改良紧线术治疗高位肛瘘的临床研究
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摘要
目的：高位肛瘘尤其是高位复杂性肛瘘的治疗已经被国内外医学界列为现代外科的难题之一。而实挂线法是处理高位肛瘘内口的重要方法之一。通过对改良紧线术与传统紧线术在高位肛瘘实挂线的随机对照研究,我们以选择更好的保护肛门功能的紧线术式治疗高位肛瘘。
方法：选择2010年6月至2011年4月在南京市中医院住院的高位肛瘘患者30例,随机分为治疗组和对照组,各15例,其中治疗组采用改良紧线术,对照组采用传统紧线术。按照试验方案对两组患者进行治疗,并分别观察和记录两组术后及紧线术后的创面疼痛,创面分泌物,肛门功能及形态等,并随访三个月。根据观察指标的评分标准进行评分。经统计学处理后,观察两组在疗效、愈合时间、复发率、术后疼痛程度、分泌物的量及肛门功能等方面的差异。
结果：本研究表明治疗组与对照组在疗效、疗程、复发率及在紧线术后创面疼痛、创面分泌物的量方面无显著性差异(P>0.05)。两组患者术后肛门功能方面,治疗组在术后1月、2月、3月的肛门失禁评分(Wexner评分)和肛门指诊评分明显优于对照组(P<0.05)。治疗组的肛门缺损深度上在脱线时、术后1月、2月、3月均明显低于于对照组(P<0.05)。而治疗组在术后3月的肛门锁孔样畸形发生率远小于对照组(P<0.05)。
结论：改良紧线术在疗效、疗程、复发率等方面及在紧线术后创面疼痛、创面分泌物的量方面与传统紧线术相当,但在保护肛门功能及减轻挂线术对于肛门形态影响方面,改良紧线术具有明显优势。
OBJECTIVE:The anal fistula is a familiar anorectal disease, but the therapy of the high anal fistula is very difficult.To seek for the internal orifice is the key of the cure of the disease. Bases of the sphincter cutting seton in the high anal fistula,we use the improved cutting seton to cure the high anal fistula,comparing with the traditional cutting seton randomly. We will elect the better one of protecting the anal funetion in the sphincter cutting seton of the high anal fistula.
METHODS:30 patients were divided into therapy group and control group randomly. There are 15 patients in therapy group and 15 patients in control group. The therapy group is treated with the improved cutting seton and the control group with the traditional cutting seton. According to the project, we observe the two groups after operation, and then investigate for three months to half a year. Using these statistic data, we can study the difference in the curative effect、the period of treatment the rate of recurrence、the function of the anal sphincter、the degree of the anal pain、the quantity of the secretion and so on.
RESULT:No difference in the curative effect、the period of treatment、the ratio of recurrence、the degree of the anal pain、the quantity of the secretion between the two groups(P>0.05).Through the Wexner score、the finger diagnose, there is a significant difference in the function of the anal sphincter after operation(P<0.05), and in the depth of the anal coloboma, there is a significant difference of off-line、1st month、2nd month and 3rd month after operation (P<0.05). In the rate of the door lock anal taratogenia, there is a significant difference of 3rd month after operation(P<0.05).
CONCLUSION:The study indicates that the improved cutting seton to cure high anal fistula is not superior to the control group in the curative effect、the period of treatment the ratio of recurrence、the degree of the anal pain、the quantity of the secretion and so on. But the improved cutting seton is dominant in protecting the function of the anal sphincter and cutting down the influence of the anal-morph with cutting seton.
方法：选择2010年6月至2011年4月在南京市中医院住院的高位肛瘘患者30例,随机分为治疗组和对照组,各15例,其中治疗组采用改良紧线术,对照组采用传统紧线术。按照试验方案对两组患者进行治疗,并分别观察和记录两组术后及紧线术后的创面疼痛,创面分泌物,肛门功能及形态等,并随访三个月。根据观察指标的评分标准进行评分。经统计学处理后,观察两组在疗效、愈合时间、复发率、术后疼痛程度、分泌物的量及肛门功能等方面的差异。
结果：本研究表明治疗组与对照组在疗效、疗程、复发率及在紧线术后创面疼痛、创面分泌物的量方面无显著性差异(P>0.05)。两组患者术后肛门功能方面,治疗组在术后1月、2月、3月的肛门失禁评分(Wexner评分)和肛门指诊评分明显优于对照组(P<0.05)。治疗组的肛门缺损深度上在脱线时、术后1月、2月、3月均明显低于于对照组(P<0.05)。而治疗组在术后3月的肛门锁孔样畸形发生率远小于对照组(P<0.05)。
结论：改良紧线术在疗效、疗程、复发率等方面及在紧线术后创面疼痛、创面分泌物的量方面与传统紧线术相当,但在保护肛门功能及减轻挂线术对于肛门形态影响方面,改良紧线术具有明显优势。
OBJECTIVE:The anal fistula is a familiar anorectal disease, but the therapy of the high anal fistula is very difficult.To seek for the internal orifice is the key of the cure of the disease. Bases of the sphincter cutting seton in the high anal fistula,we use the improved cutting seton to cure the high anal fistula,comparing with the traditional cutting seton randomly. We will elect the better one of protecting the anal funetion in the sphincter cutting seton of the high anal fistula.
METHODS:30 patients were divided into therapy group and control group randomly. There are 15 patients in therapy group and 15 patients in control group. The therapy group is treated with the improved cutting seton and the control group with the traditional cutting seton. According to the project, we observe the two groups after operation, and then investigate for three months to half a year. Using these statistic data, we can study the difference in the curative effect、the period of treatment the rate of recurrence、the function of the anal sphincter、the degree of the anal pain、the quantity of the secretion and so on.
RESULT:No difference in the curative effect、the period of treatment、the ratio of recurrence、the degree of the anal pain、the quantity of the secretion between the two groups(P>0.05).Through the Wexner score、the finger diagnose, there is a significant difference in the function of the anal sphincter after operation(P<0.05), and in the depth of the anal coloboma, there is a significant difference of off-line、1st month、2nd month and 3rd month after operation (P<0.05). In the rate of the door lock anal taratogenia, there is a significant difference of 3rd month after operation(P<0.05).
CONCLUSION:The study indicates that the improved cutting seton to cure high anal fistula is not superior to the control group in the curative effect、the period of treatment the ratio of recurrence、the degree of the anal pain、the quantity of the secretion and so on. But the improved cutting seton is dominant in protecting the function of the anal sphincter and cutting down the influence of the anal-morph with cutting seton.
引文
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[7]Pakrs AG. Pathogenesis and treatment of fistula-in-ano. Br Med J.1961.1:463-9.
[8]Edwards S. On some of the rarer fooms of rectal fistulae. Lancet.1987.Ⅰ:1089.
[9]Gustafsson UM, Kahvecioglu B, Astrom G, Ahlstrom H, Graf W. Endoanal ultrasound or magnetic resonance imaging for preoperative assessment of anal fistula:a comparative study. Colorectal Dis. 2001.3(3):189-97.
[10]Kuijpers HC, Schulpen T. Fistulography for fistula-in-ano. Is it useful. Dis Colon Rectum.1985.28(2): 103-4.
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[13]Grandjean JP, Daville O, Henry L, Milox B, Tissot O, Valette PJ. [Magnetic resonance study of complex anal fistulae. Preliminary results apropos of 28 cases]. Ann Chir.1997.51(4):314-7.
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[16]Parks J. Section of the urethral wall for correction of urethrovaginal fistulae and urethral diverticula. Am J Obstet Gynecol.1965.93(5):683-92.
[17]EISENHAMMER S. A new approach to the anorectal fistulous abscess based on the high intermuscular lesion. Surg Gynecol Obstet.1958.106(5):595-9.
[18]Hoffmann DC, Goligher JC. Lateral subcutaneous internal sphincterotomy in treatment of anal fissure. Br Med J.1970.3(5724):673-5.
[19]Elting AW. X. The Treatment of Fistula in Ano:With Especial Reference to the Whitehead Operation. Ann Surg.1912.56(5):744-52.
[20]王业皇,章阳.高何复杂性肛瘘的诊治[J].医学新知杂志.2006.(03)：127-128.
[21]李淑霞,尹伯约.切开挂线术治疗高位复杂性肛瘘56例[J].实用中医药杂志.2008.(11)：732-733.
[22]苏开荣.高位挂线低位切开缝合治疗高位复杂性肛瘘68例[J].中国实用医药.2009.(03)：128-129.
[23]林晖.同期多侧挂线治疗高位复杂性肛瘘的临床对比观察[J].大肠肛门病外科杂志.2005.(03)：194-196.
[24]丁培霖,唐武,王建东.切开挂线旷置术治疗高位复杂性肛瘘56例疗效观察[J].中国伤残医学.2010.(02)：6-8.
[25]李春雨,聂敏,张丹丹.切开挂线对口引流术治疗高位复杂性肛瘘[J].江苏医药.2008.(01)：85-86.
[26]沈习来.定向挂线治疗高位肛瘘的效果观察(附30例报告)[J].右江民族医学院学报.2008.(06)：1007-1008.
[27]陈玉根,丁义江,杨伯霖.定向挂线技术的提出与生物力学研究[J].南京中医药大学学报.2009.(05)：352-354.
[28]钱海华.高位肛瘘手术中应用高位虚挂线法与传统切开挂线的疗效比较[M].首届国际中西医结合大肠肛门病学术论坛暨第十二届全国中西医结合大肠肛门病学术会议论文集萃.2007：126.
[29]赵群男.高位虚挂引流术治疗高位肛瘘31例[J].交通医学.2006.(05)：555.
[30]李洪林,岳柏华,戴运刚.高位复杂性肛瘘切除挂浮线预期根治术[J].中国实用医药.2007.(26)：60.
[31]王进.高位虚挂引流治疗高位肛瘘59例[J].新中医.2006.(05)： 65-66.
[32]曹永清.挂线疗法在肛瘘治疗中的临床应用[J].江苏中医药.2006.(08).6-7.
[33]丁敏,黄鸿翔,曹永清.隧道式拖线引流加挂线术治疗62例肛周深部脓肿体会[J].中西医结合学报.2008.(10)：1068-1070.
[34]叶茂,龚光辉,焦鹏富.主管切开引流支管拖线术治疗复杂性肛瘘60例临床观察[J].实用中西医结合临床.2010.(01)：67.
[35]Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg.1991.78(10):1159-61.
[36]Safavi A, Gottesman L, Dailey TH. Anorectal surgery in the HIV+ patient:update. Dis Colon Rectum. 1991.34(4):299-304.
[37]Ng SC, Plamondon S, Gupta A, et al.. Prospective evaluation of anti-tumor necrosis factor therapy guided by magnetic resonance imaging for Crohn's perineal fistulas. Am J Gastroenterol.2009. 104(12):2973-86.
[38]Spradlin NM, Wise PE, Herline AJ, Muldoon RL, Rosen M, Schwartz DA. A randomized prospective trial of endoscopic ultrasound to guide combination medical and surgical treatment for Crohn's perianal fistulas. Am J Gastroenterol.2008.103(10):2527-35.
[39]Williams JG, Rothenberger DA, Nemer FD, Goldberg SM. Fistula-in-ano in Crohn's disease. Results of aggressive surgical treatment. Dis Colon Rectum.1991.34(5):378-84.
[40]Sugita A, Koganei K, Harada H, Yamazaki Y, Fukushima T, Shimada H. Surgery for Crohn's anal fistulas. J Gastroenterol.1995.30 Suppl 8:143-6.
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[53]Pares D. Pathogenesis and treatment of fistula in ano. Br J Surg.2010
[54]韩震辉,孙建权.旷置挂线治疗高位肛瘘的临床观察[J].上海中医药杂志.2008.(05)：62-63.
[2]顾伯华.实用中医外科学[M].上海科技出版社.1985.11： 336.
[3]黄乃健.中国肛肠病学[M].山东科技出版社.1996.1： 729-741.
[4]徐春甫.古今医统大全(下)[M].人民卫生出版社.2008：440.
[5]Adams F. The Genuine Works of Hippocrates Trnasiated from the Greek with a Preliminary. Discourse and Annotation. New York:William Wood.1849.
[6]Chiari H. Uber die Nalen Divertikel der Rectumsch- leimhaut und ihre Beziehung zu den Anal Fistein. Med Iahrbucher Wien.8:419-27.
[7]Pakrs AG. Pathogenesis and treatment of fistula-in-ano. Br Med J.1961.1:463-9.
[8]Edwards S. On some of the rarer fooms of rectal fistulae. Lancet.1987.Ⅰ:1089.
[9]Gustafsson UM, Kahvecioglu B, Astrom G, Ahlstrom H, Graf W. Endoanal ultrasound or magnetic resonance imaging for preoperative assessment of anal fistula:a comparative study. Colorectal Dis. 2001.3(3):189-97.
[10]Kuijpers HC, Schulpen T. Fistulography for fistula-in-ano. Is it useful. Dis Colon Rectum.1985.28(2): 103-4.
[11]吴宁,邢丽.瘘道探查造影及粘堵诊断治疗肛瘘[J].中华放射学杂志.1998.(09).
[12]Deroide G, Deroide JP. [Anal fistulae and abscesses:diagnostic and therapeutic aspects, excepting Crohn's disease]. J Chir (Paris).2000.137(2):83-92.
[13]Grandjean JP, Daville O, Henry L, Milox B, Tissot O, Valette PJ. [Magnetic resonance study of complex anal fistulae. Preliminary results apropos of 28 cases]. Ann Chir.1997.51(4):314-7.
[14]Beckingham IJ, Spencer JA, Ward J, Dyke GW, Adams C, Ambrose NS. Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano. Br J Surg. 1996.83(10):1396-8.
[15]Whiteford MH,3rd KJ, Hyman N, et al.. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum.2005.48(7):1337-42.
[16]Parks J. Section of the urethral wall for correction of urethrovaginal fistulae and urethral diverticula. Am J Obstet Gynecol.1965.93(5):683-92.
[17]EISENHAMMER S. A new approach to the anorectal fistulous abscess based on the high intermuscular lesion. Surg Gynecol Obstet.1958.106(5):595-9.
[18]Hoffmann DC, Goligher JC. Lateral subcutaneous internal sphincterotomy in treatment of anal fissure. Br Med J.1970.3(5724):673-5.
[19]Elting AW. X. The Treatment of Fistula in Ano:With Especial Reference to the Whitehead Operation. Ann Surg.1912.56(5):744-52.
[20]王业皇,章阳.高何复杂性肛瘘的诊治[J].医学新知杂志.2006.(03)：127-128.
[21]李淑霞,尹伯约.切开挂线术治疗高位复杂性肛瘘56例[J].实用中医药杂志.2008.(11)：732-733.
[22]苏开荣.高位挂线低位切开缝合治疗高位复杂性肛瘘68例[J].中国实用医药.2009.(03)：128-129.
[23]林晖.同期多侧挂线治疗高位复杂性肛瘘的临床对比观察[J].大肠肛门病外科杂志.2005.(03)：194-196.
[24]丁培霖,唐武,王建东.切开挂线旷置术治疗高位复杂性肛瘘56例疗效观察[J].中国伤残医学.2010.(02)：6-8.
[25]李春雨,聂敏,张丹丹.切开挂线对口引流术治疗高位复杂性肛瘘[J].江苏医药.2008.(01)：85-86.
[26]沈习来.定向挂线治疗高位肛瘘的效果观察(附30例报告)[J].右江民族医学院学报.2008.(06)：1007-1008.
[27]陈玉根,丁义江,杨伯霖.定向挂线技术的提出与生物力学研究[J].南京中医药大学学报.2009.(05)：352-354.
[28]钱海华.高位肛瘘手术中应用高位虚挂线法与传统切开挂线的疗效比较[M].首届国际中西医结合大肠肛门病学术论坛暨第十二届全国中西医结合大肠肛门病学术会议论文集萃.2007：126.
[29]赵群男.高位虚挂引流术治疗高位肛瘘31例[J].交通医学.2006.(05)：555.
[30]李洪林,岳柏华,戴运刚.高位复杂性肛瘘切除挂浮线预期根治术[J].中国实用医药.2007.(26)：60.
[31]王进.高位虚挂引流治疗高位肛瘘59例[J].新中医.2006.(05)： 65-66.
[32]曹永清.挂线疗法在肛瘘治疗中的临床应用[J].江苏中医药.2006.(08).6-7.
[33]丁敏,黄鸿翔,曹永清.隧道式拖线引流加挂线术治疗62例肛周深部脓肿体会[J].中西医结合学报.2008.(10)：1068-1070.
[34]叶茂,龚光辉,焦鹏富.主管切开引流支管拖线术治疗复杂性肛瘘60例临床观察[J].实用中西医结合临床.2010.(01)：67.
[35]Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg.1991.78(10):1159-61.
[36]Safavi A, Gottesman L, Dailey TH. Anorectal surgery in the HIV+ patient:update. Dis Colon Rectum. 1991.34(4):299-304.
[37]Ng SC, Plamondon S, Gupta A, et al.. Prospective evaluation of anti-tumor necrosis factor therapy guided by magnetic resonance imaging for Crohn's perineal fistulas. Am J Gastroenterol.2009. 104(12):2973-86.
[38]Spradlin NM, Wise PE, Herline AJ, Muldoon RL, Rosen M, Schwartz DA. A randomized prospective trial of endoscopic ultrasound to guide combination medical and surgical treatment for Crohn's perianal fistulas. Am J Gastroenterol.2008.103(10):2527-35.
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