一期手术治疗直肠肛管周围脓肿67例疗效观察

目的评价一期手术治疗直肠肛管周围脓肿的疗效。方法一期脓肿切开引流加挂线术治疗直肠肛管周围脓肿67例，包括肛管皮下脓肿48例，坐骨直肠间隙脓肿11例，骨盆直肠间隙脓肿8例。结果术后随访2—5年，一期治愈率97．0％(65／67)，1例形成肛瘘，1例再次形成脓肿。结论一期手术治疗直肠肛管周围脓肿，能正确处理原发感染灶(内口)，保持引流通畅，保证伤口愈合由深到浅，从里到外，防止皮肤过早愈合，疗效确切，治愈率高。     

Fistula-in-ano. Clinical features and long-term results of surgery in 199 adults

The clinical features and the long-term results of surgery for anal fistula were studied. Fistula distribution was subcutaneous (13%), intermuscular (14%), low anal (55%) or high anal (18%). There were no pelvirectal fistulas. The location was mostly posteriorly in the anus, except for the low anal fistulas, which were most frequent anteriorly. Follow-up examination was carried out on 199 patients, on average 9 years after fistula operation. The recurrence rate was 11% after laying open of fistula, with the highest rate (26%) in high anal fistula. The most common causes of recurrence were undetected internal opening and incomplete laying open of the fistulous tract proper. Most (91%) of the recurrences appeared within 18 months after surgery. Minor defects in anal control were found in 34% of the patients, and in 9% of controls matched for age and sex but with no anal surgery. Multiple operations for anal fistula, and also a gutter-shaped and a firm or hard scar in the anal canal adversely affected anal control. The amount of divided sphincter musculature did not influence the incidence of postoperative anal incontinence.     

狭长U形槽状切口在坐骨直肠间隙脓肿和坐骨直肠间隙肛瘘手术中的应用价值

为探讨狭长U形槽状切口在坐骨直肠间隙脓肿和坐骨直肠间隙肛瘘手术中的应用价值,回顾分析采用常规底小口大切口手术（对照组,205例）和狭长U形槽状切口手术（治疗组,232例）治疗的脓肿及肛瘘患者资料,对比分析两种切口对创面愈合的影响。结果显示,两组患者均痊愈出院。治疗组平均创面愈合时间（22．4d）明显短于对照组（27．7d）,P〈0．05。随访半年以上,治疗组创口无异常;对照组21例（10．2％）创口表层组织颜色变黑,7例（3．4％）创口愈合后又自行坏死溃烂。结果表明,狭长U形槽状切口有利于切口较深的坐骨直肠间隙脓肿和坐骨直肠间隙肛瘘的痊愈;     

Perianal mucinous adenocarcinoma: unusual case presentations and review of the literature

Perianal mucinous adenocarcinoma is a rare cancer constituting 3 to 11 per cent of all anal carcinomas. It may arise de novo or from a fistula or abscess cavity. We present two cases of this disease process. Case One is a 52-year-old man with a chronic history of perianal abscesses who presented to the emergency room with a large bowel obstruction. He required diversion and wide local excision with lateral internal sphincterotomy for relief of the obstruction. Pathology from the excised material revealed the unexpected diagnosis of invasive mucinous adenocarcinoma of the anus. Case Two is a 59-year-old man with a chronic history of complex fistulas and abscesses who presented to our office with a horseshoe fistula and deep postanal space abscess. Because of the nonhealing nature of the wound, biopsies from the abscess crater, fistulous tract, and the perianal skin opening were taken. The pathology department identified the specimens as invasive mucinous adenocarcinoma of the anal canal. This is an aggressive cancer often misdiagnosed clinically as benign pathology. A high index of suspicion and biopsy of fistulous tracts and abscesses are the keys to early diagnosis and treatment. With combination chemotherapy and radiation therapy in conjunction with aggressive surgical resection long-term survival might be obtained.     

Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas

BACKGROUND: Low-lying trans-sphincteric anal fistulas respond well to simple fistulectomy or fistulotomy. However, management of high fistulas has long been a serious problem because of the necessity of preserving at least some of the sphincter mechanism. The clinical results of endorectal flap advancement and fistulectomy for complex anal fistulas were assessed. METHODS: A total of 103 consecutive patients with high trans-sphincteric (n = 91) and suprasphincteric (n = 12) fistulas undergoing endorectal advancement flap repair together with core fistulectomy were included in a prospective study. Clinical outcome was assessed in terms of continence and recurrence by an independent observer for a period of 1 year after operation. RESULTS: Successful healing was achieved in 96 patients (93 per cent). Recurrent fistula occurred in six (7 per cent) of the 91 patients in the trans-sphincteric group and in one of the 12 patients in the suprasphincteric group. Continence disturbance was noted in eight patients (8 per cent). Previous repair and the level of the fistula did not adversely affect the results obtained. CONCLUSION: Core fistulectomy associated with endorectal advancement flap repair is a safe and effective technique for any high trans-sphincteric and suprasphincteric fistula, with good results in terms of recurrence and anal continence.     

肛门后正中切开术治疗后高位蹄铁型肛周脓肿及肛瘘50例

为探寻治疗后位高位蹄铁型肛周脓肿和肛瘘的有效手术方法,减少并发症,对38例后位高位蹄铁型肛周脓肿及12例后高位蹄铁型肛瘘患者采用肛门后正中切开手术治疗。结果显示,38例肛周脓肿和12例高位肛瘘全部治愈,术后肛门外观平整,无畸形,肛门功能良好。结果表明,肛门后正中位切开手术治疗高位蹄铁型肛周脓肿和肛瘘,手术操作简单,手术时间短,术中寻找内口容易,患者痛苦小,愈合后瘢痕小,肛门功能好,疗效可靠。     

Ano-cutaneous flap repair for complex and recurrent supra-sphincteric anal fistula.

BACKGROUND: Suprasphincteric fistulae remain the most difficult to cure. OBJECTIVES: The purpose of this study was to evaluate the healing rate of suprasphincteric anal fistula treated by ano-cutaneous advancement flap repair, and the impact of this procedure on continence and quality of life. METHOD: Sixteen patients with complex, recurrent or chronic suprasphincteric fistulae associated with significant tissue damage (necrotizing fasciitis, keyhole deformity and anal stenosis) or who had failed previous surgical procedures were treated by ano-cutaneous flap closure. They were assessed pre and postoperatively by the treating surgeon for wound healing and fistula recurrence and later followed up by phone interview using the St Mark's Hospital incontinence score and the Perianal Disease Activity Index (PDAI) as indicators of treatment outcome. RESULTS: Fifteen patients had successful healing of their fistula with the cutaneous flap, with recurrence in only one. The most common short-term complications were minor graft site wound separation, which healed in all cases without intervention, and wound pain, which settled over time and was not associated with recurrence. Continence improved for almost 70% of the patients, with a significant reduction in St Mark's incontinence scores (t = 2.62, 15 d.f., P = 0.02). PDAI also decreased significantly (t = 7.55, 15 d.f., P < 0.001), demonstrating improvement in quality of life for most patients. CONCLUSION: Ano-cutaneous flap can achieve healing of complex and recurrent suprasphincteric anal fistula in patients who had previously failed at other forms of treatment thus improving their quality of life and continence.     

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。     

Perianale Fisteln und Abszesse im Säuglings- und Kleinkindesalter

BACKGROUND: Perianal abscess and anal fistula in childhood are commonly treated in the same way as abscess and fistula in adults. We questioned whether they represent a cryptoglandular infection, as in adults, or two different diseases with the same symptoms. MATERIALS AND METHODS: We retrospectively analyzed all medical records of 80 children (seven male, 73 female) who underwent surgical treatment for primary perianal abscess or primary anal fistula during a 10-year period. The records were analyzed concerning age at appearance of lesion, sex, diagnosis (fistula and/or abscess), and anatomic localization of the lesion. RESULTS: Of all the children, 67.5% were treated during their 1st year of life and another 10% during their 2nd year (group 1: 77.5%, n=62). Only 22.5% were 3 or older (group 2, n=18). Group 1 contained significantly more male infants (m:f 30:1). However, much more balanced sex distribution was detected in group 2 (m:f 2.6:1), similarly to adults. Analyzing anatomic localization, a second important difference could be found: in contrast to group 2, almost two thirds of all anal fistulas/abscesses in group 1 were localized horizontally between 3:00 and 9:00 o'clock in crown-rump position. CONCLUSIONS: Divergences in preference of age, sex, and localization suggest a congenital etiology for anal fistulas and perianal abscesses in children.     

Infected midurethral tape presenting as an ischiorectal abscess

This is the first reported case of an ischiorectal abscess after a midurethral intravaginal slingplasty (IVS). The patient presented with recurrent ischiorectal abscess which was initially thought to be an unusual presentation of a fistula in ano. Subsequent examination under anaesthesia, however, revealed a fistulous tract extending from the right postero-lateral perianal opening to the vagina where the tape was noted to be eroded and infected. The abscess healed only after removal of the source of infection i.e. the IVS tape. In this report, we also discuss the two main types of meshes used as midurethral slings, the ways in which they differ and the arguments for and against using them.     

Mucosal flap in the treatment of anal fistula]

A technique of sliding flap repair for the treatment of anal fistulae is described. This technique may prevent sphincter damage. Fifty-five consecutive fistulae have been treated: 23 transsphincteric, 26 intersphincteric, 3 suprasphincteric and 3 rectovaginal fistulae. The fistulous tract is excised and cored out. The intersphincteric space is opened: any gland or inflammatory tissue is removed. The internal opening is excised. The gaps in the internal, as well as in the external, sphincter are closed. The endo-anal wound is closed, using a sliding flap of anorectal mucosa. The ischiorectal wound is left open. Healing has been achieved in every case but one within three weeks, without sphincteric functional defect. Only 3 recurrences have been observed in a mean follow-up of 24 months.     

Clinical course and management of suprasphincteric and extrasphincteric fistula-in-ano

Over an 8-year period five patients with suprasphincteric fistula and two with extraspincteric fistula a primary transsphincteric track were treated with fistulotomy, using delayed seton technique. In all but one case the fistulas had caused considerable morbidity, involving multiple episodes of abscess drainage and attempts to lay open the track before the correct diagnosis was established. No patient had recurrence of fistula and, despite complete division of the anorectal ring, and sphincter pressures were well maintained and anal continence was unchanged. The results suggest that the delayed seton technique is useful in the treatment of these very rare and complicated fistulas.     

Early Experience with the Bioabsorbable Anal Fistula Plug

PURPOSE: Management of anal fistula represents a balance between curing the condition and maintaining anal continence. Recent reports of the results of the porcine anal fistula plug have demonstrated excellent fistula healing rates without reporting significant complications. METHODS: The outcome of patients who underwent treatment for anal fistula with the Surgisis anal plug was retrospectively reviewed. RESULTS: Twenty patients were treated; three underwent concomitant anal advancement flap at the time of plug placement. Seventeen patients had a trans-sphincteric fistula, and three had an anoperineal fistula. Ten patients had previously undergone failed surgical therapy to cure their fistula, including anal advancement flap in four, muscle interposition flap in two, fistulotomy in two, and cutting seton placement in two. Mean follow-up was 7.4 months. Only 4 of 17 (24%) patients treated with the plug alone had closure of their fistula. Acute postoperative sepsis was seen in 5 of 17 (29%) patients treated with the plug alone. Four developed perianal abscesses that required incision and drainage, and one intersphincteric abscess was treated with antibiotics. Two of the patients who underwent concomitant anal advancement flaps and plug placement healed successfully. CONCLUSIONS: Contrary to other published series, the use of the Surgisis anal plug was associated with a low rate of fistula healing and a high incidence of perianal sepsis. The addition of a transanal advancement flap to the procedure may improve success rates.     

磁共振成像在深部肛周脓肿诊断中的应用

目的 探讨MRI检查在深部肛周脓肿诊断中的应用价值.方法 回顾性分析2006年1月至2007年12月南京中医药大学附属医院收治的21例临床疑诊为深部肛周脓肿患者的临床资料.术前进行MRI体表相控阵列线圈检查;以手术结果为标准,比较MRI检查和术前肛门指诊在深部肛周脓肿的分型和内口检查结果.采用X2检验分析检测数据.结果 19例患者诊断为深部脓肿,1例诊断为骶前囊肿伴感染,1例诊断为骶前占位性病变(病理检查证实为黏液腺癌).19例患者共发现25个脓腔,其中坐骨直肠间隙脓腔14个,骨盆直肠间隙脓腔5个,高位括约肌间脓腔6个.单间隙脓肿13例,多间隙脓肿6例.MRI检查与术前肛门指诊的内口诊断符合率分别为12/19和13/19,两种检查方法比较差异无统计学意义(χ2=0.116,P>0.05);深部肛周脓肿分类准确率分别为25/25和16/25,两种检查方法比较差异有统计学意义(χ2=10.970,P<0.05);手术探查发现13例患者为单间隙脓肿,6例为多间隙脓肿,而MRI检查与术前肛门指诊多间隙脓肿准确率分别为19/19和13/19,两种检查方法比较差异有统计学意义(χ2=7.125,P<0.05).结论 MRI检查能确诊并定位深部肛周脓肿病变范围及其与肛管直肠周围括约肌之间的复杂关系;对指导手术排除肛管直肠周围潜伏病变具有确切意义.     

肛瘘栓填塞治疗经括约肌型肛瘘的长期疗效及预后影响因素分析

目的评估肛瘘栓填塞治疗经括约肌型肛瘘的长期愈合率及影响肛瘘愈合的因素。方法采用回顾性病例对照研究方法,分析2008年8月至2012年9月期间于首都医科大学附属北京朝阳医院普通外科接受肛瘘栓填塞治疗的207例经括约肌型肛瘘患者的临床资料。患者纳入标准:(1)符合经括约肌型肛瘘的诊断:即瘘管穿越内括约肌及外括约肌的浅、深部之间;(2)患者病例资料完整;(3)初始接受肛瘘栓填塞治疗。排除标准:(1)直肠肛管周围急性感染或病灶感染控制不佳;(2)近期行直肠肛管周围脓肿切开引流术或自行破溃者;(3)合并有恶性肿瘤;(4)克罗恩病、炎性肠病者;(5)心、肝、脑、肺、肾功能不全者;(6)各种慢性消耗性疾病造成恶病质;(7)不能耐受手术者。随访患者的肛瘘愈合情况,采用Kaplan⁃Meier法绘制肛瘘患者累计治愈率,并用单因素和多因素logistic回归分析探究影响肛瘘愈合的因素。结果全组男性186例,女性21例,年龄15~69(平均数38)岁。肛瘘病程3~60(平均数15)个月。有3例患者既往有肛周脓肿发作史并且行肛周脓肿切开引流术(均超过3个月)。随访截至2018年10月31日,失访72例(34.8%)。在135例成功随访的患者中,平均随访时间为96(75~124)个月,肛瘘愈合75例,愈合率为55.6%。Kaplan⁃Meier生存曲线显示,肛瘘治愈率随时间延长,最终稳定在55.6%。在初次接受肛瘘栓填塞治疗失败的患者中,有6例在未接受其他治疗的情况下,肛瘘自行愈合。其中,3例于术后2年、3例于术后3年自行愈合,并未再复发。2008—2012年,肛瘘栓填塞治疗的年治愈率分别为3/6、61.5%(24/39)、42.1%(24/57)、12/15和12/18。多因素logistic回归分析显示,肛瘘病程≥6个月(OR=3.187,95%CI:1.361~7.466,P=0.008)是影响肛瘘栓填塞治疗后肛瘘愈合的独立危险因素。结论肛瘘栓填塞治疗经括约肌型肛瘘长期疗效肯定,宜尽早实施。     

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.     

Mammillary fistula

Forty women presenting with mammillary fistulas over a 6 year period have been reviewed. The events preceding the fistula were incision of a periareolar breast abscess (n = 24), breast biopsy (n = 13) and spontaneous discharge of an inflammatory mass (n = 3). Only two of the women with abscesses were lactating. Two patients had granulomatous mastitis. The remaining 36 patients were all considered to have periductal mastitis/mammary duct ectasia as the cause of their fistulas. The two mammillary fistulas associated with lactation healed spontaneously. Nine patients had the fistula excised and the wound packed; this resulted in satisfactory healing in all but one patient. Twenty-one patients had excision of the fistula and primary closure, without antibiotic cover, but only ten healed without complications and six patients required further surgical procedures for a recurrent fistula. Six patients had primary excision and closure under antibiotic cover with a penicillin and metronidazole; all healed. Mammillary fistulas are complications of the periductal mastitis/duct ectasia syndrome. They should be treated by excision and primary closure under appropriate antibiotic cover or alternatively excised and left open to granulate.     

切开挂线术治疗骨盆直肠间隙脓肿21例临床观察

为探讨切开挂线术治疗骨盆直肠间隙脓肿的临床应用价值,对21例骨盆直肠间隙脓肿患者行切开挂线术。结果21例均临床治愈,住院时间15～26d,平均20d。其中20例随访6～24个月（平均10个月）无复发,1例形成肛瘘,经再次手术治愈。结果表明,切开挂线术治疗骨盆直肠间隙脓肿具有疗程短,一次性治愈率高等优点,且有效减轻或避免了肛门缺损。     

Abscess excision and primary fistulectomy as initial therapy of peri-proctal abscess. A prospective analysis of 122 patients

A prospective study of 122 patients with anorectal abscesses was carried out to elucidate the value of abscess drainage with primary fistulectomy, when fistulas were identified. Patients were followed from 2 1/2 to 3 1/2 years with a mean follow-up of three years. In 52 patients (Group A) a primary fistula was present (42.6%), in 47 patients simultaneous excision of abscess and drainage of the intersphincteric space combined with partial sphincterotomy was performed. Recidives occurred in 17.3%. In 5 patients with a high transsphincteric or suprasphincteric fistula, a two-stage fistulectomy was done. In all 70 patients of group B no fistula was found at drainage operation. The incidence of recurrent anorectal abscess was 21.4%. In this group it is shown that the rate of recurrence was not related to a simultaneous excision of abscess and drainage of the intersphincteric space.     

Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream?

Aim

Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre.

Method

Consecutive adult patients with a minimum of 2 years’ follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively.

Results

Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence.

Conclusion

VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.