| Background and objective:Neurogenic bowel dysfunction (NBD) refers to some kind of reason caused the nerve dominating anorectum amage, which bring about the anorectal perception and movement disorders, the sphincter and pelvic floor muscle paralysis and atrophy and the loss of reflection coordinated action of fecal continence, inducing defecation and continence dysfunctions, manifesting fecal incontinence seriously affecting the life quality of children. For the neurogenic patients with defecation and continence dysfunction, we need to make a general and comprehensive evaluation in order to understand the pathogenesis, and guide the treatment preferably. In this article, the results of electrophysiological study of pelvic floor musculature, anorectal manometry and colonic transit study in children with NBD were collected for follow-up research, and the clinical efficacy in part of patients performing Malone antegrade continence enema (MACE) were also observed for the follow-up reserch. Then conclude pathophysiological characteristics of neurogenic fecal incontinence, explore the clinical efficacy of MACE and the prevention of complications, and improve the level of clinical treatment of children with NBD, in order to improve the quality of life in children with NBD preferably.Methods:Collect the278patients diagnosed as neurogenic bowel dysfunction, who were treated in pediatric surgery department of the second hospital of Shandong University in May,2005to August,2013for follow-up research. All patients (male142, female136) underwent tethered cord release, and the age of patients range from4to16years old, with an average age of8.8years old. All patients performed the electrophysiological study of pelvic floor musculature and the anorectal manometry, and were compared with the control group. The control group were20healthy children (male14, female6), and the age of these children range from4to14years old, average8.2years old. Thirty-five patients (male21, female14) underwent colonic transit study, the age of which range from3to16years old, with an average age of7.8years old, and were compared with the control group. The control group were20healthy children (male16, female4), and the age of these children range from3to15years old, average8.0years old. Fifty-one patients (male28, female23) performed MACE, the age of which range from4to16years old, with an average age of9.3years old. Review the condition of the preoperative and postoperative defecation, continence, enema and complications in51patients performing MACE. These patients followed up for6to65months, in which30cases were obtained from medical records and the clinic diagnosis and treatment records, while15cases were obtained by telephone call, with the88.2%of follow-up rate. According to the fecal incontinence Rintala criteria, quantify the preoperative and postoperative clinical manifestations of children, in order to evaluate the clinical efficacy of the procedure. Using SPSS17.0software for statistical data analysis, the results of the electrophysiological study of pelvic floor musculature, anorectal manometry, and colonic transit study applied t test, and the comparison between pre-operation and postoperation of MACE chose paired t test. P<0.05showed that the difference had statistical significance.Result:1. The results of the electrophysiological study of pelvic floor musculature: Compared with the control group, the difference of the action potential amplitude (704±9.28,786±11.85) mv and time limit (7.64±2.76,8.91±3.93) ms of the external anal sphincter and levator ani muscle in patients with NBD was statistically significant (P<0.01). Pudendal nerve motor conduction amplitude in patients with NBD was significantly lower than the control group, which was (0.46±0.30) vs (1.65±0.22) mv, and the latent period in patients with NBD was significantly prolonged than the control group, which was (2.62±0.35) vs (1.76±0.25) ms.2. The results of anorectal manometry:Compared with the control group, the anal resting pressure (33.41+14.08) mmHg and the anal largest squeeze pressure (78.00±46.81) mmHg both reduced significantly, and the first defecation sensory threshold (69.05±36.96) ml increased significantly. The difference in the maximum capacity sensory threshold between the patients group and the control group had no statistical significance.3.The results of colonic transit study:The total colonic transit time was significantly prolonged in patients with NBD than that in the control group [(72.6±6.6) vs (40.4±7.4) h, P<0.01], especially for the left half colon [(20.9±4.2) vs (9.3±4.3) h, P<0.01] and sigmoid colon [(32.8±5.2) vs (19.6±6.7) h, P<0.01].4.The clinical efficacy and evaluation in patients performing MACE:Before operation, all children can not control defecation voluntarily, had frequent soiling, and had a certain degree of social activities limited, with (5.40±2.78) of quantitative score. Postoperative follow-up results showed that children gained defecation control, had occasional soiling, and improved the quality of the life, with Score (15.69±1.44) significantly increasing (P<0.01). The frequency of enema ranged from once a day to once a week, and enema volume ranged from300ml to800ml. Enema was mainly normal saline. The children can defecate in30min-lh after enema. Only2(4.4%) out of the45patients appeared fecal leakage, and4(8.9%) appeared stomal stenosis, in which3succeeded after dilation, and1redid the operation because of difficult intubation.Conclusion:1. The results of the electrophysiological study of pelvic floor musculature shows that the action potential amplitude of the external anal sphincter and levator ani muscle in patients with neurogenic bowel dysfunction increase significantly, and the time limit is significantly prolonged; pudendal nerve motor conduction amplitude reduce significantly, and the latent period is significantly prolonged.2. The results of anorectal manometry shows that the anal resting pressure and the anal largest squeeze pressure are both reduced significantly, and the first defecation sensory threshold are increased significantly in patients with neurogenic bowel dysfunction.3. The results of colonic transit study shows that the total colonic transit time was significantly prolonged in patients with neurogenic bowel dysfunction, especially for the left half colon and sigmoid colon. 4. Malone antegrade continence enema is a effective method of treatment of neurogenic bowel dysfunction, which can improve the patients’ quality of life significantly. |
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