Sphincter preserving surgery for the treatment of complex anal fistula

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0 Introduction anal fistula is perianorectal gap suppurative infection, an infectious disease naturally formed after rupture, is a common an


0 Introduction anal fistula is perianorectal gap suppurative infection, an infectious disease naturally formed after rupture, is a common and complicated surgical infection. Complex anal fistula involving most of the anal sphincter, the recurrence with an increased risk of damage to the anal control function, clinical difficult to deal with anal sphincter injury. The main reason of anal incontinence, anal fistula is the principle of treatment to cure the fistula in maintenance of sphincter function. Under the premise of complexity anal sphincter preserving surgery is still the focus of future exploration and research. The following are several complex anal sphincter preserving surgery methods.1 drainage thread thread is divided into cutting seton drainage and hanging line, a major role for drainage, signs, stimulation and chronic Le cut. Cutting seton once is the main method for the treatment of complicated anal fistula, but. The result shows that the rate of anal incontinence after surgery is still as high as 34%-63%, and as a result of chronic Le rubber band on sphincter cut function, postoperative patients with severe pain, has been gradually replacing [1]. drainage seton drainage Seton fistula drainage to prevent abscess formation while [2]. drainage Seton completely preserved sphincter, reduce [3] incontinence, but the results showed that the treatment of complex anal fistula recurrence rate of 20%-80%[1-9]. Pinedo [10] by modified hanging line drainage: incision of internal sphincter muscle, open space, free of external sphincter, primary fistula seton drainage, treatment of complex anal fistula in 18 cases, follow-up of 16 mo without recurrence, 5.6% anal incontinence, 5% consistent with the Eitan [9] reported. Lu Jingen [12] the tunnel type towing line pipe for treating complex anal fistula, effectively protect the anorectal normal morphology and functional integrity, Paul The external anal sphincter and sphincter reflex, and minimize scar tissue caused by anal defects, so as to avoid anal incontinence, anal stenosis and anal malformation and other common complications. The cure rate is above 92%, the average healing time of 22d[11,13]. for AIDS associated with Crohn's anal fistula and anal fistula can be used over a long period of time drainage line, to limit the symptoms and protect the anal function of.2 rectal mucosa flap / perianal skin flap in rectal mucosa flap over closed passage surgery is one of the common methods in the treatment of complicated anal fistula, the specific operating practices and [14]: in probing fistula after anesthesia, mouth oval fistula resection, as the tunnel excavation from the inside. Below about 0.5 cm for half moon or trapezoidal tongue mucosa flap, mucosal flap should include mucosa, submucosa and circular muscle layer, the base is wide at the top Two times the degree, to ensure the blood supply and no tension. The lower edge of mouth mucosa flap resection, the remaining mucosa flap suture and drop anal sphincter repair, suture. Outside the mouth open drainage. Uribe [15] reported by rectal mucosal flap over treatment of anal fistula in 60 cases, follow-up of 43.8 Mo, recurrence the rate of 7.1%, 12.5% slight incontinence, 9% severe anal incontinence.Mitalas [16] of rectal mucosal flap failure patients over again by mucosal flap surgery, the cure rate was 69%, and the two operation did not increase the anal function damage. Van der Hagen [17] showed long-term recurrence of rectal mucosal flap over the operation rate of 63%. perianal skin flap surgery and rectal mucosal flap over the passage of similar, the main difference lies in the perianal skin flap by surgery to perianal skin flap for sphincter, including subcutaneous fat layer and part of the anal canal, flap pull Tension-free closure in the mouth. Jun [18] with perianal skin flap advanced in the treatment of high anal fistula in 40 cases, the cure rate was 95%, consistent with the Hossack [19] reported that the healing time was 2-3 wk, [20]. Zimmerman [21] no anal incontinence reported by perianal skin flap in the treatment of anal fistula of the cure rate was 78%, 30% patients with anal function. This method is applicable to the internal opening in the tooth line high transsphincteric anal sphincter and anal fistula, also apply to women in front of anal fistula, successful treatment of intestinal inflammation in Crohn's disease control better anal fistula rate 70%-75% of patients who failed surgery again [22,23]. [19] think Hossack perianal skin flap in the mouth can be closed by to improve the quality of life of patients, and can improve the symptoms of anal incontinence. Rectal mucosa flap by surgery and perianal skin flap on complex anal fistula treated by clearance of infection, closed inside the mouth, does not damage the About muscle, low risk of incontinence, the wound is small, avoid the keyhole deformity, repeated treatment can be critical to the success of [24]. is to ensure that the mucosal flap or flap blood supply, insufficient blood supply is the main reason for the failure. In comparison, perianal skin flap advanced surgery has more advantages: (1) no rectal mucosa, mucosa or muscle defect caused by infection, to avoid the formation of die cavity, injury of skin flap; (2) good ductility, avoid tension suture; (3) a higher success rate, easy [25].3 fibrin glue / anal fistula thrombus fibrin glue closed closed treatment of anal fistula with traditional anal fistula surgery compared to maximum advantage without sphincter injury, does not affect the anus function. After the removal of infected concrete operation before the anal gland and inside the mouth, to the hanging line drainage 4-6 wk to fistula inflammation subsided, hanging around the rubber band line to remove granulation filling, line elastic, scraping pipe, test A fistula length, absorbable suture closure in the mouth with 3-0. By measuring the length from the mouth into the injection of fibrin glue tube, fibrin glue injection, injection side edge back, until it closed mouth [14].Sentovich preliminary report of fibrin glue treatment of anal fistula cure rate was 85%[26], long-term studies they found the cure rate dropped to 60 cases of anal fistula treated with the method of 69%[27]., Zmora and [28] were 6Mo, the cure rate was 53%, the cure rate of Witte and [29] and de reported Parades [30] 55% and 50% are consistent. Although the fibrin glue in the treatment of anal fistula have certain effect, but with the passage of time, mainly due to the long-term curative effect of fibrin dropped to 16%[31,32]. glue treatment of anal fistula was the failure of fibrin glue and inflammatory tissue prolapse due to incomplete removal of lead to recurrence of anal fistula anal fistula (anal fistula plug [33]., AFP suppository) from porcine intestinal mucosa under A refined absorbable biomaterial, and human extracellular matrix structure similar to stimulate and help the injury as scaffolds for tissue repair and reconstruction. The method is as follows: [34] external orifice and pipe inspection, to clear the fistula and the branch pipe hanging line drainage 8 wk, anal fistula and full drainage branch after anesthesia, the inflammation subsided. With hydrogen peroxide, fistula, fistula resection and curettage, outside the mouth. AFP is inserted into the fistula from inside the mouth, until it is firmly fixed, AFP and anal sphincter interrupted suture, and close the mouth. In excess of AFP external trim around the mouth, without fixation and external AFP mouth, mouth open for drainage. The key to success lies in effective control of AFP fistula inflammation, inflammatory tissue will be AFP as a scaffold to stimulate tissue repair and reconstruction barrier damage, lead to the failure of the treatment of Schwandner. [34] with AFP treatment in 60 cases with anal sphincter, the cure rate was 62%, and other reports are consistent with the results of [35], and there is no risk of anal incontinence. Johnson [36] compares AFP with fibrin glue effect, show that AFP has higher cure rate. 25 cases of complex anal fistula, fibrin glue group 10 cases, group AFP 15 patients were followed up for 13.8wk, fibrin glue group the cure rate was 20%, the cure rate of group AFP 86.7%.. However, recent studies show that AFP long-term cure rate in 15%-40%[37-39]. AFP high cost, and its effectiveness remains to be studied whether the long-term postoperative dietary factors, will lead to the failure of the treatment also needs further study [40].4 intersphincteric fistula ligation transsphincteric between the fistula ligation (ligation of intersphincteric fistula tract, LIFT) by the Thailand Rojanasakul first proposed [41] methods are described with Matos [42]. LIFT mainly in the sphincter muscle Ligation and cut off the fistula, fistula scraping wall infection; Matos method is the removal of intersphincteric fistula, repair of anal sphincter opening, resection of the fistula and repair of.Matos in resection of the fistula is easy to damage the external anal sphincter, which is LIFT safe, effective area and don't lie [43]. with conventional incision, anal fistula cutting seton surgery compared to LIFT without cutting off the anal sphincter, intact anal function after operation. The specific methods are as follows. Patients with routine preoperative bowel preparation, anesthesia prone jackknife position. Using hydrogen peroxide clear internal and external anal fistula, fistula probe to probe in the Qing, guided by the intersphincteric groove skin 1.5-2.0 cm curved incision fistula in isolated sphincter between both sides will be close to the internal and external sphincter were sutured and cut the fistula, with repeated injection of hydrogen peroxide test, until the confirmation was thoroughly fistula The broken end ligation. To mouth fistula curette scraping, mouth open drainage. Postoperative to ciprofloxacin and metronidazole antibiotics such as anti-inflammatory treatment, mainly for fecal fistula in the mouth caused by residue into infected patients after timely cleaning wound [43]. cannot cause anal fistula self-healing, intersphincteric fistula due to internal and external sphincter contraction and oppression, poor drainage, repeated infection of [41]. LIFT become a closed inner port, clean the infected anal gland based on, mainly applicable to transsphincteric fistula and sphincter fistula, can also be extended to almost all of the fistula, but has not yet fully formed fistula in patients with early [43]. Rojanasakul [41] for LIFT treatment of transsphincteric anal fistula in 18 cases, the cure rate was 94.4%, the average cure time was 4 wk, no anal incontinence, long-term recurrence remains to be further studied, but they are optimistic Shanwani. [44] reports with LIFT in treatment of complex anal fistula in 45 cases, the cure rate was 82.2%, no anal incontinence, the postoperative recurrence rate was 3-8 Mo 17.7%. Aboulian [46] LIFT reported the latest treatment of 25 cases with anal sphincter, the cure rate was 68%, no anal incontinence; 8 failure cases in 1 cases received LIFT treatment again results show there are obvious advantages compared to [41,44-46] LIFT and other surgical methods in the treatment of complicated anal fistula: (1) completely retained the anal sphincter; (2) reduce tissue injury, shorten the healing time of wound; (3); (4) has the advantages of simple operation and low cost; (5) the recurrence after two surgery without any obstacles. Ligation of intersphincteric fistula tract as a new technique, the anal sphincter function the long term clinical efficacy and postoperative drainage of.5 still need further study conclusion hanging low risk line anal incontinence, but the recurrence rate is high, and the lack of evidence-based medical support. The rectum mucosa flap, perianal skin flap by surgery, fibrin glue and AFP treatment of anal fistula leading to the risk of anal incontinence is very low, but the recurrence rate is relatively high, and the operation of the technical requirements of the higher. LIFT can solve the above problems, but its long-term efficacy remains to be studied. The technology can not only cure complex anal fistula that must be considered when treatment, select the appropriate method to cure the fistula or in the premise of maintaining the anal sphincter function by reducing symptoms, so that the protection of complex anal fistula and anal function to achieve the best curative effect of.6 Williams JG MacLeod reference 1, CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae.Br J Surg 1991; 78: 1159-11612 Galis-Rozen E, Tulchinsky H, Rosen A, Eldar S, Rabau M, Stepanski A, Klausner JM, Ziv Y. Longtermoutcome of loose seton for compl Ex anal fistula:a two-centre study of patients with and withoutCrohn' s disease. Colorectal Dis 12: 358-3623 Buchanan GN, 2010; Owen HA, Torkington J, LunnissPJ, Nicholls RJ, Cohen CR. Long-term outcome followingloose-seton technique for external sphincterpreservation in complex anal fistula. Br J Surg 91: 476-4804 Takesue Y, 2004; Ohge H, Yokoyama T, Murakami Y Imamura, Y, Sueda T. Long-term results of setondrainage on complex anal fistulae in patients withCrohn' s disease. J Gas;



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