Seyfried Steffen, Bussen Dieter, Joos Andreas, Galata Christian, Weiss Christel, Herold Alexander
Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
Deutsches End- und Dickdarm-Zentrum, Mannheim, Germany.
Int J Colorectal Dis. 2018 Jul;33(7):911-918. doi: 10.1007/s00384-018-3042-6. Epub 2018 Apr 12.
Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.
All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.
The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.
Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.
尽管有现代医学技术，但解剖学上靠近肛门（高位）的肛瘘仍是结直肠手术中的一项挑战。在过去，治疗标准是进行完全瘘管切除术，但控便功能障碍发生率较高。在过去20到30年里，保留括约肌的手术已被广泛接受。它们是这些病例中所采用的技术。此外，许多患者接受了不限期治疗，即放置挂线以维持手术引流。所有肛瘘手术方式的主要问题是皮瓣手术的复发率高达30%至50%，而挂线治疗的持续率为100%。近年来，低位肛瘘的直接修复（一期重建）已被采用并显示出良好效果。这促使我们对高位肛瘘的技术进行改进。
对在曼海姆大学医学中心结直肠外科接受手术的所有患者（2003年6月至2015年11月），使用前瞻性数据库进行回顾性评估。所有接受瘘管切除术并一期括约肌重建的患者均被纳入。
平均随访11个月（7至200个月）后的一期愈合率为88.2%（424例中的374例）。考虑到进行二期括约肌修复的翻修手术，该比率达到95.8%（424例中的406例）。与括约肌相关的性别和肛瘘位置等因素对研究结果有显著影响，而重建肌肉量（毫米）、翻修次数、患者年龄、其他肛门手术以及伴随用药等变量则没有影响。通过问卷调查对148例患者亚组的控便功能进行了详细评估。即使在术前基线时，这些患者中有9.6%报告有某种程度的轻度控便功能障碍。手术后，34例患者（23.0%）出现控便功能障碍，其中23例患者存在排气失禁（15.5%），10例患者存在液体失禁（6.8%），1例患者存在固体粪便失禁。
瘘管切除术并一期括约肌重建是一种可行的手术，复发率低。在经括约肌肛瘘方面，没有其他手术显示出更好的效果。控便功能障碍对这些患者似乎影响较小。
