改良内括约肌侧切术治疗Ⅲ期肛裂疗效观察

为观察内括约肌后位侧切加肛裂病灶切除术（改良内括约肌侧切术）治疗Ⅲ期肛裂的疗效,将128例Ⅲ期肛裂患者随机分为治疗组和对照组,治疗组64例采用内括约肌左后或右后位侧切加肛裂病灶切除术,对照组64例采用传统内括约肌侧切加肛裂病灶切除术,术后随访2年,两组进行疗效对比。结果显示,两组病例均治愈,创面在术后4周内全部愈合,但治疗组在术后疼痛、创口愈合时间、复发率方面明显优于对照组。结果表明,内括约肌左后或右后位侧切加肛裂病灶切除术是传统内括约肌侧切术的改进,疗效明显优于后者。     

CO_2激光结合亚甲蓝局麻扩肛术治疗Ⅲ期肛裂的临床观察

目的观察和评价CO2激光结合亚甲蓝局麻扩肛术治疗Ⅲ期肛裂的临床疗效。方法将102例Ⅲ期肛裂患者随机分为两组,治疗组50例采用CO2激光结合0.1%亚甲蓝局麻下扩肛术,对照组52例采用内括约肌开放式侧切术。观察两组患者肛裂治愈率、愈合时间及术后疼痛、出血等并发症。结果两组的治愈率及愈合时间差异无统计学意义(P0.05);术后24~48h的疼痛比较,治疗组主要为Ⅰ级(24例),对照组主要为Ⅱ级(35例),两组疼痛差异有统计学意义(P0.05),治疗组疼痛较轻;术后出血比较,治疗组主要为0级(42例),对照组主要为Ⅰ、Ⅱ级(36例),两组术后出血差异有统计学意义(P0.05),治疗组出血较少。结论 CO2激光结合亚甲蓝局麻扩肛术治疗Ⅲ期肛裂的临床疗效与传统的内括约肌开放式侧切术相仿,但术后并发症更少,是基层治疗Ⅲ期肛裂的理想手术方式。     

移动皮瓣加齿状线成形术治疗Ⅲ期肛裂

目的：观察和评价移动皮瓣加齿状线成形术与单纯移动皮瓣成形术治疗Ⅲ期肛裂的疗效。方法：将60例Ⅲ期肛裂患者随机分为治疗组和对照组,治疗组采用移动皮瓣加齿状线成形术治疗,对照组用移动皮瓣成形术治疗,观察比较两组疼痛评分、服用止痛药剂量、术后并发症等情况。结果：在疼痛评分、服用止痛药剂量、术后并发症等方面,治疗组与对照组相比较均有统计学差异（P〈0.05）。结论：在内括约肌切断、减张移动皮瓣的基础上,将皮肤和黏膜间的缝合设计成＂齿状线＂缝合,再造一条齿线,能使Ⅲ期肛裂患者的手术后并发症减少,舒适度和满意度提高,肛门功能无影响,生活质量得到改善。     

随意皮瓣移行术与肛裂切除敞开疗法的临床比较

自2001年始，我们对肛裂患者采取轴型皮瓣移行术与切除敞开疗法进行比较，现报告如下。     

扩肛法与内括约肌切断法治疗Ⅱ期肛裂90例临床对比观察

扩肛法与内括约肌切断法是目前治疗肛裂的常用方法。通常，这两种术式均适于Ⅱ期肛裂的治疗。扩肛法侧重于Ⅰ、Ⅱ期肛裂，内括约肌切断法侧重于Ⅱ、Ⅲ期肛裂。在此，仅对这两种术式的Ⅱ期肛裂的疗效作以临床观察。近2年来，我科用非盲试验随机将收治的90例Ⅱ期肛裂患者分成两组，分别用扩肛法、内括约肌切断法治疗。现报告如下。     

痔核剥离、溃疡面切除联合内括约肌侧方切断术治疗Ⅲ期混合痔伴肛裂的疗效分析

目的:探讨痔核剥离、溃疡面切除联合内括约肌侧方切断术治疗Ⅲ期混合痔伴肛裂的疗效。方法:回顾性分析2013年4月—2015年3月收治的96例Ⅲ期混合痔伴肛裂患者,其中行痔核剥离、溃疡面切除联合内括约肌侧方切断术52例(治疗组),行痔核切除联合肛裂切除术44例(对照组)。比较两组患者术中出血量、手术时间、切口愈合时间及术后切口疼痛、切口边缘水肿、远期并发症的发生率,并随访肛裂复发情况。结果:治疗组术中出血量较对照组减少[(10.1±3.0)mLvs.(14.3±2.9)mL,t=7.049,P0.05];手术时间两组间无统计学差异[(16.7±2.1)minvs.(17.22±1.4),t=1.445,P0.05]。治疗组切口愈合时间优于对照组[(12.2±0.6)dvs.(16.8±2.6)d,t=11.746,P0.05]。治疗组术后切口疼痛、术后切口边缘水肿程度均较对照组轻,但两组间无统计学差异(χ~=3.33,P=0.068;χ~=0.023,P=0.897)。术后随访1~2年,两组均无肛裂复发,无肛门松弛;治疗组无肛周湿疹发生,对照组有9例患者出现肛周湿疹。结论:痔核剥离、溃疡面切除联合内括约肌侧方切断术治疗III期混合痔伴肛裂切口愈合时间短、术后切口疼痛轻、远期并发症的发生率低。     

肛裂切除术联合术后化学性内括约肌切开疗效观察

目的探讨肛裂切除术联合术后化学性内括约肌切开的临床疗效。方法将2013-09—2015-09间到山东省千佛山医院治疗的112例肛裂患者随机分为2组,治疗组为肛裂切除术联合术后化学性内括约肌切开术(局部涂抹硝酸异山梨酯(ISDN)软膏),对照组为单纯肛裂切除术。结果治疗组患者术后疼痛,治愈时间,肛管静息压均优于对照组,差异有统计学意义(P0.05)。结论肛裂切除术联合术后化学性内括约肌切开术,疗效显著。     

长效止痛剂注射加扩肛与单纯扩肛治疗肛裂180例对照观察

目的探讨扩肛加长效止痛剂注射治疗肛裂的临床效果。方法1999年元月至2006年6月间治疗的180Ⅱ、Ⅲ期肛裂病人，随机分为两组，在常规扩肛术的基础上于肛裂创面周围，外括约肌皮下组、浅组，内括约肌、栉膜带及肛管皮下注射长效止痛剂治疗100例为治疗组，单纯扩肛治疗80例为对照组。结果180例病人随访时间最长8年，最短时间7个月。治疗组复发3例，治愈率97％，对照组复发13例，治愈率83．75％，经统计学处理两组疗效差异有统计学意义，P〈0．005。结论肛裂行扩肛术后局部再注射长效止痛剂，由于疼痛的消除，使痉挛缓解，有利于肛裂创面愈合。     

改良侧方纵切横缝内括约肌切断术治疗肛裂的临床效果观察

目的研究改良侧方纵切横缝内括约肌切断术治疗肛裂的临床效果。方法将本院收治的者68例肛裂患根据采用便利分组法分为观察组和对照组,每组34例。对照组采用侧位开放式肛裂切除术,观察组采用改良侧方纵切横缝内括约肌切断术。观察两组的各项临床指标和治疗效果。结果观察组肛裂患者的临床总有效率、术后轻度疼痛比例均高于对照组(均P0.05),治疗后的肛管直径更长,切口愈合时间以及住院时间更短,并发症发生率更少,均优于对照组,差异均具有统计学意义(均P0.05)。结论改良侧方纵切横缝内括约肌切断术应用在肛裂的治疗中有效性和安全性良好,具有一定的临床应用价值。     

次侧方内括约肌切开加双缘结扎术治疗Ⅲ期肛裂临床观察(附150例报告)

目的观察次侧方内括约肌切开加双缘结扎术治疗Ⅲ期肛裂临床疗效及其对肛门功能的影响。方法治疗组选取Ⅲ期肛裂患者150例,均采用次侧方内括约肌切开加双缘结扎术治疗,观察创口愈合时间、随访6个月的复发率及测定手术前后肛门直肠压力,并与健康对照组比较。结果所有患者均痊愈出院,创口平均愈合时间(16±2.87)d,随访6个月无复发病例;术前肛管静息压较正常人显著升高(P0.05),肛管舒张压较前显著降低(P0.05),肛管最大收缩压及肛管自主收缩持续时间与正常人比较无明显差异(P0.05);术后肛管静息压较术前明显降低(P0.05),肛管舒张压较前明显升高(P0.05),肛管最大收缩压及肛管自主收缩持续时间与术前比较无明显差异(P0.05);术后肛管静息压、肛管舒张压、肛管最大收缩压及肛管自主收缩持续时间与正常人比较无明显差异(P0.05)。结论次侧方内括约肌切开加双缘结扎术治疗Ⅲ期肛裂疗效显著,能有效地解除内括约肌痉挛,改善肛裂溃疡面的供血不足,促进肛裂的愈合。     

Advancement flap in the management of chronic anal fissure: a prospective study

Lateral internal sphincterotomy is the surgical treatment of choice of chronic anal fissure after failure of conservative measures. Several randomized trials identified an overall risk of incontinence of 10 % mostly for flatus. Fissurectomy is the most commonly used procedure to preserve the integrity of the anal sphincters. However, a possible complication is keyhole defect that may lead to faecal soiling. In this study, chronic anal fissure (CAF) was treated by fissurectomy and anal advancement flap to preserve the anatomo-functional integrity of sphincters and to reduce healing time and the risk of anal stenosis. In patients with hypertonia, surgical treatment was combined with chemical sphincterotomy by injection of botulinum toxin to enhance tissue perfusion. Forty eight patients with CAF underwent fissurectomy and anal advancement flap. In 22 subjects with hypertonia of the internal anal sphincter, intrasphincter injection of 30 UI of botulinum toxin at the completion of the surgical operation was used. All patients were followed up to 24 months. Since the first defecation, the intensity and duration of pain were significantly reduced. Two patients had urinary retention, five had infections and three had partial breakdowns. No anal stenosis, keyhole deformity or necrosis flap was recorded. At the 24 months follow-up visit, anal incontinence was similar to those detected preoperatively. Only four recurrences were detected at 18 and 20 months. After medical treatment failure, fissurectomy with advancement flap is a valid sphincter-conserving procedure for treatment of anterior or posterior CAF, regardless of hypertonia of the internal anal sphincter.     

Keyhole Deformity: A Case Series

Objective Keyhole deformity is frequently encountered after posterior internal sphincterotomy but may be observed after lateral internal sphincterotomy or in patients without any history of previous anal surgery. The aim of the present study is to emphasize the surgical significance of this entity and discuss the possible strategies in the treatment of the deformity. Material and Methods Patients in whom keyhole deformity developed after surgical or conservative treatment applied for chronic anal fissure in our clinic and patients referred from other centers were recruited. Results Nine-hundred twenty-six patients were treated for chronic anal fissure. A hundred of these patients directly underwent lateral internal sphincterotomy. The remaining 826 patients initially received conservative management, and 676 of them eventually underwent lateral internal sphincterotomy. In total, 15 patients were diagnosed to have significant keyhole deformity. Initially, all patients received conservative treatment for keyhole deformity, which was successful in two patients. Of the 13 patients in whom conservative management failed, nine underwent advancement flap reconstruction and the remaining four diamond flap reconstruction. Conclusion Keyhole deformity is occasionally seen as a late complication of chronic anal fissure and may be well tolerated by the patients without any well-defined symptoms. The treatment strategy is directed toward the degree of functional alteration. This study was presented at the 11th Meeting of the Turkish Society of Colon and Rectal Surgery, Bodrum, August 26–30 2007.     

Changing patterns of treatment for chronic anal fissure.

To assess changing patterns of treatment for chronic anal fissure, a retrospective analysis of treatment for chronic anal fissure within one hospital between January 1990 and December 1996 was undertaken. A total of 221 patients received treatment for a chronic anal fissure in this period, of whom 209 had a surgical procedure. Manual dilatation of the anus was performed in 21 patients (10%) and has not been performed since 1995. Lateral internal sphincterotomy was performed in 183 patients (88%) and continues to be the mainstay of treatment. Five female patients (2%) were identified as having a sphincter defect by anal manometry combined with endoanal ultrasound and were treated by an anal advancement flap. From 1996 onwards, 15 patients (7%) were treated by topical glyceryl trinitrate (GTN) paste as the first line of treatment. Of these patients, nine have experienced healing of their fissure, and three have had relief of pain without healing of the fissure. Three have gone on to have a lateral internal sphincterotomy. Lateral internal sphincterotomy remains the primary form of treatment for chronic anal fissure. GTN cream has increasingly been offered as preliminary treatment over the last 12 months. Perioperative use of endoanal ultrasound allowed identification of patients who may be at high risk of postoperative incontinence from a sphincterotomy. An anal advancement flap has been used as an alternative surgical approach for these patients.     

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females

Aim Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy. Method Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap. Results Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance. Conclusion Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.     

Fissure-in-ano, to divide or not to divide?

Anal fissure is one of the most common and painful proctological pathologies affecting mainly young individuals. The physiopathology in the development of a chronic anal fissure seems to be a combination of internal anal sphincter hypertonia and poor vascularization at the posterior midline. Treatment of acute fissures is conservative with supportive therapy, leading to healing in the majority of the patients. Open or closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissures. In low pressure chronic fissures, sphincterotomy should be avoided and a V-Y island advancement flap may be an alternative procedure. Sphincterotomy can induce anal incontinence, a feared complication of this technique. Recent interest has developed in chemical sphincterotomy with local botulin toxin injections or glyceryl trinitrate application. Long-term follow-up is needed to evaluate these new therapeutic options.     

Comparative Study of Conventional Lateral Internal Sphincterotomy, V-Y Anoplasty, and Tailored Lateral Internal Sphincterotomy with V-Y Anoplasty in the Treatment of Chronic Anal Fissure

Background

Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence.

Objective

We compared conventional lateral internal sphincterotomy, V-Y advancement flap, and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure.

Patients

Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion. Participants were randomly allocated to receive conventional sphincterotomy (GI), V-Y advancement flap (GII), or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).

Main Outcome Measures

The primary outcome measure was the incontinence rate; secondary outcomes included healing rate, operative time, anal manometery, and recurrence rate.

Results

One hundred fifty patients with chronic anal fissure were randomized. Healing rate after 1?year was 84?% in GI, 48?% in GII, and 94?% in GIII, respectively (P?=?0.001). The recurrence rate was 4?% in G1, 22?% in GII, and 2?% in GIII (P?=?0.01). Incontinence rate was 14?% in GI, 0?% in GII, and 2?% in GIII (P?=?0.03).

Conclusion

Although all three procedures are simple and easy to perform, tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate, with the fewest complications and less rate of recurrence.     

Anal Stretch Plus Fissurectomy for Chronic Anal Fissure

Introduction : Anal fissure is a common disease. Usually chronic anal fissures are managed medically. When conservative management fails, surgical treatment should be considered. Lateral internal sphincterotomy has been advocated as the first choice invasive treatment but it has a reported rate of major fecal incontinence of 5%. In order to reduce the onset of major fecal incontinence after anal fissure surgery, it has been proposed to use the anal stretching plus fissurectomy.

Methods : From 2008 to 2011, 457 patients have been operated for chronic anal fissure.

Results : Twenty-seven patients underwent lateral internal sphincterotomy, two patients underwent posterior sphincterotomy and 428 patients underwent anal stretch plus fissurectomy. Satisfactory results have been reported in 95% of the cases. Transient incontinence rates have been of 3% after anal stretch and of 14,8% after lateral internal sphincterotomy (p < 0,05). Major and persistent incontinence rates have been reported in a case after later internal sphincterotomy (3%) but never after anal stretching (p = 0,059). Recurrence occurred in 2% of the patients after anal stretch and in 3% of the cases after lateral internal sphincterotomy (p = ns).

Conclusion : Lateral internal sphincterotomy and anal stretch have nearly a reported 95% of good results but the first have 3–5% rates of major incontinence.     

A Study of Fecal Incontinence in Patients with Chronic Anal Fissure: Prospective,Randomized, Controlled Trial of the Extent of Internal Anal Sphincter Division During Lateral Sphincterotomy

Background Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique. However, it may be associated with coexisting occult sphincter defects. Whether continence is related to the extent of sphincterotomy remains debatable. The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division. Methods One hundred eight patients with chronic anal fissure were prospectively studied before and after lateral internal sphincterotomy. A questionnaire was completed for each patient before and after surgery with regard to any degree of fecal incontinence. Fecal incontinence severity index was assessed using the Cleveland Clinic Incontinence Score. The patients with preoperative perfect continence were randomized into two groups (46 patients in each group): Group 1 underwent traditional lateral internal sphincterotomy (up to the dentate line) and Group 2 were underwent a conservative internal anal sphincterotomy (up to the height of the fissure apex or just below it). Results Minor degrees of incontinence were present before surgery in 16 patients (14.8%). Results of the randomized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients (6.52 %) who did not have it before surgery. Five of the six (10.86%) were in Group 1 one (2.17%) was in Group 2 (p = 0.039). Persistent incontinence occurred in two in Group 1 (4.35%). All of them were females. All have had a history of one or more vaginal deliveries. Conclusion A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy. Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon. Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing, but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex. Care should be exercised in female patients with a history of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.     

Our experience in internal medioposterior sphincterotomy with anoplasty]

BACKGROUND: The technique of the posterior medial internal sphincterotomy according to Arnous is described and advice from personal experience reported. METHODS: From 1981 to 1995 posterior medial internal sphincterotomy with anoplasty was performed in 270 patients (132 males and 138 females) affected with chronic anal fissure, alone (112 cases) or associated with hemorrhoids (80 cases); moreover, the Arnous's operation was performed as well for hemorrhoids with posterior subsidiary packet and internal sphincter hypertonia (52 cases), relapsed hemorrhoids with postoperative anal stenosis (24 cases) and postoperative anal stenosis with painful fissure and residual internal sphincter hypertonia (2 cases). RESULTS: The results have been excellent; the average stay in hospital has been 7 days and the complete recovery occurred after 4-6 weeks without early or late complications. CONCLUSIONS: The importance of anorectal manometry for the preoperative valuation of the sphincteric hypertonia is emphasized: in this manner it is possible to modulate the sphincterotomy avoiding too economic sphincteric sections with next residue hypertonia or, in the contrary, too plentiful sphincteric section with problems of continence. Finally, the internal lateral-left sphincterotomy is mentioned, which is efficacious in the treatment of acute anal fissure. However, the proctological surgeon, on the basis of his experience, will propose the most convenient technique.     

肛管内括约肌切开断端固定术治疗肛裂的临床观察

为探讨原位肛管内括约肌切开断端固定术治疗肛裂的疗效,将70例肛裂患者随机分为治疗组和对照组各35例。治疗组采用原位肛管内括约肌切开断端固定术治疗,对照组采用肛管内括约肌切断术治疗,比较两组的临床疗效及并发症等情况。结果显爪,闪纰患者在术后出血、创口感染率、肛门控制功能等方面比较均有统计学意义（P〈0．01）。结果表明,原位肛管内括约肌切外断端固定术治疗肛裂具有术后出血少、感染率低、对肛门外形影响小、无损伤性肛门失禁等优点。