经括约肌间瘘管结扎术--杨柏霖20130625

LIFT文献回顾与单中心结果分析,杨柏霖,南京中医药大学附属医院,治愈率,肛门括约肌功能,高位瘘管定义,A high fistula was defined as one encompassing more than one-third of the external sphincter complex.（瘘管侵犯1/3以上的外括约肌）Female patients are probably at risk because they have a shorter external anal sphincter anteriorly, which is prone to damage during childbirth（女性前侧外括约肌较短，且在分娩时可能被损伤）,van Koperen PJ. Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin.Dis Colon Rectum.2008;51(10):1475-81van Koperen PJ. Fibrin glue and transanal rectal advancement flap for high transsphincteric perianal fistulas; is there any advantage? Int J Colorectal Dis.2008;23(7):697-701,Sultan AH. Anal-sphincter disruption during vaginal delivery. New Engl J Med 1993;329:1905-11Fitzpatrick M. Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury. Eur J Obstet Gynecol Reprod Biol 2000;89:159-63,保留括约肌手术方法,Matos D(1993) 首先报道了经括约肌间路径治疗高位肛瘘Rojanasakul A(2007)报道经括约肌间瘘管结扎术(ligation of the intersphincteric fistula tract, LIFT),Matos D. Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg 1993;80:802-4.Rojanasakul A. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 2007;90:581-6.,LIFT适应症,Ligation of Intersphincteric Fistula Tract,Rojanasakul A. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 2007;90:581-6.,治愈率94%,Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol.2009V13N3:237-40,愈合与复发,愈合括约肌间切口及外口完全愈合失败括约肌间切口感染括约肌间切口未愈合，但未形 成括约肌肌间瘘部分失败形成括约肌间瘘完全失败在原先愈合的部位瘘管再现,Tan KK. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368-72Yassin NA. Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review. Colorectal Dis.2013;15(5):527-35,文献结果,Bleier JI;Moloo H;Goldberg SM. Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas.Dis Colon Rectum. 2010;53(1):43-6,The reason for this may have to do with etiology 病因(increased number secondary to tuberculosis in Thailand), complexity复杂性 (number of prior procedures not reported in Rojanasakul et al), surgeon experience手术者的经验 with the procedure, or other unidentified factors不确定因素.,Bleier JI;Moloo H;Goldberg SM. Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas.Dis Colon Rectum. 2010;53(1):43-6,93例患者，一次性治愈率（40%）+括约肌间瘘管切开术+二次LIFT=治愈率（57%）,Wallin UG. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum.2012;55(11):1173-8,Wallin UG. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum.2012;55(11):1173-8,治愈率低的可能原因多次手术治疗（32%）马蹄形肛瘘或多发肛瘘（16%）非单一手术医师（9），存在学习曲线和手术方式的差异性,Wallin UG. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum.2012;55(11):1173-8,Tan KK. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368-72,Tan KK. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368-72,Tan KK. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368-72,Tan KK. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368-72,复发性瘘管,17例复发性瘘管16周临床随访：11(65%)完全闭合，2(12%) 感染窦道，4例(23%)瘘管持续存在终点时间(13.5月）：2例失访；47% (7/15) 愈合，13% (2/15)肌间切口形成窦道，40%(6/15)瘘管持续存在(4)或复发(2)没有肛门自控功能的进一步损害,Lehmann,JP. Efficacy of LIFT for recurrent anal fistula. Colorectal Dis.2013(15)5:592-5,LIFT应该作为保留括约肌手术的首选方法,Abcarian AM. Ligation of intersphincteric fistula tract: early results of a pilot study. Dis Colon Rectum.2012;55(7):778-82,Mata 分析结果,Yassin NA. Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review. Colorectal Dis.2013;15(5):527-35,总病例：498例年龄：1893岁腺源性肛瘘：494（99%）随访时间：155月（中位随访时间419.5月）治愈率：4095%，平均71%（352/495，3例失访）肛门功能评估：6%（11/183）轻度肛门失禁术后疼痛、术后患者满意度、恢复正常生活时间：优并发症：外痔血栓形成 1例 出血 3例,经括约肌肛瘘470（94%）括约肌间瘘11例括约肌上方瘘9例直肠阴道瘘4例,Yassin NA. Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review. Colorectal Dis.2013;15(5):527-35,结 论,LIFT手术推荐的适应症为经括约肌肛瘘长期随访结果显示，2/3的患者LIFT治愈LIFT对肛门功能影响较小，仅6%的患者存在轻微肛门功能下降高位经括约肌肛瘘或括约肌上方瘘由于分离平面较深和之前手术疤痕，导致手术操作受限,Yassin NA. Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review. Colorectal Dis.2013;15(5):527-35,BioLIFT,LIFT+生物补片：瘘管缝扎后，在括约肌间切口内放置生物补片进行加强.至少随访1年，治愈率94%（29/31）LIFT+肛瘘栓中位随访时间14月，治愈率95%（20/21）,Neal Ellis C. Outcomes with the use of bioprosthetic grafts to reinforce the ligation of the intersphincteric fistula tract (BioLIFT procedure) for the management of complex anal fistulas.Dis Colon Rectum.2010;53(10):1361-4,Han JG. Ligation of the Intersphincteric Fistula Tract Plus Bioprosthetic Anal Fistula Plug (LIFT-Plug): a New Technique for Fistula-in-Ano. Colorectal Dis. 2012 Accepted Article, doi: 10.1111/codi.12062,Han JG. Ligation of the Intersphincteric Fistula Tract Plus Bioprosthetic Anal Fistula Plug (LIFT-Plug): a New Technique for Fistula-in-Ano. Colorectal Dis. 2012 Accepted Article, doi: 10.1111/codi.12062,Dudukgian H. Why do we have so much trouble treating anal fistula? World J Gastroenterol 2011 ,28; 17(28): 3292-96,单中心研究结果分析（单一医师操作）,患者一般情况,Abcarian AM. Ligatio