电刺激股薄肌成形术原位肛门重建的犬实验研究

目的　评价电刺激股薄肌成形术原位肛门重建的犬实验模型临床应用前景。方法　采用杂种犬 17条 ,分对照组和实验组两组 ,第 1期单行股薄肌原位游离 ,实验组术后行电刺激连续 6周 ;2组第 2期均行腹会阴联合切除肛门 股薄肌原位肛门括约肌重建 ,术后 2周测量基础新肛压、功能性新肛压和移位股薄肌肌肉耐疲劳性曲线 ,取肌肉样本进行显微结构观察。结果　实验组的I型纤维所占比例明显高于对照组 (P <0 0 0 1) ;两组间基础肛压、基础新肛压的差异无显著性意义 (P >0 0 5 ) ,而功能性新肛压的差异有显著性意义 (P <0 0 1) ;实验组的移位股薄肌肌肉耐疲劳性曲线更平缓 ,平台期更长。结论　经过长期电刺激后 ,股薄肌纤维构成发生适应性改变 ,抗疲劳性改善 ,可替代括约肌的功能。     

MRI在高位复杂性肛瘘诊断中的应用

为探讨相控阵线圈高分辨MRI对高位复杂性肛瘘的术前诊断价值．将35例高位复杂性肛瘘患者术前利用相控阵线圈高分辨MRI扫描,以手术结果为标准．将MRI检查结果及术前临床一般检查结果与手术结果进行比较。结果显示．与手术探查结果相比,术前MRI在诊断肛瘘侵犯位置高低方面的准确率为88．6％,术前一般检查的准确率为57．1％：术前MRI在肛瘘内口诊断方面的准确率为85．7％,术前一般检查的准确率为51.4％。肛瘘的MRI检查结果优于术前一般检查。结果表明,应用相控阵线圈高分辨MRI检查,能较准确地判断肛瘘侵犯部位的高低以及内口的位置、瘘管的走向．对提高手术的成功率及手术时避免肛门括约肌的损伤具有重要指导意义。     

A pilot study using total colonic manometry in the surgical evaluation of pediatric functional colonic obstruction

Background/purpose

Total colonic manometry (TCM) can directly measure intraluminal pressures and contractile function of the entire colon. The utility of TCM to guide the surgical management of functional colonic obstruction has not been reported.

Methods

Total colonic manometry was performed on all patients referred for surgical evaluation of refractory functional colonic obstruction. Manometric tracings were obtained while fasting, after feeding, and after pharmacologic stimulation.

Results

Nine patients were referred for refractory colonic obstruction. The mean age was 4.8 years, and the mean duration of follow-up was 29 months. Two patients had functional obstruction after repair of Hirschsprung’s disease, and 7 patients had idiopathic functional obstruction. In the idiopathic group, 4 distinct motility patterns were identified: (1) normal colonic motility, (2) dysmotility with massive distension, (3) persistent segmental dysmotility, and (4) global neuropathy/myopathy. Both Hirschsprung’s patients showed globally abnormal motility. Surgical management was guided by TCM results. There was significant improvement in bowel function and weight gain after manometry-guided intervention. An unnecessary laparotomy was avoided in 2 patients.

Conclusions

TCM can be valuable in deciding the need for and timing of diversion, the extent of resection required, and the suitability of the patient for restoring bowel continuity in refractory functional obstruction.     

高频线阵型超声波在肛瘘诊断中的应用

目的：探讨高频线阵型超声波在肛瘘诊断中的价值。方法：使用GE公司LOGIQ7型超声波诊断仪10MHz高频线阵型探头对26例复杂肛瘘及可疑肛瘘患者进行术前检查，并与手术结果对比。结果：超声波显示情况与手术结果完全符合。结论：高频线阵型超声波在肛瘘诊断中具有较高的价值。     

A型肉毒素内括约肌侧方注射+病灶扇形小切口切扩引流术治疗Ⅱ、Ⅲ期肛裂的临床研究

目的评价A型肉毒素内括约肌侧方注射+病灶扇形小切口切扩引流术治疗Ⅱ、Ⅲ期肛裂的安全性和有效性,探索其手术操作步骤及要点,介绍一种治疗肛裂的新手术方式。方法采用随机、平行、对照的临床试验方法,将纳入病例随机分为试验组和对照组,试验组行A型肉毒素内括约肌侧方注射+病灶扇形小切口切扩引流术,对照组行肛裂切除扩创术加部分内括约肌侧方切断术。将2组安全性指标(包括肛门狭窄、肛门失禁、急性尿潴留、术后疼痛的发生及直肠肛管测压结果)和有效性指标(包括痊愈率、手术时间、切口创面愈合时间、切口愈合分级、切口愈合后瘢痕面积大小)进行比较。结果 2组均无肛门狭窄和急性尿潴留发生;对照组肛门失禁评分高于试验组,但差异无统计学意义(P>0.05)。试验组术后(术后24 h、术后第1次排便及术后1周)疼痛评分明显低于对照组(P<0.01)。术前、术后直肠肛管测压结果 2组间比较差异无统计学意义(P>0.05)。试验组痊愈率高于对照组(P<0.05),手术时间及切口创面愈合时间均明显短于对照组(P<0.01),切口愈合优于对照组(P<0.05),切口愈合后瘢痕面积小于对照组(P<0.01)。结论 A型肉毒素内括约肌侧方注射+病灶扇形小切口切扩引流术具有治愈率高、切口愈合时间短、切口愈合后瘢痕面积小、操作快捷、手术微创化等优点;且在肛门外形和功能保护方面优于对照组,本术式具有较好的临床疗效和安全性。     

全直肠系膜切除+经肛门内括约肌切除术治疗超低位直肠癌和直肠肛管癌的近期疗效

目的探讨全直肠系膜切除(TME)+经肛门内括约肌切除术(ISR)治疗超低位直肠癌和直肠肛管癌保肛手术的安全性及可行性,并评价近期肿瘤根治效果及术后肛门功能。方法回顾性分析2009年1月至2010年12月期间四川大学华西医院胃肠外科中心行TME+ISR治疗的超低位直肠癌和直肠肛管癌86例患者的临床及随访资料。结果 86例患者均成功完成手术,肿瘤下缘距肛门1～5 cm(平均1.63 cm);肿瘤直径2～7 cm,平均3.4 cm。肿瘤系高分化4例,中分化60例,低分化22例;pTNM分期为Ⅰ期12例,ⅡA期11例,ⅡB期15例,ⅢA期2例,ⅢB期23例,ⅢC期16例,Ⅳ期7例。术后发生吻合口漏3例,肛周感染2例(其中1例因肛周严重感染引起盆腔、腹膜感染再次手术行永久性造口),吻合口出血及吻合口狭窄各2例,直肠阴道瘘、炎性肠梗阻、尿潴留和腹腔感染各1例。86例患者均获随访,平均随访时间为18个月(12～24个月)。1例于术后7个月发现肝转移,2例分别于术后7个月和12个月因肿瘤广泛浸润、转移死亡;术后1年局部复发3例(3.5%),1年生存率为97.7%(84/86),排便次数1～5次/d,控便功能按Kirwan评分标准可达1～2级。结论 TME+ISR治疗超低位直肠癌和直肠肛管癌是一种可行的、安全的、能达到根治的保肛术式,近期疗效满意。     

硝酸甘油软膏加扩肛与单纯扩肛治疗肛裂96例对照观察

目的探讨扩肛加硝酸甘油软膏治疗肛裂的临床效果。方法将2011年5月至2011年10月到常州市中医医院治疗的96例Ⅱ、Ⅲ期肛裂患者,随机分为两组,在常规扩肛术的基础上于肛裂创面外用硝酸甘油软膏治疗49例为治疗组,单纯扩肛治疗47例为对照组。结果 96例患者随访时间3～6个月。治疗组复发2例,治愈率95.9%,对照组复发9例,治愈率80.9%,两组比较差异有统计学意义,P<0.05。结论肛裂行扩肛术后局部再外用硝酸甘油软膏,有利于肛裂的治愈,减少并发症的发生。     

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases

Aim The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula. Method We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum. Results During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17–84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn’s disease (20). Of the 62 non‐Crohn’s patients previous treatment was common and included surgery (42), antibiotics alone (41) and non‐steroidal anti‐inflammatory drugs (21). Conclusion Horseshoe extension in anal fistula is uncommon. With Crohn’s disease excepted, the majority had had previous treatment.     

Five-year results of fissurectomy for chronic anal fissure: low recurrence rate and minimal effect on continence

Aim The aim of the study was to determine the long‐term outcome, recurrence rate and faecal incontinence score after fissurectomy for chronic anal fissure (CAF) not responding to conservative treatment. Method Fifty‐three consecutive patients (29 women) who underwent fissurectomy for a medically resistant CAF between 1998 and 2005 were included in the study. At a minimum follow‐up of 5 years a standardized questionnaire was sent to all patients, assessing recurrence, satisfaction with the operation (on a scale of 0–10) and faecal continence (Vaizey score, 0–24). The patients were compared with a control group of 50 healthy volunteers, matched for sex and age, who had never undergone anal surgery. Results Forty‐three (81%) patients (25 women) returned the questionnaire. The mean age was 40 (SD 12.1) years and median follow up was 8.2 (5.5–12.2) years. Five patients had a recurrent CAF (11.6%). Ninety per cent of patients would have consented to the operation again if necessary. The mean Vaizey score at follow‐up was 2.5 (SD ± 4.2). The mean Vaizey score of the four patients who had had a previous lateral sphincterotomy was 3.8 and for the eight patients who had reported a continence disturbance before fissurectomy it was 8.3. The mean Vaizey score of the 31 patients who were continent before fissurectomy was 0.8 compared with 0.4 in the control group (P = 0.9). Conclusion At 5 years or more fissurectomy for medically resistant CAF is effective with a low recurrence rate and minimal influence on continence.