肛门病手术应用低浓度小剂量利多卡因局麻的效果

目的观察低浓度小剂量利多卡因在肛门病手术中的应用效果。方法选择接受肛门病手术者100例,手术时用0．25％盐酸利多卡因5-20ml,根据病情和手术需要作局部浸润麻醉。结果通过100例的肛门手术观察,结果显示麻醉满意顺利83例,麻醉良好17例,无1例麻醉无效失败。总有效率100％。此法麻醉效果确切,未发现严重不良反应。结论此法具有易于掌握,效果好而安全的优越性,适于临床应用和推广。     

Early experience with laparoscopic abdominoperineal resection

Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients. Received: 23 April 1996/Accepted: 8 July 1996     

Primary Adenocarcinoma in the Urethrorectal Fistula

A 60-year-old Japanese man was hospitalized because of urinary leakage from the anus on October 3, 1994. Retrograde urethrography detected a fistula between the bulbous urethra and the rectum. Urethrocystoscopy revealed a tumor on the urethrorectal fistula. Tumor biopsy showed a well differentiated adenocarcinoma. Cystourethrectomy with fistulectomy, and ileal conduit urinary diversion were performed. Pathological examination revealed primary adenocarcinoma in the fistula with invasion to the prostatic urethra and bladder wall. The patient showed no evidence of a recurrence as of August, 1996.     

Cytokeratin polypeptide expression in a cloacogenic carcinoma and in the normal anal canal epithelium

Summary The aim of the present study was to explore the origin of cloacogenic carcinoma in the anal canal by immunohistochemical methods. We compared cytokeratin polypeptide expression of a cloacogenic carcinoma to normal anal epithelia, to anal squamous cell carcinoma and to basal and squamous cell carcinoma of the skin, using a battery of monoclonal anti-cytokeratin, polypeptide-specific antibodies. Our results indicate that cloacogenic carcinoma expresses cytokeratin polypeptides similar to those of the basal layer of anal squamous epithelium, of the anal transitional zone epithelium and of a layer of basal cells in the anal glands. Thus we concluded that each of the above cell types may be the cell of origin of cloacogenic carcinoma.     

陆金根运用拖线法治疗肛瘘经验探讨

介绍陆金根教授运用现代技术诊断肛瘘瘘管的走向、拖线的设置及术后创面的处理等临床经验。     

Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound

Objective  To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter.
Design  A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed.
Methods  To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans.
Main outcome measures  Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A–E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations.
Conclusions  LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.     

低切高挂半缝合半开放引流术治疗高位肛瘘

目的 :探讨治疗高位肛瘘的手术方式。方法 :5 0例高位肛瘘分为 2组 ,试验组直肠环以上瘘管挂线 ;直肠环以下瘘管切除 ,肛门外切口间断全层缝合 ,肛门内切口开放引流。对照组直肠环以上瘘管挂线 ;直肠环以下瘘管切开。结果 :(1)治愈率 :试验组 10 0 % (2 5 / 2 5 ) ,对照组 96 % (2 4 / 2 5 )。 (2 )伤口愈合时间 :试验组 (9.0 4± 1.93) d,对照组 (2 4 .6± 4 .2 2 )d (P <0 .0 1)。 (3)肛管弹性 :试验组术前优 18例、良 6例、差 1例 ;术后优 16例、良 7例、差 2例。对照组术前优 2 0例、良 3例、差 2例 ;术后优 11例、良 9例、差 5例。 (4)肛门平滑度 :试验组术后正常 2 4例 ,对照组术后正常 3例。(5 )伤口水肿 :试验组 2 3例 (92 % ) ,对照组无。 (6 )伤口疼痛 :试验组重度 2 1例、中度 3例、轻度 1例。对照组重度 2例、中度 2 0例、轻度 3例。 (7)伤口感染 :试验组 2例、对照组 1例。结论 :瘘管切除半缝合半开放引流术在保持肛门的功能、外形及缩短治疗时间上优于瘘管切开全开放引流术     

FoxP3 overexpression and CD1a+ and CD3+ depletion in anal tissue as possible mechanisms for increased risk of human papillomavirus‐related anal carcinoma in HIV infection

Aim We analysed local cellular and humoral immunity factors in the anal mucosa in an attempt to explain how HIV infection increases the risk of anal cancer in HPV‐infected patients. Method HIV‐positive cases and matched HIV‐negative controls with more than one recurrence of condylomas were included in a prospective study following treatment of the initial lesions. Patients were followed every 3 to 6 months for the development of anal intraepithelial neoplasia (AIN3) and cancer for up to 60 months. Tissue CD1a⁺, CD3⁺, CD4⁺, CD8⁺ cells and mRNAs of selected cytokines and chemokines were quantified and compared in patients with or without AIN3 or cancer using morphometric or immunohistochemistry analysis and qRT‐PCR. Results Sixty‐six individuals (22 patients and 44 controls) were included. In the case group, CD1a⁺ and CD3⁺ cell counts were significantly lower in biopsies from AIN3 and cancer specimens compared with those from AIN 1‐2 or normal biopsies (P < 0.0001). A CD1a⁺ count of < 10/mm was predictive of AIN3 and cancer (Odds ratio = 9.4, 95% CI: 5.4–18.3, P < 0.0001). IL‐8 and IL23 levels were significantly higher in cancer than in non‐cancer tissues regardless of HIV status (P = 0.02). FoxP3 expression was significantly higher in HIV‐infected cases than in controls with AIN3/cancer (P < 0.04). Conclusion Depletion of CD1a⁺ and CD3⁺ cells and overexpression of FoxP3 in the anal mucosa appear likely to contribute to the risk of HPV‐related anal cancer in HIV‐infected patients. Furthermore, overexpression of IL‐8 and IL‐23 in the anal mucosa might be responsible for the development of this cancer regardless of HIV status.     

侧位内括约肌切断术治疗肛裂前后肛肠动力学变化的临床观察

为通过肛肠动力学检测探讨侧位内括约肌切断术治疗肌裂对肛门功能的影响,采用侧位内括约肌切断术治疗肛裂60例,术前术后进行直肠肛管测压,测毓直肠肛门反射（RAR）、肛管最夫收缩压（AMCP）、肛管最长收缩时间（ALCT）、直肠静息压（RRP）、肛管静息艇（ARP）,进行对比分析。结果最示,本组60例患者均痊愈出院。术后患者ARP显著降低,与术前比较差异有统计学意义（P〈0．01）;AMCP、ALCT、RRP与术前比较差异尤统计学意义（P〉0．05）。结果表明,肛裂患者行侧位内括约肌切断术后町引起一定的肛肠动力学变化,但肛门自制功能正常。     

肛垫与性器官勃起组织同源的探讨

目的 提出了一个肛垫组织胚胎发生与性器官海绵体勃起组织同源的假说.肛垫与性器官海绵体皆起源于泄殖腔膜周围的原始间充质.当泄殖腔膜被分割为尿生殖膜与肛膜后,前者周围的间充质形成性器官海绵体的胚胎原基,后者周围的间充质形成肛垫的胚胎原基.在成体,肛垫具有勃起组织特征和血管神经配布与会阴同源等事实支持这一学说.