手术配合中药坐浴治疗陈旧性肛裂80例临床观察

为寻求治疗陈旧性肛裂可靠、效果满意的方法,将80例Ⅱ、Ⅲ期陈旧性肛裂患者随机分为两组,治疗组42例采用手术配合中药坐浴、缩肛运动治疗,对照组38例采用手术配合1：5000PP液坐浴治疗,观察两组疗效。结果显示,两组创口愈合时间差异有统计学意义（P〈0．05）,治愈率均为100％（P〉0．05）。均未出现肛门失禁及肛门功能障碍。结果表明,肛裂切除并扩肛术,配合中药冰朴散坐浴、缩肛运动治疗,减轻了患者术后痛苦,加快了创口愈合。     

A Comparison Between the Results of Fissurectomy and Lateral Internal Sphincterotomy in the Surgical Management of Chronic Anal Fissure

Background  We compare lateral internal sphincterotomy as an effective treatment of chronic fissure in ano to fissurectomy, which is as an alternative surgical treatment. Methods  Sixty two consecutive patients were divided into two groups through sequential sampling. Thirty patients underwent fissurectomy and 32 underwent lateral internal sphincterotomy. After a median follow-up of 22 months, we compared the results of the two procedures. In addition to frequent visits on a predetermined basis, a telephone inquiry into fissure recurrence and continence status was made. Results  All patients in both groups were pain-free and without bleeding within 1 week. In both groups, urinary retention was noted in one patient. Incontinence to flatus was noted in the fissurectomy (F) group in two (6.2%) patients, but no incontinence was noted in the lateral internal sphincterotomy (LIS) group. There was one patient (3.1%) with fissure recurrence in the F group but none in the LIS group. No patient in either group was afflicted with anal stenosis or perianal infections. All wounds healed within 8 weeks. Twenty nine patients (96.6%) in the LIS group and 28 (87.5%) in the F group reported satisfactory results with their procedure. Conclusion  In the surgical treatment of chronic anal fissure not responding to conservative management, LIS may be the better treatment and, perhaps, the preferable surgical technique with fewer total complications (P < 0.005).     

Lateral Internal Partial Sphincterotomy Technique for Chronic Anal Fissure

Lateral internal sphincterotomy is used for the treatment of a chronic anal fissure. There is a lack of consensus for the amount of internal sphincter division necessary in the surgical treatment of an anal fissure. The anatomy of the anal sphincters and the subcutaneous partial sphincterotomy technique are presented with fresh anal canal specimen photographs. Lateral internal partial sphincterotomy is performed in 43 patients in the office between 2012 and 2013. The patients were questioned about their bowel habitus and any problem with anal control before the operation. Postoperatively, the patients were followed up by office visits and telephone calls at 1 week, 1 month, and 6 months. Data were collected prospectively. Forty of the patients (93 %) were pain free in 1 week after the operation. Further sphincter fibers were divided in three patients (7 %) because of the persistent pain. The most common complication was the sensation of burning (n?=?9, 20.9 %) around the anus. Bleeding in three patients, itching around the anus in two patients, and incontinence to flatus in one patient were the other complications. None of the patients developed fecal incontinence in the follow-up period. Lateral internal partial sphincterotomy is a safe, effective, and reproducible technique for the management of chronic anal fissure pain.     

微波配合序贯扩肛治疗陈旧性肛裂疗效观察

目的 分析、比较2种治疗陈旧性肛裂方法的临床疗效和特点.方法 将96例陈旧性肛裂患者按就诊单双号分成2组:观察组48例,行微波配合序贯扩肛治疗;对照组48例,行后位内括约肌部分切断.对2种方法的术中出血量、创口愈合时间、创口感染率、肛门感染率、肛门控制情况、术后排便改善情况、肛门狭窄发生率及复发率进行比较分析.结果 观察组的术中出血量及创口愈合时间均少于对照组(P<0.01),肛门控制情况优于对照组(P<0.05).2组患者术后均无创口感染及肛门感染病例发生.2组术后随访1年,均无复发病例,术后排便情况均得到改善,观察组肛门狭窄发生率低于对照组(P<0.05).结论 微波配合序贯扩肛治疗陈旧性肛裂简便易行,患者痛苦小、效果好,值得推广.     

倒“V”字皮瓣修复加内括约肌切断术治疗陈旧性肛裂(附62例报道)

目的 评估倒“V”字皮瓣修复加内括约肌切断术治疗陈旧性肛裂的效果及合理性.方法 回顾性分析2000～2010年期间我院采用肛门后倒“V”字皮瓣修复加内括约肌切断治疗的62例陈旧性肛裂患者的临床资料,并对其效果进行评价.结果 62例患者经过该手术治疗,均痊愈出院.发生切口血肿4例,切口感染1例,暂时性大便渗漏4例.住院时间平均8.6d,术中出血量平均13 ml,创口愈合时间平均8d.术后随访6～15个月(平均12个月),均未出现复发,排便情况满意.结论 该术式治愈率高,并发症少,是治疗陈旧性肛裂有效而可行的一种手术方式.     

慢性肛裂手术方法的改进

目的探讨预防慢性肛裂手术并发症的技巧。方法回顾性分析近3年笔者所在单位收治的63例慢性肛裂患者的临床资料,男21例,女42例,年龄(34±12)岁(17～51岁),均行肛裂切除术,并在处理内括约肌时采用橡皮筋结扎法,观察术后并发症的发生情况。结果所有患者术后恢复良好,无一例出现术后大出血、肛裂复发、肛门失禁等并发症。结论通过采用橡皮筋结扎法处理内括约肌,避免了术后并发症的发生,该方法值得推广。     

Oral Plus Local Antibiotics Significantly Reduce the Need for Operative Intervention in Chronic Anal Fissure: a Novel Finding

Up to 40% patients with chronic fissure-in-ano require operative intervention. As of today, antibiotics, local or oral, have no role in the treatment of chronic fissure-in-ano. In a prospective study, fissure-in-ano was classified as follows: acute <6-week duration, chronic >6-week duration with normal/low anal tone, and acute-on-chronic >6-week duration with high anal tone. The resting anal tone was assessed clinically on an objective scale—DRESS score—the digital rectal examination scoring system. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment was advocated for 6 months. For refractory cases, liquid paraffin and, for high anal tone, diltiazem cream along with sitz bath were prescribed. Non-responders underwent a MRI to look for fissure deepening (presence of sinus/fistula). Healing of fissure-in-ano was assessed by absence of pain, burning, itching, or spasm after defecation and absence of tenderness on per-rectal examination. Out of 109 fissure-in-ano patients recruited over 20 months, 90 (M/F—50/40) were finally included. Mean age was 37.6 ± 12.3 years. Conservatively managed, 86.7% (78/90) patients had significant relief and were cured without requiring any further intervention. Twelve out of ninety (13.3%) patients had no/minimal relief and underwent a MRI which revealed a fissure-sinus/tract in 10/90 (11.1%). MRI was normal in 2/90 (2%). Five out of ten patients with sinus underwent surgery (laying open of the sinus) and became alright subsequently. The rest of the five patients were lost to follow-up. In chronic fissure-in-ano, the regimen of local and oral antibiotics with avoidance of constipation significantly decreases the need for operative intervention.     

陈旧性肛裂手术两种麻醉方法效果比较

为了为陈旧性肛裂手术患者寻求一种安全有效的麻醉方法,对122例陈旧性肛裂患者分别在骶管麻醉（治疗组,62例）或局部麻醉（对照组,60例）下行手术治疗,跟踪观察麻醉止痛效果和肛门松弛效果。结果显示,（1）麻醉止痛效果：治疗组显效59例（95．2％）,有效3例（4．8％）,无效0例;对照组显效21例（35．0％）,有效39例（65．0%）,无效0例;治疗组显效率明显高于对照组,P〈0．05。（2）麻醉后肛门松弛效果：治疗组显效59例（95．2％）,有效3例（4．8％）,无效0例;对照组显效15例（25．0％）,有效39例（65．0％）,无效6例（10．0％）;治疗组显效率明显高于对照组,P〈0．05。结果表明,陈旧性肛裂患者骶管麻醉下手术安全可靠,止痛效果和肛门松弛效果好。     

The Treatment of Chronic Anal Fissure with Botulinum Toxin

Background /Aims: The aim of this study was to evaluate the effectiveness of botulinum toxin for the treatment of uncomplicated dorsal chronic idiopathic anal fissure.

Material and Methods: Forty-five patients who reported post defecatory anal pain since two months or more were given a total of 20U botulinum toxin in the anal sphincter apparatus on both sides as well as below the anal fissure. Results: Thirty-seven patients received a second session of 25U botulinum toxin injection. Thirty-five patients (78%) presented completely healed anal fissure, while ten needed lateral internal sphincterotomy. All patients were followed up for 8-36 months. Two patients relapsed.

Conclusion: Local injection of botulinum toxin is a new and safe treatment; however, two sessions of injections are necessary to be effective and long-term follow-up to assess the recurrence rate of fissure is needed to evaluate further this method of treatment. Partial internal lateral sphincterotomy is no more the treatment of choice for chronic anal fissure.     

Lateral Internal Sphincterotomy for Chronic Idiopathic Anal Fissure: An Alternative Approach

Background  

An alternative approach to lateral internal sphincterotomy in the management of chronic anal fissure is presented and its potential advantages are described.     

Effect of Chronic Anal Fissure Components on Isosorbide Dinitrate Treatment

Background

Chronic anal fissure is diagnosed in the presence of persistent symptoms: The classic triad includes a linear mucosal tear exposing the internal sphincter fibers, hypertrophied anal papilla, and a sentinel skin tag. Thus, chronic anal fissure can be divided into three components: the fissure itself; hypertrophied anal papilla; the sentinel skin tag. Not every chronic anal fissure has all three components; some have two components, and others present with only a persistent fissure. The success rate of medical treatment for chronic anal fissure is reported as 42–86?%. In this study, we intended to observe the effect of said components on healing with isosorbide dinitrate treatment.

Methods

A total of 105 patients with chronic anal fissures were admitted and were divided into three groups. Patients in group I had a single component (only the fissure with a linear mucosal tear exposing the internal sphincter fibers); group II had two components (skin tag or hypertrophied papilla in addition to the fissure); group III had all three components (fissure, skin tag, hypertrophied papilla). Isosorbide dinitrate 0.25?% was applied three times a day.

Results

The success rates in the study groups were 93, 74, and 64?%, respectively. The success rate was significantly higher for group I than for groups II and III.

Conclusions

Chronic anal fissure components should be considered when evaluating the success rates of studies reporting the results of various medical treatments. The number of components seems to be an important factor that affects the results of isosorbide dinitrate treatment.     

肛管松解加病理组织切除治疗陈旧性肛裂170例临床观察

目的：分析肛管松解加病理组织切除治疗陈旧性肛裂的疗效。方法：对l70例陈旧性肛裂病人采用裂口内直视下切断外括约肌皮下部和齿状线下内括约肌部分并修剪裂口、切除局部病理组织。结果：有效率为100％，治愈168例（98．8％），好转2例（1．2％）。结论：肛管松解加病理组织切除治疗陈旧性肛裂是一种安全可靠的治疗方法。     

长效止痛剂肛周封闭配合扩肛术治疗陈旧性肛裂

为观察长效止痛剂肛周封闭配合扩肛术治疗陈旧性肛裂的疗效，将420例陈旧性肛裂患者随机分为治疗组和对照组，每组210例，分别采用长效止痛剂封闭配合扩肛术（治疗组）及传统的肛裂侧切术（对照组）进行治疗。结果表明，治疗组比对照组恢复快，术后并发症少，痛苦小，容易操作，对肛门括约肌损伤小，创口愈合快，复发率低，无需住院，是一种较理想的治疗方法。     

Simple Cutaneous Advancement Flap Anoplasty for Resistant Chronic Anal Fissure: A Prospective Study

Background  A proportion of patients with chronic anal fissure have persistent symptoms and pathology despite optimum conservative therapies. Lateral anal sphincterotomy, the standard surgical treatment, is associated with functional compromise in a minority of patients. Sphincter-sparing anoplasty has been advocated as an alternative procedure for those with “low pressure” sphincters. The aim of this study was to determine the efficacy of simple cutaneous advancement flap anoplasty (SCAFA) when applied to consecutive patients with chronic anal fissure irrespective of anal tone and the patient’s gender. Method  This was a prospective outcome study of 51 consecutive patients treated with SCAFA over a 6.5-year period. Results  Surgery was well tolerated. There were three (5.9%) early flap dehiscences, all of which were treated with repeat SCAFA, and one of those three patients remained symptomatic at 2 months. All fissures healed in the short term. Three other patients subsequently developed fissures at sites remote from the original pathology. Continence was unaffected by the procedure. Conclusions  Simple cutaneous advancement flap anoplasty should be considered as a first-line surgical treatment of chronic anal fissure, irrespective of patient gender and anal tone. Mr. Pasquale Giordano had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Presented in part at the Association of Coloproctology of Great Britain & Ireland Annual Meeting, Birmingham, England, 2004 and published in abstract form in Colorectal Dis 2004; 6(Suppl 1):29.     

Medical and Surgical Treatment of Chronic Anal Fissure: A Prospective Study

The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). From 1/04 to 09/06, 156 patients with typical CAF completed the study. All patients were treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, patient was assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (19 ± 8 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. Overall healing rates were 65.3 and 96.3% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL were 39.8 and 46%, respectively. Thirty-six patients (23.1%) responded to further medical therapy. Fifty-four patients (34.6%) underwent BTX or LIS. Healing rate after BTX was 81.8%. LIS group showed a 100% healing rate with no morbidity and postoperative incontinence. In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence. Presented at the SSAT Annual Meeting, May 2007,Washington, DC, USA.     

两种内括约肌切断术治疗慢性肛裂286例疗效比较

为观察两种内括约肌切断术治疗慢性肛裂的效果,将286例肛裂患者分为两组,I组采用肛裂切除术加后位内括约肌切断术．Ⅱ组采用侧方皮下内括约肌切断术进行治疗。结果显示,两组近期均治愈,I组术中出血较多,创口愈合慢,但肛门括约肌松解彻底,无复发,术后并发症少;Ⅱ组术中出血较少,创口愈合快,但易形成血肿,易复发。结果表明,对慢性肛裂患者行内括约肌切断术治疗应视其具体情况而定,术式选择应个体化。     

Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.     

Conservative and Surgical Treatment of Chronic Anal Fissure: Prospective Longer Term Results

Introduction  

The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF).     

控制性括约肌侧切术治疗陈旧性肛裂的临床疗效

为探讨控制性括约肌侧切术治疗陈旧性肛裂的疗效，将118例陈旧性肛裂患者随机分为两组，分别采用控制性内括约肌侧切术（治疗组）和传统的内括约肌侧切扩肛术（对照组）治疗，并对比分析两组治疗结果。结果显示，两组患者均一次性治愈，均无大便失禁发生。但治疗组和对照组分别有1例和6例肛门气体失禁。随访至今，治疗组无复发，对照组复发1例。结果表明，控制性括约肌侧切术减少了不必要的组织损伤，更好地保护了肛门功能，可～次性治愈陈旧性肛裂，且操作简单，适合基层医疗单位推广应用。     

Anal Canal Pressure in Anal Fissure Before and After Internal Sphincterotomy

Purpose: To assess whether the anal canal pressure is increased in patients with a chronic anal fissure and to examine the effects of internal anal sphincterotomy (IASy) on this pressure.

Materials and method: Anorectal manometry was performed in 28 patients in whom an anal fissure had been diagnosed by means of physical examination and anuscopy. After IASy the manometric measurement was repeated on the 15^th postoperative day and compared with the value obtained in twelve healthy volunteers.

Results: In patients with chronic anal fissure, the mean maximal resting pressure (MRP) was found to be 112.38 ± 8.35 cm H20 pre-operatively and 66.23 ± 8.44 cm H20 postoperatively, with a significant drop after IASy (p < 0.001). The MRP value was found as 75.16 ±10.22 cm H20 in the control group. The pre-operative MRP values in patient group was found to be higher than in the control group (p < 0.001).

Conclusions: In patients with chronic anal fissure, the anal canal MRP pressures decreased significantly following IASy and complete clinical recovery was attained.