侧的重要神经血管一般不超过中线,因此,后正中纵切口所造成的神经血管损伤最小;(3)通过纵形切口后矢状入路可获得直肠盲端、外括约肌的良好显露,解剖关系清楚,可以直视下分离外括约肌并实施重建手术工作,并能在直视下处理瘘管,避免术后瘘管复发;(4)多数高位无肛畸形都没有肛门内括约肌,内括约肌发育程度与畸形的类型有关,即位置越高,发育越差,甚至完全缺如。中位无肛,直肠盲端增厚部分可能为内括约肌,高位无肛瘘口周围可能有内括约肌样改变,应尽量保留。因此作直肠拖出过程中,要保留直肠远端的结构。这些残余的内括约肌或肌样组织在术后保持关闭肛门及防止溢粪等方面起到重要作用;(5)Pena手术前或同时作乙状结肠造口,以保证重建的肛门在无便的情况下顺利恢复,最大限度地减少污染;(6)术中一定要使用电刺激仪,在电刺激引导下,确定直肠置于肌肉复合体中央,并保证按层次缝合。据多个文献报道:术中修复外括约肌复合体时除注意修复直肠后方的纤维外,外括约肌复合体前方的肌纤维也要注意修复,这对排便控制起到相当重要的作用。缝合时松紧适宜,如果外括约肌复合体不能完全包绕直肠时,仅将其固定在直肠壁的两侧即可,不可强行缝合,以免造成狭窄,Pena手术前或同时做肠造口有利于肛门愈合,是必要的,中位无肛行乙状结肠造口,高位无肛行横结肠造口,以免造瘘口位置低,影响Pena手术时直肠拖出。 二、一期肛门成形术手术方法 一期中高位肛门闭锁手术主要方法:患儿手术在气管插管全身麻醉下进行,常规留置导尿管,取俯卧位,选用后正中矢状切口,切口长度上至尾骨尖上方的1-2cm处,下达正常肛穴上方2cm,在正常肛穴处另行“X”或倒“V”切口,将肛周皮肤予以保留,骶部纵形切口依次切开皮肤、皮下组织,避免伤到肛门外括约肌肌纤维,电刺激仪引导下切开旁矢状纤维、肛提肌,可纵行劈开尾骨,显露欠佳时也可将尾骨切除,注意保留肛门括约肌复合体,找到直肠末端后,于其后壁、侧壁、前壁分别斜形缝置丝线数针有利牵引,然后游离直肠在直肠粘膜下层针状电刀分离,有时游离至腹膜返折以上,若有尿道瘘管可同时处理位于前壁的瘘管,游离的直肠能保证在无张力条件下能自肛门括约肌复合体下穿过并拖至肛门处进行吻合,在肛穴处作前述切口后保留长约1cm间隙,同样依次切开皮肤,皮下组织,肛门外括约肌皮下肌纤维,在电刺激仪指引下通过横纹肌复合体正中作一隧道,将隧道钝性扩张至直径约1.5cm,以利直肠末端通过横纹肌复合体正中。将直肠无扭转穿过隧道脱下与肛周皮肤全层缝合,若直肠壁扩张肥厚,可在直肠远端做尾状修剪及成形可有利通过隧道,然后修复横纹肌复合体,注意修复直肠后方的纤维体,外括约肌复合体前边的肌纤维也要修复,固定直肠及肛门括约肌浅层等。骶部切口缝合肛提肌,彻底止血后关闭切口,术毕将凡士林纱布包绕的肛管经肛门放入作为直肠支架。(未完)
先天性肛门闭锁是在胚胎第4~8周时由尿生殖隔向泄殖腔移行受阻所致,是常见的消化道畸形,占消化道畸形的首位,发生率约为1/1500~1/5000,男多于女,男女比例约为3:1,无种族差异,部分病例有家性发病族倾向;据国内畸形监测网统计,在我国的发生率是2.81/万。 肛门闭锁的发生是正常胚胎发育期发生障碍的结果。引起肛门闭锁的原因不清楚,近年来许多作者认为肛门闭锁与遗传因素有关。直肠为结肠的终端部分,上接乙状结肠,下端穿过盆底与肛管相接。肛门内括约肌由直肠下端环肌增厚构成,环绕肛门3/4,有直肠纵肌和肛提肌的纤维穿过。内括约肌为平滑肌,受自主神经支配,对排便有不随意的节制功能,平时处于紧张收缩状态,保持肛管关闭。排便时内括约肌松弛肛管开放。 肛门外括约肌为随意肌,围绕肛管分成三个肌环,顶环由外括约肌深部及耻骨直肠肌构成,起于耻骨联合,分布于肛管上部的后方和两侧;中环由外括约肌组成,起自尾骨尖,分成两半围绕肛管两侧再向前联合;底部为外括约肌皮下部构成,起于肛门前方皮肤,围绕肛门两侧,在肛门后方联合。三环由会阴神经、肛门神经支配。外括约肌能控制排便,收缩时顶环与底环牵拉肛管后壁向下;中环将肛管向后牵拉,造成三环收缩时间不同方向牵拉,从而加强括约肌功能,形成铰链闭合肛门,以对抗内括约肌的松弛作用,当外括约肌松弛是粪便排出。三环中的顶、中环作用强大,切断后能引起失禁。肛提肌为盆底重要肌肉,有三部分构成,即耻骨直肠肌、耻骨尾骨肌和髂骨尾骨肌,由骶神经和肛门神经或或会阴神经支配。本病如不早治疗,可影响患儿生长发育、甚至导致死亡,因此,早期治疗对本病显得十分重要。目前,治疗的方法有很多种,其手术方法有等多种术式,如:Stephens的骶会阴肛门成形术及Pena的后矢状入路肛门成形术,Nicolai一Rehbein的改良手术等各有其特点,效果也各异。1980年deVire和Pen提出由骶尾部正中作后矢状切口,将横纹肌复合体(包括耻骨直肠肌和肛门外括约肌)肌纤维从正中分开,然后将直肠置于横纹肌复合体之中形成肛门,这样不但能利用耻骨直肠肌,而且也充分利用了外括约肌。近年来不少学者发现直肠肛门畸形,特别是中高位畸形在直肠远端及瘘管处肠壁环肌局限性增厚,即有内括约肌或内括约肌雏形,因此强调在行肛门成形术时也应尽量保留和利用肛门内括约肌。随着人们生活水平的提高,对患儿手术要求及近期并发症及远期生活质量要求也较高。(未完)
Intussusceptionoccurswhenoneportionofthebowelslidesintothenext,muchlikethepiecesofatelescope.Whenthisoccurs,itcancreateablockageinthebowel,withtheintestinalwallpressingagainstoneanother.This,inturnleadstoswelling,inflammation,anddecreasedbloodflowtothepartoftheintestinesinvolved.Intussusceptionoccursmostofteninbabiesbetween5through10monthsofage(80%ofcaseswithin24monthsold)affectsbetween1and4infantsoutof1,000ismorecommoninboysthaningirls.Inmostinfantsandtoddlerswithintussusception,theetiologyisunclear.Thisgroupisbelievedtohaveidiopathicintussusception.OnetheorytoexplainthepossibleetiologyofidiopathicintussusceptionisthatitoccursbecauseofanenlargedPeyerpatch;thishypothesisisderivedfrom3observations:often,theillnessisprecededbyanupperrespiratoryinfection,theileocolicregionhasthehighestconcentrationoflymphnodesinthemesentery,andenlargedlymphnodesareoftenobservedinpatientswhorequiredsurgery.WhethertheenlargedPeyerpatchisareactiontointussusceptionoracauseofitisunclear.Infantsandchildrenwithintussusceptionhaveintenseabdominalpain.Theseverepainmakesthechildtodrawthekneesup.Thepainisusuallyintermittent,butrecursandmaybecomestronger.Asthepaineases,thechildmaystopcryingforawhileandseemtofeelbetter.Astheillnessprogresses,thechildmaybecomeprogressivelyweakandmaydevelopafeverandappeartogointoshock.Somebabieswillonlyhavethesymptomofdrowsinesswhentheyhaveintussusception.Ininfants,thecausesofintussusceptionareunknown.Becauseitisseenmostofteninspringandfall,though,sometheoriessuggestapossibleconnectiontothekindsofvirusesthatkidscatchduringtheseseasons,includingupperrespiratoryinfections.Insomecases,intussusceptionmayfollowarecentboutofgastroenteritis(or"stomachflu").Bacterialorviralgastrointestinalinfectionsmaycauseswellingoftheinfection-fightinglymphtissuethatlinestheintestine,whichmayresultinpullingonepartoftheintestineintotheother.Intussusceptionisaprocessinwhichasegmentofintestineinvaginatesintotheadjoiningintestinallumen,causingbowelobstruction.Withearlydiagnosis,appropriatefluidresuscitation,andtherapy,themortalityrateofintussusceptionislessthan1%.Iftheobstructiveprocesscontinues,thepressurereachesapointatwhicharterialinflowisinhibited,andinfarctionensues.Theintestinalmucosaisextremelysensitivetoischemiabecauseitisfarthestawayfromthearterialsupply.Ischemicmucosasloughsoff,leadingtoaclassic"currantjellystool",amixtureofsloughedmucosa,blood,andmucus.Ifuntreated,transmuralgangreneandperforationoftheleadingedgeoftheintussusceptummayoccur.Inapproximately2-12%ofchildrenwithintussusception,asurgicalleadpointisfound.Occurrenceofsurgicalleadpointsincreaseswithageandindicatesthattheprobabilityofnonoperativereductionishighlyunlikely.Examplesofleadpointsareasfollows:Meckel'sdiverticulum.Enlargedmesentericlymphnode.Benignormalignanttumorsofthemesenteryoroftheintestine,includinglymphoma,polyps,ganglioneuroma,andhamartomasassociatedwithPeutz-Jegherssyndrome.Intussusceptioncanaccountforasmanyas25%ofabdominalsurgicalemergenciesinchildrenyoungerthan5years.Theoutcomeinpatientswithintussusceptionisexcellentifdiagnosedandtreatedearly.
微创外科治疗已逐渐被广大群众认识并接受,这也成为人们选择医学治疗的必备设备之一。所谓微创治疗是指通过腔镜技术介入人体组织器官或腔隙进行的有创检查或治疗,较之传统开放治疗,有着创伤小,视野清楚,患者术后恢复快等特点。这项技术已经越来越多的应用到了临床医学的各个领域。 小儿疝气,医学名腹股沟斜疝是小儿外科最常见的疾病之一,也是小儿外科最多需要手术治疗的疾病。与其他常见疾病一样,微创手术的开创和发展也给小儿疝气的治疗带来了新的选择。人们在关注疾病治愈的同时,也越来越关注术后美观。因此,有更多的患者会追求更有效、可靠、合理的治疗。 多数人对它的了解只是名词概念,这也让他们在治疗选择中存有很大疑问。让家长们首先明确的是小儿疝气可以使用腹腔镜手术治疗,但是,并不是所有病人都适合这种方法。也就是说,两种方法各有优势,不同的病人应选择不同的方法。传统手术历经数几十年的临床检验,已被证实确实可靠,适用于所有疝气患儿,一般医院也都能开展。而腹腔镜手术是近几年刚新兴的治疗方式,只有在医疗条件较好、医疗水平较高的大医院且有传统手术经验的医生才可以很好地应用。随着临床经验的积累,我们认为经腹腔镜治疗小儿疝气有一定的优势。我们科目前实行的经脐窝腹腔镜套扎技术使得切口更小、更隐蔽,解决了人们对美观的要求。经腹腔镜手术可以减少术后阴囊水肿或血肿的发生,因可以同时探查并治疗对侧,术后双侧复发率也会较低。 根据目前的临床经验,我们认为尤其对于女孩疝气、双侧疝气、复发疝气,交通性鞘膜积液,使用改良单孔腹腔镜套扎手术具有较好的治疗效果,建议家长选择使用。但是,对于巨大疝、滑疝、非交通性睾丸或精索鞘膜积液,还是选择传统手术较为适合。
In 1892,Thomson designated biliary atresia as a specific disease entity in the Edinburgh Medical Journal.Ladd reported the first successful surgery for correctable biliary atresia in 1928.In 1953,Gross noted that biliary atresia was the most common cause of neonatal obstructive jaundice,but with most infant haveing noncorrective disease. Hepatic portoenterostomy (the Kasai procedure) is the standard operation forthe treatment of biliary atresia and has been the cornerstone of therapy for nearly 30 years.The extrahepatic biliary structures are totally excised en bloc,and the fibrous cone transected at the liver hilus is anastomosed to a Roux-en-Y jejunal limb. Cholangitis is the most frequent and serious complication after hepatic portoenterostomy.Cholangitis is heralded bu fever, decreased bile flow,and progressive jaundice.
Inguinal Hernias and Hydroceles Indirect inguinal hernias are fundamentally the result of failure of the processus vaginalis to close.The processus vaginalis is an invagination of the peritoneum through the internal ring that can first be identified during the third month of the processus vaginalis is a result of intra-abdominal pressure,whereas others believe that it is an active process. The intra-abdominal testis passes through the processus duing the seventh to ninth months of gestation,and the processus vaginalis lying above the testicle obliterates,closing the internal inguinal ring,while the distal portion persists as the tunica vaginalis. When this fails to occur,patency of the processus vaginalis result,potentially causing an indirect inguinal hernia or a hydrocele.In females,the canal of Nuck corresponds to the processus vaginalis and communicates with the labia majora,the female homologue of the scrotum.The canal of Nuck normally closes around the seventh month of gestation,earlier than in males.
包皮龟头炎症及包茎手术时机大多数男性儿童在2~3岁前多少会有生理性包茎现象,这种情况下如果没有明显的排尿困难像排尿鼓包或反复包皮龟头红肿及流出白色物并感染等问题,是不需要特殊处理的。 3岁到学龄前期的儿童,如果包皮外口仍较狭小导致包皮不能上翻显露龟头,则建议家长在孩子洗澡时为孩子轻轻翻一翻包皮。若能显露出龟头那说明没有包茎现象。若显露龟头困难,可早点找儿童外科专业医师看一下是否存在包皮龟头粘连还是真正的包茎。还有一部分男孩在青春期第二性征开始发育后,包皮会变松弛,龟头才显露出来。一般地到学龄前若包茎明显,包皮外口狭窄环呈瘢痕样难以显露龟头就需要手术治疗了。还有大部儿童是包皮龟头部分粘连形成的包茎现象,并不是真正意义上的严重包茎,这可以通过锻炼能显露龟头,实在锻炼困难可以试行包皮粘连分离小手术治疗。 到青春期后包皮上翻仍困难的儿童,则应积极考虑行包皮手术治疗了。手术目的是扩大包皮口,完全暴露龟头。手术应根据个体情况,应注意不要单纯做简单的包皮环切术,可选择包皮成形术。有的需要系带成形。还有小部分蹼状阴茎需要阴茎阴囊成形术。