新編14肛瘺診治進展

1、肛瘺診治進展 －－從《06版肛瘺臨床診治指南》再談肛瘺的治療,★ 2019年中華醫(yī)學(xué)會外科學(xué)分會肛腸外科學(xué)組根據(jù)國內(nèi)外醫(yī)學(xué)的最新進 展和廣大醫(yī)務(wù)工作者在臨床應(yīng)用后提出的意見和建 議,制訂了《肛瘺診治標(biāo)準(zhǔn)》； ★ 2019年7月提出《肛瘺臨床診治指南》：由中華醫(yī)學(xué)會外科學(xué)分會結(jié)直腸肛門外科學(xué)組、中華中醫(yī)藥學(xué)會肛腸分會、中國中西醫(yī)結(jié)合學(xué)會結(jié)直腸肛門病專業(yè)委員會共同制訂；,☆2019年7月《肛瘺臨床診治指南》；

2、☆美國結(jié)直腸外科醫(yī)生協(xié)會（ASCRS: American Society of Colo-Rectal Surgeon ）：Guideline 指南；,??治療原則（06版）： 1) 手術(shù)治療是肛瘺的主要手段，基本原則是：去除病灶，通暢引流，盡可能減少肛管括約肌損傷，保護肛門功能； 2)由于肛瘺的復(fù)雜性和一些特殊的病理背景，肛瘺術(shù)后有一定的復(fù)發(fā)率； 手術(shù)是治療肛瘺的惟一可靠的辦法，但手術(shù)成功率報

3、道不一，尤其是高位肛瘺，首次手術(shù)復(fù)發(fā)率高達50％，再次手術(shù)失敗率仍高達10％以上；,??治療原則（續(xù)，06版） 3）鑒于高位復(fù)雜性肛瘺的特殊病理和生理環(huán)境及肛門功能的重要性，“帶瘺生存，亦可作為一個原則加以選擇，不應(yīng)為盲目追求手術(shù)根治而忽視其可能帶來的嚴重并發(fā)癥； 4）中藥治療僅限于患者恢復(fù)期的調(diào)整和暫不適合手術(shù)者。,The goals in the treatment of fistula-in-ano

4、 （ASCRS）：To eliminate the septic foci and any associated epithelialized tracks；2) to do so with the least amount of functional derangement. 3）There is no single technique appropriate for the treatment of all fistu

5、las-in-ano and, therefore, treatment must be directed by the surgeon’s experience and judgment.,手術(shù)方式：1）肛瘺切開（除）術(shù)：適用于單純性肛瘺 肛瘺切開術(shù)較好，肛瘺切除術(shù)創(chuàng)面較大，愈合時間相對較長，可發(fā)生肛門失禁。,Treatment of a Simple Fistula-in-Ano：1. Simple anal

6、fistulas may be treated by fistulotomy. ?Fistulotomy is preferable to fistulectomy. Despite similar recurrence rates, the latter results in larger wounds with a longer healing time and higher rates of incontinenc

7、e.,?The recurrence rate for fistulotomy is generally between 2 and 9 percent with a functional impairment generally between 0 and 17 percent. Any functional derangement will tend to improve for up to two years after surg

8、ery. ?One randomized, controlled trial reported faster healing and better preservation of anal squeeze pressures when anal fistulotomy wounds were marsupialized compared with simply laid open.,2. Simple

9、anal fistulas may be treated with trackdebridement and fibrin glue injection. Fibrin glue is an easy and repeatable treatment for fistula in- ano with relatively few side effects and little to no risk of fecal in

10、continence. Successful healing ratesfrom 60 to 70 percent can be achieved. Risk factorsfor failure include Crohn’s disease, rectovaginalfistula, human immunodeficiency virus, and short fistula length.,2）掛線術(shù)：合理選擇切割掛線和

11、引流掛線。 一期切割掛線：適用于高位肛瘺涉及到大部分肛門外括約肌淺部以上者； 二期切割掛線：適用于部分高位肛瘺合并有難以處理的殘腔，或需二次手術(shù)及術(shù)后引流。 長期引流掛線: 適用于高位經(jīng)括約肌克羅恩病肛瘺患者，以預(yù)防復(fù)發(fā)性膿腫的形成和保持肛門的功能。 短期引流掛線：盡管目前臨床報導(dǎo)短期掛線引流治療肛瘺有效，完全保留了括約肌，不會導(dǎo)致肛門失禁，但因其復(fù)發(fā)率高，臨床應(yīng)用需慎重。,3) 粘膜

12、瓣推移術(shù)： 適用于高位肛瘺內(nèi)口明確且不伴嚴重感染的患者和女性前側(cè)肛瘺。,Treatment of a Complex Fistula-in-Ano：1. Guideline: Complex anal fistulas may be treatedwith debridement and fibrin glue injection. As with simple fistula-in-ano, f

13、ibrin glue is an easy, repeatable treatment for a complex fistula-in-ano. Using this technique, healing rates from 14 to 60 percent have been achieved in small studies.,2. Guideline: Complex anal fistulas may be treated

14、with endorectal advancement flap closure. ? The use of an endorectal advancement flap is an attractive modality for the treatment of a complex fistula-in-ano.,?Successful healing rate : 55 to 98 percent of patien

15、ts. Although the sphincter mechanism is not divided during the construction of an endorectal advancement flap, minor incontinence has been reported in up to 31 percent of the patients and major incontinence in up to 12

16、percent. ?Predictors of poor outcome ： undrained sepsis, cancer or radiation etiology, rectovaginal fistula diameter >2.5 cm, fistula present fewer than 6 weeks, and active Crohn’s proctitis.,3. Guideline: Compl

17、ex fistulas may be treated bythe use of a seton and/or staged fistulotomy: Setons may be used to induce perisphincteric fibrosisalong the fistula track so that when the fistulotomy iseventually performed, or th

18、e seton gradually tightened,the muscular defect and amount of incontinence is limited. A seton may also be utilized to facilitate staged fistulotomy. The seton is used to mark the external sphincter for later division

19、after the subcutaneous components have healed. Although these two techniques have low recurrence rates (0–8 percent), the rates for minor (34–63 percent) and major incontinence (2–26 percent) are significant.,關(guān)于高

20、位復(fù)雜性肛瘺掛線的探討,??高位肛瘺是否需要掛線 由于現(xiàn)代解剖學(xué)肛瘺切除的廣泛開展，除術(shù)中處理病變較徹底外，對肌肉的保護亦十分明確，對內(nèi)口的尋找及處理亦更準(zhǔn)確，再加上對肛管直腸環(huán)的功能及作用認識的深入，因此，在既往被認為非掛線不可的病例，均可以行直接切開處理，只有那些病變十分復(fù)雜，瘺道完全穿過肛管直腸環(huán)或其大部的病例，才考慮掛線。 但是，目前來看，對絕大多數(shù)高位復(fù)雜性肛瘺采用掛線療法更為穩(wěn)妥；對于女性前方的肛

21、瘺，如位置較深，即使是在外括約肌深部以下最好也采用掛線療法。,??需要掛線的組織 掛線應(yīng)掛到瘺管頂端，不留死腔，這樣可將瘺管全部掛開，避免引流不暢和頂端存在死腔；可避免直接切開直腸黏膜時的出血；上部黏膜勒開較快，基本不影響勒割速度。對于大束組織，可以一次大束掛線適當(dāng)緊線，如一次緊線勒割不開，可再次緊線。,??實掛或虛掛 掛線療法主要運用于外括約肌深部以上的高位瘺管和膿腫的治療，運用的是緊線掛線法(實掛)；

22、 運用于低位肛瘺和膿腫等的治療，用于各種高、低位復(fù)雜性瘺管和膿腔的掛線引流，采用的是不緊線的掛線法，又稱“虛掛”或“浮掛”法；這是掛線療法運用的一次進步。 目前臨床上，對于外括約肌深部以下的瘺管和膿腔可采用虛掛引流法。對于外括約肌深部以上的瘺管或膿腔多采用實掛，也有采用虛掛的。,??緊線 切開與掛線后括約肌斷端最終均以局部纖維化而與周圍組織粘連固定，掛線法顯著優(yōu)于切開法之處在于：切開組兩斷端的缺

23、口距離大，中間為大面積瘢痕所填充；掛線組兩斷端距離小，中間為小面積瘢痕修復(fù)。 為了保持斷端有足夠的時間粘連固定，必須選擇合適的緊線時問，并控制橡皮筋掛線的緊線力度，以使橡皮筋在適當(dāng)?shù)臅r間內(nèi)脫落，不致脫落過快或過慢。 對于掛線脫落的時間，大多數(shù)專家均認為，應(yīng)控制在l0—l4天左右或以上，并采用分次緊線術(shù)。,??多處掛線 多條高位瘺管的肛瘺，臨床常采用多處掛線的方法治療。 手術(shù)時應(yīng)先緊扎一個

24、，其余掛浮線，緩慢緊線，以免幾根橡皮線同時切斷肛管直腸環(huán)而影響肛門括約肌的功能。 多側(cè)的掛線橡皮筋脫落期宜間隔4—5天為宜；,克羅恩病肛瘺（06版） 1）在全身治療的同時盡量以保守治療為主。 2）無癥狀的克羅恩病肛瘺：無需手術(shù)治療： 3）低位克羅恩病肛瘺：采用瘺管切開術(shù)； 4）復(fù)雜性克羅恩病肛瘺：可長期掛線引流作姑息性治療；如直腸粘膜肉眼大體正?？刹捎猛埔浦蹦c粘膜

25、瓣閉合內(nèi)口。,Treatment of Fistula-in-Ano With Crohn’s Disease（ASCRS):1. Guideline: Asymptomatic Crohn’s fistulas neednot be treated. Asymptomatic Crohn’s fistulas may remain dormant and require no intervention. The

26、se patients, therefore, need not be subjected to the morbidity of operative intervention.,2. Guideline: Simple, low Crohn’s fistulas may betreated by fistulotomy. Healing rates after fistulotomy or

27、intersphincteric andlow transsphincteric Crohn’s fistulas range from 62 to100% with reported minor incontinence rates of 0 to12%. These wounds may take up to three to six months to heal.,3. Guideline: Complex Crohn’s

28、fistulas may be well palliated with long-term draining setons. The goal of a long-term loose (draining) seton for Crohn’s fistulas is to reduce the number of subsequent septic events by providing continuous dr

29、ainage and preventing closure of the external skin opening. This goal can be achieved in 48to 100% of such patients. Recurrent sepsis is seen approximately one-third of the time.,4. Guideline: Complex Crohn’s fistulas m

30、ay betreated with advancement flap closure if the rectalmucosa is grossly normal. Endorectal or anodermal advancement flaps also can be used in patients with complex fistulas from Crohn’s disease. Active procti

31、tis is considered a contraindication. Short-term success (generally 50– 75%) is lower in patients with Crohn’s disease and continues to diminish with longer follow-up, demonstrating the chronic relapsing natu

32、re of this disease. Short-term success rates for rectovaginal fistulas associated with Crohn’s disease are even lower at 40 to50%.,肛瘺手術(shù)治療成功的關(guān)鍵或失敗的原因分析：術(shù)前關(guān)注：??病因、診斷是否清楚； 病史？ 非腺源性肛瘺 ？術(shù)前檢查？??治療方式選擇是