复杂性肛瘘保留括约肌手术的治疗进展

目前复杂性肛瘘的治疗普遍存在复发率高、肛门功能保护不足的现状.传统的肛瘘切开术和切割挂线术损伤肛门括约肌,易致肛门失禁,已逐渐被保留括约肌术式,如推移瓣、肛瘘栓、经括约肌间瘘管结扎术等所取代.本文将对复杂性肛瘘保留括约肌手术治疗进展作一综述.     

51例原位肛门重建患者的远期疗效观察

应用肛管直肠压力和反射，直肠容量，括约肌肌电及排粪造影等指标，检测了５１例原位肛门重建患者术后２￣８年的肛门节制功能。结果证明，重建肛门节制功能的恢复随时间延长逐渐完善，至术后３年达正常或接近正常，其后改观甚少，中，青年患者恢复快，且完善，替代括约肌的肌肉来源与肛门节制功能恢复的速度和程度密切相关。     

先天性肛门直肠畸形术后肛门功能客观检查方法研究进展

先天性肛门直肠畸形是儿童常见的消化道畸形,手术是唯一的治疗方式,术后肛门功能恢复情况直接影响患儿远期生活质量.对肛门功能进行客观、全面的评估是治疗功能障碍的前提.目前,临床主要釆用直肠肛管测压、同位素排便造影、肛门外括约肌肌电图、肛门括约肌神经电生理检查以及肛管直肠内超声等单项或多项检查方法联合进行肛门功能综合评定.     

小儿术后大便失禁的理疗与康复

我们对1985～1993年时行肛门外括约肌重建术的18例患儿(行神经压榨股薄肌转移肛门外括约肌重建术11例,臀大肌瓣转移肛门括约肌重建术7例,男10例,女8例;年龄2～15岁)术后随访1～9年,发现坚持康复训练者7例,其排便功能均在半年内恢复,而训练不佳的11例中仅4例在1年内恢复排便功能。     

肛管直肠周围脓肿的手术治疗研究进展

肛管直肠周围脓肿为肛肠科常见病之一,手术仍然是治疗该病最有效的方式.手术方式大体经历了以下3个标志性阶段的演变,即从最初的单纯切开引流,待形成肛瘘后行二期手术,发展到一期根治术,再到以强调保护肛门功能为主的保留括约肌术式.随着这些术式在临床的推广运用,不仅使脓肿复发率和肛瘘发生率逐渐减少,还从很大程度上保护了肛门的精细功能及外观的完整性,大大减轻了患者痛苦并提高了生活质量.     

三维肛肠超声检查在高位肛瘘术后肛门括约肌复合体损伤评估中的应用

目的探讨三维肛肠超声检查在高位肛瘘术后肛门括约肌复合体损伤评估中的应用价值。方法行高位肛瘘切开挂线引流术治疗的患者42例,术后行三维肛肠超声检查,采用Starck评分评估肛门括约肌复合体损伤程度,包括肛管直肠环、肛提肌、肛门内括约肌、外括约肌;采用Wexner评分评估肛门控便失禁情况;行肛门直肠测压,包括肛管静息压、肛门紧缩压下降程度、高压带长度。结合患者术后临床表现进行分析。结果超声检查发现,27例有不同程度的肛门括约肌复合体形态学异常,2例为肛门括约肌复合体(包括耻骨直肠肌、部分内括约肌、部分外括约肌深部)整体损伤。13例有不同程度肛门控便功能障碍,2例术后1个月出现不完全性肛门失禁,6个月后症状消失。Starck评分为0.9~1.8(1.3±0.4)分。Wexner评分为0分者29例,1~5分者7例,6~10分者4例,11~15分者2例。肛门直肠测压示肛管最大收缩压、直肠静息压、肛管静息压较术前有所下降,但差异无统计学意义(P均>0.01)。结论三维肛肠超声检查有助于对高位肛瘘患者术后肛门括约肌复合体损伤程度进行评估,方法安全有效,可信度较高。     

直肠中下段癌保肛术式62例体会

直肠癌根治术，越来越多地倾向于保留肛门括约肌的功能，保肛术式的实施，使病人的生存质量得以明显改善。1988-01／1997-12我们对62例中低位直肠癌病人实施了保肛术式，效果满意，现总结报告如下。     

LIFT术与肛瘘切开术治疗经括约肌肛瘘的近远期肛门功能变化观察

目的观察经括约肌间瘘管结扎术（LIFT）与肛瘘切开术治疗经括约肌肛瘘的近远期肛门功能变化。 方法选取深圳市南山区人民医院2015年9月至2017年2月收治的120例经括约肌肛瘘患者,随机分为观察组与对照组,每组各60例。对照组采取肛瘘切开术,观察组采取LIFT术。比较两组手术时间、创面愈合时间及术后第1 d、第3 d及第7 d的创面VAS疼痛评分,术后1个月的总治愈率、术后并发症总发生率及随访6个月的复发率,比较两组术前、术后1个月及术后6个月的肛门功能（应用盆底肌电图和肛门直肠压力测定进行评价）。 结果观察组创面愈合时间为（27.44±6.12）d,短于对照组（32.71±8.35）d（t=-3.943,P=0.000）;两组术后第1 d与第3 d的VAS疼痛评分无明显差异（P>0.05）,观察组术后第7 d的VAS疼痛评分为（2.11±0.66）分,低于对照组（3.56±0.91）分（t=-9.991,P=0.000）。观察组与对照组愈合率分别为90.00%和93.33%,复发率分别为13.33%和10.00%,差异无统计学意义（P>0.05）。观察组术后并发症总发生率为3.33%,低于对照组13.33%（χ²=3.927,P=0.048）。观察组术后1个月与6个月的耻骨直肠肌、内括约肌、外括约肌运动单位电位（MUP）平均时限及肛管静息压与肛管最大收缩压与术前比较无统计学意义（P>0.05）,对照组均下降（P<0.05）;观察组术后1个月与6个月的耻骨直肠肌、内括约肌、外括约肌MUP平均时限及肛管静息压与肛管最大收缩压均高于对照组。 结论LIFT术治疗经括约肌肛瘘可减轻手术对括约肌的损伤,从而减轻患者术后疼痛、促进创面愈合,减少术后并发症,使患者近远期肛门功能得到保护。     

低位直肠癌切除术后影响功能因素分析及对策

直肠癌是常见的消化道恶性肿瘤，在我国多数是位于腹膜返折以下的低位直肠癌。近年来，随着直肠癌理论研究的深入和手术技术的提高，低位直肠癌保肛手术率在逐年上升。目前临床上常用的保肛术式有低位前切除术（LAR）、经括约肌间切除术（ISR）等，但保肛术后出现的各种肛门功能问题一直困扰着患者和医生。笔者通过回顾文献并结合自身经验就低位直肠癌保肛术后影响肛门功能的因素及处理对策进行探讨。     

肛门括约肌病变及其意义

对９８例肛裂病人的肛门括约肌标本行病理学观察，结果括约肌退行性变占２５．５１％，退行性变和纤维化占７３．４７％。括约肌病变导致单纯肛裂者２６例，肛裂并肛门狭窄７２例，认为肛门括约肌退行性变或纤维化是肛裂与肛门狭窄的发病基础。     

A technique for the dynamic assessment of anal sphincter function

A technique which renders continuous measurement of the cross-sectional area and pressure of the anal canal possible during distension and contraction of the anal sphincter has been developed. Electromyography of the external sphincter is measured simultaneously. With this technique a more detailed assessment of anal sphincter function is possible, including the opening and closing pressures of the sphincter at rest, anal compliance, anal hysteresis and the maximal closing pressure during squeeze. The results of in vitro measurements, measurements on 16 healthy subjects and 6 patients with faecal incontinence are presented.     

Should we care about the internal anal sphincter?

The internal anal sphincter is currently regarded as a significant contributor to continence function. Four physiological and morphological aspects of the internal anal sphincter are presented as part of the current evidence base for its preservation in anal surgery. 1) The incidence of continence disturbance following deliberate internal anal sphincterotomy is underestimated, although there is presently no prospective imaging or physiologic data supporting the selective use of sphincter-sparing surgical alternatives. 2) Given that the resting pressure is a measure of internal anal sphincter function, its physiologic representation (the rectoanal inhibitory reflex) shows inherent differences between incontinent and normal cohorts which suggest that internal anal sphincter properties act as a continence defense mechanism. 3) Anatomical differences in distal external anal sphincter overlap at the point of internal anal sphincter termination may preclude internal anal sphincter division in some patients where the distal anal canal will be unsupported following deliberate internal anal sphincterotomy. 4) internal anal sphincter-preservation techniques in fistula surgery may potentially safeguard postoperative function. Prospective, randomized trials using preoperative sphincter imaging and physiologic parameters of the rectoanal inhibitory reflex are required to shape surgical decision making in minor anorectal surgery in an effort to define whether alternatives to internal anal sphincter division lead to better functional outcomes.     

Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures

Lateral sphincterotomy diminishes internal anal sphincter hypertonia and thereby reduces anal canal pressure. This improves anal mucosal blood flow and promotes the healing of anal fissures. However, sphincterotomy can be associated with long term disturbances of sphincter function. The optimal treatment for an anal fissure is to induce a temporary reduction of anal canal resting pressure to allow healing of the fissure without permanently disrupting normal sphincter function. Broader understanding of the intrinsic mechanisms controlling smooth muscle contraction has allowed pharmacological manipulation of anal sphincter tone. We performed an initial Medline literature search to identify all articles concerning "internal anal sphincter" and "anal fissures". This review is based on these articles and on additional publications obtained by manual cross referencing. Internal anal smooth muscle relaxation can be inhibited by stimulation of non-adrenergic non-cholinergic enteric neurones, parasympathetic muscarinic receptors, or sympathetic beta adrenoceptors, and by inhibition of calcium entry into the cell. Sphincter contraction depends on an increase in cytoplasmic calcium and is enhanced by sympathetic adrenergic stimulation. Currently, the most commonly used pharmacological agent in the treatment of anal fissures is topical glyceryl trinitrate, a nitric oxide donor. Alternative agents that exhibit a similar effect via membrane Ca2+ channels, muscarinic receptors, and alpha or beta adrenoceptors are also likely to have a therapeutic potential in treating anal fissures.     

Influence of pudendal block on the function of the anal sphincters.

The function of the anal sphincters has been studied by obtaining continuous recordings of the pressure in the anal canal and the electromyographic activity in the striated sphincter muscles during expansion of the ampulla recti by means of an air balloon. Ten healthy subjects were examined before and after the striated muscles had been entirely paralysed by bilateral pudendal block, making it possible to record the activity from the internal sphincter alone. The results show that the internal sphincter contributes about 85% of the pressure in the anal canal at rest but only about 40% after a sudden substantial distension of the rectum. During constant substantial rectal distension, the internal sphincter accounts for about 65% of the anal pressure. It is concluded that the internal sphincter in the adult is chiefly responsible for anal continence at rest. In the event of sudden substantial distension of the rectum, continence is maintained by the striated sphincter muscles, whereas both sphincter systems probably have an important function during constant distension of the rectum.     

Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy

PURPOSE: The aim of lateral internal anal sphincterotomy when treating anal fissure is to divide the distal one-third to one-half of the internal anal sphincter. This study aimed to evaluate prospectively the extent of disruption to the internal anal sphincter following lateral anal internal sphincterotomy and also to establish the prevalence of symptoms of anal incontinence in these patients. METHODS: Fifteen patients with anal fissure (ten females and five males) had bowel symptoms assessed and anal endosonography performed preoperatively and two months after lateral internal anal sphincterotomy. RESULTS: Anal endosonography was normal preoperatively in all but two females who had anterior external sphincter defects (presumedly from previous obstetric trauma). Postoperatively, apart from one male in whom no defect could be identified, all had an internal anal sphincter defect corresponding to the site of lateral internal anal sphincterotomy. In nine of the ten females, the defect involved the full length of the internal anal sphincter, but in the other four males, the defect involved the distal internal anal sphincter only. All were continent preoperatively, but after lateral internal anal sphincterotomy, three females became incontinent to flatus (two of whom had a preoperative external sphincter defect). CONCLUSION: In contrast to lateral internal anal sphincterotomy in males, division of the internal anal sphincter in most females tends to be more extensive than intended. This is probably related to their shorter anal canal. In some females, lateral internal anal sphincterotomy may compromise sphincter function and precipitate anal incontinence, particularly in the presence of other sphincter defects. Care should be exercised especially in the presence of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.     

Endosonographic evidence of injury to the internal anal sphincter after low anterior resection

PURPOSE: Transanal stapled anastomosis has been associated with continence disturbances and reduced postoperative anal sphincter function. The aim of the present work was to study the effect of transanal stapling on anal sphincter morphology by endoanal ultrasound. METHODS: Thirty-nine consecutive patients undergoing stapled low anterior resection for rectal carcinoma were assessed. Each patient was assessed by endoluminal ultrasound before surgery, immediately after surgery, and at 3, 6, 9, 12, and 24 months after surgery. RESULTS: There were no preoperative internal and sphincter defects observed. Three female patients were observed to have preoperative evidence of external anal sphincter defects. After low anterior resection, seven patients were found to have internal anal sphincter defects, which persisted after the two-year follow-up. There were no additional external anal sphincter injuries. Three patients with internal anal sphincter injuries required the use of pads for poor bowel function. CONCLUSIONS: Up to 18 percent of patients who underwent stapled low anterior resection had long-term evidence of internal anal sphincter injury. The external sphincter does not appear to be affected by the procedure.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Dynamic anal manometry: physiological variations and pathophysiological findings in fecal incontinence.

A recently developed technique for dynamic anal manometry was used to study 40 healthy volunteers and 23 patients with fecal incontinence. Seven parameters of anal function were measured. Intraindividual variation of the parameters was studied in 5 females and 5 males. The results of dynamic anal manometry were compared with standard pull-through static anal manometry and correlated well. During opening of the anal sphincter at rest, compliance increased with increasing distension. Males had higher maximal closing pressures during squeeze and lower anal compliance during squeeze than females. There was no sex differences of the sphincter measurements at rest. Age had little effect, and gender had no effect on the measurements. With standard anal manometry, 6 of 23 patients with fecal incontinence both had maximal resting pressure and maximal squeeze pressure within the normal range. When dynamic anal manometry was used, all 23 patients showed one or more abnormal values. The method of dynamic anal manometry provides an opportunity for a more thorough assessment of anal sphincter function than previous manometric methods.     

Measurement of the Anal Sphincter Strength by a Simple Method Suitable for Routine Use

By determination of the ability of the anal sphincter to retain a metal ball, a simple method for routine measurement of the anal sphincter strength has been worked out. The sphincter strength was defined as the force, expressed in grammes, necessary to pull the metal ball through the anal sphincter. The lowest value recorded in a group of normals was 450 g (males 600 g, females 450 g). As the maximum value observed in a group of patients with anal incontinence was 175 g, a clear discrimination between normal and incompetent anal function was obtained. In 9 patients with preserved rectum after a previous subtotal colectomy, 8 had values within the normal range. One fell below the lowest value for normals, predicting anal incompetence after ileoproctostomy.     

Is there really sphincter spasm in anal fissure?

To assess sphincter function in patients with anal fissure, anal manometry has been performed in ten patients. Anal resting pressure was increased, but both sphincters functioned normally. The increased anal resting pressure was neither due to internal nor to external sphincter spasm.     

低位直肠癌精准功能保肛（PPS）时代真的来了吗?——PPS在低位直肠癌保肛中的应用与研究

直肠癌是目前较为常见的恶性肿瘤,其中低位直肠癌占50%以上,根治性手术是目前最有效的治疗方式。低位直肠癌保肛一直是结直肠外科领域的热点与难点,近年来在保肛率和保肛质量上一直未取得突破性进展,其根本原因是没有良好的手术视野和创新性的手术器械。通过特制器械辅助,精准功能保肛手术可在直视下完成低位直肠癌病灶的精准切除和肠管断端的确切缝合,为低位直肠癌的保肛治疗提供了新方法。