|
保留括约肌手术治愈肛瘘是肛肠外科医生 孜孜不倦的追求，更成为一种理念贯穿肛 瘘治疗的始终。从本期开始，将连续探讨 「肛瘘保留括约肌手术」。 本期，结合邵万金教授团队的临床实践 经验，将TROPIS的发展历史进行文献 解读，并结合典型病例进行图解分析， 以期为临床应用提供指导。 TROPIS的渊源 下图从不同角度显示肛门直肠周围结构及重要间隙 Eisenhammer认为括约肌间肛腺感染是形成肛瘘（或脓肿）的主要原因（1958年），下图可显示腺管（红色箭头）穿透内括约肌并在括约肌平面内以腺体结构终止（蓝色箭头）。 例如，慢性肛裂反复感染引起的高位脓肿（下图） 括约肌间肛腺感染可向周围蔓延，最终形成不同形式的肛瘘（或脓肿）。 Parks（1976年）和 Hanley（1985年）在实践中指出：高位肌间脓肿可向上蔓延，进入肛提肌上间隙形成急性脓肿。 完全内括约肌切开术使脓肿从肠腔内引流。 错误的手术入路可能导致“医源性的复杂的括约肌上/外肛瘘”。
两个重要间隙 2016年，任东林教授团队提出两个重要的“后深间隙”，分别指：
与 DPIS 相关的复杂瘘管和脓肿
不同严重程度的DPAS病变
The DPAS is well defined on MRI. It lies superior to the anococcygeal ligament and inferior to the anococcygeal raphe, dorsal to the puborectalis and ventral to the coccyx.The intrasphincteric spaces include the deep intersphincteric space and the superficial intersphincteric space, for which the heights correspond with the puborectalis and deep portion of the EAS. Normally the DPIS is a latent space undetectable on MRI. 正常情况下 ，DPAS 在 MRI 定位非常明确；而DPIS 在 MRI 中并不显露，当有感染形成时将此间隙撑开，形成密闭的小脓肿，当压力过大时则向组织薄弱的地方突破蔓延，形成各种类型的复杂性肛瘘。在大多数情况下，浅表括约肌间隙中的腺源性脓肿将向上延伸进入 DPIS。由于 DPIS 与周围的深部肛周间隙相连，因此 DPIS 的继发性病变可能单侧或双侧穿过后外侧的其他深部间隙，并导致高位经括约肌、括约肌上或肛提肌上瘘。DPIS 病变也可沿环周扩散，并形成深括约肌间或括约肌间的马蹄状瘘管。 马蹄形瘘管（或脓肿）的不同平面
与DPIS病变相关的复杂瘘管
The DPIS is often involved in complex posterior cryptoglandular fistulas. TROPIS术 高位复杂性肛瘘手术失败或复发的原因是没有处理DPIS。2017年，Garg提出经肛括约肌间切开术 (transanal opening of intersphincteric space，TROPIS)。TROPIS手术则会对DPIS进行处理。 In this study, the intersphincteric space was drained and laid open through the transanal route. The space was not closed and kept open so that it healed by secondary intention. The aim of this step was eradication of sepsis and healing of fistula. Since the external sphincter was not cut or damaged, the risk to incontinence was expected to be minimal. This simple procedure, transanal opening of intersphincteric space (TROPIS) through the internal opening, was done in complex high fistula-in-ano. The main aim of this procedure is to achieve fistula healing without doing any damage to external sphincter. This is achieved by removing sepsis on both sides of the external sphincter so that both sides heal well. Sepsis eradication is done by transanal opening up of fistula tract ‘inside the external sphincter’ and curetting the tract ‘outside the external sphincter’. Postoperatively, both sides are kept clean till complete healing happens. Inadequate cleaning of one side would lead to passage to infected fluid from this side to the other side leading to non-healing of that side as well. Therefore both the steps are crucial for the success of operation. TROPIS 手术仅切开部分内括约肌，无需切开外括约肌，即使肌间脓肿过大波及到外括约肌，此入路对外括约肌的损伤也是最小的，因此对肛门功能影响很小。 61 patients with high complex fistula-in-ano were included(follow-up:6-21 months). Male/Female:59/2, age-42.3 ±9.5 years. 85.2%(52) were recurrent, 83.6%(51) had multiple tracts, 36.1%(22) had horseshoe tract, 34.4%(21) had supralevator extension and 26.2%(16) had associated abscess. 95.1%(58) were posterior fistula out of which 90.2%(55) were in posterior midline. Nine patients were excluded (due to tuberculosis, lost to follow-up). Fistula healed completely in 84.6%(44/52) and didn’t heal in 15.4%(9/52). 4/9 of these were reoperated and fistula healed in three patients. Thus overall healing rate was 90.4% (47/52). There was no significant change in incontinence scores. Garg采用该手术治疗61例高位复杂性肛瘘患者，中位随访期9个月，治愈率高达90.4%，术后患者肛门失禁评分无明显变化。 手术前和手术治疗后
Parks 将瘘管走形进行分类，形成肛瘘最经典的分型方法：“Parks分型”（1976年），并列出了各类分型所占的比例。
而最新研究表明，括约肌间型肛瘘占所有肛瘘类型的75%以上，因此掌握 TROPIS 术可以有效治疗大部分肛瘘。 病例分享
王浩医生 广东省中医院肛肠外科主治医师 擅长以下疾病的手术治疗和微创治疗： 结直肠肿瘤的微创治疗（结直肠癌；直肠癌低位保肛） |
|
|
