括约肌间瘘管结扎术治疗复杂性肛瘘

括约肌间瘘管结扎术(ligation of intershpincteric fistula tract,LIFT)是治疗复杂性肛瘘,特别是经括约肌肛瘘的新术式.2007年由泰国医生Rojanasakul首次提出,其优势在于早期治愈率高,且肛门失禁率为零,而且完全保留括约肌.近几年来,LIFT手术的临床研究表明其疗效差异较大.本文试对LIFT手术的临床研究现状作一综述.     

肛瘘保留括约肌手术最新研究进展

<正>肛瘘不能自愈,需要医疗干预,手术是治疗肛瘘最重要的手段。治疗肛瘘的手术有很多,各有其优缺点,但大致可由2大类组成：(1)传统及其改良术式（瘘管切开术、切开挂线术等）;(2)肛门括约肌保留术式（sphincter saving techniques,SST）,含括约肌间瘘管结扎术（ligation of intersphincteric fistula tract,LIFT）、经肛门直肠黏膜瓣推移术（endoanal advancement flap,ERAF）、保留外括约肌的瘘管切开术（external sphincter-sparing anal fistulotomy,     

肛瘘激光消融闭合术致瘘道创面坏死一例报道

由于手术理念的转变，肛门括约肌功能的保护越来越受到人们的重视。肛瘘激光消融闭合术是一种新颖的括约肌保留术式。它疗效显著，术后患者几乎感受不到疼痛感，并且最大限度地保护了肛门功能，将肛门失禁风险最小化。     

克罗恩病肛瘘的诊断与治疗

克罗恩病并发肛瘘经过数年的发展会损伤肛门括约肌. 细致的肛管直肠检查能正确评价脓肿和肛瘘. 理想的治疗方法是选择合适药物与外科手术相结合. 伴有胃肠道炎症的患者必须结合药物治疗. 低位单纯性肛瘘可采用瘘管切开术, 复杂性肛瘘患者必须个体化治疗. 然而,选择正确的手术方法和药物治疗比较困难. 现就克罗恩肛瘘的诊断与治疗进行阐述.     

经括约肌间瘘管结扎术联合负压封闭引流治疗复杂性肛瘘疗效观察

目的 观察经括约肌间瘘管结扎术（LIFT）与负压封闭引流（VSD）联合治疗复杂性肛瘘的临床疗效。方法 80例复杂性肛瘘患者随机分为联合组和传统组各40例,传统组行切开肛瘘挂线旷置术,联合组行LIFT与VSD联合术,术后随访6个月。两组术后创口愈合时间、术后并发症、住院费用。结果 联合组与传统组创口愈合时间短传统组,治愈率高于传统组,住院费用低于传统组,P均〈0.05;联合术出现术后并发症传统组2例患者出现肛门漏气但无溢液。结论 LIFT联合VSD治疗复杂性肛瘘疗效较好,术后创口愈合时间短,并发症较少。     

克罗恩病肛瘘研究进展

肛瘘是克罗恩病患者长期不良预后的预测因素,克罗恩病肛瘘（pfCD）严重影响患者的生命质量。pfCD的治疗提倡手术与药物治疗相结合,生物制剂尤其是TNF-α抑制剂的出现,极大地改善了pfCD患者的预后。近年发现一些新型生物制剂、间充质干细胞等治疗方式有助于缓解病情,对于复杂性肛瘘,保留括约肌等术式可极大减少尿失禁等术后并发症,给pfCD患者带来新的希望。本文就pfCD的诊治进展作一综述。     

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.     

切开挂线对口引流术治疗高位复杂性肛瘘合并高血压患者的疗效观察

目的探讨高位复杂性肛瘘合并高血压应用切开挂线对口引流术治疗的疗效。方法选取我院肛肠科2014年2月~2015年2月收治的高位复杂性肛瘘合并高血压患者80例,依据入院先后顺序分为对照组与观察组,各40例。对比两组患者的疗效。结果两组患者均达到治愈标准。但观察组住院时间、创面恢复时间均短于对照组,肛门括约肌功能恢复正常率高于对照组,差异有统计学意义(P0.05)。观察组无复发,对照组复发3例。结论高位复杂性肛瘘合并高血压患者采用切开挂线对口引流术治疗,可缩短病程,改善肛门括约肌功能,预防复发,对保障患者生存质量意义显著。     

肛周脓肿三间隙引流术的理论基础及临床应用进展

肛周脓肿三间隙引流术(three-cavity clearance, TCC)是一种完全保留肛门括约肌的创新术式,能有效降低术后肛瘘形成的概率,减少脓肿的复发,创伤小,风险低,值得在临床进一步推广和研究.本文就肛周脓肿TCC的理论基础、临床应用及相关问题予以探讨.     

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

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。     

Treatment of anal fistula with FiLaC®: results of a 10-year experience with 175 patients

Techniques in Coloproctology - Treatment of fistula-in-ano with fistula laser closure (FiLaC®) is a sphincter-saving procedure indicated for patients with complex anal fistulas. The aim of our...     

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas

Background  

Video-assisted anal fistula treatment (VAAFT) is a novel minimally invasive and sphincter-saving technique for treating complex fistulas. The aim of this report is to describe the procedural steps and preliminary results of VAAFT.     

Micro-fragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study accessing safety and feasibility

Background

The aim of the present study was to evaluate the safety and efficacy of autologous, micro-fragmented and minimally manipulated adipose tissue injection associated closure of the internal opening in promoting healing of complex anal fistula.

Methods

A pilot study was conducted on patients referred to our center with anal fistula, from April 2015–December 2016. Inclusion criteria were age over 16 years old and a diagnosis of complex anal fistula according to the American Gastroenterological Association classification The patients were divided into 2 groups; the “first time group” (Group I) in which micro-fragmented adipose tissue injection with closure of the internal opening was the first sphincter-saving procedure, and the “recurrent group” (Group II) consisting of patients who had failed prior sphincter-saving procedures. The procedure was carried out 4–6 weeks after seton placement. Follow-up visits were scheduled at 7 days, and 1, 3, 6 and 12 months after surgery. Fistula healing was defined as the closure of the internal and external openings without any discharge.

Results

Out of 47 patients with complex transsphincteric anal fistula, 19 met the inclusion criteria and were selected to undergo the procedure. Twelve of these patients (Group I) had micro-fragmented adipose tissue injection as first-line treatment, and 7 (Group II) had failed previous sphincter-saving procedures. The mean operative time was 55 ± 6 min (range 50–70 min). The mean postoperative pain score measured with the visual analog pain scale was 2 ± 1.4 (range 0–4). No intraoperative difficulties related to the use of the kit were recorded. There were no cases of postoperative fever or abdominal sepsis related to the procedure and no post-treatment perianal bleeding or impaired anal continence. Only 3 cases of minor abdominal wall hematoma that did not require any treatment and 1 case of perianal abscess were observed. Patients were evaluated for a mean follow-up time of 9 ± 3.1 months (range 3–12 months). The overall healing rate was 73.7, 83.3% for Group I and 57.1% for Group II.

Conclusions

The injection of autologous, micro-fragmented and minimally manipulated adipose tissue associated with closure of the internal opening is a safe, feasible and reproducible procedure and may enhance complex anal fistula healing.

     

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator,suprasphincteric, extrasphincteric,high outersphincteric,and high intrarectal fistulas

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.     

Excision of anal fistula with closure of the internal opening: functional and manometric results

PURPOSE: The aim of this study was to evaluate the results concerning recurrence and continence after sphincter-saving surgery for fistula-in-ano. METHODS: Forty-two patients with anal fistula traversing the sphincter were operated on with fistula excision and closure of the internal opening. Patients answered a questionnaire concerning bowel habits and continence before and 3 and 12 months after surgery. A subgroup of 19 patients were also examined with anal manometry. RESULTS: Twenty-three (55 percent) patients healed primarily after surgery and a further 10 (24 percent) after one reoperation, whereas 7 (17 percent) required 2 to 4 reoperations until healed. In two patients therapy was changed to cutting seton treatment. After 1 year 21 of 36 (58 percent) patients reported improved or unaffected continence and 11 (31 percent) reported a slight and 4 (11 percent) a major decrease in continence. Detailed data on preoperative continence were missing for five patients, and one had a colostomy at late follow-up. Anal manometry showed a significant decrease in resting pressure after three months and a further decrease in both resting and squeeze pressures after one year. CONCLUSION: Surgery for anal fistula with excision and advancement flap has a fairly high initial recurrence rate but a good final success rate. A decrease in continence is seen also after this kind of surgery for anal fistula. Manometric results suggest that this is associated with an impaired internal anal sphincter function.     

Fibrin glue for anal fistulas

The aim of this study was to evaluate the long-term success and complication rate of fibrin-glue treatment of anal fistulas. Patients with an anal fistula presenting to a single surgeon over a 3-yr period were enrolled in this study. At their first operation, all 48 patients (26–72 yr old) underwent anoscopy, biopsy, destruction of the internal gland, and placement of a draining seton. Approximately 2 months later, after preoperative bowel preparation, the seton was removed, the internal opening closed with a single suture, and fibrin glue instilled by way of the external opening to seal the fistula tract. Patients were followed closely to document the results of treatment and any complications. Long-term follow-up was done by telephone interview. Cause of the anal fistula was cryptoglandular in 36 patients (75%), Crohn's disease in 5 (10%), and miscellaneous in 7 (15%). Median follow-up was 22 months (range, 6–46). After a single treatment with fibrin glue, 29 fistulas (60%) closed. Retreatment with fibrin glue brought the successful number of fistula tracts closed to 33 (69%). The 15 patients (29%) who failed either one or two treatments with fibrin glue were successfully treated with either fistulotomy or advancement flap. Bowel function and fecal incontinence were not altered by the fibrin-glue treatment. In one patient who failed fibrin glue, the fibrin-glue treatment might have created a more complicated fistula tract. Late recurrences (>6 months) occurred in three patients (6%), two of whom were successfully retreated with fibrin glue. Fibrin-glue treatment of anal fistulas is successful in up to 69% of patients if initial failures are retreated. This sphincter-saving technique is associated with minimal complications and no functional detriment. Late recurrences are unusual.     

S3-Leitlinie: Kryptoglanduläre Analfisteln

Background

With an incidence of 2 in 10,000/year, fistula-in-ano of cryptoglandular origin is a common disease, affecting predominantly young males. Incorrect treatment can adversely effect quality of life, particularly in terms of stool continence.

Methods

A systematic review of the literature has been undertaken.

Results

Since relevant randomized studies are scant, the level of evidence is low. The classification of anal fistulas depends on the relation between fistula channel and anal sphincter. Anamnesis and clinical examination are sufficient to establish the indication for surgery. In addition, an intraoperative probe and/or staining of the fistula channel should be performed. Endoanal ultrasound and magnetic resonance tomography are similar in predictive value. These modalities may be able to provide additional information in complex fistulas. The treatment of anal fistulas consists of one of the following surgical procedures: lay-open technique, seton drainage, plastic reconstruction with suture of the sphincter or occlusion with biomaterials. The lay-open technique should only be performed in superficial fistulas. The risk of impaired postoperative continence increases with the thickness of the divided sphincter muscle. A sphincter-saving procedure should be undertaken for all high anal fistulas. The results of the different techniques using plastic reconstruction are largely comparable. A lower healing rate is seen with occlusion using biomaterials.

Conclusion

This clinical S3 guideline provides instructions for the diagnosis and treatment of cryptoglandular fistula-in-ano for the first time in Germany.     

Coloanal anastomosis for distal third rectal cancer

PURPOSE: Jeopardizing cure and risking high local recurrence have served as arguments against sphincter-saving resection for patients with distal third rectal cancer. This prospective study examines and compares the local recurrence and survival rates in patients with distal third rectal cancer treated by either coloanal anastomosis or abdominoperineal resection. METHODS: Between 1977 and 1993, 174 patients underwent coloanal anastomoses and 38 patients underwent abdominoperineal resection. All tumors were located 4 to 7 cm from the anal verge. One hundred ninety-three patients (91 percent) underwent rectal excision with a curative intent. Mean follow-up was 66 months after sphincter-saving resection and 65 months after abdominoperineal resection. RESULTS: Mean anastomotic height from the anal verge was 2.3 cm after sphincter-saving resection. Overall local recurrence rate was 7.9 percent after sphincter-saving resection and 12.9 percent after abdominoperineal resection. The five-year actuarial survival rate was 78 percent after sphincter-saving resection and 74 percent after abdominoperineal resection. CONCLUSION: Local recurrence and survival are not compromised in patients with distal third rectal cancer when treated by sphincter-saving resection, provided that oncologic principles are not violated. Coloanal anastomosis can be performed with an acceptable morbidity.     

Why do we have so much trouble treating anal fistula？

Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing...     

VAAFT for complex anal fistula: a useful tool,however, cure is unlikely

Techniques in Coloproctology - Therapeutic options for complex anal fistula (CAF) are limited. Video-assisted anal fistula treatment (VAAFT) allows examination of these anatomically complex...