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。     

直肠腔内超声在肛瘘手术中的意义

目的：研究探讨应用直肠腔内超声提高肛瘘，尤其是复杂肛瘘的手术成功率。方法：对70例肛瘘患者随机分检查治疗组、对照治疗组，并对两组瘘管，及内口与手术符合率作回顾性比较分析、总结。结果：检查治疗组手术成功率100％，对照治疗组手术成功率86．7％。结论：直肠腔内超声对提高肛瘘手术成功率具有重要的指导作用。     

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.     

解剖学肛瘘切除术结合挂线疗法治疗高位复杂性肛瘘 (附36例报告)

目的：探索治疗高位复杂性肛瘘较理想的手术方式。方法：应用解剖学肛瘘切除术结合挂线疗法治疗，对高位复杂性肛瘘施行手术治疗。结果：33例一期治愈，3例二期治愈，无肛门失禁、肛门狭窄等并发症。结论：解剖学肛瘘切除术结合挂线疗法，是一种治疗高位复杂性肛瘘较理想的手术方式。     

Adenocarcinoma in the anal canal associated with a fistula: Report of a case

Adenocarcinoma in the anal canal associated with an anal fistula is extremely rare, and in most cases its origin is difficult to ascertain because the primary sites have already been destroyed before any diagnosis of malignancy is able to be made. We report herein the case of a 62-year-old man found to have papillary adenocarcinoma with partial mucinous carcinoma associated with an anal fistula. The tumor was not exposed to the mucosal surface of the anal canal or rectum and an abdominoperineal resection was carried out. Macroscopic findings suggested that the tumor had developed from the anal fistula; however, the tumor showed a positive result when tested for O-acetylated sialic acids. This test also proved positive in the mucus of normal rectal mucosa, but not in the mucus of the anal glands. We speculated that the results of these tests may indicate that this tumor could have originated from the rectal mucosa, from where it migrated into the anal fistula.     

Implantation of Rectal Cancer in an Anal Fistula: Report of a Case

A 53-year-old man who had had an anal fistula for 20 years was admitted to our hospital with a large intestinal obstruction. Barium enema and colonoscopy confirmed advanced rectal cancer and we palpated a soft tumor, 3 cm in diameter, with inflammatory induration on the right side of the rectum. After draining a perianal abscess caused by the anal fistula, we performed low anterior resection. Histological examination of the perianal necrotic tissue obtained during resection of the perianal tumor encompassing the anal fistula revealed adenocarcinoma. Since the histology of the perianal lesion was identical to that of the rectal cancer, a diagnosis of cancer implantation rather than carcinoma originating in the anal fistula was entertained. Although the recurrence of rectal cancer by mucosal implantation is not uncommon, the coincidental implantation of rectal cancer in an anal fistula is extremely rare.     

手术治疗358例肛瘘的临床分析

目的 探讨不同类型肛瘘的最佳治疗方法.方法 回顾总结358例不同类型肛瘘的治疗过程,低位肛瘘一次切除,高位肛瘘低位切开,高位挂实线,窦道(支管)挂浮线;科学有效的术后治疗.结果 一次手术治愈324例,一次手术治愈率90.5%;二次手术治愈34例,13例为第一次手术病灶切除不完全,21例为手术后换药不妥而假愈合.结论 不...     

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。     

手术治疗蹄铁型肛瘘110例效果观察

为提高蹄铁型肛瘘的疗效,采用主管道切开部分瘘管对口引流术,主管道切开挂线、支管对口引流术,瘘管切除部分缝合术,瘘管切除术治疗蹄铁型肛瘘110例,全部治愈。结果表明,应用合理术式治疗蹄铁型肛瘘可降低手术难度,缩短疗程,且复发率低,术后无肛门畸形、狭窄及失禁等并发症和后遗症。     

Anal fistula plug in the treatment of anal fistula: Local experience in Chinese patients

Background: Anal fistula plug was recently introduced as an alternative treatment for anal fistula. However, there is, so far, no published data on the use of the anal fistula plug both locally and in the Chinese population. Methods: From January 2007 to July 2008, consecutive Chinese patients with transphincteric or suprasphincteric anal fistula scheduled for elective surgery were enrolled. Anal fistula plug was used if examination under anaesthesia reviewed an internal opening. Baseline manometry pressure study was carried out for patients with recurrent fistulae. The operative technique was standardized. Measured outcomes included healing and recurrence rates, operating time, length of stay, and time for patients to return to work or normal activity. Results: Eleven patients underwent anal fistula plug placement, with a median follow up of 19 months. Five had completely healed fistulae, including three patients with recurrent fistulae. The success rate was 45 per cent. In the three patients with recurrent fistulae, no significant difference was demonstrated in the resting pressure between preoperative and postoperative values. There is an observable trend that proportionally more recurrent fistulae were healed by anal fistulae plug placement when compared to primary fistulae (100% vs 25%); the difference, however, did not reach statistical significance (P = 0.06, Fisher's exact test). At the conclusion of this study, no recurrence was noted in the five patients with confirmed healing. Conclusions: Our preliminary experience indicates anal fistula plug placement is safe and non-invasive. However, the efficacy appears lower than initially reported. Based on our data the routine use of an anal fistula plug cannot be recommended. In our opinion, anal fistula plug placement can be considered in patients with more complex, high fistulae and in those who have recurrent fistulae despite previous surgery. It provides a non-invasive alternative in these patients, in whom postoperative incontinence is a real concern.     

The internal sphincter in anorectal malformations: morphologic investigations in neonatal pigs

The knowledge of sphincter anatomy in anorectal malformations is still inadequate and contradictory. Therefore, morphologic investigations were carried out in 33 neonatal piglets with congenital anal atresias. Of the 24 male animals 12 had high anomalies with a rectourethral fistula. The remaining 12 piglets had low anomalies; in nine cases we were able to demonstrate an anocutaneous fistula. Of the nine female animals, six had high anomalies with a rectovaginal fistula. The three female piglets with low anomalies had an anovestibular or an anocutaneous fistula. In all animals we could demonstrate a normal internal sphincter, which surrounded the proximal part of the fistulae. The position of the internal sphincter therefore depended on the localization of the fistula orifice into the rectal pouch. This differed greatly. The form of the internal sphincter also differed greatly. Sometimes the muscle had the form of a tube or an acute-angled funnel as in healthy piglets. However, mostly the internal sphincter was spread out wide and had the form of a disc or a flat dish. The proximal region of the fistulae in anal atresias has most features of a normal anal opening: (1) it is surrounded by an internal sphincter, (2) the rectal pouch in the region of the internal sphincter as well as the fistulae are hypoganglionotic, (3) the proximal fistula region is lined by transitional epithelium, and (4) it contains anal glands. We, therefore, consider that the fistula should be designated as an ectopic anal canal. The most important result was the demonstration of a normal internal sphincter even in high and intermediate anomalies of anal atresias.(ABSTRACT TRUNCATED AT 250 WORDS)     

Implantation of Rectal Cancer Cells in a Fistula in Ano: Report of a Case

We report a case of implantation of tumor cells within a fistula in ano. A 36-year-old man with a 16-year history of an anal fistula underwent an operation for rectal carcinoma. Three weeks later, the anal fistula was resected. A histological examination of the specimen showed atypical cells; moreover, rectal carcinoma had proliferated in the granulation tissue lying underneath the intact squamous epithelium. Because there was no continuity to the rectal carcinoma or the anal glands, we diagnosed implantation of rectal cancer cells in a fistula in ano. Received: February 19, 2001 / Accepted: July 17, 2001     

切开缝合挂线旷置术治疗复杂性肛瘘

为了探讨切开缝合、挂线旷置术治疗复杂性肛瘘的效果,我们对肛瘘支管管道采用肛门横线前切除缝合、肛门横线后旷置引流,对低位肛瘘的主管管道给予切开松弛缝合,对高位肛瘘给予切开缝合配合挂线。结果显示,120例平均疗程26d,近期治愈率100％,随访1～5年,仅2例复发,远期治愈率98．3％。结果表明,该疗法体现了缩小创面、减少损伤、肛门瘢痕少、肛门无变形、不影响肛门功能、安全可靠、疗程短、一次治愈率高等治疗原则。     

Colloid Carcinoma Arising in an Anal Fistula: Case Report with a Brief Review of the Literature

Malignant change in an anal fistula is an extremely rare but an important and dangerous complication. Less than 75 cases have been described in the English, and Scandinavian literature. We now report a case of colloid carcinoma arising in an anal fistula because of its rarity and other interesting features     

Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy

Aim To date fistulotomy is still the treatment of choice for patients with a transsphincteric fistula passing through the lower third of the external anal sphincter, because it is a simple, effective and safe procedure with a minimal risk of incontinence. However, data suggest that the risk of impaired continence following division of the lower third of the external anal sphincter is not insignificant, especially in female patients with an anterior fistula and patients with diminished anal sphincter function. It has been shown that ligation of the intersphincteric fistula tract (LIFT) is a promising sphincter‐preserving technique. Therefore, we questioned whether LIFT could replace fistulotomy in patients with a low transsphincteric fistula. Method A consecutive series of 22 patients with a low transsphincteric fistula of cryptoglandular origin underwent LIFT. Continence scores were determined using the Rockwood Fecal Incontinence Severity Index. Results Median follow‐up was 19.5 months. Primary healing was observed in 18 (82%) patients. In the four patients without primary healing, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulotomy with preservation of the external anal sphincter. The overall healing rate was 100%. Six months after surgery, the median incontinence score was not changed significantly. Conclusion Low transsphincteric fistulae can be treated successfully by LIFT, without affecting faecal continence. Division of the lower part of the external anal sphincter is no longer necessary in the treatment of low transsphincteric fistulae, which is essential for patients with compromised anal sphincters.     

改良切开挂线术治疗马蹄型肛瘘的临床观察

目的:探讨改良切开挂线术治疗马蹄形肛瘘的临床应用价值.方法:采用改良切开挂线术治疗马蹄形肛瘘患者50例.对照组为同期切开挂线术治疗患者42例.观察两组手术时间、术后创面出血情况、术后疼痛、创面愈合时间、肛门瘢痕大小、肛门畸形、肛门功能状况以及术后复发情况.结果:治疗组与对照组比较,手术时间、术中及术后渗血时间、术后疼痛持续时间、创面愈合时间皆缩短;肛门瘢痕小;肛门畸形发生率低;肛门部分失禁发生率低;术后复发率两者差异无统计学意义.结论:改良切开挂线术治疗马蹄形肛瘘较切开挂线术效果好,值得临床推广应用.     

脱细胞异体真皮基质材料治疗复杂肛瘘52例

目的探讨脱细胞异体真皮基质材料(acellularextracellular matrix,AEM)治疗复杂肛瘘的临床效果。方法2008年7月～2010年3月对52例复杂肛瘘采用近端肛瘘切开结合远端肛瘘AEM填塞进行治疗。结果 42例一期愈合,10例延迟愈合。52例随访12个月无复发,AEM成功率为80.8%(42/52),肛瘘治愈率为100%(52/52)。结论应用AEM治疗复杂肛瘘具有微创、疗程短和不损害肛门功能及外形的优势。     

半封闭式缝合治疗肛瘘的临床观察

目的探讨半封闭式缝合治疗肛瘘的临床疗效。方法选择120例肛瘘患者,随机分为治疗组和对照组各60例。所有患者均采用低切高挂治疗。治疗组的切口采用半封闭式缝合,对照组的创面完全敞开。观察两组临床疗效、治愈时间和术后切口感染等情况。结果治疗组创面愈合时间明显短于对照组（P〈0.05）,并且术后切口感染未有明显增加。结论半封闭式缝合治疗肛瘘,痛苦小,疗程短,是较理想的手术方法。     

脱细胞真皮基质治疗伴高位盲瘘的复杂性肛瘘疗效观察(附39例报告)

目的探讨高位盲瘘的微创治疗方法,研究脱细胞真皮基质在高位盲瘘治疗中的应用价值。方法 39例高位盲瘘患者,手术分2期进行,经括约肌或括约肌间肛瘘合并高位盲瘘Ⅰ期齿线下瘘管切开、内口挂线并高位盲瘘旷置引流,括约肌上肛瘘切开内口并高位盲瘘旷置引流;Ⅱ期高位盲瘘脱细胞真皮基质填塞治疗。观察Ⅱ期手术时间、术中出血、术后疼痛、住院总天数、住院总费用及复发率等临床及相关指标。结果 39例患者中有26例获得Ⅰ期治愈,13例患者治疗失败,改行肛瘘切开挂线术后痊愈。高位盲瘘脱细胞真皮填塞术手术治愈率66.7%。括约肌上并发高位盲瘘治愈2例,治愈率100%,经括约肌并发高位盲瘘治愈6例,治愈率50%,括约肌间并发高位盲瘘治愈18例,治愈率72%。结论应用脱细胞真皮基质材料治疗高位盲瘘具有损伤小、愈合时间短、肛门失禁率低、外形保留好等优势,值得进一步推广。     

生物组织补片填塞治疗肛瘘的临床研究

目的比较生物组织补片填塞治疗肛瘘与传统肛瘘切除或挂线治疗的疗效、并发症等。方法 70例各种类型肛瘘患者随机分为治疗组(生物组织补片填塞治疗)和对照组(传统治疗),统计2组术后创面疼痛情况、分泌物情况、伤口愈合时间、有效率、复发率、肛门功能及肛门畸形情况。结果 2组患者相比,治疗组患者术后中重度疼痛时间、中重度分泌物时间、伤口愈合时间均显著优于对照组,肛门功能损伤率对照组远大于治疗组,而2组的复发率之间无显著性差异。结论生物补片填塞治疗肛瘘疗效确切,手术痛苦小,创伤小,恢复快,住院时间短,肛管括约肌功能损伤风险小,未见肛门畸形等特点,具有广阔的应用前景。