Bodzin J H
Sinai Inflammatory Bowel Disease Center, Bingham Farms, Michigan 48125, USA.
Am Surg. 1998 Jul;64(7):627-31; discussion 632.
A 20-year review of the inflammatory bowel disease surgical database of the author was analyzed for Crohn's disease (CD) patients who had a surgical approach to perianal fistula disease (PAD). Of 333 patients with CD operated between July 1977 and February 1997, 51 had procedures for PAD (15.3%), and 7 of these patients had laser ablation of severe, debilitating complex PAD (13.7%). These patients have traditionally been treated by diverting ileostomy or proctectomy with permanent diversion. Others have advocated conservative management with long-term antibiotics, staged operations, and insertion of multiple loose setons to promote drainage. This technique was adapted from the laser procedure now advocated for severe hydradenitis suppurativa. The hand-held CO2 laser was used to unroof all fistulas external to the external sphincter. Fistulas were identified by probing. Infected granulation tissue was removed by laser ablation until normal fat or muscle was revealed. Intersphincteric abscesses were unroofed, and a single seton was placed around the external sphincter for all but submucous fistulas. Patients were usually operated as outpatients with pain control effected with oral and transnasal agents. A laparoscopically performed temporary diverting ileostomy was used in one early patient in the series. Patients were followed, and progress was documented by physical examination and photographs. Quality of life was assessed. All patients improved remarkably from their preoperative state. The 4 patients in the group operated more than 1 year before this review have all demonstrated complete healing. The three more recent patients are in various stages of healing. Continence was preserved in 7 of 7 patients. No patient has required rectal excision. Recurrence thought to be related to associated hydradenitis has occurred in 1 patient. Laser ablation is a valuable technique in the management of patients with severe, debilitating complex PAD complicating CD. It effectively eradicates the septic tracks and pockets while preserving sphincter function. It obviates the need for diversion with or without proctectomy.
对作者的炎症性肠病手术数据库进行了为期20年的回顾分析，纳入采用手术方法治疗肛周瘘病（PAD）的克罗恩病（CD）患者。在1977年7月至1997年2月期间接受手术的333例CD患者中，51例接受了PAD手术（15.3%），其中7例患者接受了激光消融术治疗严重、使人衰弱的复杂性PAD（13.7%）。传统上，这些患者接受转流性回肠造口术或直肠切除术并永久性转流治疗。其他人则主张采用长期抗生素、分期手术以及插入多个宽松的挂线引流来进行保守治疗。该技术改编自目前用于严重化脓性汗腺炎的激光手术。使用手持式二氧化碳激光对肛门外括约肌以外的所有瘘管进行去顶。通过探查确定瘘管。用激光消融去除感染的肉芽组织，直到露出正常脂肪或肌肉。对括约肌间脓肿进行去顶，除黏膜下瘘管外，所有瘘管均在肛门外括约肌周围放置单个挂线引流。患者通常作为门诊病人接受手术，通过口服和经鼻用药控制疼痛。该系列中的一名早期患者采用了腹腔镜下进行的临时转流性回肠造口术。对患者进行随访，通过体格检查和拍照记录病情进展。评估生活质量。所有患者均较术前状态有显著改善。在本次回顾前1年多接受手术的该组4例患者均已完全愈合。最近的3例患者处于不同的愈合阶段。7例患者中有7例保留了控便能力。没有患者需要进行直肠切除。1例患者出现了被认为与相关汗腺炎有关的复发。激光消融是治疗合并CD的严重、使人衰弱的复杂性PAD患者的一种有价值的技术。它能有效根除感染通道和脓腔，同时保留括约肌功能。它避免了进行或不进行直肠切除的转流需求。
