2013年东南大学医学院研究生复试面试试题 临床三组(外科学)

343D iseases of the C olon & R eCtum V olume 56: 3 (2013)BACKGROUND: ligation of intersphincteric fistulatract is a novel surgical technique in the treatment of transsphincteric fistula-in-ano that has been shown to be successful in the short term. median follow-up in current literature ranges from 5 to 9 months. however, the long-term success rate is unknown.OBJECTIVE: this study describes our long-term resultsin performing the ligation of intersphincteric fistula tract procedure.DESIGN: this study is a retrospective review.PATIENTS: thirty-eight patients from august 2008 tooctober 2011 were evaluated.INTERVENTIONS: all patients underwent the ligation ofintersphincteric fistula tract for fistula-in-ano.MAIN OUTCOME MEASURES: Patient and fistulacharacteristics, primary healing rate, secondary healing rate, previous treatments, and failures were reviewed.RESULTS: the median follow-up was 26 months (range,3–44 months), and 26 patients (68%) were followed for greater than 12 months. the overall primary healing rate was 61% (23 of 38), and it was 62% (16 of 26) in patients followed for over 12 months. eighty percent (12/15) of the failures are early failures (persistent symptoms or failure at ≤6 months), and 20% are late failures (>6 months) with 1 failure occurring 12 months postprocedure. increase in length of fistula tract wasassociated with decreased healing (oR 0.55, 95% Ci 0.34–0.88, p = 0.01). there were no intraoperative complications and no reported incontinence.CONCLUSION: our study demonstrates favorable long-term results for the ligation of intersphincteric fistula tract procedure. it appears that long tracts negativelyaffect healing, and late failures can occur up to 12 months postoperatively. understanding the type of failure can help guide subsequent treatment to maximize healing success.KEY WORDS: fistula-in-ano; ligation of intersphinctericfistula tract; long-term; failure type; Durability; fistula tract length.ligation of intersphincteric fistula tract (lift) is a novel surgical technique described by Rojanasakul et al 1 in the treatment of transsphincteric fistula-in-ano. it has been shown to be successful in the short term with no reported incontinence. We have previously reported a primary healing rate of 68%, which is comparable to healing rates of 57% to 94% at other institutions.1–8 Currently published median follow-up ranges from 5 to 9 months,1–8 but several authors have found that late recurrences can occur 7 to 8 months after surgery.4,6 thus, the short-term success rates described may be an overestimate of the true success rate. extended follow-up is needed to better understand the long-term outcome of lift. the current study reports our long-term experience.MATERIALS AND METHODSa retrospective analysis was performed on all patients who underwent the lift procedure from august 2008 to oc-tober 2011, at harbor-uCla medical Center, a university-affiliated los angeles County institution. the study was approved by the institutional review board at the los an-Long-term Results of Ligation of Intersphincteric Fistula Tract (LIFT) for Fistula-in-AnoWendy Y. liu, m.D.1 • armen aboulian, m.D.2 • amy h. Kaji, m.D., Ph.D.1 Ravin R. Kumar, m.D.11 harbor-uCla medical Center, Division of Colon and Rectal surgery, torrance, California2 Cleveland Clinic foundation, Department of Colorectal surgery, Cleveland, ohioDis Colon Rectum 2013; 56: 343–347Doi: 10.1097/DCR.0b013e318278164c © the asCRs 2013Financial Disclosures: none reported.Podium presentation at the meeting of the american society for Colon and Rectal surgeons, san antonio, texas, June 2 to 6, 2012.Correspondence: Ravin R. Kumar, m.D., Division of Colon and Rectal surgery, harbor-uCla medical Center, 1000 West Carson st, Box 25, torrance, California 90502. e-mail: rkumar@ ORIGINAL CONTRIBUTIONl iu et al:l onG-teRm R esults of the lift P RoCeDuRe 344geles Biomedical institute of harbor-uCla medical Cen-ter. all patients had transsphincteric fistula-in-ano that was not amenable to fistulotomy because of significant ex-ternal sphincter involvement and the risk of incontinence.a single surgeon experienced with the lift procedure performed all of the operations.the lift procedure is performed as described in our previous publication.5 Patients received preoperative bowel preparation with sodium phosphate enema. the procedure is performed with the patient in the prone jackknife posi-tion under general or regional anesthesia, with appropriate preoperative antibiotics. after confirming that there is no active sepsis or abscess, the fistula tract is delineated by us-ing a probe or hydrogen peroxide injection. the length of the tract is recorded as the direct linear distance between the external skin opening and the anal verge. then, a pedi-atric feeding tube and/or a lacrimal duct probe is placed in the fistula tract. a curvilinear skin incision is made directly over the intersphincteric groove to enter the intersphinc-teric space. With the external sphincter retracted laterally, the fistula tract is dissected, isolated, and divided just lat-eral to the internal sphincter. exposure is attained with lift retractors courtesy of Dr Rojanasakul or s retractors.a small segment of the intersphincteric tract is excised. the medial stump of the tract site was closed over the internal sphincter muscle by using absorbable sutures in a figure-of-8 fashion. the lateral tract opening in the intersphinc-teric space is closed over the external sphincter muscle with absorbable sutures. satisfactory closure is confirmed by injecting hydrogen peroxide from the external skin open-ing. the external tract is cleared by using a curette and/ or cautery, and the skin opening is widened and left open for drainage. the primary mucosal internal opening within the anal canal is closed using a figure-of-8 stitch. the in-tersphincteric space is irrigated and closed with absorbable sutures in layers.the majority of the patients had seton placed for 4 to 8 weeks before the lift procedure. others underwent lift as the primary procedure, and the fistula tract is well delineated with no underlying significant sepsis at the time of surgery. all procedures took place in an outpatient set-ting. Patients were discharged with instructions for 1 week of oral metronidazole, stool softener, bulking agents, sitz bath, and pain medication. follow-up was scheduled at 1, 2, 6 weeks, 3 months, 6 months, and 12 months after sur-gery. at each visit, patients were asked to report any sub-jective change in continence to gas, liquid, or solid stool.Primary healing is defined as complete healing of both the external opening and intersphincteric incision with complete resolution of symptoms, without addition-al interventions. We categorized patients with persistent symptoms or reappearance of symptoms before 6 months as early failures. late failures are those with resolution of symptoms in the early period but return of symptoms after 6 months. Patients who healed completely were con-tacted every 6 months thereafter to assess for any recur-rence of symptoms. Patients with persistent symptoms were initially managed conservatively unless there was significant sepsis requiring early intervention. examina-tion under anesthesia was planned if symptoms worsen or continue to persist after 6 months. the anatomical features of failures were determined during examination under anesthesia using probes and hydrogen peroxide in-jection. similarly to the report by tan et al,6we classified failures into 3 types. type i failures represented residual sinus tracts without an internal opening. type ii failures represented a downstaged tract from the intersphincteric incision to the internal opening. type iii failures are com-plete failures that extend from previous internal opening to one or more external skin openings.statistical analysis was performed by using sas v 9.2 (sas institute, Cary, nC). Results were expressed as me-dians with interquartile ranges for continuous variables. Wilcoxon tests were performed to assess for significant differences between groups that healed vs those that did not. When categorical variables were compared, the χ2 or fisher exact tests were performed, as appropriate. the Ka-plan-meier method was used to perform a survival analy-sis, which demonstrates the durability of success after the lift procedure over time (fig. 1). subjects were censored at the last follow-up date. the index date, or first day of the survival period, was the date of the operation. RESULTSthirty-nine lift procedures were performed on 38 patients by a single surgeon (table 1). the patients consist of 28 men (74%) and 10 women (26%), with a median age of 42 years and median symptom duration of 24 months (range, 2–72 months). median follow-up was 26 months (range, 3–44 months), and 26 patients (68%) had follow-up exceeding 12 months. Previous definitive fistula repairs (fistula plug, fibrin glue, or mucosal advancement flap) had failed in 7 patients (18%). twenty-nine patients (76%) RateofsuccessRate of success0.10.20.30.40.50.60.70.80.93691215Months of follow-upFIGURE 1. Durability of LIFT over time. LIFT = ligation of intersphincteric fistula tract.D iseases of the C olon &R eCtum V olume 56: 3 (2013)345had a seton before their lift procedure. five patients had posterior midline fistulas and/or a history of horseshoe abscesses. the median fistula tract length was 4 cm (range, 2–10 cm) with 66% having tract length longer than 3 cm.of the 38 patients, 23 (61%) healed after the initial lift procedure without the need for further interventions (table 2). in patients followed for more than 12 months, the primary healing rate is 62% (16/26). figure 1 shows the durability of lift procedure success over time. of the patients who healed primarily, median time to healing was 8 weeks (range, 4–36 weeks). When looking at the im-pact of fistula length on primary healing, our data showed that for every 1 cm increase in fistula length, the oR for healing decreases by 0.55 (95% Ci 0.34–0.88, p = 0.01) (table 3). the median length of fistula tract is shorter in the healed group compared with the failed group (4 cm vs 6 cm, p= 0.004) (table 4). When choosing 3 cm as an arbitrary cutoff point, fistula tracts less than 3 cm had sig-nificantly higher primary healing (85% vs 48%, p = 0.04) (table 3). the healing rates for patients with and without previous seton are 62% (18/29) and 56% (5/9), with an oR of 1.3 (95% Ci 0.3–5.9, p = 1.0). the healing rates for patients with and without previous fistula procedures are 71% (5/7) and 58% (18/31), with an oR of 2.3 (95% Ci 0.4–13.3, p = 0.4). additionally, age, sex, comorbidities, and symptom duration have no statistically significant in-fluence on healing (table 4).When looking at the 15 patients in whom treatment failed, the median time to failure was 4 months, and, in 1 patient, failure occurred 12 months post-lift. eighty percent (12/15) of the failures are early failures (persistent symptoms or failure at ≤6 months), and 20% (3/15) are late failures (>6 months). of the 15 total failures, 3 were type i, 1 was type ii, and 9 were type iii (fig. 2). two additional patients with failures are awaiting evaluation. of the 3 patients with type i failure, 2 healed after curettage and 1 is pending after drain placement. the type ii patient, who had downstaged to an intersphincteric fistula, healed after intersphincteric fistulotomy. of the 9 patients with type iii failures, 5 had single external skin openings and 4 had multiple external skin openings. in the single skin opening group, one healed after repeat lift (explaining 39 lift procedures on 38 patients), 1 healed after fistula plug, 1 is recovering from a second fistula plug, and 2 patients are pending further treatments. in the group with multiple skin openings, 1 healed after fistulotomy/curettage, 1 experienced failure after fistula plug, and 2 are pending after cutting seton/fistulotomy.no subjective incontinence was reported, and no in-traoperative complication occurred. two patients had vaginal fungal infection postoperatively and recovered uneventfully with topical cream treatment. DISCUSSIONlift is a novel procedure that several studies have shown to have good short-term success in the treatment of transsphincteric fistula-in-ano.1–8 this study shows a primary healing rate of 62% after 12 months with minimal risk of incontinence. additionally, we found the range of healing time to be from 4 to 36 weeks after surgery. therefore, in patients with persistent symptoms, it may be prudent to observe and manage symptoms with local care up to 6 months or more before planning for additional treatment. this could potentially avoidTABLE 1.Demographic and clinical dataTotal number of patients38Total LIFT procedures39Sex, % male74 (n = 28) Median age, y (range)42 (26–58) Median symptom duration, mo (range)24 (2–72) Previous setons, %76 (n = 29) Previous definitive fistula operations, %18 (n = 7) LIFT as first procedure, %18 (n = 7) Median fistula tract length, cm (range) 4 (2–10) Fistula tract length ≤3 cm, %34 (n = 13) Fistula tract length >3 cm, %66 (n = 25) Posterior midline or history of horseshoe abscess, %13 (n = 5) ComorbiditiesHIV1History of diverticulitis1Hyperlipidemia2Diabetes mellitus5Hypertension5 LIFT = ligation of intersphincteric fistula tract.TABLE 2.Overall results (total n = 38)Primary healing, %61 (n = 23/38) Primary healing after 12 mo, %62 (n = 16/26) Median follow-up, mo (range)26 (3–44)Follow-up exceeding 12 mo, % patients68 (n = 26) Median healing time, wk (range)8 (4–36)Healing in posterior midline fistulas or historyof horseshoe abscess, %60 (n = 3/5)Median time to failure, mo (range) 4 (persistentsymptoms-12) Early failures (≤6 mo), %80 (n = 12/15) Late failures (>6 mo), %20 (n = 3/15) Incontinence, %0TABLE 3.Effect of fistula length on healing rateHealing rate, (%)Difference Fistula tract length ≤3 cm85 (n = 11/13)p = 0.04Fistula tract length >3 cm48 (n = 12/25)Effect of length of fistula tracton healingNA OR 0.55 (95%CI0.34–0.88),p = 0.01 NA = not applicable.l iu et al:l onG-teRm R esults of the lift P RoCeDuRe 346some unnecessary operations. of course, some patients may require earlier intervention if their symptoms worsen or they develop significant sepsis. We also found that, although the majority of lift failures present early, some occur beyond 6 months and as late as 12 months after the initial procedure. therefore, we suggest extended follow-up of at least 12 months after initial surgery to be certain that complete healing has occurred.lift failures can be multidimensional. identifying the type of failure can help direct subsequent therapy. some recommend the routine adoption of endorectal ul-trasound to evaluate all suspected failures.6 in our series,TABLE parison of healed and failed groupHealed group (n = 23)Failure group(n = 15)DifferenceSex, male16/23 (69.6%)12/15(80.0%)χ2 = 0.5,Fisher exactp = 0.7 Age, median (IQR)42 (35–51)42 (39–46)Wilcoxonp = 0.7 Symptom duration, mo, median (IQR)24 (12–28)24 (13–48)Wilcoxonp = 0.4 Fistula length, cm, median (IQR) 4 (3–4) 6 (4–6)Wilcoxonp = 0.004 Fistula tract length ≤3 cm11/23 (47.8%)2/15 (13.3%)χ2 = 4.7,Fisher exactp = 0.04 Any comorbidities9/23 (39.1%)5/15 (33.3%)χ2 = 0.1,Fisher exactp = 1.0 IQR = interquartile range.FIGURE 2. Patterns of failures after initial LIFT procedure and outcome. LIFT = ligation of intersphincteric fistula tract.D iseases of the C olon &R eCtum V olume 56: 3 (2013)347we were able to demonstrate the types of failure with in-traoperative evaluation by using probes and injection of hydrogen peroxide. We feel that the ultrasound or other imaging modalities could be reserved for select failures with complex tracts not demonstrable by intraoperative evaluation. Potentially one of the greatest advantages of the lift procedure is that, in some cases, it converts a complex, difficult-to-treat fistula to a more manageable one with minimal risk of sphincter injury. type i failures can be managed with curettage of the tract, silver nitrate applications and short-term antibiotics, and local incision and drainage for underlying sepsis. type ii failures can be managed with simple or staged intersphincteric fistuloto-my. type iii failures can be managed with a cutting seton followed by plans for a repeat definitive fistula procedure such as lift, fistula plug, or mucosal advancement flap.mcG ee and colleagues9 have found that fistula tract length longer than 4 cm predicts improved healing with anal fistula plugs. this may be due to a longer tract provid-ing a better scaffolding for the plug, which decreases plug dislodgment. to our knowledge, in the current lift liter-ature, there is no description of an association between fis-tula tract length and healing. in our series, we found that longer fistula tracts correlate with a lower primary healing rate. one caveat is that our method for measuring tract length may not be as accurate for patients with curved tracts. nevertheless, we believe that the reason for this ob-served correlation is that the lift procedure eliminates the communication and a portion of the intersphincteric tract between the internal and external openings. there-fore, longer tract length should not in theory promote im-proved healing with the lift procedure. in fact, longer tract may potentially be more prone to having persistent epithelial tissue, inflammation, and sepsis, making healing more difficult. in our series, 2 of the type i failures with persistent sinus tract healed after local care with curettage and cauterization of the tract. We postulate that thorough curettage, cauterization, and peroxide irrigation of the ex-ternal tract at the initial operation and widening of the external opening to facilitate drainage may minimize per-sistent sepsis and improve healing.our study represents one of the longest follow-up se-ries to date, with a median follow-up of 26 months and 68% of the patients followed for more than 1 year. fur-thermore, all procedures were performed by a single expe-rienced surgeon, which eliminates the variation in surgeon technique as a potential confounding factor. the primary weakness of this study is that it is a retrospective single-institution study with small sample size. it lacks adequate power to detect any potential effect on healing by the pres-ence of previous fistula procedures, setons, and patient preoperative characteristics. there is also an element of selection bias by the surgeon. the surgeon may opt not to perform the lift procedure if the fistula tract is difficult to delineate because of body habitus or difficult anatomic location such as posterior midline/horseshoe tracts. an-other weakness of the study is that continence was sub-jectively evaluated on the basis of the patient’s opinion. the use of a formal continence scale would yield more ac-curate results. larger, long-term prospective randomized controlled studies are needed to validate the true success rate of lift and to identify disease characteristics that can assist in better patient selection to achieve better outcome. 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