开窗旷置术治疗高位复杂性肛瘘的临床和实验研究
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摘要
目的：本课题旨在通过系统的临床观察和实验研究，探讨开窗旷置术治疗高位复杂性肛瘘的临床疗效及机理。
方法：将60例高位复杂性肛瘘患者随机分为开窗旷置术组(治疗组)和切开挂线术组(对照组)进行临床疗效的观察和对比，并对每组中的20例患者进行手术前后肛管直肠压力，肛门外括约肌肌电图及直肠感觉与肛门节制功能的对比。
结果：1、开窗旷置术治疗高位复杂性肛瘘能明显缩短创面愈合时间，减少肛门周围组织的损伤，减少术后并发症，远期肛门括约功能良好，明显优于切开挂线术。
2、开窗旷置术术后肛管最大收缩压，肛管静息压，肛管舒张压，肛门外括约肌静息波幅，大力收缩波幅，直肠阈值量，直肠恒定量，肛门首漏量，肛门保留量均降低，但下睁幅度明显小于切开挂线术(P＜0.01)。肛管最长收缩时间缩短，但缩短幅度明显小于切开挂线术(P＜0.01)。
结论：开窗旷置术是治疗高位复杂性肛瘘的一种理想术式，该术式是利用肛肠动力学原理，通过彻底清除原发病灶，减少对肛门括约肌及周围组织的损伤来保护肛门括约功能。
Objective: To evaluate the curative effect of the fenestration and putting aside therapy on HCAF and to discuss its mechanism by systematic clinical and experiment study.
Methods: Sixty cases of patients were divided randomly into the control group and the treatment group. The former was treated with incision and thread-drawing therapy, and the latter with fenestration and putting aside. A comparative study on clinical curative effect between the control group and the treatment group was conducted by examining the anorectal manometry, MEG of external sphincter muscle of anus, the rectal sensory function and the anal continence function in 20 cases selected from each group randomly.
Results:1.Fenestration and Putting aside therapy could shorten the recovery time of the wound, decrease the damage of crissal tissue and postoperative complication, and have a satisfactory long-term function of anal sphincter. It was better than the incision and thread-drawing therapy.
2.The items in both groups such as the postoperative anal maximal contraction pressure, the anal rest pressure, the anal relaxant pressure, the amplitude of quiescent wave, the maximal contractile wave of external sphincter of anus, the rectal sensory threshold, the rectal constant volume, the
treatment group had a less declined range compared with the control group(P<0.01). The anal longest contraction time decreased too in both groups but the treatment group was better than the control group(P<0.01).
Conclusion: Fenestration and putting aside therapy is a satisfactory surgical method in the treatment of HCAF. It makes use of the anorectal dynamics, and can clean the primary focus of disease thoroughly, protect the function of anal sphincter muscle by reducing the damage of anal sphincter muscle and crissal tissue.
方法：将60例高位复杂性肛瘘患者随机分为开窗旷置术组(治疗组)和切开挂线术组(对照组)进行临床疗效的观察和对比，并对每组中的20例患者进行手术前后肛管直肠压力，肛门外括约肌肌电图及直肠感觉与肛门节制功能的对比。
结果：1、开窗旷置术治疗高位复杂性肛瘘能明显缩短创面愈合时间，减少肛门周围组织的损伤，减少术后并发症，远期肛门括约功能良好，明显优于切开挂线术。
2、开窗旷置术术后肛管最大收缩压，肛管静息压，肛管舒张压，肛门外括约肌静息波幅，大力收缩波幅，直肠阈值量，直肠恒定量，肛门首漏量，肛门保留量均降低，但下睁幅度明显小于切开挂线术(P＜0.01)。肛管最长收缩时间缩短，但缩短幅度明显小于切开挂线术(P＜0.01)。
结论：开窗旷置术是治疗高位复杂性肛瘘的一种理想术式，该术式是利用肛肠动力学原理，通过彻底清除原发病灶，减少对肛门括约肌及周围组织的损伤来保护肛门括约功能。
Objective: To evaluate the curative effect of the fenestration and putting aside therapy on HCAF and to discuss its mechanism by systematic clinical and experiment study.
Methods: Sixty cases of patients were divided randomly into the control group and the treatment group. The former was treated with incision and thread-drawing therapy, and the latter with fenestration and putting aside. A comparative study on clinical curative effect between the control group and the treatment group was conducted by examining the anorectal manometry, MEG of external sphincter muscle of anus, the rectal sensory function and the anal continence function in 20 cases selected from each group randomly.
Results:1.Fenestration and Putting aside therapy could shorten the recovery time of the wound, decrease the damage of crissal tissue and postoperative complication, and have a satisfactory long-term function of anal sphincter. It was better than the incision and thread-drawing therapy.
2.The items in both groups such as the postoperative anal maximal contraction pressure, the anal rest pressure, the anal relaxant pressure, the amplitude of quiescent wave, the maximal contractile wave of external sphincter of anus, the rectal sensory threshold, the rectal constant volume, the
treatment group had a less declined range compared with the control group(P<0.01). The anal longest contraction time decreased too in both groups but the treatment group was better than the control group(P<0.01).
Conclusion: Fenestration and putting aside therapy is a satisfactory surgical method in the treatment of HCAF. It makes use of the anorectal dynamics, and can clean the primary focus of disease thoroughly, protect the function of anal sphincter muscle by reducing the damage of anal sphincter muscle and crissal tissue.
引文
[1] 何永恒，杨亲昭，李春眉等．分段开窗旷置结合切扩挂线术治疗长瘘道高位复杂性肛瘘．中国肛肠病杂志，1998；18(5)：18
[2] 顾伯康．中医外科学．北京：人民卫生出版社，1987；361
[3] 杨向东，曹吉勋，沈龙生等．肛瘘内口闭锁药捻脱管法术后直肠感觉节制功能的研究．中国肛肠病杂志，1995；(3)：11
[4] 陈关兴．改道截根术治疗复杂性肛瘘198例报告．大肠肛门外科杂志，1998；4(3)：96
[5] Mccountrt JS, et al. Setons in the surgical management of fistula in ano. Br J Surg 1995; 82: 448.
[6] Bartolo D C, et al. The role of partial denervation of the puborectalis in idiopathic faceal intinence. Br J Surg 1988;70:664
[7] Sainia F, et al. A prospective manometric Study of the effect of anal fistula Surgery on anorectal function. Acta Chir Scand 1985; 151:279
[8] 张东铭．盆底与肛门病学．贵阳：贵州科技出版社，2001：25
[9] Kennedy HL, et al.Fistulotomy without external sphincter division of high anal fistulae. Br J Surg 1990; 77:898
[10] Williams JG, et al. Seton treatment of high anal fistulae. Br J Surg 1991; 78:1159
[11] Rusell K, et al. Dis Colon Rectum 1993; 36:573
[12] 罗运权摘译．挂线引流治疗经肛门外括约肌瘘临床疗效的观察．国外医学外科分册，1999；17(4)：256
[13] 唐建林摘译．切开挂线法治疗32例高位经括约肌瘘或括约肌上方瘘的临床疗效观察，国外医学外科分册，2000；18(3)：190
[14] 张思奋，罗湛滨，任东林．高位复杂性肛瘘的解剖学切除术．广东医学，2001；22(12)：1098
[15] Takano M. Anatomical fistulectomy. J Jan Soc Coloproctol 1992;45:41
[16] 董平．旷置引流法治疗复杂性肛瘘38例．中国肛肠病杂志，2000；20(5)：26
[17] 黄乃健，胡林山，晃山等．内口切开术治疗低位肛瘘的治疗和实验研究．中国肛肠病杂志，2000；20(5)：3
[18] 范亚明．单纯内口切开改道引流术治疗马蹄形肛瘘116例疗效总结．中国肛
肠病杂志．2001；21(5)：15
[19] 余苏萍，李柏辛，丁义江等．高位复杂性肛瘘手术前后盆底肌电图与肛管直肠压力测定的研究．中国肛肠病杂志，1998；18(5)：3
[20] 王传华，王海艳．开窗挂线疗法治疗高位复杂性肛瘘180例体会．中国实用外科杂志，1998；18(37)：167
[21] 张庆荣，临床肛门大肠外科学．天津：天津科技翻译出版公司，1992；9
[22] Hermann G.Desfosses L.CR Acad Sci 1980;90:1301
[23] 任东林．有关高位复杂性肛瘘治疗的几个问题．广东医学，2001；22(12)：1093
[24] Shafik A.Dis Colon Rectum 1998;23:37
[25] 胡伯虎．大肠肛门病治疗学．北京：科学技术文献出版社，2001；314
[26] Van Tets WF, et al. Seton treatment of perianal fistula with high anal or rectal opening. Br J Surg 1995;82:895
[27] Hanley PH, et al. Dis Colon Rectum 1985;28:528
[28] Christensen A, et al. Dis colon Rectum 1986;29:454
[29] 董平，肛管直肠动力学在肛瘘手术中的意义．中国实用外科杂志，1998；18(9)：552
[2] 顾伯康．中医外科学．北京：人民卫生出版社，1987；361
[3] 杨向东，曹吉勋，沈龙生等．肛瘘内口闭锁药捻脱管法术后直肠感觉节制功能的研究．中国肛肠病杂志，1995；(3)：11
[4] 陈关兴．改道截根术治疗复杂性肛瘘198例报告．大肠肛门外科杂志，1998；4(3)：96
[5] Mccountrt JS, et al. Setons in the surgical management of fistula in ano. Br J Surg 1995; 82: 448.
[6] Bartolo D C, et al. The role of partial denervation of the puborectalis in idiopathic faceal intinence. Br J Surg 1988;70:664
[7] Sainia F, et al. A prospective manometric Study of the effect of anal fistula Surgery on anorectal function. Acta Chir Scand 1985; 151:279
[8] 张东铭．盆底与肛门病学．贵阳：贵州科技出版社，2001：25
[9] Kennedy HL, et al.Fistulotomy without external sphincter division of high anal fistulae. Br J Surg 1990; 77:898
[10] Williams JG, et al. Seton treatment of high anal fistulae. Br J Surg 1991; 78:1159
[11] Rusell K, et al. Dis Colon Rectum 1993; 36:573
[12] 罗运权摘译．挂线引流治疗经肛门外括约肌瘘临床疗效的观察．国外医学外科分册，1999；17(4)：256
[13] 唐建林摘译．切开挂线法治疗32例高位经括约肌瘘或括约肌上方瘘的临床疗效观察，国外医学外科分册，2000；18(3)：190
[14] 张思奋，罗湛滨，任东林．高位复杂性肛瘘的解剖学切除术．广东医学，2001；22(12)：1098
[15] Takano M. Anatomical fistulectomy. J Jan Soc Coloproctol 1992;45:41
[16] 董平．旷置引流法治疗复杂性肛瘘38例．中国肛肠病杂志，2000；20(5)：26
[17] 黄乃健，胡林山，晃山等．内口切开术治疗低位肛瘘的治疗和实验研究．中国肛肠病杂志，2000；20(5)：3
[18] 范亚明．单纯内口切开改道引流术治疗马蹄形肛瘘116例疗效总结．中国肛
肠病杂志．2001；21(5)：15
[19] 余苏萍，李柏辛，丁义江等．高位复杂性肛瘘手术前后盆底肌电图与肛管直肠压力测定的研究．中国肛肠病杂志，1998；18(5)：3
[20] 王传华，王海艳．开窗挂线疗法治疗高位复杂性肛瘘180例体会．中国实用外科杂志，1998；18(37)：167
[21] 张庆荣，临床肛门大肠外科学．天津：天津科技翻译出版公司，1992；9
[22] Hermann G.Desfosses L.CR Acad Sci 1980;90:1301
[23] 任东林．有关高位复杂性肛瘘治疗的几个问题．广东医学，2001；22(12)：1093
[24] Shafik A.Dis Colon Rectum 1998;23:37
[25] 胡伯虎．大肠肛门病治疗学．北京：科学技术文献出版社，2001；314
[26] Van Tets WF, et al. Seton treatment of perianal fistula with high anal or rectal opening. Br J Surg 1995;82:895
[27] Hanley PH, et al. Dis Colon Rectum 1985;28:528
[28] Christensen A, et al. Dis colon Rectum 1986;29:454
[29] 董平，肛管直肠动力学在肛瘘手术中的意义．中国实用外科杂志，1998；18(9)：552