Abstract：
Introduction: A modified pull-through (PT) distinguished by complete full-thickness removal of the posterior rectal cuff, initially developed as an open procedure in 1980, has been performed with laparoscopic assistance since 1997. Postoperative bowel dysfunction improved when the anatomic landmark for PT surgery was revised from the dentate line (DL) to the anorectal (or Herrmann\'s) line (ARL) in 2007. A 40-year (1980-2019) review of 153 consecutive rectal/rectosigmoid type Hirschsprung\'s disease (HD) patients is presented. Methods: Data for postoperative bowel dysfunction and Hirschsprung-associated enterocolitis (HAEC) classified according to the American Pediatric Surgical Association (APSA) scale were obtained retrospectively. Results: PT was open (n = 43) and laparoscopic (n = 110). Dissection was DL (n = 57) and ARL (n = 96). Over 40 years, 5/153 patients (3.3%) had postoperative obstructive symptoms (POS), and 10/153 patients (6.5%) had 13 episodes of postoperative HAEC; APSA grades were: I (n = 4); II (n = 8); and III: (n = 1) presenting with explosive diarrhea (10/13; 76.9%), fever (10/13; 76.9%), abdominal distension (9/13; 69.2%), or bloody stools/shock (1/13 with grade III; 7.7%). The grade III case had histologically-proven transitional zone PT. Postoperative HAEC developed in 3/5 (60.0%) POS+ patients and 7/148 (4.7%) POS- patients (P = .002). Symptom duration and treatment were not correlated with APSA grades. Conclusions: Complete full-thickness posterior rectal cuff excision and using the ARL reduced postoperative HAEC significantly in this series. Despite being anatomically distinct, the DL is inadequate as a precise landmark for PT surgery because it lacks functional relevance. The APSA scale could benefit from timely review to improve its clinical and prognostic value.
摘要：
简介：改良的拉穿（PT），其特征是完全全层去除后直肠袖带，最初是在1980年作为开放手术开发的，自1997年以来一直在腹腔镜辅助下进行。2007年，当PT手术的解剖标志从齿状线（DL）修改为肛门直肠（或Herrmann\'s）线（ARL）时，术后肠功能障碍得到改善。介绍了153例连续直肠/直肠乙状结肠型Hirschsprung病（HD）患者的40年（1980-2019年）回顾。方法：回顾性获得根据美国小儿外科协会（APSA）量表分类的术后肠功能障碍和先天性巨结肠相关性小肠结肠炎（HAEC）的数据。结果：PT为开腹（n=43）和腹腔镜（n=110）。夹层为DL(n=57)和ARL(n=96)。40多年来,5/153例患者（3.3%）有术后梗阻症状（POS），10/153患者（6.5％）有13次术后HAEC发作；APSA等级为：I（n=4）；II（n=8）；III：（n=1）呈现爆发性腹泻（10/13；76.9％），发烧（10/13；76.9％），腹胀（9/13；69.2％），或血便/休克（III级1/13；7.7％）。III级病例具有组织学证实的过渡区PT。术后HAEC在3/5（60.0%）POS+患者和7/148（4.7%）POS-患者中发生（P=0.002）。症状持续时间和治疗与APSA等级无关。结论：在该系列中，完整的全层直肠后袖切除术和使用ARL显着降低了术后HAEC。尽管在解剖学上不同，DL作为PT手术的精确标志是不够的,因为它缺乏功能相关性.APSA量表可从及时复查中获益，以提高其临床和预后价值。
