肛瘘

肛周脓肿和肛瘘天津市人民医院天津市肛肠研究所李会晨温故而知新可以为师矣概述肛周脓肿肛瘘肛瘘是外科最棘手的疾病之一复发性复杂性不确定性肛周脓肿和肛瘘的概念肛周脓肿和肛瘘是同一疾病过程的两个阶段解剖学基础–肛窦•肛隐窝：也称肛窦，肛瓣与两个肛柱之间的凹面存在浅显空间并形成小窝称为肛隐窝（Morgagni′scrypt）。•肛窦呈漏斗型，上口朝向肠腔。•一般为6～8个。深约0.3cm±。但有的特别是后部者较深。•在肛窦底部常有肛腺开口。解剖学基础—肛腺•通常一个肛腺开口于一个肛隐窝并有少量黏液排出。•肛腺较多分布在肛管后部。•肛腺腺管少数位于黏膜下。可以向首尾两个方向延伸。•据Parks报告约2/3穿入内括约肌。1/2越过内括约肌进入联合纵肌平面解剖学基础--肛门周围间隙肛门周围间隙是肛管和直肠周围的一些潜在的空间。其中充满结缔组织和脂肪组织.一旦受到细菌感染，就形成肛周脓肿。与肛周脓肿关系密切的有坐骨直肠间隙和肛管后深间隙。解剖学基础--肛门周围间隙肛管后深间隙是肛门后部重要间隙。位于肛管与尾骨之间。顶部是附着于尾骨前面的肛提肌，底部是外括约“浅部”肌束，两侧与坐骨直肠窝相通。1950年Courtney仔细描述此一间隙，因而称为“Courtney间隙”。Courtney间隙可能扮演着沟通两个坐骨直肠窝感染的重要角色。解剖学基础--肛门部肌肉肛窦和肛腺结构示意图腺源性？肛周脓肿是由于肛腺感染引起。Eisenhammer对肛周脓肿称为“成瘘性肛周脓肿”，把此种肛瘘称为“腺源性肛瘘日本学者”1976年”提出的：“不与肛隐窝腺相联系的肛瘘是不存在的”解剖学基础1733Winslow和1754Haller肛窦1878Chiari首次描述了肛腺的结构。1880Herrman和Desfosses肛腺与肛瘘的关系1930年Bremer报导，开口于肛窦的肛腺有6~8个Tucker和Hellwig于1935年发表肛腺的组织学观察，证实在肛瘘患者的肛腺腺体周围有感染存在。他们还提出，这种肛腺感染之所以常常慢性化，是因为感染肛腺的开口处有上皮组织向内延伸之故Morgan和Thompson于1956年写的文章描述，肛管部内外括约肌间纵肌纤维终末部分的变化，强调肛腺感染到括约肌间时，可随上述纤维进入会阴或坐骨直肠窝肛窦和肛腺结构示意图trackandextensions辅助检查方法瘘管造影直肠腔内超声MRIcontrastenemaidentifiesmissedextra-sphinctericanalfistulafromsigmoiddiverticulardiseaselikebirdwatchingthroughalavatorywindow?pussycat?blackbirdacomparisonbetweendigitalexaminationandanalendosonographyinanalfistulaesurgicalconsultantultrasoundp=findingsintersphincteric131110nstransphincteric141411nssuprasphincteric000-extrasphincteric410nssuperficial440nssupralevator11700.03infralevator7700.02total5544210.001magnificent,butexpensivelevatormusclepostrectalhighsignal,trackingtorightMRIsamecase鉴别诊断会阴部尿道瘘骶骨前瘘先天瘘骶尾部瘘肛门周围化脓性汗腺炎结核性肛瘘慢性结肠炎并发肛瘘先天直肠瘘概述肛周脓肿肛瘘肛周脓肿-asimpleclassificationperianal,ischioanal,intersphincteric,supralevator.TREATMENT概述肛周脓肿肛瘘肛瘘分类括约肌间瘘经括约肌间瘘括约肌上方瘘括约肌外侧瘘肛瘘分类SumikoshiClassificationⅠⅡLSimpleComplicatedHSCⅢUni.SCBilateralSCⅣSupralevatorClassificationoffistula-in-anoⅡL→Int.sph.low（belowPuborectalis）ⅡH→Int.sph.high（abovePuborectalis）Ⅲ→・Horseshoe・Trans.sph.loworhighⅣ→SupralevatorParks’ClassificationofFistula-in-AnoIntersphinctericfistulasSimplelowtractHighblindtractHightractwithrectalopeningRectalopeningwithoutaperinealopeningExtrarectalextensionSecondarytopelvicdiseaseTrans-sphinctericfistulasUncomplicatedHighblindtractSuprasphinctericfistulasUncomplicatedHighblindtractExtrasphinctericfistulasSecondarytoanalfistulaSecondarytotraumaSecondarytoanorectaldiseaseCausedbypelvicinflammation括约肌间肛瘘Intersphinctericfistula:simplelowtractIntersphinctericfistula:highblindtract..括约肌间肛瘘Intersphinctericfistula:hightractwitharectalopeningIntersphinctericfistula:hightractwithoutaperinealopening.括约肌间肛瘘Intersphinctericfistula:secondarytopelvicdiseaseIntersphinctericfistula:extrarectalextensionParks’ClassificationofFistula-in-AnoIntersphinctericfistulasSimplelowtractHighblindtractHightractwithrectalopeningRectalopeningwithoutaperinealopeningExtrarectalextensionSecondarytopelvicdiseaseTrans-sphinctericfistulasUncomplicatedHighblindtractSuprasphinctericfistulasUncomplicatedHighblindtractExtrasphinctericfistulasSecondarytoanalfistulaSecondarytotraumaSecondarytoanorectaldiseaseCausedbypelvicinflammation经括约肌肛瘘Transsphinctericfistula:uncomplicatedtypeTrans-sphinctericfistula:highblindtractParks’ClassificationofFistula-in-AnoIntersphinctericfistulasSimplelowtractHighblindtractHightractwithrectalopeningRectalopeningwithoutaperinealopeningExtrarectalextensionSecondarytopelvicdiseaseTrans-sphinctericfistulasUncomplicatedHighblindtractSuprasphinctericfistulasUncomplicatedHighblindtractExtrasphinctericfistulasSecondarytoanalfistulaSecondarytotraumaSecondarytoanorectaldiseaseCausedbypelvicinflammation括约肌外肛瘘Suprasphinctericfistula:uncomplicatedtypeSuprasphinctericfistula:highblindtractParks’ClassificationofFistula-in-AnoIntersphinctericfistulasSimplelowtractHighblindtractHightractwithrectalopeningRectalopeningwithoutaperinealopeningExtrarectalextensionSecondarytopelvicdiseaseTrans-sphinctericfistulasUncomplicatedHighblindtractSuprasphinctericfistulasUncomplicatedHighblindtractExtrasphinctericfistulasSecondarytoanalfistulaSecondarytotraumaSecondarytoanorectaldiseaseCausedbypelvicinflammationExtrasphinctericfistula:secondarytoanalfistulaExtrasphinctericfistula:secondarytotraumaExtrasphinctericfistula:secondarytoanorectaldiseaseExtrasphinctericfistula:secondarytopelvicdisease临床表现排脓疼痛瘙痒全身症状诊断指肛检查肛窦钩检查探针检查注入色素X线检查索罗门定律注入丙烯酸树脂肛管压力测定索罗门定律治疗非手术治疗手术治疗手术治疗-治疗原则确定内口瘘管清除手术创口修整括约肌的处理根治和括约肌功能的一对矛盾敞开疗法保存括约肌的手术方法ParksfistulectomyMATSUSHIMAHOSPITALCOLOPROCTOLOGYCENTER敞开：LayopenInt.sph.lowtypeTrans.sph.lowtypeLayopen・PL←Post→PR・Rp←Ant→Lp→Keyholedeformity→IncontinenceParksfistulectomyversus.lay-opentechnique挂线技术紧挂线松挂线化学挂线保存括约肌的手术方法生物蛋白胶封闭法肛门塞法黏膜瓣移进术LIFTtechniqueforfibringlueanalfistulaplugsuturablebioprostheticplugfromCookSurgicalInclyophilisedporcineintestinalsubmucosarehydrate,thenwedgesnuglyintract(notcurretted/excised)anchorwithCCGsutureatinternalopeninginternalopeningexternalopening黏膜瓣移近LIFTligationofintersphinctericfistulatract评价小结腺源性感染的真正理解内口的处理是手术成败的关键根治和肛门功能