�������CT�ڸ�����λ����е�Ӧ��̽��

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。     

CT三维重建应用于复杂肛瘘诊治的体会

目的 探讨CT瘘管造影在复杂性肛瘘中的临床应用价值.方法 对17例复杂性肛瘘患者进行64排CT瘘管造影检查,CT图像进行三维表面重建(3D-SSD)处理.并与术中所见进行比较.结果 CT瘘管造影及其后处理影像可以清晰显示复杂肛瘘瘘管的分支系统.在其指导下行肛瘘根治术的患者,经过至少1年随访,治愈率100%.结论 CT瘘管造影结合三维重建技术可以指导复杂性肛瘘的临床手术治疗,是提高手术治愈率的重要诊断方法,值得进一步推广.     

三维肛肠超声诊断肛瘘的临床应用价值

为探讨三维肛肠超声扫描结合瘘管双氧水造影在肛瘘诊治中的临床应用价值,对14例肛瘘患者进行,三维肛肠超声检查,将术前获取的三维超声重建图像资料与肛瘘手术结果进行比较。结果显示,14例均经三维肛肠超声检查,10例为单纯性肛瘘,4例为复杂件肛瘘;其中低佗肛瘘5例,高位肛瘘9例,均经手术证实;其中三维肛肠超声检查括约肌间瘘7例,经括约肌瘘4例,括约肌上瘘3例（而手术证实为括约肌间瘘6例,经括约肌瘘5例,括约肌上瘘3例）。三维肛肠超声结合双氧水造影能准确提高瘘管内口及支管的显影,14例患者存在15个肛瘘内口及2例存在支管,其中1例存在1个潜在内口。结果表明,三维肛肠超声瘘管三维图像重建可清晰显示瘘管的具体位置（内、外口）、形态、走行特点及其与肛管内外括约肌、肛提肌、耻骨直肠肌的关系。三维肛肠超声结合瘘管双氧水造影可以精确地对肛瘘进行定位、分型诊断,为手术提供最直观、立体、准确的依据。     

MSCT在直肠癌术前保肛评估中的应用

目的探讨MSCT在直肠癌术前保肛评估中的应用价值。方法对130例拟接受外科手术治疗的直肠癌患者于术前行MSCT平扫及三期动态增强扫描。术前评估可保肛的标准包括肿瘤下缘至肛提肌的距离≥1cm、直肠周围脏器未受侵、直肠周围无广泛淋巴结及癌结节转移。以手术结果为标准,评价MSCT直肠癌术前保肛评估的效能。并对MSCT术前评估与手术结果的一致性进行分析。结果 MSCT术前保肛评估的敏感度为94.12%(96/102),特异度为57.14%(16/28),准确率为86.15%(112/130),阳性预测值为88.89%(96/108),阴性预测值为72.73%(16/22)。MSCT术前评估与手术结果具有较好的一致性(Kappa=0.57,P0.05)。结论 MSCT直肠癌术前保肛评估具有较高的准确率。     

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。     

改良经括约肌间瘘管结扎术治疗低位肛瘘的可行性研究

目的评价改良经括约肌间瘘管结扎术(ligation of the intersphincteric fistula tract,LIFT)治疗低位肛瘘的临床疗效和安全性。方法低位肛瘘病人20例,行改良LIFT术,随访3~15个月,中位随访时间10个月,记录病人创面愈合情况和肛门功能(Wexner评分)。结果创面愈合时间(15.3±4.8)天,一期手术治愈率75.0%,2例低位复杂性肛瘘病人术后单纯缝合创面感染裂开,3例(其中低位单纯性肛瘘1例,低位复杂性肛瘘2例)缝合创面感染裂开且内口与肛管相通,经相应处理后创面均愈合;1例低位单纯性肛瘘病人术后3个月复发,至随访终点时,总治愈率为95.0%,其中12例低位复杂性肛瘘总治愈率为100%。术前Wexner评分均为0分;随访终点Wexner评分0分18例,2分1例,1分1例。结论改良LIFT术更好地权衡了瘘管清除和保护肛门功能之间的关系,保留括约肌完整,瘘管清除彻底,治愈率高,复发率低,无肛门缺损和畸形,对肛门控便功能影响小。     

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。     

超声术前检查复杂肛旁脓肿、肛瘘86例的观察

目的总结超声检查在复杂肛旁脓肿、肛瘘中的优缺点。方法对肛旁脓肿72例,肛瘘合并肛旁脓肿形成14例的超声检查结果进行回顾性分析,并与临床手术结果进行对比。结果86例脓肿与手术结果吻合率达91.9%,漏诊率仅5.8%,瘘管的吻合率较低,仅为21.5%。结论B超术前检查,为临床诊断、手术根治术有较好参考价值。     

腔内超声和磁共振成像在复杂性肛瘘术前诊断中的应用价值对比

目的评价直肠腔内超声(endoanal ultrasound,EAUS)与磁共振成像(MRI)对复杂性肛瘘术前诊断的应用价值。方法对28例临床诊断为复杂性肛瘘的病人术前进行EAUS和MRI检查,以手术结果为标准,分析两种检查的准确率,比较它们的临床应用价值。结果 28例复杂性肛瘘中,EAUS和MRI检查显示内口数量分别为22个、27个,瘘管数量分别为37条、43条。手术病检结果示28例均为复杂性肛瘘,内口共计28个,瘘管44条。MRI检出复杂性肛瘘的内口显示率为96.4%(27/28),瘘管显示率为97.7%(43/44),均高于EAUS检出的内口显示率(78.6%,22/28)和瘘管显示率(84.1%,37/44),二种检查方法比较差异均有统计学意义(χ2值分别为20.83、33.23,均P0.05)。结论 EAUS和MRI在复杂性肛瘘的术前诊断上均有较高的应用价值,但在内口的位置及数量、瘘管的分布及走行上,MRI的准确率更高。在有条件的医院,建议优先选用MRI作为复杂性肛瘘的术前检查方案。     

27例中晚期结肠癌的多层螺旋CT诊断及临床价值探讨

为探讨多层螺旋CT（MSCT）三维重建技术在中晚期结肠癌诊断中的应用价值,回顾分析27例经病理证实的中晚期结肠癌患者资料,患者术前均行MSCT多期扫描及后处理（包括多平面重建、最大密度投影和CT血管造影等）,并将MSCT显示的影像特征与手术证实的结果进行对比分析。结果显示,MSCT能显示肠腔及肠壁的改变、病灶与周围组织的关系,并可显示周围组织器官的侵犯情况及有无远处转移。本组MSCT显示结肠癌的敏感性达100％（27／27）;对大肠癌TNM分期的准确率为：T分期92．59％（25／27）,N分期88．89％（24／27）,M分期85．19％（23／27）;显示肿瘤供血血管准确率为100％（27／27）。1例T2期高估为T3期,1例T1期高估为T3期。3例淋巴结转移和4例远处转移未检出。结果表明,MSCT三维重建技术可以较好地显示病灶及病灶与周围脏器的关系,对中晚期结肠癌TNM分期的判断准确性高,对临床评估肿瘤的可切除性及制定治疗方案具有重要意义。     

��ά�س�����ɨ����������Ӱ��λ��ϸ����ٴ��о�

??Three-dimensional endoanal ultrasound for the locational diagnosis of anal fistula: a preliminary application study BEI Shao-sheng??DING Ke, WANG Jian-xin, et al??Department of Anorectal Surgy??the Second Hospital of Shandong University??Jinan 250033??China Corresponding author??DING Ke??E-mail??dingke@163.com Abstract Objective To evaluate the effectiveness and applied value of three-dimensional (3D)-Endoanal ultrasound combined with hydrogen peroxide angiography for the locational diagnosis of anal fistula. Methods 3D-endoanal ultrasound examination was performed in 17 patients with clinically suspected anal fistulas between November 2008 and January 2009 at the Second Hospital of Shandong University and results were compared with surgical findings. Results Seventeen patients were confirmed by 3D-endoanal ultrasound examination. Nine patients had simple fistulas. Eight patients had complex fistulas. At the same time 7 patients had low located fistulas, and 10 patients had high located fistulas including 8 patients with trsphincter fistulas, 1 patient with inter sphincter fistula and 1 patient with extra-sphincter fistula. All patients were confirmed by operation. But on surgery’s professional examination 1 case with high located fistulas was remisdiagnosed as low located fistulas.3D-Endoanal ultrasound had a accuracy of 90.9%. The 3D shape and track of fistula could be well shown the site of anal fistula and its relationship with the phincter complex and the levator animuscle. Conclusion 3D-Endoanal ultrasound examination combined with fistulography is a very effective and reliable method for the locational diagnosis of anal fistula.     

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。     

Clinical role of a modified seton technique for the treatment of trans-sphincteric and supra-sphincteric anal fistulas

Purposes

We have devised a modified seton technique that resects the external fistula tract while preserving the anal sphincter muscle. This study assessed the technique when used for the management of complex anal fistulas.

Methods

Between January 2006 and December 2007, 239 patients (208 males and 31 females, median age: 41 years) underwent surgery for complex anal fistulas using the technique. Of the 239 patients, 198 patients had trans-sphincteric fistula and 41 patients had supra-sphincteric fistula.

Results

The durations of the surgeries were 17 min (47, 13) [median (range, interquartile range)] for trans-sphincteric fistulas and 38 (44, 16) for supra-sphincteric fistulas. The durations of the surgeries were significantly (P < 0.05) longer for supra-sphincteric fistula than trans-sphincteric fistula. The hospital stays were 4 (13, 2) days and 5 (14, 3) days, respectively, for trans- and supra-sphincteric fistulas. The durations of seton placement until the spontaneous dropping of the seton were 42 (121, 48) and 141 (171, 55) days respectively. The recurrence rate was 0 % in patients with trans-sphincteric fistulas and 4.9 % (2 of 41) in patients with supra-sphincteric fistulas (P < 0.01). Serious incontinence was not observed.

Conclusions

The technique provided favorable results for the treatment of complex anal fistulas and could be safely applied while preserving the sphincter function and conserving fecal continence.     

Comparison of hydrogen peroxide instillation with Goodsall's rule for fistula-in-ano

Background : Identification of the internal opening is an essential step in the management of fistula‐in‐ano. The predictive accuracy of Goodsall’s rule is compared with instillation of hydrogen peroxide for fistulas‐in‐ano. Methods : Thirty‐five patients (32 male, three female; median age 42 years; range: 6 months–70 years) were studied. Hydrogen peroxide solution was injected into the external opening of the fistula track and effervescence was observed at the internal opening within the anal canal. A fistula track was either excised or incised. Setons were placed within high fistulas. Results : There were 24 simple fistulas, compared to 11 complex fistulas (horseshoe, n = 4; abscess, n = 4). Eighteen external openings were anterior and 17 were posterior. Thirty‐four of 35 (97%) internal openings were identified. Only 20 internal openings were in accordance with Goodsall’s rule (positive predictive value: 59%). Predictive accuracy was greater for anterior external openings (13 of 18 (72%)) versus posterior external openings (six of 17 (41%); P = 0.016). For recurrent fistulas, seven of 17 fistula tracks had an internal opening in accordance with Goodsall’s rule, resulting in a positive predictive value of 41%. (Positive predictive value: anterior 67%vs posterior 12.5%; P = 0.0009.) Conclusion : The overall predictive accuracy of Goodsall’s rule was poor chiefly because of poor predictive accuracy in posterior and recurrent fistulas. The use of Goodsall’s rule alone in decision‐making before surgical intervention is not recommended.     

女性尿瘘的治疗体会(附13例报告)

目的　探讨女性尿瘘的诊治,对巨大复杂的膀胱尿道阴道瘘的手术修补法进行探讨。方法　经阴道修补膀胱阴道瘘4例, 尿道阴道瘘3例,膀胱尿道阴道瘘2例,经腹阴道联合途径修补复杂性女性尿瘘4例,其中输尿管阴道瘘1例。结果　一次性修 复痊愈率(甲级)达84.6%、有效率(乙级)达92.3%。结论　术前仔细检查及评估手术方案是缩短手术时间、减少术中创伤的重 要环节,精细的外科手术技巧是确保手术成功的关键,经腹阴道联合手术途径修补术是治疗巨大复杂女性尿瘘的有效方法。     

Bioprosthetic plugs for complex anal fistulas: an early experience

PURPOSE: The goal in the treatment of anal fistulas is to eliminate the fistula without a change in continence. No single technique exists that is appropriate for the treatment of all fistulas. Options include fistulotomy, use of setons, fibrin sealant, and advancement flaps. Recently, a bioprosthetic fistula plug has been described. The purpose of this study is to report the author's early experience with the bioprosthetic fistula plug and to compare the results of bioprosthetic plug closure of complex anal fistulas with those achieved with advancement flap repair. METHODS: A retrospective analysis of prospectively collected data was performed for patients treated with an anal fistula. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, procedure performed, pain scores, and fistula recurrence. RESULTS: Overall, 95 patients comprised the control group (43 men and 52 women), with transsphincteric or rectovaginal fistulas in 51 and 44 patients, respectively, managed by advancement flap repair of their fistula. The fistula recurred in 31 patients (32.6%) during a median follow-up of 10 months. Overall,18 patients had their fistula managed using the porcine fistula plug (12 men and 6 women), with transsphincteric or rectovaginal fistulas in 13 and 5 patients, respectively. The fistula recurred in 2 patients (12%) during a median follow-up of 6 months. CONCLUSION: Use of a porcine fistula plug for the management of complex anal fistulas is a new technique that, in the early experience, seems to yield results similar to advancement flap repair.     

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。     

Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review

BACKGROUNDA complex anal fistula is a challenging disease to manage.AIMTo review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.METHODSAnal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores.RESULTSA total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug (n = 56), 50.3% in PERFACT (n = 175), 86% in TROPIS (n = 408), and 98.6% in fistulotomy (n = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, P = 0.057, not significant).CONCLUSIONFistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.