三维肛管直肠腔内超声在肛瘘诊治中的应用

目的 探讨三维肛管直肠腔内超声定位肛瘘内口、显示瘘管走行的价值.方法 2008年11月至2010年1月应用三维肛管直肠腔内超声检查肛瘘患者127例,在三维立体模块中根据声像图特征进行内口定位、瘘管走行追踪.结果 定位内口116例,准确率91.3%(116/127),其中112例患者内口开口于齿线处,4例发现内口于直肠壶腹;127例患者定位主管,准确率100%(127/127),其中经括约肌瘘75例,括约肌间瘘47例,括约肌上瘘2例,括约肌外瘘3例;定位支管37例,准确率100%(37/37).结论 应用三维肛管直肠腔内超声检查肛瘘,能够准确定位内口、显示瘘管走行,能为临床治疗方法的选择提供必要的诊断依据.     

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目的探讨多层螺旋CT(MSCT)平扫、增强并结合瘘管造影对肛瘘进行定位诊断的临床应用价值。方法2004年7月至2006年5月间温州医学院附属第一医院对32例临床疑诊为肛瘘的病人使用16层螺旋CT扫描和瘘管造影。原始图像采用多平面重建(MPR)和容积重建(VR)技术进行三维重建,后处理图像由放射科专业医生完成。将术前获取的影像学资料与显微肛瘘手术和随访结果进行比较。结果MSCT上4例未发现肛瘘,5例为单纯性肛瘘,23例为复杂性肛瘘,均经过手术证实,肛肠专科检查将8例复杂性肛瘘误诊为单纯性肛瘘。MSCT上低位肛瘘6例,高位肛瘘22例,均经过手术证实,其中肛肠专科检查将8例高位肛瘘误诊为低位肛瘘,MSCT上3例括约肌外瘘误诊为括约肌上瘘。MSCT对术前内口、支管、脓腔评价的准确率分别为62.1%、89.3%、100.0%。MSCT后处理重建技术中,MPR包括曲面重建(CPR)可清晰显示瘘管的具体位置及其与肛管内外括约肌、肛提肌的关系,VR能三维再现瘘管的形态和走行特点。结论MSCT平扫、增强并结合瘘管造影是一种有效而可靠的对肛瘘进行定位诊断的检查方法,可以为手术提供有效依据。     

肛瘘MRI术前诊断价值与术中结果对照分析

【摘要】〓目的〓探讨术前磁共振(MRI)检查对肛瘘的定位、分型的临床指导意义。方法〓50例肛瘘患者行MRI检查,根据MRI所见,定位瘘道位置,依据窦道与肛门内外括约肌关系进行分型,并与术中所见结果相对照。结果〓手术证实50例患者中,30例为单纯性肛瘘,20例为复杂性肛瘘。括约肌间型20例,经括约肌型12例,括约肌上型6例,括约肌外型3例,表浅型9例。原发性瘘管72个,内口78个,外口77个,肛周脓肿17个。MRI诊断原发瘘管、内口、肛周脓肿的灵敏度分别为93.1%、96.2%、100%,特异度分别为91.5%、97.5%、91.3%。结论〓MRI可准确地判断肛瘘的分型、瘘管数量、走行、支管、内口的位置及有无肛周脓肿形成,为临床手术治疗提供重要指导信息。     

MRI在肛瘘诊断中的应用价值(附381例报告)

目的研究MRI在肛瘘诊断中的临床应用价值。方法对381例肛瘘患者行MRI扫描,由两位高年资放射科医生阅片,明确瘘管走向,内口位置,有无存在支管,及主要瘘管与肛门括约肌之间关系并与手术探查结果进行对照。结果 381例肛瘘中肛管括约肌间型为256例(67.19%),经肛管括约肌型为91例(23.88%),肛管括约肌上型为26例(6.82%),肛管括约肌外型为8例(2.10%)。其中,括约肌间瘘患者中MRI检查对于内口的确定,主、支管的判断准确率均为100%。MRI对内口的判断准确率,经括约肌间型肛瘘(96.72%),高于肛管括约肌上型(76.92%)及肛管括约肌外型(66.67%)。而对于所有分型肛瘘其主、支管判断准确率均较高(90%)。结论说明核磁共振成像技术对于判断瘘管走向,是否存在支管上有优势。对临床选择正确的治疗方法具有重要意义。     

肛瘘的磁共振成像检查(英)

肛瘘手术治疗需准确定位瘘管。目前,各种报道过的术前肛瘘检查方法,包括肛门内超声扫描（AES）、CT等影像检查,对复杂瘘管的确诊定位率很低,难以达到手术的要求。本文作者使用磁共振成像（MRI）对35例肛瘘进行检查,并将MRI检查结果分别与AES结果、手术结果对比分析后认为:对有复杂继发瘘管、脓肿（尤其是坐骨直肠窝深部脓肿）、蹄形瘘、脓毒症的病例和肛瘘手术失败,临床难以确诊的疑难病例,MRI检查有其绝对的优越性和准确率。对复杂继发瘘的确诊,MRI优于AES,而对普通无支管的原发性瘘和瘘内口的确诊,MRI与AES无显著统计差异。同时AES仅对括约肌间瘘有明显确诊价值,而无法确诊括约肌外瘘、经括约肌瘘和坐骨直肠窝内脓肿。MRI还发现手术遗漏的瘘3例,其中复发脓毒症2例,蹄形瘘长期不愈1例。因此MRI检查在正确引导手术成功有令人鼓舞的巨大价值。无法确诊上皮化肛瘘是MRI检查的缺点。田于MRI检查费用高于AES,因此临床检查要考虑对病人的实用价值。     

肛管腔内三维超声联合瘘管造影对肛瘘的诊断价值

探讨肛管腔内三维超声联合H2O2瘘管造影对肛瘘患者的诊断价值。60例肛瘘住院手术患者,术前均行肛管腔内三维超声及H2O2瘘管造影检查,以手术结果为准,对照分析两者在肛瘘分类、分型及内口位置的诊断准确率。术后随访1年,记录治愈率及复发情况。结果显示,H2O2瘘管造影对肛瘘临床分类及肛瘘内口判断的诊断准确率高于肛管腔内三维超声(P<0.05);两者对肛瘘Parks分型诊断的准确率均较高(P>0.05)。60例患者均治愈,术后随访1年,2例复发。结果表明,肛管腔内三维超声联合H2O2瘘管造影检查能够对肛瘘进行准确的分型、分类,并进一步提高肛瘘内口定位的准确率,具有较高的诊断价值。     

动态3D直肠腔内超声结合瘘道造影诊断复杂性肛瘘的应用价值

目的:探讨应用过氧化氢增强瘘道造影下动态3D直肠腔内超声诊断复杂性肛瘘的应用价值.方法:将60例复杂性肛瘘患者随机分成观察组和对照组,各30例.对照组术前常规行经直肠腔内超声检查,观察组采用过氧化氢增强瘘道造影下动态3D直肠腔内超声检查.观察2组内口、主管、支管的位置及数量和与括约肌的关系,并与术后结果进行比较.结果:...     

慢性瘘管性肛周脓肿26例治疗体会

肛周慢性瘘管性脓肿由内口、瘘管和瘘管盲端的慢性脓肿组成 ,其性质属内盲瘘 (即无外口的肛瘘 )。自 1998年以来 ,笔者采用穿刺染色方法进行瘘管及内口染色 ,选择近段病灶切开搔刮或挂线、远段病灶切除缝合的术式 ,治疗 2 6例 ,效果满意 ,现报道如下。1　临床资料本组 2 6例中 ,男 2 1例 ,女 5例 ;年龄 12～ 46岁 ,平均 32岁 ;病程 2月～ 3年 ,平均 7 2月。术中证实低位肌间脓肿 1例 ;肛周皮下脓肿 2 5例 ,其中瘘管经括约肌间低位 2 1例 ,经括约肌间高位 4例。有 1例经外括约肌间低位瘘管者发出一分支管绕过外括约肌浅部以上与脓腔相通。瘘…     

三维肛管直肠腔内超声诊断肛瘘40例

目的:探讨三维肛管直肠腔内超声在肛瘘诊断中的价值.方法:对40例肛瘘患者行三维肛管直肠腔内超声检查,观察肛瘘内口位置、瘘管主管及支管走行等情况,并与术中探查情况进行对比.结果:40例中肛瘘内口定位正确38例(95%),肛瘘主管定位正确39例(98%),支管定位正确11例(85%).结论:三维肛管直肠腔内超声对肛瘘的诊断具有重要作用,是具有较高应用价值的影像检查手段.     

二维和三维腔内超声技术应用于肛瘘诊断的比较研究

目的：评估二维和三维腔内超声技术诊断肛瘘的准确性。方法收集2012年1—12月南京市中医院肛肠科住院接受手术治疗的47例肛瘘患者临床影像资料。以术中探查结果为金标准,对二维和三维两种腔内超声检查的诊断结果进行kappa一致性检验。结果二维和三维腔内超声对瘘管内口的诊断均表现出与术中探查结果较好的一致性（kappa系数0．776比0．636）;三维腔内超声对括约肌间瘘、高位经括约肌瘘和括约肌上瘘的诊断与术中探查结果的一致性均极好,并优于二维超声,kappa系数分别为0．810比0．592,0．863比0．548,1．000比0．672;对于分支瘘管的诊断,三维超声也优于二维超声（kappa系数分别为0．659比0．535）;对于合并脓肿的诊断,三维和二维超声一致性均极好（kappa系数：0．881比0．816）。结论三维腔内超声能清晰显示瘘管与括约肌的关系,尤其对高位、合并分支瘘管的复杂性肛瘘,较二维超声的诊断准确性更高。     

H2O2造影下直肠腔内超声在肛瘘术前诊断中的应用价值

摘要为探讨H2O2造影下直肠腔内超声在肛瘘术前诊断中的应用价值,将110例肛瘘患者随机分为观察组和对照组,各55例,观察组患者术前于H2O2造影下行直肠腔内超声检查,对照组患者术前行普通盲肠腔内超声检查．观察两组主瘘管、支瘘管及内口的显影情况,将其结果与术中所见进行对比。结果显示。观察组和对照组主瘘管诊断的准确率分别为92．7%（51／55）和90．9％（50／55）,P〉0．05;支瘘管诊断准确率分别为85．4％（35／41）和63．2％（24／38）。P〈0．05;内口诊断的准确率分别为90．4％（47／52）和55．1％（27／49）,P〈0．05。结果表明,H2O2造影下直肠腔内超声呵清晰地对肛瘘主瘘管、吏瘘管、内口显影,在肛瘘的术前诊断中具有较高的应用价值。     

H2O2造影直肠腔内超声对肛瘘诊治的意义

目的：探讨H2O2造影直肠腔内超声对提高肛瘘病灶检出率及降低复发率的意义。方法：将110例肛瘘患者随机分为常规直肠腔内超声组（以下简称常规组）、H2O2造影直肠腔内超声组（以下简称H2O2组）,分别观察常规组和H2O2组主瘘管显影率、支瘘管显影率、内口显影率以及术后复发率。结果：常规组与H2O2组的主瘘管显影率分别为90.9%和92.7%,P＞0.05;支瘘管显影率分别为63.2%和85.4%,P＜0.05;内口显影率分别为49.1%和80%,P＜0.05;术后复发率分别为18.2%和5.5%,P＜0.05。结论：肛瘘患者术前行H2O2造影直肠腔内超声,对于提高肛瘘诊断准确率、微小病灶（支瘘管）检出率及降低术后复发率有重要意义。     

Pre-operative assessment of anal fistulas using endoanal ultrasound

Objective To study the accuracy of endoanal ultrasound in pre‐operative assessment of cryptoglandular anal fistulas, with respect to the site of the internal opening, type and depth of the fistula tract. Patients and methods A consecutive series of 151 patients with anal sepsis underwent pre‐operative endoanal ultrasound assessment of a suspected anal fistula. Hydrogen peroxide was used to define the tract when there was doubt as to the course of the fistula. All patients subsequently had surgical exploration under anaesthesia, irrespective of findings at sonography. The site of the internal opening, depth and type of fistula were recorded at surgery, and concordance with the ultrasound was assessed. Results One hundred and forty‐five patients were subsequently shown to have a fistula at surgical exploration. Type of fistula: Two thirds were transsphincteric (63%) and one third were inter sphincteric (32%), with a few submucosal, and supra sphincteric fistulas. Ultrasound correctly predicted surgical findings in 82% of patients (124/151). Concordance was highest for transsphincteric fistulas (87%). Internal opening: Accuracy of predicting the site of the internal opening was 93% (140/151). The commonest site for the internal opening was the midline posteriorly (49%), followed by the midline anteriorly (25%), the rest lay laterally. Fistula depth: Ultrasound and surgical assessment of the depth of fistulas was concordant in 120 of 145 patients (83%). Conclusions Endoanal ultrasound has a high accuracy of predicting the site of internal opening of an anal fistula. Endoanal ultrasound is able to assess the type and depth of a fistula. This information is useful for pre‐operative planning of fistula treatment.     

Combined parasacral, vaginal and endorectal approach in surgical treatment of giant rectocele

Authors operated on their Surgical departement 67 years old women with incomplete evacuation, and digital support during defecation, giant rectocele and massive vaginal vault prolaps. Authors realized cinedefecography and detected giant rectocele, depth was 8 cm, anorectal angle was 120 degrees. They stated Resting pressure 40 cm H2O, and Maximum squeeze pressure 50cm H2O by anorectal manometry. Authors verified external anal sphincters defect by endoanal ultrasound and determined Pudendal nerve terminal motor latency (PN TML) and recorded pathologic values of n.pudendal latency ( left branch 2,7 msec., right branch 4,3 msec). In concerning massive vaginal vault prolaps, huge rerectocele and clinical incompletely evacuation with self digital support during defecation with present defect od external anal sphincters and pathologic values of PN TML, authors indicated and made combined transvaginal, endorectal and perineal reconstructive operative performance. In the present time two years after the surgery radiologic mean depth of the rectocele was significantly reduced (preoperatively 8cm; postoperatively 1 cm). Anorectal angle is 100 degrees. Values of the PN TML is normaly (left branch of n. pudendalis 1,7 msec and right branch of n. pudendalis 1,9 msec). Authors recorded Resting pressure 60 cm H2O and Maximum squeeze pressure 110 cm H2O by anorectal manometry. They didnt visualized any external anal sphincters defect by anal ultrasound. Postoperatively difficult evacuation completely disappeared and digital support was no longer necessary during evacuation.     

术前三维肛管直肠腔内超声检查对肛瘘的应用价值

目的：探讨三维肛管直肠腔内超声（3D-EAUS）检查在肛瘘术前评估中的应用价值。方法前瞻性纳入2012年3月至2013年3月第二炮兵总医院结直肠肛门外科连续收治的诊断明确、拟行手术的100例肛瘘患者,采用计算机产生随机号的方法随机分为超声组和对照组,每组各50例。超声组术前采用3D-EAUS检查,对照组术前常规检查、采用指诊或探针探查,比较两组肛瘘内口定位、肛瘘分型及是否存在分支瘘管的准确率。结果与对照组比较,超声组的内口定位准确率较高,超声组和对照组分别为96．0％（48／50）和82．0％（41／50）（P＝0．02）。超声组与对照组对复杂性肛瘘的诊断分别为96．7％（29／30）比74．1％（20／27）（P＝0．021）;对肛瘘分型的诊断分别为96．0％（48／50）比78％（39／50）（P＝0．01）;对是否存在分支瘘管的诊断分别为94．0％（47／50）比84．0％（42／50）（P＝0．025）。但对于简单性肛瘘,两组内口定位准确率相当[95．0％（19／20）比91．3％（21／23）, P＝1．000]。结论三维肛管直肠腔内超声在内口定位、瘘管分型及分支瘘管的诊断方面具有较高的应用价值,尤其对复杂性肛瘘患者,值得在临床推广。     

A unique 3D endoanal ultrasound feature of perianal Crohn’s fistula: the ‘Crohn ultrasound fistula sign’

Aim Using a high‐resolution 3D endoanal ultrasound, we have observed that some perianal fistulas show a hypoechogenic fistula tract surrounded by a well‐defined hyperechogenic area with a thin hypoechogenic edge in patients with Crohn’s disease [‘Crohn’s Ultrasound Fistula Sign’ (CUFS)], unlike conventional fistula tracks. The study aimed to determine the prevalence of CUFS in a consecutive series of patients with anal fistula. Method Of 157 patients (median age 45, range 14–86 years, 100 males) with perianal fistula were examined with 3D endoanal ultrasound. All 3D volumes were stored and analysed retrospectively by two independent observers blinded to the clinical information of the patients. Results There were 29 patients with Crohn’s disease of whom 20 (69%) showed CUFS. CUFS was absent in 125 (98%) of 128 patients without Crohn’s disease. The positive and negative predictive value of CUFS for Crohn’s disease was 87% and 93%, respectively. The kappa value of the two independent observers was 0.77, indicating a substantial interobserver agreement. Conclusion This study provides a new 3D endoanal ultrasound criterion, CUFS, of perianal fistula in patients with Crohn’s disease. The sign can be used to discriminate a Crohn’s from other types of fistula, which may be useful in the management of patients with anal fistula.     

Attitudes to the treatment of chronic anal fissure in ano after failed medical treatment

Objective The treatment of chronic fissure may be medical or surgical. Indications for assessment, which is the better treatment and under what circumstances, are vital for the appropriate management. The aim of the study was to assess the management of this condition by an expert group of surgeons. Methods Consultant members of the Association of Coloproctology of Great Britain and Ireland (n = 452) were approached and requested to answer a preset multiple‐choice questionnaire. The questionnaire was designed to assess their management strategy and their approach to investigation and treatment under different clinical situations. Results The overall response was 78% (n = 356). Medical treatment was the first line treatment in 95% of the responders. Lateral anal sphincterotomy without pre‐operative endoanal ultrasound and/or anorectal physiology was performed by 57%. Anal dilatation was performed selectively by 36% but only 35% of these would perform a pre‐operative endoanal ultrasound or anorectal physiology. Conclusion In the selected group of clinicians lateral anal sphincterotomy remains the procedure of choice in both sexes. Pre‐operative assessment using endoanal ultrasound and anorectal physiology is used selectively especially in postpartum women. Anal dilatation remains a subjective procedure and though used selectively, is performed without pre‐operative endoanal ultrasound and/or anorectal physiology in majority of cases.     

Gore Bio‐A® Fistula Plug: a new sphincter‐sparing procedure for complex anal fistula

Aim The surgical treatment of a complex anal fistula remains controversial, although ‘sphincter‐saving’ operations are desirable. The Gore Bio‐A^® Fistula Plug is a new bioprosthetic plug that has been proposed for the treatment of complex anal fistula. This study reports preliminary data following implantation of this plug. Method Eleven patients with a complex anal fistula underwent insertion of Gore Bio‐A^® Fistula Plugs. The disc diameter and number of tubes in the plug were adapted to the fistula to allow accommodation of the disc into a submucosal pocket, and the excess tubes were trimmed. During the follow‐up period, patients underwent clinical and physical examinations and three‐dimensional endoanal ultrasound. Results Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three and four tubes were inserted into the fistula plug in seven, three and one patient, respectively. The median follow‐up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Treatment success was noted for eight (72.7%) of 11 patients at the last follow‐up appointment. Conclusion Implanting a Gore Bio‐A^® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success.