保留括約肌手術(shù)治愈肛瘺是肛腸外科醫生
孜孜不倦的追求，更成為一種理念貫穿肛
瘺治療的始終。從本期開(kāi)始，將連續探討
「肛瘺保留括約肌手術(shù)」。
本期，結合邵萬(wàn)金教授團隊的臨床實(shí)踐
經(jīng)驗，將TROPIS的發(fā)展歷史進(jìn)行文獻
解讀，并結合典型病例進(jìn)行圖解分析，
以期為臨床應用提供指導。
TROPIS的淵源
下圖從不同角度顯示肛門(mén)直腸周?chē)Y構及重要間隙
Eisenhammer認為括約肌間肛腺感染是形成肛瘺（或膿腫）的主要原因（1958年），下圖可顯示腺管（紅色箭頭）穿透內括約肌并在括約肌平面內以腺體結構終止（藍色箭頭）。
例如，慢性肛裂反復感染引起的高位膿腫（下圖）
括約肌間肛腺感染可向周?chē)?，最終形成不同形式的肛瘺（或膿腫）。
Parks（1976年）和 Hanley（1985年）在實(shí)踐中指出：高位肌間膿腫可向上蔓延，進(jìn)入肛提肌上間隙形成急性膿腫。
完全內括約肌切開(kāi)術(shù)使膿腫從腸腔內引流。
錯誤的手術(shù)入路可能導致“醫源性的復雜的括約肌上/外肛瘺”。
兩個(gè)重要間隙
2016年，任東林教授團隊提出兩個(gè)重要的“后深間隙”，分別指：
與 DPIS 相關(guān)的復雜瘺管和膿腫
不同嚴重程度的DPAS病變
The DPAS is well defined on MRI. It lies superior to the anococcygeal ligament and inferior to the anococcygeal raphe, dorsal to the puborectalis and ventral to the coccyx.The intrasphincteric spaces include the deep intersphincteric space and the superficial intersphincteric space, for which the heights correspond with the puborectalis and deep portion of the EAS. Normally the DPIS is a latent space undetectable on MRI.
正常情況下 ，DPAS 在 MRI 定位非常明確；而DPIS 在 MRI 中并不顯露，當有感染形成時(shí)將此間隙撐開(kāi)，形成密閉的小膿腫，當壓力過(guò)大時(shí)則向組織薄弱的地方突破蔓延，形成各種類(lèi)型的復雜性肛瘺。在大多數情況下，淺表括約肌間隙中的腺源性膿腫將向上延伸進(jìn)入 DPIS。由于 DPIS 與周?chē)纳畈扛刂荛g隙相連，因此 DPIS 的繼發(fā)性病變可能單側或雙側穿過(guò)后外側的其他深部間隙，并導致高位經(jīng)括約肌、括約肌上或肛提肌上瘺。DPIS 病變也可沿環(huán)周擴散，并形成深括約肌間或括約肌間的馬蹄狀瘺管。
馬蹄形瘺管（或膿腫）的不同平面
與DPIS病變相關(guān)的復雜瘺管
The DPIS is often involved in complex posterior cryptoglandular fistulas.
TROPIS術(shù)
高位復雜性肛瘺手術(shù)失敗或復發(fā)的原因是沒(méi)有處理DPIS。2017年，Garg提出經(jīng)肛括約肌間切開(kāi)術(shù) (transanal opening of intersphincteric space，TROPIS)。TROPIS手術(shù)則會(huì )對DPIS進(jìn)行處理。
In this study, the intersphincteric space was drained and laid open through the transanal route. The space was not closed and kept open so that it healed by secondary intention. The aim of this step was eradication of sepsis and healing of fistula. Since the external sphincter was not cut or damaged, the risk to incontinence was expected to be minimal. This simple procedure, transanal opening of intersphincteric space (TROPIS) through the internal opening, was done in complex high fistula-in-ano.
The main aim of this procedure is to achieve fistula healing without doing any damage to external sphincter. This is achieved by removing sepsis on both sides of the external sphincter so that both sides heal well. Sepsis eradication is done by transanal opening up of fistula tract ‘inside the external sphincter’ and curetting the tract ‘outside the external sphincter’. Postoperatively, both sides are kept clean till complete healing happens. Inadequate cleaning of one side would lead to passage to infected fluid from this side to the other side leading to non-healing of that side as well. Therefore both the steps are crucial for the success of operation.
TROPIS 手術(shù)僅切開(kāi)部分內括約肌，無(wú)需切開(kāi)外括約肌，即使肌間膿腫過(guò)大波及到外括約肌，此入路對外括約肌的損傷也是最小的，因此對肛門(mén)功能影響很小。
61 patients with high complex fistula-in-ano were included(follow-up:6-21 months). Male/Female:59/2, age-42.3 ±9.5 years. 85.2%(52) were recurrent, 83.6%(51) had multiple tracts, 36.1%(22) had horseshoe tract, 34.4%(21) had supralevator extension and 26.2%(16) had associated abscess. 95.1%(58) were posterior fistula out of which 90.2%(55) were in posterior midline. Nine patients were excluded (due to tuberculosis, lost to follow-up).
Fistula healed completely in 84.6%(44/52) and didn’t heal in 15.4%(9/52). 4/9 of these were reoperated and fistula healed in three patients. Thus overall healing rate was 90.4% (47/52). There was no significant change in incontinence scores.
Garg采用該手術(shù)治療61例高位復雜性肛瘺患者，中位隨訪(fǎng)期9個(gè)月，治愈率高達90.4%，術(shù)后患者肛門(mén)失禁評分無(wú)明顯變化。
手術(shù)前和手術(shù)治療后
Parks 將瘺管走形進(jìn)行分類(lèi)，形成肛瘺最經(jīng)典的分型方法：“Parks分型”（1976年），并列出了各類(lèi)分型所占的比例。
而最新研究表明，括約肌間型肛瘺占所有肛瘺類(lèi)型的75%以上，因此掌握 TROPIS 術(shù)可以有效治療大部分肛瘺。
病例分享
王浩醫生
廣東省中醫院肛腸外科主治醫師
擅長(cháng)以下疾病的手術(shù)治療和微創(chuàng )治療：
結直腸腫瘤的微創(chuàng )治療（結直腸癌；直腸癌低位保肛）
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