肛瘘诊治进展课件

肛瘘诊治进展肛瘘诊治进展 从从0606版肛瘘临床诊治版肛瘘临床诊治指南指南再谈肛再谈肛瘘的治疗瘘的治疗1 1 肛瘘诊治进展1 20022002年中华医学会外科学分会肛肠外科学组根据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国内外医学的最新进 展和广大医务工作者在临床应用后展和广大医务工作者在临床应用后提出的意见和建提出的意见和建 议议,制订了制订了肛瘘诊治肛瘘诊治标准标准；20062006年年7 7月提出月提出肛瘘临床诊治肛瘘临床诊治指南指南：由中华医：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；会共同制订；2 2220062006年年7 7月月肛瘘临床诊治指南肛瘘临床诊治指南；美国结直肠外科医生协会（美国结直肠外科医生协会（ASCRS:ASCRS:American Society of Colo-Rectal Surgeon American Society of Colo-Rectal Surgeon）：）：Guideline Guideline 指南；指南；3 32006年7月肛瘘临床诊治指南；3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，首次手术复发率功率报道不一，尤其是高位肛瘘，首次手术复发率高达高达5050，再次手术失败率仍高达，再次手术失败率仍高达1010以上；以上；4 4治疗原则（06版）：4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。5 5治疗原则（续，06版）5The 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.6 6The goals in the treatment of 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。7 7手术方式：7Treatment 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.8 8Treatment of a Simple Fistula-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.9 9 The recurrence rate for2.Simple 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 incontinence.Successful healing ratesfrom 60 to 70 percent can be achieved.Risk factorsfor failure include Crohns disease,rectovaginalfistula,human immunodeficiency virus,and short fistula length.10102.Simple anal fistulas may be 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。1111113)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。12123)粘膜瓣推移术：12Treatment 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,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.1313Treatment of a Complex Fistu2.Guideline:Complex anal fistulas may be treatedwith endorectal advancement flap closure.The use of an endorectal advancement flap is an attractive modality for the treatment of a complex fistula-in-ano.14142.Guideline:Complex anal fis 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.1515 Successful healing rat3.Guideline:Complex 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 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.16163.Guideline:Complex fistulas关于高位复杂性肛瘘挂线的探讨关于高位复杂性肛瘘挂线的探讨1717关于高位复杂性肛瘘挂线的探讨17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。1818高位肛瘘是否需要挂线18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。1919需要挂线的组织19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。2020实挂或虚挂20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。2121紧线21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；2222多处挂线22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。2323克罗恩病肛瘘（06版）23Treatment of Fistula-in-Ano With Crohns Disease（ASCRS):1.Guideline:Asymptomatic Crohns fistulas neednot 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.2424Treatment of Fistula-in-Ano Wi2.Guideline:Simple,low Crohns fistulas may betreated by fistulotomy.Healing rates after fistulotomy or intersphincteric andlow transsphincteric Crohns 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.25252.Guideline:Simple,low Croh3.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 48to 100%of such patients.Recurrent sepsis is seen approximately one-third of the time.26263.Guideline:Complex Crohns 4.Guideline:Complex Crohns fistulas may 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 Crohns disease.Active proctitis is considered a contraindication.Short-term success(generally 50 75%)is lower in patients with Crohns disease and continues to diminish with longer follow-up,demonstrating the chronic relapsing nature of this disease.Short-term success rates for rectovaginal fistulas associated with Crohns disease are even lower at 40 to50%.27274.Guideline:Complex Crohns 肛瘘手术治疗成功的关键或失败的原因分析：术前关注：病因、诊断是否清楚；病史？非腺源性肛瘘？术前检查？治疗方式选择是否适当；术中关注：处理方法是否适当：内口、主管支管处理、通畅引流等；术后关注：术后随访、创面检查、紧线等是否及时；2828肛瘘手术治疗成功的关键或失败的原因分析：28谢 谢2929谢 谢29