Sailer M, Fuchs K H, Kraemer M, Thiede A
Chirurgische Universitätsklinik, Würzburg.
Zentralbl Chir. 1998;123(7):840-5; discussion 846.
Most anal fistulas can be easily dealt with by simple fistulotomy. So called complex fistulas-in-ano need a differentiated, individually tailored surgical approach in order to avoid recurrence and sphincter incompetence. Complex fistulas comprise either tracks with high trans-, supra-, or extrasphincteric extension or fistulas that are complicated by multiple side branches, chronic inflammatory disease, previous operations etc. Prior to treatment a thorough preoperative diagnostic work-up is warranted. A precise intraoperative evaluation is paramount to allow radical excision of all inflamed tissue, often necessitating anal sphincter division with subsequent reconstruction. The treatment plan involves staged operations over a period of many months, usually with the (laparoscopic) fashioning of a protective stoma at the primary operation. Analysing our patients in the study period from 1/95 to 12/96 our different surgical approaches and their results are presented and discussed. During this period 96 patients with a fistula-in-ano were operated upon in the Department of Surgery at Würzburg University Hospital, of which 11 (11.5%) had complex disease. We encountered one early and one late recurrence as well as a parastomal hernia and a stoma prolapse. Anal continence was re-assessed three months following reversal of colostomy. All patients (n = 7) who had perfect continence preoperatively remained unchanged. Preoperatively, four patients were incontinent for gas and liquid stool. Two of these were fully continent, one remained unchanged at re-assessment. The fourth patient did not undergo stoma reversal as yet, because all examinations revealed an incompetent sphincter. This patient is therefore fully incontinent. Successful treatment of complex anal fistulas needs an individual approach and planning over a lengthy period of time, requiring a high level of motivation on the part of both patient and surgeon.
大多数肛瘘通过简单的肛瘘切开术即可轻松处理。所谓复杂性肛管肛瘘需要采用个体化的、有针对性的手术方法，以避免复发和括约肌功能不全。复杂性肛瘘包括具有高位经括约肌、括约肌上或括约肌外延伸的瘘管，或伴有多个侧支、慢性炎症性疾病、既往手术等并发症的肛瘘。治疗前需进行全面的术前诊断评估。精确的术中评估对于彻底切除所有炎症组织至关重要，这通常需要进行肛门括约肌切开并随后重建。治疗方案通常包括在数月内分阶段进行手术，初次手术时通常（通过腹腔镜）造一个保护性造口。本文呈现并讨论了我们在1995年1月至1996年12月研究期间对患者采用的不同手术方法及其结果。在此期间，维尔茨堡大学医院外科对96例肛管肛瘘患者进行了手术，其中11例（11.5%）患有复杂性疾病。我们遇到了1例早期复发和1例晚期复发，以及1例造口旁疝和1例造口脱垂。在结肠造口还纳术后三个月重新评估肛门控便能力。所有术前控便能力良好的患者（n = 7）保持不变。术前，4例患者存在气体和液体粪便失禁。其中2例完全恢复控便能力，1例在重新评估时情况未变。第4例患者尚未进行造口还纳，因为所有检查均显示括约肌功能不全。因此，该患者完全失禁。成功治疗复杂性肛瘘需要个体化的方法和长时间的规划，这需要患者和外科医生双方都有高度的积极性。
