Nwaejike N, Gilliland R
Department of Surgery, Altnagelvin Hospital, Londonderry, UK.
Colorectal Dis. 2007 Oct;9(8):749-53. doi: 10.1111/j.1463-1318.2007.01227.x.
Some conditions, previously managed by general surgeons, may be treated more successfully by colorectal specialists. This argument is well established for rectal cancer but does it also apply to benign conditions? This study compares the treatment strategies and outcomes for fistulae-in-ano by general and colorectal surgeons in a district general hospital.
Patients who had surgery for fistula-in-ano from January 1992-October 2003 were identified from theatre records. Case notes were reviewed for data on type of fistula, aetiology, surgery performed and recurrence. All patients were sent a questionnaire requesting details of recurrence and incontinence. The severity of incontinence was assessed using the Faecal Incontinence Quality of Life Scale (FIQOLS) and the Faecal Incontinence Severity Index (FISI).
Eighty four patients (male = 53) were identified. Colorectal surgeons performed surgery in 34 and general surgeons in 50 patients. These groups were comparable with terms of age, gender, aetiology (colorectal: IBD = 5, cryptoglandular = 21: general IBD = 14, cryptoglandular = 24; P = 0.28; Chi-squared test), and type of fistulae (colorectal: inter-sphincteric = 20, trans-sphincteric = 13: general inter-sphincteric = 30, trans-sphincteric = 18: P = 1.0; Fisher's exact test). Colorectal surgeons carried out fewer fistulotomies (47.1%vs 84.0%; P < 0.001; Fisher's exact test), more staged fistulotomies with Setons (44.1%vs 10.0%: P < 0.001; Fisher's exact test), and had fewer recurrences (9.7%vs 30.0%: P < 0.05; Fisher's exact test) when compared with general surgeons. Five patients with recurrence from the general surgery group were subsequently referred to the colorectal surgeons; four patients had further surgery (fistulotomy = 2; staged fistulotomy = 2) with no recurrence to date; one patient required proctectomy. Forty seven (64.4%) patients answered the questionnaire. There was no difference between patients operated on by colorectal or general surgeons with regards the frequency (43.5%vs 62.5%: P = 0.25; Fisher's exact test) or severity [FISI 26 (21-38); median (inter-quartile range) vs 26 (17-38); median (inter-quartile range: P = 0.85; Mann-Whitney test) of faecal incontinence. There was no difference between the groups with regards any of the four scales that comprised the FIQOLS.
The number of included patients is far too low to draw any conclusions but there were some interesting trends. For similar patient samples, colorectal surgeons seem to adopt a more conservative approach and have fewer recurrences than general surgeons. These differences are not reflected in the frequency or severity of postoperative incontinence.
一些以前由普通外科医生处理的病症，可能由结直肠专科医生治疗会更成功。这一观点在直肠癌治疗方面已得到充分证实，但在良性病症中是否也适用呢？本研究比较了地区综合医院普通外科医生和结直肠外科医生对肛瘘的治疗策略及治疗效果。
从手术记录中确定1992年1月至2003年10月期间接受肛瘘手术的患者。查阅病历以获取瘘管类型、病因、所施行手术及复发情况的数据。向所有患者发送问卷，询问复发及失禁的详细情况。使用大便失禁生活质量量表（FIQOLS）和大便失禁严重程度指数（FISI）评估失禁的严重程度。
共确定了84例患者（男性53例）。结直肠外科医生为34例患者实施了手术，普通外科医生为50例患者实施了手术。这些组在年龄、性别、病因（结直肠外科：炎性肠病5例，隐窝腺性21例；普通外科：炎性肠病14例，隐窝腺性24例；P = 0.28；卡方检验）及瘘管类型（结直肠外科：括约肌间型20例，经括约肌型13例；普通外科：括约肌间型30例，经括约肌型18例；P = 1.0；Fisher精确检验）方面具有可比性。与普通外科医生相比，结直肠外科医生进行的瘘管切开术较少（47.1%对84.0%；P < 0.001；Fisher精确检验），采用挂线分期瘘管切开术较多（44.1%对10.0%：P < 0.001；Fisher精确检验），且复发较少（9.7%对30.0%：P < 0.05；Fisher精确检验）。普通外科组有5例复发患者随后转诊至结直肠外科医生处；4例患者接受了进一步手术（瘘管切开术2例；分期瘘管切开术2例），至今未复发；1例患者需要行直肠切除术。47例（64.4%）患者回复了问卷。结直肠外科医生或普通外科医生手术的患者在大便失禁频率（分别为43.5%对62.5%：P = 0.25；Fisher精确检验）或严重程度[FISI 26（21 - 38）；中位数（四分位间距）对26（17 - 38）；中位数（四分位间距）：P = 0.85；Mann - Whitney检验]方面无差异。在构成FIQOLS的四个量表中的任何一个方面，两组之间也无差异。
纳入患者数量过少，无法得出任何结论，但存在一些有趣的趋势。对于相似的患者样本，结直肠外科医生似乎采取了更保守的方法，且复发比普通外科医生少。这些差异在术后失禁的频率或严重程度方面未体现出来。
