安阿玥运用低位切开高位旷置法治疗高位肛瘘的经验总结及临床研究
|
摘要
本论文主要通过三大部分论述了安阿玥运用低位切开高位旷置法治疗高位肛瘘的经验总结及临床研究,第一部分是文献综述,第二部分是安阿玥教授学术思想和治疗高位肛瘘的临床经验总结,第三部分是安阿玥教授治疗高位肛瘘的临床观察与研究。
第一部分包括中医对肛瘘的认识及高位肛瘘国内外的研究现状分析。中医对肛瘘的认识又分为肛瘘的历史沿革、肛瘘的病因病机、肛瘘的中医治法。这里主要介绍了中医学理论里对肛瘘病名的追溯,对肛瘘的病因病机的探讨以及对肛瘘治疗的历史进程。详细论述了历代中医医家对肛瘘的认识以及诸多的治疗方法,包括内治法和外治法。尤其对于挂线疗法进行了详尽的介绍,包括使用的药物和器具,充分证实了肛瘘的挂线疗法始于中医,传承发扬于中医,并一直沿用至今,不断改进,仍然是目前治疗肛瘘的主要方法,是我们中医治疗中的一块瑰宝。高位肛瘘国内外的研究现状分析部分,系统论述了现代医学对于肛瘘的发病原因及机理的探究,包括肛腺感染学说、中央间隙感染、性激素水平学说等,并对肛瘘的诊断方法进行了总结,包括探针检查、美兰及双氧水瘘管染色法、放射线检查、超声检查、螺旋CT三维重建技术、磁共振成像及过氧化氢增强腔内超声等。对于肛瘘的手术治疗从括约肌保留术式和括约肌切断术式进行了归纳总结,比较了各自的优缺点和适应症。并重点论述了与本疗法有关的各种挂线疗法的特点,比较了各自的优略,为后面的论述打下了坚实的基础。
第二部分主要介绍了安阿玥教授学术思想和治疗高位肛瘘的临床经验总结。因为本学位论文是师承学位论文,所以把导师的学术思想作为重点论述。首先对安教授进行了介绍,然后对他的学术思想进行了总结,包括重视辨证论治,重视整体观念及重视外治。虽然肛肠疾病主要的表现在局部,以局部的症状及体征为主,但安教授并未因此而忽略了全身气血阴阳的辨证分析。他非常重视整体观念和全身的辨证分析。经常运用八纲辨证,调理全身气血阴阳的平衡,以达到治疗或配合治疗局部肛肠疾病的目的。由于肛肠疾患的外在表现比较突出,所以安教授更加重视其的外治,包括中药外治及手术治疗。安教授治疗高位肛瘘的临床经验总结,更是本文论述的重中之重。高位肛瘘由于病变位置高、管道多弯曲复杂,常有深部死腔,治疗上存在难度大、复发率高并发症后遗症多等问题,因而被国内外专家称为难治性肛瘘。现在临床上普遍采用挂线疗法治疗。传统的挂线法被认为可以防止肛门失禁,但挂线法存在盲目制造内口易复发外,还存在术后长时间难以忍受的疼痛,较长时间的恢复期,较重的瘢痕及其引起的肛门功能障碍而导致的肛门不全失禁。安教授采用抓主要矛盾分而治之的方法,巧妙地解决了高位复杂性肛瘘的治疗难题。安教授认为,高位肛瘘只是瘘管高,而内口并不高,极个别病例在直肠壁有口也不是内口,而是破溃口,内口只能在齿线。所以瘘管只要敞开后引流通畅就不必完全切开瘘管,高位的瘘管扩创旷置并插乳胶管进行引流,使其引流通畅,经过引流而达到治疗的目的。其钝性损伤轻微而且可逆,对肛管直肠环的损伤造成的功能障碍亦轻微,而且对肛管直肠环的形态没有造成破坏,缩短创面的愈合时间。如果坏死灶已达肛管直肠环,不切开直肠环就不能达到引流通畅的目的,那么安教授经多年临床验证认为,可于一侧切开肛管直肠环的下2/3,这样不会引起肛门失禁,避免了挂线给病人带来的痛苦,肛直环也得到了尽可能的保护,而且,瘘管彻底敞开,引流通畅,与挂线的慢性切割相比大大减少了复发的机会。具有创伤小、括约肌损伤小、术后疼痛轻、无肛门畸形、功能完好、术后病程短的特点。具体技术包括高位肛瘘内口定位的研究,高位肛瘘瘘管探查的研究,肛瘘手术的治疗原则和难点,手术切口的设计,术后分期换药,安阿玥教授高位肛瘘治疗方法的研究,安阿玥教授治疗高位肛瘘的方法与传统挂线疗法的对比研究、手术方法及中药在肛瘘术后的应用。
第三部分是安阿玥教授治疗高位肛瘘的临床观察与研究。
目的：高位肛瘘,其瘘管位于外括约肌深部以上,是肛门直肠疾病治疗中非常棘手的一个疾病。我们肛肠专科医生这些年一直努力去寻找一种更好的既能够大大减轻病患痛苦又能够提高疗效的治疗方法,这是我们的目标。高位肛瘘的治疗方法很多,但是每一种治疗方法都有各自不同的适应症。我们在传统的低位切开、高位挂线法(简称切开挂线法)治疗高位肛瘘的基础上进行改良,创造一种低位瘘管切开,高位瘘管钝性扩创,留置乳胶管引流的方法(简称低位切开高位旷置法)治疗高位肛瘘。本课题通过观察两种手术方法的治愈率、术后疼痛、肛门功能等指标,探讨低位切开高位旷置法与切开挂线法治疗高位肛瘘作对比研究,研究对比低位切开高位旷置法在治疗高位肛瘘方面的优劣,为肛肠专科医生在高位肛瘘治疗上的研究提供依据。
方法：选择32例单纯高位肛瘘患者,均为骨盆直肠窝脓肿后遗高位肛瘘而内口在相应齿线位者,且直肠腔内无溃破口者。随机分为两组,治疗组和对照组,各16例。治疗组采用低位切开高位旷置法治疗,对照组采用低位切开高位挂线法治疗。对两组患者作对照观察,随访半年。观察指标主要有术后第3天、7天的症状和体征,创口的愈合情况及时间,肛门的括约功能及复发率等情况。制定评分标准,对结果进行评分,最后进行统计学处理,得出其在疗效与疗程、肛门功能及复发率、术后肛门疼痛程度、肛门分泌物等方面的差异。之所以只观察32例,主要是基于挂线疗法痛苦大,疗程长,疼痛重的考虑。
结果：在观察治疗单纯性高位肛瘘的治疗效果上和半年内高位肛瘘复发率的分析总结,疗效方面,统计学处理,两组无显著差异(P>0.05)。经过随访半年,治疗组无复发,对照组复发2例,经检验无统计学差异(P>0.05)。由于本研究的样本量相对较小,从数据上看似乎可以表明对照组复发例数较治疗组多,但是经统计学检验,两组复发率无显著性差异,所以有关研究有待进一步深入进行。疗程方面,治疗组为22-36天,平均为24.63天,对照组为28-54天,平均为32.98天,统计学处理两组有显著差异(P<0.05)。术后创面疼痛程度,通过计分等手段进行统计学处理后两组间存在着显著性差异(P<0.05)。创面分泌物的量两组间无显著性差异(P>0.05)。两组患者术后肛门功能经过患者主观测评、肛门指诊有显著性差异(P<0.05)。
结论：低位切开高位旷置法在疗效、复发率等方面并不优于切开挂线法,但在保护肛门功能、减轻术后疼痛、缩短疗程等方面则明显优于低位切开高位挂线法。
目前临床上比较广泛应用的是低位切开高位挂线疗法,使用弹性橡皮筋(或丝线),异物刺激括约肌的作用,让断离的括约肌残端与周围组织有一个异物炎症性粘连的作用,使周围组织逐渐切开、引流与修复同时进行,让断离的括约肌残端不会突然很大面积的豁开,可以有效地保持肛管直肠角,防止并减少肛管直肠环的损伤,可以维持肛门的括约功能,最终防止了肛门失禁后遗症的发生。但是这种低位切开高位挂线术是利用探针在瘘道的上面人工造口,因橡皮筋通过瘘管探测更深,所挂组织又比较厚,并且要勒断所有的括约肌,所以患者常常感受疼痛较剧,痛苦不堪,肛门收缩和舒张功能受到一定的影响。
现代外科的发展趋势之一是微创手术,以避免不必要的入侵原理,最大限度地减少手术范围,以减少短期和长期因手术患者的生理和心理痛苦,来达到同样的甚至是更好的治疗效果。根据这一发展趋势,我的导师安阿玥教授通过多年的临床实践和研究,创出了低位切开,高位旷置留置乳胶管引流术。该术式旷置法的优点是尽可能少地破坏括约肌,使痛苦减少,疗程缩短。
肛瘘是由肛腺感染,主要病变在肛窦,即内口在齿状线附近,这一观点是国内外学者所公认的。高位肛瘘形成的原因,是由于炎症沿联合纵肌纤维向上扩散。虽然瘘管位置多位于齿线以上,但内口依然位于齿线处。所有肛瘘手术都是在解决两个问题,即切开内口,使瘘管引流通畅。这为低位切开,高位旷置留置乳胶管引流术治疗高位肛瘘提供了重要的理论依据。在传统中医挂线疗法基础上,结合国外的保留括约肌手术方法,采取以低位切开、高位旷置留置乳胶管法治疗高位肛瘘。与传统低切高挂术相比,本方法有临床推广应用价值。
The article is divided into three major sections to discuss the experience and clinical research about An'A'Yue uses low incision and high indwelling method in treating high anal fistula, the first part is the literature review, the second part is to summarize the clinical experience of Professor An'A'Yue's academic thought and treatment of high anal fistula, the third part is the clinical observation and research of Professor An'A'Yue in the treatment of high anal fistula.
The first part includes Traditional Chinese Medicine to the cognition of anal fistula and the present situation of high anal fistula at homeland and abroad. Traditional Chinese Medicine to the cognition of anal fistula divide into the Historical Evolution, Etiology and Pathogenesis and the Therapy of anal fistula. In this part mainly introduces the theory of traditional Chinese medicine on the back of the name of anal fistula anal, discuss the etiology and pathogenesis of anal fistula and the of history about the treatment of anal fistula. All previous dynasties Chinese medicine physicians understanding of anal fistula and a variety of treatments is discussed, including internal treatment and external treatment. Especially for hang line therapy has carried on the detailed introduction, including the use of drugs and devices, fully confirmed the anal fistula hang line therapy began in TCM, heritage, carry forward the Chinese medicine and has been in use today, continuous improvement, it is still the main method of treatment of anal fistula, and it is a piece of treasure in our treatment of traditional Chinese medicine. The section of research status analysis about high anal fistula at home and abroad, system elaborated the modern medicine to explore causes and mechanism in the pathogenesis of anal fistula, including anal gland infection theory, central clearance of infection theory, sex hormone levels theory, etc. and the methods to the diagnosis of anal fistula is summarized, including probe check, MEILAN and hydrogen peroxide fistula staining, radiographic inspection and ultrasonic inspection, spiral CT3d reconstruction technology, magnetic resonance imaging and hydrogen peroxide to enhance intracavity ultrasound. Summarized anal fistula surgery, concluding Sphincter surgery and Sphincter cutting operation, and compared the respective advantages and disadvantages and indications. Comparison of the respective advantages and disadvantages and indications the characteristics of the therapy of and all kinds of hanging line related to this treatment is discussed, and comparing the respective optimal slightly, has laid a solid foundation to the back of the paper.
The second part is to summarize the clinical experience of Professor An'A'Yue's academic thought and treatment of high anal fistula, Because the thesis of this dissertation is Shicheng, so the tutor's academic ideas as the emphasis in this paper. Firstly introduce professor An, and then summarize to his academic thoughts, including emphasis on syndrome differentiation, attaches great importance to external treatment. Although anorectal diseases mainly displays in local, give priority to with local symptoms and signs, but professor An has not ignored analysis different syndrome of the whole body about qi and blood, Yin and Yang. He attaches great importance to the overall concept and systemic dialectical analysis. He often uses the eight principles differentiation, regulates the balance of body Qi and blood, Yin and Yang, to achieve the goal of treatment or cooperate with local anorectal diseases. Because of the external performance of anorectal disease is more outstanding, the professor An pay more attention to the external treatment, including traditional Chinese medicine external treatment and surgical treatment. The clinical experience of Professor An'A'Yue's academic thought and treatment of high anal fistula is the most important in this paper. High anal fistula complex since high lesion location, pipe bend, dead space, often have deep treatment difficulty complications, recurrence rate is high, such as after-effects more problems,so called intractable anal fistula by experts at home and abroad. Traditional hanging line method is thought to prevent the anus incontinence, but hang line method exist in mouth that is easy to relapse, has unbearable pain for a long time, a long time to recovery. Professor An grasp the principal contradiction of divide and conquer method, ingeniously solved the difficult treatment problems of high complexity anal fistula. Professor An says high anal fistula is high fistula, but the inside mouth is not high, very few cases in intestinal wall straight mouth is not the inside mouth, but burst mouth, mouth can only in the dentate line. So that don't have to completely incision fistula after the open drainage unobstructed, high fistula debridement and latex tube drainage, drainage unblocked, after drainage and achieve the goal of treatment. Its mild and reversible blunt injury, damage caused by the dysfunction of anorectal ring also slightly, and morphology of anorectal ring caused no damage, shorten wound healing time. If the focal necrosis has reached the anorectal ring, don't cut rectal ring will not be able to achieve the purpose of the drainage unobstructed, So professor An thinks that can be cut in one side anorectal ring2/3by years of clinical validation. It won't cause anal incontinence, to avoid the the pain of hanging line to patients, anal straight ring also got as far as possible protection, moreover, fistula completely open, drainage unobstructed, compared with the chronic cutting hang line greatly reduces the chance of recurrence. It has the characteristics of small trauma, small sphincter injury, little pain postoperative, no anal deformity with good condition, short duration postoperative anal deformity. Specific techniques include the study of high anal fistula location inside the mouth, the study of high anal fistula probing, the principle and difficulty treatment of anal fistula operation, incision design, postoperative staging dressing, the research of professor An to treat high anal fistula, method of professor An with the traditional drawing in the treatment of high anal fistula comparison research, surgical methods and applications of Chinese traditional medicine after anal fistula surgery.
The third part is about the clinical observation and research of Professor An he treat high anal fistula.
Objective:High anal fistula, the fistula is located above the deep part of the external sphincter, which is a very difficult disease in the treatment of anorectal disease. Anorectal specialist has been tried to find a better both can greatly alleviate the suffering of patients and improve the efficacy of treatment these years, which is our goal. High anal fistula many ways, but each of these treatments has its own different indications. We create a low fistulotomy, high fistula blunt debridement, indwelling latex tube drainage (referred to as the low incision and high indwelling) for the treatment of high anal fistula on the basis the traditional low incision, high seton (referred to as the incision line). Cure rate, postoperative pain, anal function were the subject by observing two surgical methods, explore the low cut high exclusion and cut seton treatment of high anal fistula for comparative studies, the study compared the low cut high exclusion the advantages and disadvantages of the method in the treatment of high anal fistula, provide the basis for anorectal specialist in the treatment of high anal fistula.
Methods:Select the32patients with high anal fistula patients are ischial rectal fossa abscess aftermath of high anal fistula bit in the corresponding tooth line inside the mouth, and the rectal cavity mouth without ulceration. They were randomly divided into two groups, the treatment group and the control group,16cases. The treatment group received low cut high exclusion treatment and the control group received low cut high seton treatment. Our test program will have follow-up of three to six months about two groups of patients as control treatment observation. We will be a detailed record of3days,7days, symptoms and signs, wound healing and time, anal sphincter function and recurrence rates of the two groups of patients after surgery. We develop OUTCOME MEASURES score, score indicators. Finally, the score results for statistical analysis, obtained a difference in terms of efficacy and treatment anal sphincter function in and recurrence rate, degree of anal pain, the amount of anal secretions.
Result:Observed the therapeutic effect of the treatment of simple high anal fistula and high anal fistula recurrence rate within six months, we analyzed and summarized that experimental treatment group and the control group in the total effect, the test has no significant difference (P>0.05). After follow-up three to six months, in which the experimental treatment group0cases of recurrence, the recurrence of experimental control group2cases, no significant difference (P>0.05) by the test. Treatment group treatment for22-36days with an average of 24.63days, while the control group treatment for28-54days, with an average of32.98days, the results were statistically analyzed two groups on the course of treatment a statistically significant difference (P<0.05). Postoperative wound pain level meter grading means statistically significant difference (P<0.05) between the two groups. The amount of wound secretions was no significant difference (P>0.05). Postoperative anal function after the patient's subjective evaluation, anal DRE were significant differences (P<0.05), two groups of patients with anal pain level, the amount of secretions3days after surgery,7days have significant differences (P<0.05).
Conclusion:Low cut the high exclusion method was not superior in terms of efficacy, relapse rate than the cut set on, but in the protection of anal function, post-operative pain and shorten the course of treatment was significantly better than the low cut high seton. It is key to choose the most appropriate operation for the high anal fistula. Fistulotomy method is not better than the cutting set on method in treatment effect, recurrence rate. But fistulotomy has apparent advantage over the cutting set on method in maintaining anal function, reducing pain and shortening period of treatment.
In recent years, the cutting set on method is widely used in clinical application. Through the stimulation of rubber of band (thread) friction, the separating Sphincter remnant end and surrounding tissues generate inflammation adhesion. This makes tissues gradually breaking, draining, and recovering happen in the same time. Thus muscle will not break widely in a sudden. It prevents and reduces the damage to anal tube rectum link, helps keeping anal tube rectum angle and anal sphincter function. It also prevents sequel from anal incontinence. The cutting set on method uses probe to create a man made entrance on top of fistula surface. As rubber of band inlaying into the fistula surface deeply, there is a lot of tissue attached to rubber. Rubber cuts off the whole sphincter. Patient experiences huge pain after operation. This method also has influence on ability of anal contraction.
The trend of modern surgery development is micro wound. The principle is to avoid unnecessary damage, reduce the scope of operation, ensure patient experiences less pain physically and mentally, achieve same or even better results as possible. After years of clinical research, professor An invented fistulotomy method. The advantage of fistulotomy is that it minimizes the damage to sphincter. It is less painful to patient. The period of treatment is also shorter. As per recognition in our profession, fistula is caused by infection on anus gland. Focus infection is normally on sious anales. The inner hole is near dentate line。This infection spreads upwards along and around association muscle fiber. Even the position of fistula is high, the break is not necessarily in the upper enteric cavity ulcer. So it means the inner hole of fistula and the top of fistula are different. Based on the above fact and traditional Chinese cutting set on method, fistulotomy method is developed. It combined the advantage of maintaining sphincter in western practice while ensuring inner hole is well looked after. The observation result here shows that comparing to the cutting set on method; fistulotomy method demonstrates better treatment effect, less pain and shorter period. It also protects the function of sphincter effectively.
第一部分包括中医对肛瘘的认识及高位肛瘘国内外的研究现状分析。中医对肛瘘的认识又分为肛瘘的历史沿革、肛瘘的病因病机、肛瘘的中医治法。这里主要介绍了中医学理论里对肛瘘病名的追溯,对肛瘘的病因病机的探讨以及对肛瘘治疗的历史进程。详细论述了历代中医医家对肛瘘的认识以及诸多的治疗方法,包括内治法和外治法。尤其对于挂线疗法进行了详尽的介绍,包括使用的药物和器具,充分证实了肛瘘的挂线疗法始于中医,传承发扬于中医,并一直沿用至今,不断改进,仍然是目前治疗肛瘘的主要方法,是我们中医治疗中的一块瑰宝。高位肛瘘国内外的研究现状分析部分,系统论述了现代医学对于肛瘘的发病原因及机理的探究,包括肛腺感染学说、中央间隙感染、性激素水平学说等,并对肛瘘的诊断方法进行了总结,包括探针检查、美兰及双氧水瘘管染色法、放射线检查、超声检查、螺旋CT三维重建技术、磁共振成像及过氧化氢增强腔内超声等。对于肛瘘的手术治疗从括约肌保留术式和括约肌切断术式进行了归纳总结,比较了各自的优缺点和适应症。并重点论述了与本疗法有关的各种挂线疗法的特点,比较了各自的优略,为后面的论述打下了坚实的基础。
第二部分主要介绍了安阿玥教授学术思想和治疗高位肛瘘的临床经验总结。因为本学位论文是师承学位论文,所以把导师的学术思想作为重点论述。首先对安教授进行了介绍,然后对他的学术思想进行了总结,包括重视辨证论治,重视整体观念及重视外治。虽然肛肠疾病主要的表现在局部,以局部的症状及体征为主,但安教授并未因此而忽略了全身气血阴阳的辨证分析。他非常重视整体观念和全身的辨证分析。经常运用八纲辨证,调理全身气血阴阳的平衡,以达到治疗或配合治疗局部肛肠疾病的目的。由于肛肠疾患的外在表现比较突出,所以安教授更加重视其的外治,包括中药外治及手术治疗。安教授治疗高位肛瘘的临床经验总结,更是本文论述的重中之重。高位肛瘘由于病变位置高、管道多弯曲复杂,常有深部死腔,治疗上存在难度大、复发率高并发症后遗症多等问题,因而被国内外专家称为难治性肛瘘。现在临床上普遍采用挂线疗法治疗。传统的挂线法被认为可以防止肛门失禁,但挂线法存在盲目制造内口易复发外,还存在术后长时间难以忍受的疼痛,较长时间的恢复期,较重的瘢痕及其引起的肛门功能障碍而导致的肛门不全失禁。安教授采用抓主要矛盾分而治之的方法,巧妙地解决了高位复杂性肛瘘的治疗难题。安教授认为,高位肛瘘只是瘘管高,而内口并不高,极个别病例在直肠壁有口也不是内口,而是破溃口,内口只能在齿线。所以瘘管只要敞开后引流通畅就不必完全切开瘘管,高位的瘘管扩创旷置并插乳胶管进行引流,使其引流通畅,经过引流而达到治疗的目的。其钝性损伤轻微而且可逆,对肛管直肠环的损伤造成的功能障碍亦轻微,而且对肛管直肠环的形态没有造成破坏,缩短创面的愈合时间。如果坏死灶已达肛管直肠环,不切开直肠环就不能达到引流通畅的目的,那么安教授经多年临床验证认为,可于一侧切开肛管直肠环的下2/3,这样不会引起肛门失禁,避免了挂线给病人带来的痛苦,肛直环也得到了尽可能的保护,而且,瘘管彻底敞开,引流通畅,与挂线的慢性切割相比大大减少了复发的机会。具有创伤小、括约肌损伤小、术后疼痛轻、无肛门畸形、功能完好、术后病程短的特点。具体技术包括高位肛瘘内口定位的研究,高位肛瘘瘘管探查的研究,肛瘘手术的治疗原则和难点,手术切口的设计,术后分期换药,安阿玥教授高位肛瘘治疗方法的研究,安阿玥教授治疗高位肛瘘的方法与传统挂线疗法的对比研究、手术方法及中药在肛瘘术后的应用。
第三部分是安阿玥教授治疗高位肛瘘的临床观察与研究。
目的：高位肛瘘,其瘘管位于外括约肌深部以上,是肛门直肠疾病治疗中非常棘手的一个疾病。我们肛肠专科医生这些年一直努力去寻找一种更好的既能够大大减轻病患痛苦又能够提高疗效的治疗方法,这是我们的目标。高位肛瘘的治疗方法很多,但是每一种治疗方法都有各自不同的适应症。我们在传统的低位切开、高位挂线法(简称切开挂线法)治疗高位肛瘘的基础上进行改良,创造一种低位瘘管切开,高位瘘管钝性扩创,留置乳胶管引流的方法(简称低位切开高位旷置法)治疗高位肛瘘。本课题通过观察两种手术方法的治愈率、术后疼痛、肛门功能等指标,探讨低位切开高位旷置法与切开挂线法治疗高位肛瘘作对比研究,研究对比低位切开高位旷置法在治疗高位肛瘘方面的优劣,为肛肠专科医生在高位肛瘘治疗上的研究提供依据。
方法：选择32例单纯高位肛瘘患者,均为骨盆直肠窝脓肿后遗高位肛瘘而内口在相应齿线位者,且直肠腔内无溃破口者。随机分为两组,治疗组和对照组,各16例。治疗组采用低位切开高位旷置法治疗,对照组采用低位切开高位挂线法治疗。对两组患者作对照观察,随访半年。观察指标主要有术后第3天、7天的症状和体征,创口的愈合情况及时间,肛门的括约功能及复发率等情况。制定评分标准,对结果进行评分,最后进行统计学处理,得出其在疗效与疗程、肛门功能及复发率、术后肛门疼痛程度、肛门分泌物等方面的差异。之所以只观察32例,主要是基于挂线疗法痛苦大,疗程长,疼痛重的考虑。
结果：在观察治疗单纯性高位肛瘘的治疗效果上和半年内高位肛瘘复发率的分析总结,疗效方面,统计学处理,两组无显著差异(P>0.05)。经过随访半年,治疗组无复发,对照组复发2例,经检验无统计学差异(P>0.05)。由于本研究的样本量相对较小,从数据上看似乎可以表明对照组复发例数较治疗组多,但是经统计学检验,两组复发率无显著性差异,所以有关研究有待进一步深入进行。疗程方面,治疗组为22-36天,平均为24.63天,对照组为28-54天,平均为32.98天,统计学处理两组有显著差异(P<0.05)。术后创面疼痛程度,通过计分等手段进行统计学处理后两组间存在着显著性差异(P<0.05)。创面分泌物的量两组间无显著性差异(P>0.05)。两组患者术后肛门功能经过患者主观测评、肛门指诊有显著性差异(P<0.05)。
结论：低位切开高位旷置法在疗效、复发率等方面并不优于切开挂线法,但在保护肛门功能、减轻术后疼痛、缩短疗程等方面则明显优于低位切开高位挂线法。
目前临床上比较广泛应用的是低位切开高位挂线疗法,使用弹性橡皮筋(或丝线),异物刺激括约肌的作用,让断离的括约肌残端与周围组织有一个异物炎症性粘连的作用,使周围组织逐渐切开、引流与修复同时进行,让断离的括约肌残端不会突然很大面积的豁开,可以有效地保持肛管直肠角,防止并减少肛管直肠环的损伤,可以维持肛门的括约功能,最终防止了肛门失禁后遗症的发生。但是这种低位切开高位挂线术是利用探针在瘘道的上面人工造口,因橡皮筋通过瘘管探测更深,所挂组织又比较厚,并且要勒断所有的括约肌,所以患者常常感受疼痛较剧,痛苦不堪,肛门收缩和舒张功能受到一定的影响。
现代外科的发展趋势之一是微创手术,以避免不必要的入侵原理,最大限度地减少手术范围,以减少短期和长期因手术患者的生理和心理痛苦,来达到同样的甚至是更好的治疗效果。根据这一发展趋势,我的导师安阿玥教授通过多年的临床实践和研究,创出了低位切开,高位旷置留置乳胶管引流术。该术式旷置法的优点是尽可能少地破坏括约肌,使痛苦减少,疗程缩短。
肛瘘是由肛腺感染,主要病变在肛窦,即内口在齿状线附近,这一观点是国内外学者所公认的。高位肛瘘形成的原因,是由于炎症沿联合纵肌纤维向上扩散。虽然瘘管位置多位于齿线以上,但内口依然位于齿线处。所有肛瘘手术都是在解决两个问题,即切开内口,使瘘管引流通畅。这为低位切开,高位旷置留置乳胶管引流术治疗高位肛瘘提供了重要的理论依据。在传统中医挂线疗法基础上,结合国外的保留括约肌手术方法,采取以低位切开、高位旷置留置乳胶管法治疗高位肛瘘。与传统低切高挂术相比,本方法有临床推广应用价值。
The article is divided into three major sections to discuss the experience and clinical research about An'A'Yue uses low incision and high indwelling method in treating high anal fistula, the first part is the literature review, the second part is to summarize the clinical experience of Professor An'A'Yue's academic thought and treatment of high anal fistula, the third part is the clinical observation and research of Professor An'A'Yue in the treatment of high anal fistula.
The first part includes Traditional Chinese Medicine to the cognition of anal fistula and the present situation of high anal fistula at homeland and abroad. Traditional Chinese Medicine to the cognition of anal fistula divide into the Historical Evolution, Etiology and Pathogenesis and the Therapy of anal fistula. In this part mainly introduces the theory of traditional Chinese medicine on the back of the name of anal fistula anal, discuss the etiology and pathogenesis of anal fistula and the of history about the treatment of anal fistula. All previous dynasties Chinese medicine physicians understanding of anal fistula and a variety of treatments is discussed, including internal treatment and external treatment. Especially for hang line therapy has carried on the detailed introduction, including the use of drugs and devices, fully confirmed the anal fistula hang line therapy began in TCM, heritage, carry forward the Chinese medicine and has been in use today, continuous improvement, it is still the main method of treatment of anal fistula, and it is a piece of treasure in our treatment of traditional Chinese medicine. The section of research status analysis about high anal fistula at home and abroad, system elaborated the modern medicine to explore causes and mechanism in the pathogenesis of anal fistula, including anal gland infection theory, central clearance of infection theory, sex hormone levels theory, etc. and the methods to the diagnosis of anal fistula is summarized, including probe check, MEILAN and hydrogen peroxide fistula staining, radiographic inspection and ultrasonic inspection, spiral CT3d reconstruction technology, magnetic resonance imaging and hydrogen peroxide to enhance intracavity ultrasound. Summarized anal fistula surgery, concluding Sphincter surgery and Sphincter cutting operation, and compared the respective advantages and disadvantages and indications. Comparison of the respective advantages and disadvantages and indications the characteristics of the therapy of and all kinds of hanging line related to this treatment is discussed, and comparing the respective optimal slightly, has laid a solid foundation to the back of the paper.
The second part is to summarize the clinical experience of Professor An'A'Yue's academic thought and treatment of high anal fistula, Because the thesis of this dissertation is Shicheng, so the tutor's academic ideas as the emphasis in this paper. Firstly introduce professor An, and then summarize to his academic thoughts, including emphasis on syndrome differentiation, attaches great importance to external treatment. Although anorectal diseases mainly displays in local, give priority to with local symptoms and signs, but professor An has not ignored analysis different syndrome of the whole body about qi and blood, Yin and Yang. He attaches great importance to the overall concept and systemic dialectical analysis. He often uses the eight principles differentiation, regulates the balance of body Qi and blood, Yin and Yang, to achieve the goal of treatment or cooperate with local anorectal diseases. Because of the external performance of anorectal disease is more outstanding, the professor An pay more attention to the external treatment, including traditional Chinese medicine external treatment and surgical treatment. The clinical experience of Professor An'A'Yue's academic thought and treatment of high anal fistula is the most important in this paper. High anal fistula complex since high lesion location, pipe bend, dead space, often have deep treatment difficulty complications, recurrence rate is high, such as after-effects more problems,so called intractable anal fistula by experts at home and abroad. Traditional hanging line method is thought to prevent the anus incontinence, but hang line method exist in mouth that is easy to relapse, has unbearable pain for a long time, a long time to recovery. Professor An grasp the principal contradiction of divide and conquer method, ingeniously solved the difficult treatment problems of high complexity anal fistula. Professor An says high anal fistula is high fistula, but the inside mouth is not high, very few cases in intestinal wall straight mouth is not the inside mouth, but burst mouth, mouth can only in the dentate line. So that don't have to completely incision fistula after the open drainage unobstructed, high fistula debridement and latex tube drainage, drainage unblocked, after drainage and achieve the goal of treatment. Its mild and reversible blunt injury, damage caused by the dysfunction of anorectal ring also slightly, and morphology of anorectal ring caused no damage, shorten wound healing time. If the focal necrosis has reached the anorectal ring, don't cut rectal ring will not be able to achieve the purpose of the drainage unobstructed, So professor An thinks that can be cut in one side anorectal ring2/3by years of clinical validation. It won't cause anal incontinence, to avoid the the pain of hanging line to patients, anal straight ring also got as far as possible protection, moreover, fistula completely open, drainage unobstructed, compared with the chronic cutting hang line greatly reduces the chance of recurrence. It has the characteristics of small trauma, small sphincter injury, little pain postoperative, no anal deformity with good condition, short duration postoperative anal deformity. Specific techniques include the study of high anal fistula location inside the mouth, the study of high anal fistula probing, the principle and difficulty treatment of anal fistula operation, incision design, postoperative staging dressing, the research of professor An to treat high anal fistula, method of professor An with the traditional drawing in the treatment of high anal fistula comparison research, surgical methods and applications of Chinese traditional medicine after anal fistula surgery.
The third part is about the clinical observation and research of Professor An he treat high anal fistula.
Objective:High anal fistula, the fistula is located above the deep part of the external sphincter, which is a very difficult disease in the treatment of anorectal disease. Anorectal specialist has been tried to find a better both can greatly alleviate the suffering of patients and improve the efficacy of treatment these years, which is our goal. High anal fistula many ways, but each of these treatments has its own different indications. We create a low fistulotomy, high fistula blunt debridement, indwelling latex tube drainage (referred to as the low incision and high indwelling) for the treatment of high anal fistula on the basis the traditional low incision, high seton (referred to as the incision line). Cure rate, postoperative pain, anal function were the subject by observing two surgical methods, explore the low cut high exclusion and cut seton treatment of high anal fistula for comparative studies, the study compared the low cut high exclusion the advantages and disadvantages of the method in the treatment of high anal fistula, provide the basis for anorectal specialist in the treatment of high anal fistula.
Methods:Select the32patients with high anal fistula patients are ischial rectal fossa abscess aftermath of high anal fistula bit in the corresponding tooth line inside the mouth, and the rectal cavity mouth without ulceration. They were randomly divided into two groups, the treatment group and the control group,16cases. The treatment group received low cut high exclusion treatment and the control group received low cut high seton treatment. Our test program will have follow-up of three to six months about two groups of patients as control treatment observation. We will be a detailed record of3days,7days, symptoms and signs, wound healing and time, anal sphincter function and recurrence rates of the two groups of patients after surgery. We develop OUTCOME MEASURES score, score indicators. Finally, the score results for statistical analysis, obtained a difference in terms of efficacy and treatment anal sphincter function in and recurrence rate, degree of anal pain, the amount of anal secretions.
Result:Observed the therapeutic effect of the treatment of simple high anal fistula and high anal fistula recurrence rate within six months, we analyzed and summarized that experimental treatment group and the control group in the total effect, the test has no significant difference (P>0.05). After follow-up three to six months, in which the experimental treatment group0cases of recurrence, the recurrence of experimental control group2cases, no significant difference (P>0.05) by the test. Treatment group treatment for22-36days with an average of 24.63days, while the control group treatment for28-54days, with an average of32.98days, the results were statistically analyzed two groups on the course of treatment a statistically significant difference (P<0.05). Postoperative wound pain level meter grading means statistically significant difference (P<0.05) between the two groups. The amount of wound secretions was no significant difference (P>0.05). Postoperative anal function after the patient's subjective evaluation, anal DRE were significant differences (P<0.05), two groups of patients with anal pain level, the amount of secretions3days after surgery,7days have significant differences (P<0.05).
Conclusion:Low cut the high exclusion method was not superior in terms of efficacy, relapse rate than the cut set on, but in the protection of anal function, post-operative pain and shorten the course of treatment was significantly better than the low cut high seton. It is key to choose the most appropriate operation for the high anal fistula. Fistulotomy method is not better than the cutting set on method in treatment effect, recurrence rate. But fistulotomy has apparent advantage over the cutting set on method in maintaining anal function, reducing pain and shortening period of treatment.
In recent years, the cutting set on method is widely used in clinical application. Through the stimulation of rubber of band (thread) friction, the separating Sphincter remnant end and surrounding tissues generate inflammation adhesion. This makes tissues gradually breaking, draining, and recovering happen in the same time. Thus muscle will not break widely in a sudden. It prevents and reduces the damage to anal tube rectum link, helps keeping anal tube rectum angle and anal sphincter function. It also prevents sequel from anal incontinence. The cutting set on method uses probe to create a man made entrance on top of fistula surface. As rubber of band inlaying into the fistula surface deeply, there is a lot of tissue attached to rubber. Rubber cuts off the whole sphincter. Patient experiences huge pain after operation. This method also has influence on ability of anal contraction.
The trend of modern surgery development is micro wound. The principle is to avoid unnecessary damage, reduce the scope of operation, ensure patient experiences less pain physically and mentally, achieve same or even better results as possible. After years of clinical research, professor An invented fistulotomy method. The advantage of fistulotomy is that it minimizes the damage to sphincter. It is less painful to patient. The period of treatment is also shorter. As per recognition in our profession, fistula is caused by infection on anus gland. Focus infection is normally on sious anales. The inner hole is near dentate line。This infection spreads upwards along and around association muscle fiber. Even the position of fistula is high, the break is not necessarily in the upper enteric cavity ulcer. So it means the inner hole of fistula and the top of fistula are different. Based on the above fact and traditional Chinese cutting set on method, fistulotomy method is developed. It combined the advantage of maintaining sphincter in western practice while ensuring inner hole is well looked after. The observation result here shows that comparing to the cutting set on method; fistulotomy method demonstrates better treatment effect, less pain and shorter period. It also protects the function of sphincter effectively.
引文
[1]李雨农.中华肛门病学.重庆：科学技术文献出版社重庆分社,2000.P366.
[2]胡伯虎.大肠肛门病治疗学.北京：北京科学技术文献出版社,2001.P313.
[3]黄卫平.肛肠病专家彭显光教授学术经验与临证特色[J].中国农村医学,1997,25(3)：8-11.
[4]李雨农.中华肛门病学.重庆：科学技术文献出版社重庆分社,2000,P366.
[5]潘远根,旷惠桃.《五十二病方》看先秦时期痔疹科成就[J].中华医史杂志,1983,13(3)：190.
[6]黄乃健.中国肛肠病学.山东：山东科学技术出版社,1996.P729.
[7]李曰庆.中医外科学.北京：中国中医药出版社,2002.P266.
[8]安阿玥.实用肛肠病学[M].山东：山东科学技术文献出版社,1989.164-165.
[9]黄乃健.中医肛肠病学[M].北京：科学出版社,1996.103-106.
[10]宋·王怀隐等编.太平圣惠方[M].人民卫生出版社,1982.7.
[11]明·陈实功原著,刘忠恕,张若兰点校.外科正宗[M].天津科学技术出版社,1993.196.
[12]黄乃健.中国肛肠病学.济南：山东科学技术出版社,1996.P752.
[13]李雨农.中华肛肠病学.重庆：科学技术文献出版社,1990.P381.
[14]唐学贵,伍静.中西医结合诊治复杂性肛瘘[J].川北医学院学报,2007,2(1)：2.
[15]Shafik A. A new concept of the anatomy of anal sphincter mechanism and the physiology of defecation[M]. Colo-proctology 1990; 12(6):369.
[16]Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation [J]. Diseases of the Colon&Reetum,1979,22(8):539-549.
[17]Kikuehi M YT, Nakamura H. Neerotizing lymphadenitis:possible acute toxoplasmosis infection[J]. Virehows Arehiv,1977,376(3):247-253.
[18]黄凤,王军省.圆头塑料空心探针在肛瘘手术中的应用研究[J].中国中西医结合外科杂志,2012,02：200-201.
[19]李东冰等,肛门直肠周围脓肿的诊断与治疗,中国临床医生,2002年第30卷,第八期.
[20]张火俊,傅传刚,王培军等.螺旋CT三维重建技术在肛瘘诊断中的应用[J].中国实用外科杂志,2001,21(11)：673.
[21]Mahjoubi B, Haizadch-Kharazi H, Mirzaei R, etal. Diagnostic accuracy of body coil MRI in describing the characteristics of perianal fistulas [J]. Colorectal Dis, 2006,8(3):202-207.
[22]Al-Khawari HA, Gupta R, Sinan TS, et al. Role of magnetic resonance imaging in the assessment of perianal fistulas[J]. MedPrinc Pract 2005,14(1):46-52.
[23]Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its miplications for patient management[J]. Radiographics,2000,20: 623-637.
[24]Buchanan G, Halligan S, Williams A, et al. Effect of MRI on clinical outcome of recurrent fistula-in-ano[J]. Lancet 2002,360(9346):1661-1662.
[25]Ratto C, Grillo E, Parello A, et al. Endoanal ultrasound-guided surgery for anal fistula[J]. Endoscopy,2005,37(8):722-728.
[26]Buchanan GN, Bartram CI, William s AB, et al. Value of hydrogen peroxide enhancement of three-dimensional end anal ultra sound in fistula-in-ano[J]. Dis Colon Rectum,2005,48(1):141-147.
[27]Parks AG. Pathogenesis and treatment of fistula-in-ano. Br Med J,1961,1: 463-469.
[28]熊芳,黄斌,秦澎湃,熊蕾蕾,沈远.端扫式凸阵腔内探头与旋转式腔内探头术前超声评估肛瘘准确性的比较[J].中华医学超声杂志(电子版),2012,01：20-24.
[29]刘占彦,李燕,马剑海,王艳红.微创小切口挂线旷置术治疗高位肛瘘76例临床观察[J].河北中医,2011,(05)：795-796.
[30]Buchanan GN, Owen HA, Torkington J, etal. Long-term outcome following loose-seton technique for external sphincter preservation in complex anal fistula. Br J Surg,2004,91:476-480.
[31]Williams JG, Madleod CA, Rothenberger DA, et al. Seton treatment of high anal fistulae[J]. Br J Surg,1991(78):1159-1161.
[32]钱海华,曾莉.低位切开结合引流挂线治疗高位肛瘘55例[J].南京中医药大 学学报,2011,(05)：428-430.
[33]Jamshidi R,Scheeter WP. Biological dressings for the management of enteric fistulas in the open abdomen:apreliminary report. Arch Surg,2007,142(8):793-796.
[34]闵连永,王业皇,徐芳.生物补片在高位肛瘘内口修补术中的应用[J].结直肠肛门外科,2009,(01)：46-47.
[35]赵英武,杨中权.生物蛋白胶封堵术治疗高位肛瘘的临床应用[J].结直肠肛门外科,2008,(06)：402-403.
[36]张玉茹,田磊等.生物蛋白胶填充在高位复杂肛瘘治疗中的应用[J].山东医药,2011,(19)：98-99.
[37]陆金根,王琛等.隧道式拖线术治疗单纯性肛瘘的临床研究[J].中西医结合学报,2006,(02)：140-146.
[38]倪士吕,显微肛瘘切除术治疗高位肛瘘[J].温州医学院学报,2006,36(3)：250-251.
[39]杨柏林,丁义江.肛瘘挂线治疗[J].大肠肛门病外科杂志,2005,(01)：79-81.
[40]李雨农.内口切开及药线管道引流术治疗肛瘘初步报告[J].中国肛肠病杂志,1984,4(1)：18.
[41]王刃,杨迈.肛瘘治疗进展[J].大肠肛门病外科杂志,1997,3(3)：61,63.
[42]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,2008,24(11)：732-733.
[43]丁义江.高位复杂性肛瘘的诊治进展[J].大肠肛门病外科杂志,2002,8(3)：138-139.
[44]戴民勇.切开挂线法治疗高位复杂性肛瘘[J].医学导刊,2008,2：18-19.
[45]王保华.切开挂线法治疗高位复杂性肛瘘[J].中国实用医药,2011,6(10)：119-120.
[46]戴宗林.中西医结合治疗高位肛瘘[J].中国中西医结合外科杂志,2000,6(2)：31.
[47]陈兴长.切开挂线术治疗高位肛瘘46例[J].福建医药杂志,2002,24(3)：67.
[48]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,2009,4(3)：128-129.
[49]石世平,张永中.切开缝合挂线术治疗高位肛瘘58例回顾性分析[J].中国中 医急症,2010,19(7)：1121.
[50]钱海华.朱秉义教授运用挂线疗法治疗高位肛瘘经验[J].南京中医药大学学报,2009,25(5)：387.
[51]沈习来.定向挂线治疗高位肛瘘的效果观察[J].右江民族医学院学报,2008,30(6)：1007-1008.
[52]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,2008.42(5)：62-63.
[53]包散丹等.旷置挂线术与传统挂学术治疗高位肛瘘的对比分析[J].内蒙古医学杂志,200,41(9)：1068.
[54]赵群男.高位虚挂引流术治疗高位肛瘘31例[J].交通,2006,20(5)：555.
[55]李春雨,张丹丹,王军等.二种手术方式治疗高位复杂性肛瘘的疗效比较[J].山西医药杂志：上半月,2008,(001)：12-14.
[56]张少军,杨巍,应光耀,高洪娣,熊国华.低位挂线高位扩创引流术治疗高位肛瘘的临床观察[J].世界中西医结合杂志,2013,03：249-251+289.
[57]李东冰,谢振年,王芳丽,蔡亭,贾小强,曹威巍,郝丽丽.跳跃式接力切开短程挂线治疗蹄铁形高位肛瘘[J].中国中西医结合外科杂志,2012,06：606-608.
[58]李春雨,焦放,聂敏.切开挂线对口引流治疗高位复杂性肛瘘118例[J].大肠肛门病外科杂志,1999,5(3)：32-34.
[1]曾丽红.中药坐浴在切开挂线法治疗高位肛瘘中的临床疗效观察[J].中医药导报,2011,17(4)：69-70.
[2]郭毅.李柏年治疗高位肛瘘经验探讨[J].中国临床医生,2005,33(7)：54.
[3]李辉等.高位肛瘘的术式选择与比较[J].中国医刊,2011,46(2)：63.
[4]姜春英.高位肛瘘的手术治疗[J].中国中西医结合外科杂志,2003,9(2)：86-87.
[5]韩震辉.旷置挂线治疗高位肛瘘的临床观察[J].上海中医药杂志,2008.42(5)：62-63.
[6]谷云飞,药捻式置管引流治疗高位肛瘘38例江苏中医药2003年第24卷第1期,31-32).
[7]李雨农主编.中华肛肠病学.科学技术文献出版社重庆分社,1990.
[8]赖象权等.高位肛瘘完整切除缝合术624例疗效观察[J].贵州医药,2004,28(2)：157-158.
[9]范学顺等.采用非挂线疗法一次治愈高位肛瘘156例小结,Bull Med Res Janu2001,30(1)：58.
[10]王晏美等.不同术式治疗高位肛瘘98例临床观察[J].北京中医药大学学报,2005,28(3)：90-91.
[11]张有生.肛肠科手册.沈阳：沈阳科学技术出版社,1985,P89.
[12]Hallan RI, Marzouk DEMM, Waldron DJ, et al Comparison of digital andmanometric assessment of anal sphincter function Br J Surg 1989; 76:973.
[13]钟英才.旷置切开挂线术治疗复杂性肛瘘30例临床观察[J].中国中医急症,2009,18(6)：891-892.
[14]戴民勇.切开挂线法治疗高位复杂性肛瘘[J].医学导刊,2008,(02)：18-19.
[15]郑丽华等.肛管直肠环大部离断术治疗单纯性高位肛瘘的临床观察[J].中国医刊,2010,45(12)：62.
[16]王晏美等.不同术式治疗高位肛瘘98例临床观察[J],北京中医药大学学报,2005,28(3)：90-91.
[17]范学顺等.采用非挂线疗法一次治愈高位肛瘘156例小结,Bull Med Res Janu2001,30(1)：58.
[18]钱海华.朱秉宜教授利用挂线疗法治疗高位肛瘘经验[J],南京中医药大学学报,2009,25(5)：387.
[19]蒋千超,徐炳牛,狳斌等.复杂性肛瘘213例治疗体会.现代中西医结合杂志[J],2003,12(5)：501-502.
[20]马英,左进等.高位复杂性肛瘘的治疗体会[J].新中医,2004.36(2)：73.
[21]杨万里.高位复杂性肛瘘术后处理体会[J].四川中医,2001,19(2)：59.
[22]艾中立,钱群.肛瘘复发的原因与对策[J].大肠肛门病外科杂志,2002,8(3)：143-144.
[2]胡伯虎.大肠肛门病治疗学.北京：北京科学技术文献出版社,2001.P313.
[3]黄卫平.肛肠病专家彭显光教授学术经验与临证特色[J].中国农村医学,1997,25(3)：8-11.
[4]李雨农.中华肛门病学.重庆：科学技术文献出版社重庆分社,2000,P366.
[5]潘远根,旷惠桃.《五十二病方》看先秦时期痔疹科成就[J].中华医史杂志,1983,13(3)：190.
[6]黄乃健.中国肛肠病学.山东：山东科学技术出版社,1996.P729.
[7]李曰庆.中医外科学.北京：中国中医药出版社,2002.P266.
[8]安阿玥.实用肛肠病学[M].山东：山东科学技术文献出版社,1989.164-165.
[9]黄乃健.中医肛肠病学[M].北京：科学出版社,1996.103-106.
[10]宋·王怀隐等编.太平圣惠方[M].人民卫生出版社,1982.7.
[11]明·陈实功原著,刘忠恕,张若兰点校.外科正宗[M].天津科学技术出版社,1993.196.
[12]黄乃健.中国肛肠病学.济南：山东科学技术出版社,1996.P752.
[13]李雨农.中华肛肠病学.重庆：科学技术文献出版社,1990.P381.
[14]唐学贵,伍静.中西医结合诊治复杂性肛瘘[J].川北医学院学报,2007,2(1)：2.
[15]Shafik A. A new concept of the anatomy of anal sphincter mechanism and the physiology of defecation[M]. Colo-proctology 1990; 12(6):369.
[16]Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation [J]. Diseases of the Colon&Reetum,1979,22(8):539-549.
[17]Kikuehi M YT, Nakamura H. Neerotizing lymphadenitis:possible acute toxoplasmosis infection[J]. Virehows Arehiv,1977,376(3):247-253.
[18]黄凤,王军省.圆头塑料空心探针在肛瘘手术中的应用研究[J].中国中西医结合外科杂志,2012,02：200-201.
[19]李东冰等,肛门直肠周围脓肿的诊断与治疗,中国临床医生,2002年第30卷,第八期.
[20]张火俊,傅传刚,王培军等.螺旋CT三维重建技术在肛瘘诊断中的应用[J].中国实用外科杂志,2001,21(11)：673.
[21]Mahjoubi B, Haizadch-Kharazi H, Mirzaei R, etal. Diagnostic accuracy of body coil MRI in describing the characteristics of perianal fistulas [J]. Colorectal Dis, 2006,8(3):202-207.
[22]Al-Khawari HA, Gupta R, Sinan TS, et al. Role of magnetic resonance imaging in the assessment of perianal fistulas[J]. MedPrinc Pract 2005,14(1):46-52.
[23]Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its miplications for patient management[J]. Radiographics,2000,20: 623-637.
[24]Buchanan G, Halligan S, Williams A, et al. Effect of MRI on clinical outcome of recurrent fistula-in-ano[J]. Lancet 2002,360(9346):1661-1662.
[25]Ratto C, Grillo E, Parello A, et al. Endoanal ultrasound-guided surgery for anal fistula[J]. Endoscopy,2005,37(8):722-728.
[26]Buchanan GN, Bartram CI, William s AB, et al. Value of hydrogen peroxide enhancement of three-dimensional end anal ultra sound in fistula-in-ano[J]. Dis Colon Rectum,2005,48(1):141-147.
[27]Parks AG. Pathogenesis and treatment of fistula-in-ano. Br Med J,1961,1: 463-469.
[28]熊芳,黄斌,秦澎湃,熊蕾蕾,沈远.端扫式凸阵腔内探头与旋转式腔内探头术前超声评估肛瘘准确性的比较[J].中华医学超声杂志(电子版),2012,01：20-24.
[29]刘占彦,李燕,马剑海,王艳红.微创小切口挂线旷置术治疗高位肛瘘76例临床观察[J].河北中医,2011,(05)：795-796.
[30]Buchanan GN, Owen HA, Torkington J, etal. Long-term outcome following loose-seton technique for external sphincter preservation in complex anal fistula. Br J Surg,2004,91:476-480.
[31]Williams JG, Madleod CA, Rothenberger DA, et al. Seton treatment of high anal fistulae[J]. Br J Surg,1991(78):1159-1161.
[32]钱海华,曾莉.低位切开结合引流挂线治疗高位肛瘘55例[J].南京中医药大 学学报,2011,(05)：428-430.
[33]Jamshidi R,Scheeter WP. Biological dressings for the management of enteric fistulas in the open abdomen:apreliminary report. Arch Surg,2007,142(8):793-796.
[34]闵连永,王业皇,徐芳.生物补片在高位肛瘘内口修补术中的应用[J].结直肠肛门外科,2009,(01)：46-47.
[35]赵英武,杨中权.生物蛋白胶封堵术治疗高位肛瘘的临床应用[J].结直肠肛门外科,2008,(06)：402-403.
[36]张玉茹,田磊等.生物蛋白胶填充在高位复杂肛瘘治疗中的应用[J].山东医药,2011,(19)：98-99.
[37]陆金根,王琛等.隧道式拖线术治疗单纯性肛瘘的临床研究[J].中西医结合学报,2006,(02)：140-146.
[38]倪士吕,显微肛瘘切除术治疗高位肛瘘[J].温州医学院学报,2006,36(3)：250-251.
[39]杨柏林,丁义江.肛瘘挂线治疗[J].大肠肛门病外科杂志,2005,(01)：79-81.
[40]李雨农.内口切开及药线管道引流术治疗肛瘘初步报告[J].中国肛肠病杂志,1984,4(1)：18.
[41]王刃,杨迈.肛瘘治疗进展[J].大肠肛门病外科杂志,1997,3(3)：61,63.
[42]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,2008,24(11)：732-733.
[43]丁义江.高位复杂性肛瘘的诊治进展[J].大肠肛门病外科杂志,2002,8(3)：138-139.
[44]戴民勇.切开挂线法治疗高位复杂性肛瘘[J].医学导刊,2008,2：18-19.
[45]王保华.切开挂线法治疗高位复杂性肛瘘[J].中国实用医药,2011,6(10)：119-120.
[46]戴宗林.中西医结合治疗高位肛瘘[J].中国中西医结合外科杂志,2000,6(2)：31.
[47]陈兴长.切开挂线术治疗高位肛瘘46例[J].福建医药杂志,2002,24(3)：67.
[48]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,2009,4(3)：128-129.
[49]石世平,张永中.切开缝合挂线术治疗高位肛瘘58例回顾性分析[J].中国中 医急症,2010,19(7)：1121.
[50]钱海华.朱秉义教授运用挂线疗法治疗高位肛瘘经验[J].南京中医药大学学报,2009,25(5)：387.
[51]沈习来.定向挂线治疗高位肛瘘的效果观察[J].右江民族医学院学报,2008,30(6)：1007-1008.
[52]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,2008.42(5)：62-63.
[53]包散丹等.旷置挂线术与传统挂学术治疗高位肛瘘的对比分析[J].内蒙古医学杂志,200,41(9)：1068.
[54]赵群男.高位虚挂引流术治疗高位肛瘘31例[J].交通,2006,20(5)：555.
[55]李春雨,张丹丹,王军等.二种手术方式治疗高位复杂性肛瘘的疗效比较[J].山西医药杂志：上半月,2008,(001)：12-14.
[56]张少军,杨巍,应光耀,高洪娣,熊国华.低位挂线高位扩创引流术治疗高位肛瘘的临床观察[J].世界中西医结合杂志,2013,03：249-251+289.
[57]李东冰,谢振年,王芳丽,蔡亭,贾小强,曹威巍,郝丽丽.跳跃式接力切开短程挂线治疗蹄铁形高位肛瘘[J].中国中西医结合外科杂志,2012,06：606-608.
[58]李春雨,焦放,聂敏.切开挂线对口引流治疗高位复杂性肛瘘118例[J].大肠肛门病外科杂志,1999,5(3)：32-34.
[1]曾丽红.中药坐浴在切开挂线法治疗高位肛瘘中的临床疗效观察[J].中医药导报,2011,17(4)：69-70.
[2]郭毅.李柏年治疗高位肛瘘经验探讨[J].中国临床医生,2005,33(7)：54.
[3]李辉等.高位肛瘘的术式选择与比较[J].中国医刊,2011,46(2)：63.
[4]姜春英.高位肛瘘的手术治疗[J].中国中西医结合外科杂志,2003,9(2)：86-87.
[5]韩震辉.旷置挂线治疗高位肛瘘的临床观察[J].上海中医药杂志,2008.42(5)：62-63.
[6]谷云飞,药捻式置管引流治疗高位肛瘘38例江苏中医药2003年第24卷第1期,31-32).
[7]李雨农主编.中华肛肠病学.科学技术文献出版社重庆分社,1990.
[8]赖象权等.高位肛瘘完整切除缝合术624例疗效观察[J].贵州医药,2004,28(2)：157-158.
[9]范学顺等.采用非挂线疗法一次治愈高位肛瘘156例小结,Bull Med Res Janu2001,30(1)：58.
[10]王晏美等.不同术式治疗高位肛瘘98例临床观察[J].北京中医药大学学报,2005,28(3)：90-91.
[11]张有生.肛肠科手册.沈阳：沈阳科学技术出版社,1985,P89.
[12]Hallan RI, Marzouk DEMM, Waldron DJ, et al Comparison of digital andmanometric assessment of anal sphincter function Br J Surg 1989; 76:973.
[13]钟英才.旷置切开挂线术治疗复杂性肛瘘30例临床观察[J].中国中医急症,2009,18(6)：891-892.
[14]戴民勇.切开挂线法治疗高位复杂性肛瘘[J].医学导刊,2008,(02)：18-19.
[15]郑丽华等.肛管直肠环大部离断术治疗单纯性高位肛瘘的临床观察[J].中国医刊,2010,45(12)：62.
[16]王晏美等.不同术式治疗高位肛瘘98例临床观察[J],北京中医药大学学报,2005,28(3)：90-91.
[17]范学顺等.采用非挂线疗法一次治愈高位肛瘘156例小结,Bull Med Res Janu2001,30(1)：58.
[18]钱海华.朱秉宜教授利用挂线疗法治疗高位肛瘘经验[J],南京中医药大学学报,2009,25(5)：387.
[19]蒋千超,徐炳牛,狳斌等.复杂性肛瘘213例治疗体会.现代中西医结合杂志[J],2003,12(5)：501-502.
[20]马英,左进等.高位复杂性肛瘘的治疗体会[J].新中医,2004.36(2)：73.
[21]杨万里.高位复杂性肛瘘术后处理体会[J].四川中医,2001,19(2)：59.
[22]艾中立,钱群.肛瘘复发的原因与对策[J].大肠肛门病外科杂志,2002,8(3)：143-144.