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中文摘要
目的:通过两种手术方法的对比研究，探索、选择切开挂线联合臵管冲洗术在治疗复杂肛瘘的临床应用意义和价值。
方法:将60例复杂肛瘘患者随机分成试验组和对照组，其中试验组30例采用切开挂线联合臵管冲洗术，对照组30例采用切开挂线术。观察两组病例手术中出血、术后疼痛、术后创面分泌物、术后排便情况、肛管压力变化、术后感染、切口水肿、创面愈合时间、肛门功能及随访五个月内的复发情况等，并进行评分分析，应用统计软件SPSS15.0进行统计分析，P<0.05为有临床意义。
结果:虽然在术中出血、术后当天疼痛、、、切口水肿，肛门功能、、随访复发情况及疗效评价上两组无显著差异(P>0.05)，但试验组在手术时间、术后创面分泌物，术后继发感染，创面愈合时间术后术后排便情况、及总体疗效综合评分上明显优于对照组(P<0.05)。
结论:切开挂线联合臵管冲洗术不仅可以有效地治疗复杂肛瘘，防止术后并发症发生，防止肛瘘复发，良好地保护肛门功能，并且在减少术后创面分泌物、术后伤口感染等并发症方面有明显优势。证明切开挂线联合臵管冲洗术优于对照组术式，值得临床推广。 关键词:切开挂线联合臵管冲洗术 临床研究 复杂肛瘘
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ABSTRACT
Objective: through two kinds of operation method contrast research, exploration, selection of incision and thread-drawing combined catheterization lavage in the treatment of complex anal fistula clinical application value and significance.
Methods: 60 cases of complex anal fistula patients were randomly divided into experimental group and control group, the treatment group of 30 cases
The incision and thread-drawing combined catheterization lavage, a control group of 30 cases with incision and thread-drawing.Observation of two cases of bleeding in operation, postoperative pain, postoperative wound exudates, postoperative defecation, anal canal pressure change, postoperative infection, wound edema, wound healing time, anal function and followed up for five months, recurrence, and score analysis, using the statistical software SPSS15.0 for statistical analysis, P < 0.05 to have clinical significance.
Results: Although the intraoperative bleeding, postoperative pain, edema, day, incision, anal function, follow-up, relapse and evaluated the efficacy of no significant difference between the two groups (P > 0.05), but the experimental group in the operation time, postoperative wound exudates, secondary to postoperative infection, wound healing time and
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postoperative defecation, and the efficacy of the overall composite score is obviously superior to the control group (P < 0.05).
Conclusion: read-drawing combined catheter irrigation technique can not only effectively in treatment of complex anal fistula, preventing postoperative complication, prevention of recurrence of anal fistula, well protect the anal function, and in reducing postoperative wound exudates, postoperative wound complications such as infection has obvious advantages, prove thread-drawing combined catheterization lavage was better than that of the control group operation, worthy of clinical application.
Key words: thread-drawing combined catheterization lavage in the treatment of complex anal fistula clinical study of complex anal fistula
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引言
肛瘘即指肛管或直肠因病理原因形成的与肛门周围皮肤相通的一种异常管道。临床表现为：肛周脓肿自行溃破或只作切开引流后遗留反复肿痛流脓，外口经久不愈，有流脓、疼痛、瘙痒、全身症状如发热、寒战、乏力等主要特征。患者以青壮年为主.。据文献报道肛瘘在我国肛管直肠疾病发病人数的1.67%--3.6%，其发病机率占肛门直肠疾病的8%-25%。其中肛瘘病例的18%—23%为复杂性肛瘘。复杂性分为低位肛瘘复杂性肛瘘和高位复杂性瘘。两者共同点是:有两个以上外口和瘘管与内口相通，侵犯外括约肌深部。低位肛瘘复杂性肛瘘瘘管在外括约肌深部以下，高位复杂性瘘主管通过外括约肌深部以上，侵犯耻骨直肠肌、肛提肌以上。复杂性肛瘘不会自愈，其明确的诊断及适当准确手术运用是治愈该病的保障。临床诊断复杂性肛瘘的方法，包括询问临床症状及体征，配合肛门镜检查，肛门指检查，染色检查，挤压检查，探针检查，肛窦钩检查，X线造影法，腔内超声，MRI，螺旋CT等。目前手术治疗是唯一可以彻底治愈肛瘘的方法。准确找到内口，正确处理内口，清除死腔，引流通畅，保护肛门括约肌功能，减少肛周皮肤的损伤是手术治疗的关键与重点。复杂性肛瘘由于部分瘘管道侵犯肛门外括约肌的深部，通过肛管直肠环，且瘘口多，瘘管行走迂曲所以手术操作困难。如果完全切开肛管直肠环必将造成肛门括约肌的断裂，会出现术后不同程度的肛门失禁；不完全切开，创面引流不畅容易受阻，且很难治愈。
目前肛瘘主要手术方式分为括约肌切断术和括约肌保存术。括约肌保留手术因存在引流通畅故治愈率较偏低的弊端，所以如今国内外大多专家学者主张采用括约肌切断手术。括约肌切断手术包括中医传统的挂线疗法，其是肛瘘特别是复杂性肛瘘经典手术方法。挂线疗法的具有?以线代刀?慢性切割、良好引流作用，异物刺激作用、能最
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大限度地保护肛门括约肌的优点。但也有术后痛苦大，伤口愈合时间长(平均需30天以上)，难以避免肛门功能存在不同程度失禁难等缺点。后人继承和发展的切开挂线疗法作为一种慢性?切开?和牢固持久的对口引流术，也有引流不畅，肛门功能不同程度失禁，容易感染，复发率高等不足。所以，探索寻求一种处理好内口，保障引流通畅，肛门功能损伤少的手术方式，已成为肛肠医务工作者的期望与追求。近年来，本人导师，通过长期观察探索实践，探索出:切开挂线联合臵管冲洗术治疗复杂肛瘘的新术式。通过临床观察，证明该术式具有创口引流充分，痛苦较轻，愈后创面平整细小，肛门功能破坏少，肛周皮肤破损少等良好效果。该课题的研究，是通过对照观察，科学的统计评价，该术式的具有使绝大部分复杂性肛屡的手术治疗达到病程短，肛门括约功能完好、治率高的满意效果，具有先进性，创新性、实用性值得推广应用。