肛瘘诊治进展课件

肛瘘诊治进展 从06版肛瘘临床诊治指南再谈肛 瘘的治疗 2002年中华医学会外科学分会肛肠外科学组根据国 内外医学的最新进 展和广大医务工作者在临床应用后提 出的意见和建 议,制订了肛瘘诊治标准； 2006年7月提出肛瘘临床诊治指南：由中华医 学会外科学分会结直肠肛门外科学组、中华中医药学会 肛肠分会、中国中西医结合学会结直肠肛门病专业委员 会共同制订； 2006年7月肛瘘临床诊治指南； 美国结直肠外科医生协会（ASCRS: American Society of Colo-Rectal Surgeon ） ：Guideline 指南； 治疗原则（06版）： 1) 手术治疗是肛瘘的主要手段，基本原则是：去 除病灶，通畅引流，尽可能减少肛管括约肌损伤， 保护肛门功能； 2)由于肛瘘的复杂性和一些特殊的病理背景，肛 瘘术后有一定的复发率； 手术是治疗肛瘘的惟一可靠的办法，但手术成 功率报道不一，尤其是高位肛瘘，首次手术复发率 高达50，再次手术失败率仍高达10以上； 治疗原则（续，06版） 3）鉴于高位复杂性肛瘘的特殊病理和生理环境 及肛门功能的重要性，“带瘘生存，亦可作为一个 原则加以选择，不应为盲目追求手术根治而忽视其 可能带来的严重并发症； 4）中药治疗仅限于患者恢复期的调整和暂不适 合手术者。 The goals in the treatment of fistula-in-ano （ ASCRS）： 1)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 fistulas-in-ano and, therefore, treatment must be directed by the surgeons experience and judgment. 手术方式： 1）肛瘘切开（除）术：适用于单纯性肛瘘 肛瘘切开术较好，肛瘘切除术创面较大， 愈合时间相对较长，可发生肛门失禁。 Treatment of a Simple Fistula-in-Ano： 1. Simple anal 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 incontinence. 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 surgery. 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 anal fistulas may be treated with track debridement 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 incontinence. Successful healing rates from 60 to 70 percent can be achieved. Risk factors for failure include Crohns disease, rectovaginal fistula, human immunodeficiency virus, and short fistula length. 2）挂线术：合理选择切割挂线和引流挂线 。 一期切割挂线：适用于高位肛瘘涉及到大部 分肛门外括约肌浅部以上者； 二期切割挂线：适用于部分高位肛瘘合并有 难以处理的残腔，或需二次手术及术后引流。 长期引流挂线: 适用于高位经括约肌克罗恩 病肛瘘患者，以预防复发性脓肿的形成和保持肛 门的功能。 短期引流挂线：尽管目前临床报导短期挂线 引流治疗肛瘘有效，完全保留了括约肌，不会导 致肛门失禁，但因其复发率高，临床应用需慎重 。 3) 粘膜瓣推移术： 适用于高位肛瘘内口明确且不伴严重感染 的患者和女性前侧肛瘘。 Treatment of a Complex Fistula-in-Ano： 1. Guideline: Complex anal fistulas may be treated with debridement and fibrin glue injection. As with simple fistula-in-ano, fibrin 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 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 patients. 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 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 Crohns proctitis. 3. Guideline: Complex fistulas may be treated by the use of a seton and/or staged fistulotomy: Setons may be used to induce perisphincteric fibrosis along the fistula track so that when the fistulotomy is eventually performed, or the 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 after the subcutaneous components have healed. Although these two techniques have low recurrence rates (08 percent), the rates for minor (3463 percent) and major incontinence (226 percent) are significant. 关于高位复杂性肛瘘挂线的探讨 高位肛瘘是否需要挂线 由于现代解剖学肛瘘切除的广泛开展，除术 中处理病变较彻底外，对肌肉的保护亦十分明 确，对内口的寻找及处理亦更准确，再加上对 肛管直肠环的功能及作用认识的深入，因此， 在既往被认为非挂线不可的病例，均可以行直 接切开处理，只有那些病变十分复杂，瘘道完 全穿过肛管直肠环或其大部的病例，才考虑挂 线。 但是，目前来看，对绝大多数高位复杂性肛 瘘采用挂线疗法更为稳妥；对于女性前方的肛 瘘，如位置较深，即使是在外括约肌深部以下 最好也采用挂线疗法。 需要挂线的组织 挂线应挂到瘘管顶端，不留死腔，这样可 将瘘管全部挂开，避免引流不畅和顶端存在死 腔；可避免直接切开直肠黏膜时的出血；上部 黏膜勒开较快，基本不影响勒割速度。对于大 束组织，可以一次大束挂线适当紧线，如一次 紧线勒割不开，可再次紧线。 实挂或虚挂 挂线疗法主要运用于外括约肌深部以上的高 位瘘管和脓肿的治疗，运用的是紧线挂线法(实 挂)； 运用于低位肛瘘和脓肿等的治疗，用于各种 高、低位复杂性瘘管和脓腔的挂线引流，采用 的是不紧线的挂线法，又称“虚挂”或“浮挂 ”法；这是挂线疗法运用的一次进步。 目前临床上，对于外括约肌深部以下的瘘管 和脓腔可采用虚挂引流法。对于外括约肌深部 以上的瘘管或脓腔多采用实挂，也有采用虚挂 的。 紧线 切开与挂线后括约肌断端最终均以局部纤 维化而与周围组织粘连固定，挂线法显著优于 切开法之处在于：切开组两断端的缺口距离大 ，中间为大面积瘢痕所填充；挂线组两断端距 离小，中间为小面积瘢痕修复。 为了保持断端有足够的时间粘连固定，必须 选择合适的紧线时问，并控制橡皮筋挂线的紧 线力度，以使橡皮筋在适当的时间内脱落，不 致脱落过快或过慢。 对于挂线脱落的时间，大多数专家均认为 ，应控制在l0l4天左右或以上，并采用分次 紧线术。 多处挂线 多条高位瘘管的肛瘘，临床常采用多处挂线 的方法治疗。 手术时应先紧扎一个，其余挂浮线，缓慢紧 线，以免几根橡皮线同时切断肛管直肠环而影 响肛门括约肌的功能。 多侧的挂线橡皮筋脱落期宜间隔45天为宜 ； 克罗恩病肛瘘（06版） 1）在全身治疗的同时尽量以保守治疗为主 。 2）无症状的克罗恩病肛瘘：无需手术治疗 ： 3）低位克罗恩病肛瘘：采用瘘管切开术； 4）复杂性克罗恩病肛瘘：可长期挂线引流 作姑息性治疗；如直肠粘膜肉眼大体正常可采 用推移直肠粘膜瓣闭合内口。 Treatment of Fistula-in-Ano With Crohns Disease（ ASCRS): 1. Guideline: Asymptomatic Crohns fistulas need not be treated. Asymptomatic Crohns fistulas may remain dormant and require no intervention. These patients, therefore, need not be subjected to the morbidity of operative intervention. 2. Guideline: Simple, low Crohns fistulas may be treated by fistulotomy. Healing rates after fistulotomy or intersphincteric and low transsphincteric Crohns fistulas range from 62 to 100% with reported minor incontinence rates of 0 to 12%. These wounds may take up to three to six months to heal. 3. Guideline: Complex Crohns fistulas may be well palliated with long-term draining setons. The goal of a long-term loose (draining) seton for Crohns fistulas is to reduce the number of subsequent septic events by providing continuous drainage and preventing closure of the external skin opening. This goal can be achieved in 48 to 100% of such patients. Recurrent sepsis is seen approximately one-third of the time. 4. Guideline: Complex Crohns fistulas may