经括约肌间瘘管结扎术-杨柏霖20130625课件

LIFT文献回顾与单中心结果分析杨柏霖

南京中医药大学附属医院治愈率肛门括约肌功能高位瘘管定义Ahighfistulawasdefinedasoneencompassingmorethanone-thirdoftheexternalsphinctercomplex.（瘘管侵犯1/3以上的外括约肌）Femalepatientsareprobablyatriskbecausetheyhaveashorterexternalanalsphincteranteriorly,whichispronetodamageduringchildbirth（女性前侧外括约肌较短，且在分娩时可能被损伤）vanKoperenPJ.Long-termfunctionaloutcomeandriskfactorsforrecurrenceaftersurgicaltreatmentforlowandhighperianalfistulasofcryptoglandularorigin.DisColonRectum.2008;51(10):1475-81vanKoperenPJ.Fibringlueandtransanalrectaladvancementflapforhightranssphinctericperianalfistulas;isthereanyadvantage?IntJColorectalDis.2008;23(7):697-701SultanAH.Anal-sphincterdisruptionduringvaginaldelivery.NewEnglJMed1993;329:1905-11FitzpatrickM.Prospectivestudyoftheinfluenceofparityandoperativetechniqueontheoutcomeofprimaryanalsphincterrepairfollowingobstetricalinjury.EurJObstetGynecolReprodBiol2000;89:159-63MatosD(1993)首先报道了经括约肌间路径治疗高位肛瘘RojanasakulA(2007)报道经括约肌间瘘管结扎术(ligationoftheintersphinctericfistulatract,LIFT)MatosD.Totalsphincterconservationinhighfistulainano:resultsofanewapproach.BrJSurg1993;80:802-4.RojanasakulA.Totalanalsphinctersavingtechniqueforfistula-in-ano;theligationofintersphinctericfistulatract.JMedAssocThai2007;90:581-6.LIFT适应症LigationofIntersphinctericFistulaTractRojanasakulA.Totalanalsphinctersavingtechniqueforfistula-in-ano;theligationofintersphinctericfistulatract.JMedAssocThai2007;90:581-6.治愈率94%RojanasakulA.LIFTprocedure:asimplifiedtechniqueforfistula-in-ano.TechColoproctol.2009V13N3:237-40文献结果BleierJI;MolooH;GoldbergSM.Ligationoftheintersphinctericfistulatract:aneffectivenewtechniqueforcomplexfistulas.DisColonRectum.2010;53(1):43-693例患者，一次性治愈率（40%）+括约肌间瘘管切开术+二次LIFT=治愈率（57%）WallinUG.Doesligationoftheintersphinctericfistulatractraisethebarinfistulasurgery?DisColonRectum.2012;55(11):1173-8治愈率低的可能原因多次手术治疗（32%）马蹄形肛瘘或多发肛瘘（16%）非单一手术医师（9），存在学习曲线和手术方式的差异性WallinUG.Doesligationoftheintersphinctericfistulatractraisethebarinfistulasurgery?DisColonRectum.2012;55(11):1173-8TanKK.Theanatomyoffailuresfollowingtheligationofintersphincterictracttechniqueforanalfistula:areviewof93patientsover4years.DisColonRectum.2011;54(11):1368-72TanKK.Theanatomyoffailuresfollowingtheligationofintersphincterictracttechniqueforanalfistula:areviewof93patientsover4years.DisColonRectum.2011;54(11):1368-72TanKK.Theanatomyoffailuresfollowingtheligationofintersphincterictracttechniqueforanalfistula:areviewof93patientsover4years.DisColonRectum.2011;54(11):1368-72TanKK.Theanatomyoffailuresfollowingtheligationofintersphincterictracttechniqueforanalfistula:areviewof93patientsover4years.DisColonRectum.2011;54(11):1368-72LIFT应该作为保留括约肌手术的首选方法AbcarianAM.Ligationofintersphinctericfistulatract:earlyresultsofapilotstudy.DisColonRectum.2012;55(7):778-82

Mata分析结果YassinNA.Ligationoftheintersphinctericfistulatractinthemanagementofanalfistula.Asystematicreview.ColorectalDis.2013;15(5):527-35结论LIFT手术推荐的适应症为经括约肌肛瘘长期随访结果显示，2/3的患者LIFT治愈LIFT对肛门功能影响较小，仅6%的患者存在轻微肛门功能下降高位经括约肌肛瘘或括约肌上方瘘由于分离平面较深和之前手术疤痕，导致手术操作受限YassinNA.Ligationoftheintersphinctericfistulatractinthemanagementofanalfistula.Asystematicreview.ColorectalDis.2013;15(5):527-35BioLIFTLIFT+生物补片：瘘管缝扎后，在括约肌间切口内放置生物补片进行加强.至少随访1年，治愈率94%（29/31）LIFT+肛瘘栓中位随访时间14月，治愈率95%（20/21）NealEllisC.Outcomeswiththeuseofbioprostheticgraftstoreinforcetheligationoftheintersphinctericfistulatract(BioLIFTprocedure)forthemanagementofcomplexanalfistulas.DisColonRectum.2010;53(10):1361-4HanJG.LigationoftheIntersphinctericFistulaTractPlusBioprostheticAnalFistulaPlug(LIFT-Plug):aNewTechniqueforFistula-in-Ano.ColorectalDis.2012'AcceptedArticle',doi:10.1111/codi.12062DudukgianH.Whydowehavesomuchtroubletreatinganalfistula?WorldJGastroenterol2011,28;17(28):3292-96单中心研究结果分析

（单一医师操作）

患者一般情况平均年龄（范围）y38.2（25~62）性别男18女6吸烟否15是9肛瘘病史3.4（6月~20年）肛瘘病因腺源性感染23TB感染1手术史8/24（1~3次）瘘管分类单一经括约肌肛瘘14马蹄形肛瘘8多发性肛瘘2外口与瘘管位置前侧8后侧6（2例多发瘘管）侧方2马蹄形弯曲瘘8BCDEFGA1.双氧水测试能够有效确定内口部位，提供肌间切口

的位置；2.紧贴外括约肌表面分离，可以确保进入解剖间隙，

避免括约肌损伤；3.瘘管缝扎能够有效减少结扎结滑脱的风险；4.瘘管结扎后，双氧水测试以确定瘘管被有效结扎；5.肌间瘘管切断后，再次双氧水测试以确保括约肌外

侧瘘管被有效结扎，可以降低完全失败的风险。结果术中瘘管处理搔刮10部分隧道式挖除12瘘管全部挖除，外括约肌缺损修补2平均住院时间14.25天（10~25天）平均随访时间15.9月（3~44月）治疗结果(%)愈合率66.7%（16/24）部分失败肌间感染率8.3%（2/24）括约肌间瘘16.7%（4/24)完全失败8.3%（2/24）肛门失禁评分（Wexnerincontinencescore）手术前后无明显变化失败的处理部分失败：6天（4~9天）2例患者肌间感染但未形成括约肌间瘘——换药愈合4例患者肌间感染并与肛管相通——立即切开，愈合完全失败（均有手术史）1例术后早起外口与内口相通——瘘管切开术1例早期愈合，7月时复发总治愈率：91.7%（愈合+部分失败处理后愈合）WallinUG.Doesligationoftheintersphinctericfistulatractraisethebarinfistulasurgery?DisColonRectum.2012;55(11):1173-8失败原因单因素分析愈合n=22失败n=2P性别

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