Garg Pankaj, Yagnik Vipul D, Kaur Baljit, Menon Geetha R, Dawka Sushil
Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India.
Department of Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India.
World J Clin Cases. 2022 Jul 16;10(20):6845-6854. doi: 10.12998/wjcc.v10.i20.6845.
The transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS).
To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division.
Patients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10 postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey's scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE.
Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) ( = 0.00001, -test).
Division of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).
经肛门括约肌间间隙开放术（TROPIS）用于治疗复杂性肛瘘，该手术保留了肛门外括约肌（EAS），但涉及部分切开肛门内括约肌（IAS）。
确定TROPIS手术中切开IAS后失禁的发生率，并评估术后定期进行凯格尔运动（KE）是否可以预防因IAS切开导致的失禁。
纳入因高位复杂性肛瘘接受手术且术前无大便失禁问题（评分=0）的患者。所有患者均接受TROPIS手术，并建议每天进行50次KE（盆底收缩运动）。KE于术后第10天开始，持续1年。在术后即刻（KE前组）和长期随访时（KE后组）客观评估失禁情况（采用改良的Vaizey评分）。比较两组的失禁评分以评估KE的疗效。
本研究纳入了2018年7月至2020年7月期间接受手术的102例肛瘘患者。其中男性90例，平均年龄42.3±12.8岁，中位随访时间为30个月（18 - 42个月）。3例患者失访。有65例复发性肛瘘，92例有多条瘘管，42例伴有脓肿，46例为马蹄形肛瘘，34例为括约肌上肛瘘。所有患者均经磁共振成像证实为高位肛瘘（累及>1/3的EAS）。总体上，31%的患者发生失禁（KE前组），其中急迫性和气体性失禁占大多数（28.3%）。KE前组的平均失禁评分为1.19±1.96（31例患者，固体便失禁=0，液体便失禁=7，气体失禁=8，急迫性失禁=24），KE后组为0.26±0.77（13例患者，固体便失禁=0，液体便失禁=2，气体失禁=3，急迫性失禁=10）（P = 0.00001，t检验）。
IAS切开导致失禁，主要是急迫性失禁，也有轻度的气体和液体失禁。然而，定期进行KE可显著减少失禁的发生（包括失禁患者数量及这些患者的评分严重程度）。
