To observe the clinical effects of treatment of high anal fistula under the guidance of the three-stage collaterals theory. Methods Patients with high anal fistula who were hospitalized from 2007 to 2010 were collected and treated, and the clinical results were summarized, and the diagnosis and treatment of high anal fistula were discussed in depth. The results were summarized, and the clinical results were discussed in depth. Results Among 139 patients treated, 132 patients (95.0%) were cured at one time. 7 patients (5%) were treated with dilation and drainage due to poor drainage of the wound at a later stage.
The average healing time was 52 days, and all patients had no change in preoperative and postoperative anal function, and there was no air and fluid leakage. Conclusion The treatment of high-grade anal fistula under the guidance of the three-level collaterals theory was effective.
High anal fistula is one of the difficult diseases in anorectology. It accounts for about 1.67%-3.6% of anorectal diseases in China and about 8%-25% in foreign countries [1]. Its treatment methods are more and its efficacy is uncertain. And there are numerous defects. 139 patients were treated in our department with the guidance of tertiary collaterals doctrine and the efficacy was confirmed. It is summarized as follows.
1. data and methods
1.1 General information
One hundred and thirty-nine patients, 92 males and 47 females, with the oldest being 75 years old and the youngest 16 years old, with an average age of 43. 5 years, with the longest history of 30 years and the shortest of 1 week, with an average of 45 days, were selected to be seen in our anorectal ward from January 1, 2007, to December 31, 2010, for high anal fistula. The longest history was 30 years, the shortest was 1 week, and the average was 45 days. 35 cases of high-grade simple anal fistula (invading only the deep posterior or deep anterior anal canal) were found (there was no invasion of the deep anterior anal canal in this group).
There were 94 cases of high-grade complex anal fistulae (invading more than two of the deep anterior anal canal, deep posterior anal canal, lateral puborectalis, posterior rectal space, and pelvic rectal space at the same time). In some patients, while invading the above-mentioned hiatuses, the lesions invaded the sciatic rectal hiatus, the superficial posterior anal canal hiatus, the superficial anterior anal canal hiatus, and even reached the anterior perineal area. Patients with invasion of the colorectal space alone were excluded.
1.2 Methods
1.21 Surgical methods
After successful anesthesia (lumbar or general anesthesia), the surgical field was exposed in a lithotomy position, with routine local disinfection, sterile towels, and disinfection of the anal canal and lower rectal segment. Then, the gap and extent of the fistula invaded by the anal canal and the primary internal orifice were carefully examined by finger palpation. If the primary internal orifice is in the posterior median position, a radial incision is first made on the posterior median side of the anus, or on the side of the perianal area if the lesion invades both sides, the incision is made on the side of the severe lesion.
A gradual incision is made along the external anal sphincter to reach the fistula, and all the interstices invaded by the fistula are incised and necrotic tissue is removed. If the fistula encroaches into the pelvic-rectal space, the pubococcygeal muscle is cut to facilitate drainage. It is important to note that there are two paths of fistula invasion from the deep posterior anal canal to the pelvic-rectal space: one is through the space between the pubococcygeal muscle and the iliocococcygeal muscle, and the other is between the puborectal muscle and the pubocococcygeal muscle. When cutting the pubococcygeus muscle, the former is cut from the outside to the inside and special care should be taken not to injure the puborectalis muscle at this time, and the latter is cut from the inside to the outside.
If the fistula invades the lateral gaps of the puborectalis muscle on both sides and spreads behind the pubic symphysis, an appropriate incision should be made at the 10-point and/or 2-point positions for counter-oral drainage. If the fistula spreads beyond the perirectal space, an appropriate incision should also be made at the appropriate location to drain the fistula. The incision is then enlarged outside the anus to facilitate adequate drainage.
The fistula is then explored through the primary internal opening between the puborectalis muscle and the superficial (or deep) external anal sphincter with a probe, and the superficial (or deep) sphincter muscle is cut, the caudal ligament is severed, the deep posterior anal canal space is fully exposed, the lower part of the external sphincter skin and the internal sphincter are preserved, a rubber strip is introduced with the probe, and a loose hanging wire is performed. If there is an ulcerated internal opening (secondary internal opening) in the wall of the pelvic rectal space or the posterior rectal space, the fistula is then treated with a loose hanging wire, i.e., a segmental hanging wire.
If the fistula is located in the deep anterior anal canal, a radial incision is made with the anus as the center to completely reveal the deep anterior anal canal, and then the canal leading to the anus is explored and treated with loose hanging. If there is any fistula that extends beyond the anterior midline to the opposite side, an incision should be made to drain it. After surgery, the wound was filled with red powder oil gauze and bandaged with pressure.
1.22 Postoperative management
After 24 hours of surgery, the stool can be defecated. After defecation, use 1 packet of Jinxuan Hemorrhoid Fumigation San to flush the sitz bath, 2 times/day, and red oil powder gauze (self-prepared) plus Ma Yinglong hemorrhoid cream to change the medicine, 2 times/day. Diosmin 1.5 grams / time, 2 times / day, orally, after three days to 1 gram / time, 2 times / day. Combine with western antibiotics to prevent and control infection. In case of pain, timely analgesia was given.
If there is urinary retention, acupressure (Zhongji, Guanyuan) or hot compress or injection of Neostigmine 1mg at the foot Sanli point or catheterization. If there is bleeding, stop the bleeding immediately or apply Panax notoginseng powder externally. If there is constipation, use Shanzhu Yunyunyuan 9g 3 times/day, orally, or use Chinese herbs internally to identify the symptoms. 1.23 Precautions
The anal sphincter should be protected to the maximum extent possible during the operation, i.e., the cuspidal collaterals, and the puborectal muscle must not be damaged as long as there is no ulcerated ulcer on the intestinal wall of the pelvic rectal space or posterior rectal space (secondary to the internal opening). If the fistula is in the deep posterior space of the anal canal, it is important to find out if there is any pus cavity along the lateral space of the puborectal muscle, posterior rectal space, or both pelvic rectal spaces, and if there is, it is important to fully incise and drain it.
If there are pus cavities invading the posterior rectal space and the pelvic rectal space on both sides, it is also necessary to carefully investigate whether there are ulcers in the intestinal wall, and if so, to carry out segmental thread treatment. If the fistula is in the deep anterior anal canal, attention must be paid to whether there is a pus cavity extending to the opposite side through the superficial anterior anal canal, and if so, drainage is performed to the opposite side. When changing the medication after surgery, be sure to prevent pseudo-healing within a week, if any. When changing the dressing, be sure to pay attention to the deep growth of the incision.
The tissue from which the rubber strip is hung should be incised about two weeks after surgery to facilitate drainage. During the healing process, measures should be taken to slow down the growth of the extra-anal incision as much as possible to avoid poor drainage of the deep incision.
1.3 Criteria for judging the efficacy
Healing: complete closure of the inner and outer openings of the fistula, complete repair of the open wound, good skin growth, and no recurrence during the six-month follow-up; ineffective: the inner and outer openings are not closed, the wound is painful, and there is still discharge from the canal or recurrence within 3 months [2].
2, Results
139 patients were cured in 132 cases at one time, accounting for 95.0%. 7 patients were treated with dilation and drainage due to poor drainage of the wound at a later stage, accounting for 5%, and the secondary cure rate was 100%. The longest hospitalization was 52 days and the shortest was 14 days, with an average of 24.5 days; the longest wound healing time was 206 days and the shortest was 45 days, with an average of 58.65 days; postoperative anal itching was observed in 3 cases, which may be related to the formation of postoperative wound ectopic scar. All patients had no change in anal function before and after surgery, and there was no air and fluid leakage.
3. Discussion
3.1 Diagnostic issues
The diagnosis of anal fistula is currently confusing. Professor Zhang Dongming [3] in his “Pelvic floor and anal pathology” has discussed in detail the perirectal space and muscles of the anal canal. In the analysis of the diagnostic criteria based on the 1994 edition of the Diagnostic Efficacy Criteria for Chinese Medicine Evidence (ZY/T001.7-94) of the Ministry of Health [4] and the Clinical Diagnostic and Treatment Guidelines for Anal Fistulae (2006 edition) of the Chinese Society of Traditional Chinese Medicine, Anal Branch, the expression that the fistulae of high anal fistulae travel above the rectal ring or above the deep layer of the anal sphincter, the perianal rectal hiatus invaded by high anal fistulae should be the deep posterior anal canal hiatus, the deep anterior anal canal hiatus, the deep rectal hiatus, the deep anterior anal canal hiatus, and the deep rectal hiatus. The deep anterior anal canal space, the posterior rectal space, and the pelvic rectal space.
A fistula that invades one of these spaces is a high-grade simple fistula, while a fistula that invades two or more of these spaces is a high-grade complex fistula. In terms of clinical treatment, fistulas in the above-mentioned interstitial spaces all involve or cut off the puborectalis muscle, which is a component muscle of the anorectal ring, or the superficial or deep part of the external anal sphincter, which is the intermediate collaterals. Thus, all involve the protection of anal function.
Therefore, it is also scientific to diagnose anal fistulas in each of these interstices as high anal fistulas. However, the upper boundary of the pus cavity of an infection in the sciorectal space can also reach above the rectal ring, but the fistula formed travels in the lower part of the anal sphincter skin, i.e., between the basal collaterals and the superficial part, i.e., the intermediate collaterals, and the fistula is removed without involving the muscles that make up the rectal ring of the anal canal, so an anal fistula that simply invades the sciorectal space is a low-grade anal fistula.
3.2 Protection of the function of the anal canal
The restraining function of the anal canal is mainly achieved through the muscles surrounding the anal canal. According to Shafik’s triple collaterals theory, the muscles around the anal canal are divided into three collaterals from top to bottom, namely the cusp, middle and basal collaterals, each of which has its own attachment point, muscle bundle direction and innervation, and is encased in its own fascial sheath.
The apical collaterals and intermediate collaterals have bony attachments, so their contractile force is stronger. Although the basal collaterals have no bony attachment, they are located directly under the anal skin without the intervention of the internal sphincter and can effectively close the anus for self-control purposes. Therefore, each collaterals can be regarded as an independent sphincter, and anal self-control can be maintained by single collaterals contraction. However, Prof. Dongming Zhang also expressed deep doubts about the lack of effect of damage to the cuspidors collaterals on anal self-control. We also have ample experience to prove that the puborectalis muscle of the cusp top tab cannot be damaged casually.
From the perspective of the pressure in the anal canal rectum, the normal function of the internal and external anal sphincter is the basis for the generation of pressure in the anal canal rectum. “About 80% of the anal canal pressure in the resting state is formed by the contraction of the internal sphincter tone, and the remaining 20% is constituted by the contraction of the external sphincter tone. In the case of active contraction of the anal sphincter, the anal canal pressure is significantly elevated, and the pressure generated is primarily created by contraction of the external sphincter.”
”The puborectalis muscle plays an important role in bowel self-control, and this role is exercised mainly through its maintenance of the anorectal angle and the defecation receptors located within itself, and it is now generally accepted that the puborectalis muscle is the receptor center for bowel self-control [8].” The length of the high pressure zone of the anal canal is also formed by the tension of the internal and external anal sphincter, which is also a reflection of the normal or not of the anal self-control function.
The surgical approach we have designed for high perianal abscesses completely protects the puborectalis muscle, and the subcutaneous part of the external anal sphincter and the internal sphincter are treated with hanging wires, which also basically ensures their integrity. What is cut is the superficial and/or deep part of the external sphincter that affects the drainage of the wound (in a few cases, the deep part of the external sphincter is absent [9]). In this way, the puborectalis muscle of the apical collaterals is protected intact, the rectus angle is maintained in its original state, and the subcutaneous part of the external anal sphincter of the basal collaterals and the internal sphincter are also largely ensured intact due to the hanging treatment.
This way, the length of the anal canal hypertensive area and the resting pressure of the anal canal were well protected, as evidenced by the fact that none of the 139 patients had anal function problems after surgical treatment. If the abscess is in the pelvic rectal space and posterior rectal space, once it collapses in the rectum, it forms a secondary internal opening, then the hanging wire has to pass through the puborectal muscle, and the way to protect the puborectal muscle is to slowly cut the puborectal muscle with the slow directional hanging wire technique, and the patient’s anal canal restraint function can also be well protected.
3.3 Incision design issues
The design of the incision is important for adequate drainage of the abscess, the integrity of the anal canal and postoperative aesthetics. It is crucial to make a radial incision centered on the anal canal, and it is desirable to remove less skin tissue and more subcutaneous fatty tissue, and the ducts leading to each interstitial space should be unobstructed, so as not to produce excessive incisional tension, which may affect drainage.
After the anal caudal ligament is cut off near the tailbone part of the removal, care should be taken not to injure or expose the tailbone, so as not to cause infection of the bone. When cutting the pubococcygeal muscle to reveal the pelvic-rectal gap, it is appropriate to determine the size of the invasive canal, and it is appropriate to remove more when it is large and less when it is small, and it is always appropriate to have a funnel-shaped incision that is large outside and narrow inside. The incision for counter-oral drainage is preferable to a cross incision without loss of skin.
Subcutaneous fatty tissue can be removed appropriately to allow for unobstructed drainage. In addition, sometimes the fistula extends through the submucosal space to the submucosa, and care should be taken to protect the puborectalis muscle when making the incision, and it is advisable to treat the mucosal tissue by incisional ligation to avoid bleeding; the hanging wire method can also be used when the submucosal pus cavity is obvious, and mucosal bleeding can also be avoided. The tension direction of the skin of the main incision should be outward to avoid inward closure of the wound during growth. The method is to make a decompression incision at the edge of the wound.
3.4 Postoperative treatment
Postoperative medication change after high anal fistula is the key to cure the disease. The first thing to note is the prevention and elimination of early pseudo-healing of the wound, because the early exudate of the wound is more and more likely to adhere to the wound, and because the painful patient does not take a thorough bath, therefore, the early wound is generally prone to pseudo-healing within a week. At this time, the change of medicine should pay special attention to the finger examination, once the wound is found to have adhesions, should be promptly propped open.
After wiping and disinfecting the wound, dry the wound with dry gauze strips and place the drainage strips loosely to facilitate drainage. The lateral side of the wound should be pressurized so that the lateral side of the wound does not grow too fast and affect the drainage of the deeper part of the wound and make the operation fail. In the past, we used to cut off the tissues hung by the rubber strip by tightening the thread several times, which was extremely painful for the patients. After two weeks of surgery, the tissues hanging from the rubber strips have been mechanized, and direct incision has no effect on the function of the incised muscle.
In this group of cases, we used the direct incision method to treat all the tissues hanging from the rubber band, and the patients did not show any signs of decreased anal function. Giving Diosmin orally after surgery can improve the local microcirculation of the wound, reduce exudation, eliminate tissue edema, and have the effect of promoting normal growth of the wound. Jinxuan Hemorrhoid Fumigation San has the effect of clearing heat and detoxifying, relieving pain and reducing swelling. After external washing, it not only cleans the wound, but also has anti-inflammatory, edema prevention and pain relief effects. Thus, it also promotes the healing of the wound.