Limura Elsa, Giordano Pasquale
Elsa Limura, Pasquale Giordano, Department of Colorectal Surgery, Whipps Cross Hospital, Barts Health NHS Trust, London E11 1NR, United Kingdom.
World J Gastroenterol. 2015 Jan 7;21(1):12-20. doi: 10.3748/wjg.v21.i1.12.
Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.
肛瘘的理想手术治疗应旨在根除感染并促进瘘管愈合，同时保留括约肌和控便机制。对于简单且位于最远端的肛瘘，诸如瘘管切开术等传统手术方式似乎相对安全，因此在临床实践中被广泛接受。然而，对于涉及相当一部分肛门括约肌的更复杂肛瘘，人们仍高度担心会损伤括约肌以及随后出现功能不良的后果，而这在传统手术治疗后是相当不可避免的。因此，在过去二十年中，已引入了许多保留括约肌的肛瘘治疗方法，其共同目标是将对肛门括约肌的损伤降至最低并保留最佳功能。其中，括约肌间瘘管结扎术似乎安全有效，对于复杂肛瘘可常规考虑采用。另一种技术是肛瘘塞，它由猪小肠黏膜下层制成，安全但长期随访效果一般，成功率在24%至88%之间。失败率可能是由于其从瘘管中挤出。为避免这种情况，引入了一种新设计的塞子（GORE BioA®），但其疗效的长期数据较少。纤维蛋白胶的愈合率较差且变化较大（14%至74%）。FiLaC和视频辅助肛瘘治疗方法分别使用激光和电极能量，成本高昂且尚未在临床实践中得到充分评估。最近，有人描述了一种使用自体脂肪来源干细胞的疗法。它们在肛瘘中再生组织和抑制炎症反应的特性必须得到更好的研究，相关研究仍在进行中。本文的目的是回顾相关文献，描述新的保留括约肌技术的优点和局限性。
