经括约肌间瘘管结扎法则

1、LIFTLIFT文献回顾与单中心结果分析文献回顾与单中心结果分析 经括约肌间瘘管结扎法则治愈率肛门括约肌功能经括约肌间瘘管结扎法则高位瘘管定义l A high fistula was defined as one encompassing more than one-third of the external sphincter complex.（瘘管侵犯瘘管侵犯1/3以上的外括约肌以上的外括约肌） Female patients are probably at risk because they have a shorter external anal sphincter anteriorl

2、y, 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 t

3、ransanal rectal advancement flap for high transsphincteric perianal fistulas; is there any advantage? Int J Colorectal Dis.2008;23(7):697-701Sultan AH. Anal-sphincter disruption during vaginal delivery. New Engl J Med 1993;329:1905-11Fitzpatrick M. Prospective study of the influence of parity and op

4、erative technique on the outcome of primary anal sphincter repair following obstetrical injury. Eur J Obstet Gynecol Reprod Biol 2000;89:159-63经括约肌间瘘管结扎法则保留括约肌手术方法经括约肌间瘘管结扎法则 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

5、. 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.经括约肌间瘘管结扎法则LIFT适应症经括约肌间瘘管结扎法则Ligation of I

6、ntersphincteric Fistula TractRojanasakul A. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 2007;90:581-6.治愈率治愈率94%经括约肌间瘘管结扎法则Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol.2009V13N

7、3:237-40经括约肌间瘘管结扎法则愈合与复发 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. Ligati

8、on of the intersphincteric fistula tract in the management of anal fistula. A systematic review. Colorectal Dis.2013;15(5):527-35经括约肌间瘘管结扎法则文献结果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):

9、43-6经括约肌间瘘管结扎法则 The reason for this may have to do with etiology 病因病因(increased number secondary to tuberculosis in Thailand), complexity复杂性复杂性 (number of prior procedures not reported in Rojanasakul et al), surgeon experience手术者的经手术者的经验验 with the procedure, or other unidentified factors不确定因素不确定因素.B

10、leier 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经括约肌间瘘管结扎法则93例患者，一次性治愈率（例患者，一次性治愈率（40%）+括约肌间瘘管切开术括约肌间瘘管切开术+二次二次LIFT=治愈率（治愈率（57%）Wallin UG. Does ligation of the intersphincteric fistula trac

11、t raise the bar in fistula surgery? Dis Colon Rectum.2012;55(11):1173-8经括约肌间瘘管结扎法则Wallin UG. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum.2012;55(11):1173-8经括约肌间瘘管结扎法则 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. Do

12、es ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum.2012;55(11):1173-8经括约肌间瘘管结扎法则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;

13、54(11):1368-72经括约肌间瘘管结扎法则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经括约肌间瘘管结扎法则Tan KK. The anatomy of failures following the ligation of intersphincteric tract

14、 technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368-72经括约肌间瘘管结扎法则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经

15、括约肌间瘘管结扎法则复发性瘘管 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经括约肌间瘘管结扎法则LIFTLIFT应该作为保留括约肌手术的首选方法应该作为保留括约肌手术的首选方法Ab

16、carian AM. Ligation of intersphincteric fistula tract: early results of a pilot study. Dis Colon Rectum.2012;55(7):778-82 经括约肌间瘘管结扎法则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经括约肌间瘘管结扎法则

17、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 rev

18、iew. Colorectal Dis.2013;15(5):527-35经括约肌间瘘管结扎法则结 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

19、(5):527-35经括约肌间瘘管结扎法则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 fis

20、tulas.Dis Colon Rectum.2010;53(10):1361-4Han 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经括约肌间瘘管结扎法则Han JG. Ligation of the Intersphincteric Fist

21、ula 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经括约肌间瘘管结扎法则Dudukgian H. Why do we have so much trouble treating anal fistula? World J Gastroenterol 2011 ,28; 17(28): 3292-96经括约肌间瘘管结扎法则单中心研究结

22、果分析（单一医师操作）经括约肌间瘘管结扎法则患者一般情况平均年龄（范围）平均年龄（范围）y38.2（2562）性别性别男 18 女 6吸烟吸烟否 15 是 9肛瘘病史肛瘘病史3.4 （6月20年）肛瘘病因肛瘘病因腺源性感染 23 TB感染 1手术史手术史 8/24 （13次）瘘管分类瘘管分类单一经括约肌肛瘘 14马蹄形肛瘘 8多发性肛瘘2外口与瘘管位置外口与瘘管位置前侧 8后侧 6（2例多发瘘管）侧方 2马蹄形弯曲瘘 8经括约肌间瘘管结扎法则Abcarian AM. Ligation of intersphincteric fistula tract: early results of a p

23、ilot study. Dis Colon Rectum.2012;55(7):778-82 经括约肌间瘘管结扎法则BCDEFGA经括约肌间瘘管结扎法则经括约肌间瘘管结扎法则经括约肌间瘘管结扎法则1.双氧水测试能够有效确定内口部位，提供肌间切口双氧水测试能够有效确定内口部位，提供肌间切口 的位置；的位置；2.紧贴外括约肌表面分离，可以确保进入解剖间隙，紧贴外括约肌表面分离，可以确保进入解剖间隙， 避免括约肌损伤；避免括约肌损伤；3.瘘管缝扎能够有效减少结扎结滑脱的风险；瘘管缝扎能够有效减少结扎结滑脱的风险；4.瘘管结扎后，双氧水测试以确定瘘管被有效结扎；瘘管结扎后，双氧水测试以确定瘘管被有效结

24、扎；5.肌间瘘管切断后，再次双氧水测试以确保括约肌外肌间瘘管切断后，再次双氧水测试以确保括约肌外 侧瘘管被有效结扎，可以降低完全失败的风险。侧瘘管被有效结扎，可以降低完全失败的风险。经括约肌间瘘管结扎法则结 果术中瘘管处理术中瘘管处理搔刮搔刮 10部分隧道式挖除部分隧道式挖除 12瘘管全部挖除，外括约肌缺损修补瘘管全部挖除，外括约肌缺损修补 2平均住院时间平均住院时间14.25天（天（1025天）天）平均随访时间平均随访时间15.9月（月（344月）月）治疗结果治疗结果(%)愈合率愈合率66.7% （16/24）部分失败部分失败肌间感染率肌间感染率 8.3%（2/24）括约肌间瘘括约肌间瘘 16.7%（4/24)完全失败完全失败8.