Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1420_Библиотеки_им_академика_М_И_Перельмана.pdf
208
Fig. 10.5 Free indication of gracilis
sphincter; the second is to nd the boundary of
the interval. Generally, there will be no bleeding.
(3) The free tissue ap should be paid attention to
so as to protect the blood supply of the tissue,
generally starting from the top in the separation
process, carefully identifying the tissue supply
blood vessels to protect. Freely isolate the tissue
before repairing the stula, thus ensuring that
there is a certain period of time to observe the
blood supply of the tissue, and at the same time
ensure that the free tissue has sufcient length,
and the method of measuring the length by
pulling and separating the tissue can be adopted.
It is also necessary to ensure that the tissue has
sufcient thickness so that the blood supply can
be effectively ensured and that the thickness of
the interval can be made standard. (4) When the
same tissue is isolated, care should be taken not
to leave dead space; during the suturing process,
the blood supply to the original end of the tissue
cannot be blocked to avoid tissue necrosis. (5)
When closing the perineal body, pay attention to
the drainage. You can use a rubber piece to pull
out from the incision. Generally, the drainage
piece can be removed after 48 h. (6) After the
operation, enteral nutrition is generally used to
control defecation for 1 week, so it is completely
unnecessary to make a preventive stoma.
R. Shi and F. Liu
mucosa (Crohn’s disease with proctitis), the
injection of sclerosing agent will cause the rectal
mucosa to be hardened. Transvaginal valvular
valve repair or stula resection combined with
stratied suture can also achieve good results.
Surgical methods: (1) good exposure of the
posterior wall of the vagina, the surgeon should
stick a nger into the anus to jack up the mouth.
Dilute adrenaline uid is injected under the vaginal mucosa around the stula. A circular incision
should be made 0.5cm from the edge of the stula with a curved scalpel blade, deep to the vaginal fascia. (2) The vaginal margin of the incision
is to be pulled with a tissue forceps, and the vaginal mucosa and the rectal wall are to be centrifuged about 2cm around the mouth with a curved
blade. The vaginal mucosa of the mouth should
be slightly separated from the center by about
2mm, and the scar of the mouth should not be
removed. (3) The suture is to be sutured along the
edge of the mouth with a No. 1 silk thread, and
the suture should not pass through the rectal
mucosa. The larger mouth (>2cm) will be interrupted by suture. (4) The vaginal submucosal
connective tissue should be sutured with a No. 1
silk thread to reinforce the front of the stula. (5)
The vaginal mucosa should be sutured intermittently with a 3-0 absorbable line. The vagina is to
be lled with an iodov gauze roll.
Tang Jie etal. used this procedure to treat 13
patients with rectal vaginal stula. The postoperative vaginal defecation symptoms disappeared,
and patients were discharged. The hospital stay
was 11–16 days, with a median of 12 days. All
patients were followed up for 0.5–7 years, with
an average of 2.5 years. All 13 patients were able
to defecate normally. There was no venting and
defecation in the vagina. The rectal examination
and vaginal speculum were well examined. The
rectal vaginal stula healed well. There was no
recurrence of rectal vaginal stula. No symptoms
such as vaginal stricture occurred.
Transvaginal Repair
Transvaginal surgery is used by most gynecologists and has certain advantages in some special
cases. For patients who have failed multiple rectal valvuloplasty or patients with unhealthy rectal
Transperitoneal Repair
Transabdominal repair is often used for vaginal
bladder stula or vaginal colon hernia repair and
rectal vaginal stula after rectal cancer surgery.
Laparoscopic surgery is sometimes used, and
10 Diagnosis andTreatment ofSpecial Anal Fistula
209
laparoscopic direct vision helps to identify the
structure and facilitate separation.
Wang Gangcheng etal. reported the method
of colonic transanal extraction combined with
pedicled omental packing. The specic methods
are as follows: (1) the patient takes the lithotomy
position. After the anesthesia is successful, the
perineal group of surgeons expand the anus,
revealing the ushing rectal anastomosis, vaginal and rectal vaginal stula. Then, they should
disinfect and remove the ulcerated tissue around
the vaginal stula. (2) Open the abdominal cavity along the original incision and extend the
incision upward to expose the greater omentum,
transverse colon, and left colon. Free the
descending colonic peritoneum, spleen colon
ligament, gastric colon ligament, broken submucosal vein, and descending colonic rst-class
ovoid arch trafc branch, so that the left colon is
completely free from the middle of the transverse colon, and pay attention to protect the
arteries and veins in the colon. (3) Separate the
pelvic adhesions and free the colon above the
anastomosis. Care should be taken to protect the
bilateral ureters and mesenteric vessels and completely detach the pelvic intestines. (4) The
intestinal clamp should block the proximal intestinal tube, prevent the intestinal contents from
being contaminated and contaminate the abdominal pelvic cavity, and the intestinal tube is freed
from the anastomosis to the lower rectum. The
anastomosis is 3.0cm below the rectum, and the
stump stops bleeding. (5) Again, the rectal
stump, vaginal and rectal vaginal stula should
be rinsed and disinfected. (6) The left colon is to
be pulled out of the body through the rectal
stump and the anus and is xed to the skin. When
xing the intestine, avoid suturing the mesenteric vessels and preventing intestinal necrosis.
(7) Free the omentum. The large omentum with
the right aortic vein of the gastric retina is completely freed from the left aortic vein of the gastric retina to the root from the abdomen and
avascular zone of the stomach. (8) Isolation and
repair. The pedicled omentum is passed through
the transverse colon and the small mesenteric
avascular zone (vertical distance) to the pelvic
oor, and the omentum is placed under the vaginal opening. The perineal group should use the
absorbable line to suture the vaginal stula
together with the underlying omentum while
avoiding the omental inclusions in the vaginal
incision so as not to affect the healing of the stula. (9) After 3–4 weeks, after the adhesion
between the colon and the anus is rm, remove
the extraintestinal tube outside the anus.
Wang Gangcheng and others treated 12
patients with this method. The operation was successful, and the median operation time was
95 min. The median amount of bleeding was
250ml. Eight patients recovered well after operation, and the anus was drained from 5 to 8 days.
Among the other four patients, two had pulmonary infection and two had incisional fat liquefaction. Eight to 12 days after surgery, the anus
was drained. Nine of the 12 patients underwent
vaginal examination at 3 weeks post-surgery. The
posterior vaginal wall was dense, with no emptiness, and a pelvic CT examination was carried
out. There was no uid in the vaginal rectal space,
and the intestine was removed. In the other three
cases, vaginal examination was performed 3
weeks after operation. The posterior vaginal wall
was loose and emptied. The posterior wall of the
vagina and the omentum were not adhered tightly.
After 6 weeks under a pelvic CT examination,
there was no effusion in the vaginal rectal space.
The limp was removed from the intestine. All 12
patients were followed up for 3 months. Among
them, ve patients developed anal stenosis 1
month after operation and were cured by intermittent anal sphincter. There was no intestinal
retraction and vaginal discharge of intestinal contents or venting, which were all successfully
repaired. Barium enema indicates that the rectal
vaginal stula disappears.
Some literature reports the use of sleeve segmental resection of the rectal intestine and
suture of the stula, the proximal intestine, and
anal dentate line anastomosis for the treatment
of rectal vaginal stula. However, this method is
complicated to operate and may affect the function of the anal sphincter, so it has few clinical
applications.
210
R. Shi and F. Liu
Kraske Posterior Approach
In 2009, Schouten etal. reported the use of the
Kraske posterior approach in the treatment of
eight patients with recurrent low-grade rectal
vaginal stula, through the sleeve resection of the
rectum, proximal rectum, and dentate line direct
anastomosis, and achieved a better effect. The
patient takes the folding position, corresponding
to the left end of the tailbone area from the junction of the appendix to the anal external sphincter
for longitudinal incision, the distal end of the tailbone is removed, the pelvic oor is exposed, and
the lower part of the posterior wall of the rectum
is cut longitudinally to expose the anterior wall of
the rectum. The truncated section of the rectum is
cut to ensure a sufcient range of resection.
Identify the enlarged stula, remove the scar tissue, layer the suture of the vaginal and rectal
muscle layer, open the drainage of the vaginal
mucosa, pull the proximal rectum and the dentate
line to manually suture the anastomosis, close the
pelvic oor peritoneum, drain the wound, and
close the layer incision.
The method reported by Qiu Huizhong is that
the patient takes the prone position, the hips are
raised as much as possible, and the sides of the
buttocks are stretched to the sides with a wide
tape to expose the perineum as much as possible.
From the appendix joint, make a midline incision
to the anal margin, about 12cm long, and cut the
skin and subcutaneous layer. Determining
whether to remove the tailbone should be done
according to the distance from the anal margin of
the mouth. If the distance from the anal margin is
greater than 6cm, the tailbone should be removed;
otherwise, it may not be removed. The anal external sphincter and the puborectalis muscle were
cut off in groups, and the posterior wall of the
rectum should be cut upward from the anal margin until the stula of the anterior wall of the rectum is revealed. After revealing the stula, rst
remove the scar around the stula, then lift the
rectal wall at the edge of the stula to carefully
dissect the inammatory adhesion between the
rectum and the vaginal wall. After separation, the
rectal wall and the vaginal wall are free. The edge
is preferably greater than 2–3cm to minimize the
tension during stitching. Then, the vaginal wall
and the rectal wall of the stula should be sutured
intermittently. Finally, the incision on the posterior wall of the rectum is to be sutured, and the
anal external sphincters should be cut to repair
the suture. If the tailbone is removed during the
operation, a drainage is placed in the coccyx at
the end of the operation. Qiu used this method to
treat 23 cases of rectal vaginal stula, and 3 cases
of wound infection occurred after operation. The
wounds healed after a dressing change. The 23
patients were all hospitalized 8.0 ± 1.0 days.
After being followed up for more than 3 months,
some were admitted to the hospital again. After
examination, 19 cases (82.6%) healed, and 4
cases (17.4%, including one case of loss of follow- up) were not healed. All patients were followed up for 3 months to 7 years with an average
of 20.8 months. The 23 patients had no postoperative anal dysfunction except for possibly one
who did not follow up. Nineteen patients who
were successfully repaired had no recurrence of
rectal vaginal stula after colostomy.
The author believes that this method is slightly
complicated, traumatic, technically demanding,
easy to infect, and needs a high level of
attention.
By Perineal Incisional Repair (Musset)
Perineal rectal incision through the perineal
approach has a unique advantage in the treatment
of middle and lower rectal vaginal stula with
anal sphincter injury. The main point of the perineal rectal stula is to convert the recto-vaginal
stula into a grade IV perineal laceration and
then suture the laceration layer by layer. The biggest advantage of this procedure is that the surgical eld is wide, the surgical path is shallow and
straight, and it can fully enter the stula and
sphincter defects so as to carry out adequate
sphincter folding and perineal reconstruction.
However, incision of the anal sphincter has the
risk of postoperative anal incontinence.
Musset uses a surgical method that directly
cuts the perineal body from the rectum and the
vagina to the rectal vaginal stula, sutures the
rectal wall, the levator ani muscle and the external sphincter, and nally sutures the vaginal wall.
The main points of the procedure are as follows:
10 Diagnosis andTreatment ofSpecial Anal Fistula
211
fully revealing the stula, the morphological
changes are made to the full layer of the vaginal
body, and the skin, the subcutaneous, the lower
sphincter of the stula, and the stula are directly
connected (Fig. 10.6). After the infection and
necrotic tissue are removed, the vagina is separated sharply. The interstitial tissue between the
posterior wall and the anterior wall of the rectum
is freely distributed upward to the proximal side
of the stula by 2–3 cm and is released to the
lower edge of the external sphincter and levator
ani muscle. After complete hemostasis, the upper
layer of the rectal wall is to be rst sutured with
the strong absorption of Weishengwei 4.0, and
then the levator ani muscles and the external
sphincter muscles are to be sutured with absorbable lines. The suture of the muscles is not suitable for knotting. Finally, the vaginal full layer
and perineal incision are sutured (Fig. 10.7).
Antibiotics should be used for 5 days to prevent
infection. After fasting for 3 days, patients were
fed on the fourth day, and solid food was taken
after 1 week. After the anal canal was placed for
3 days, the catheter was kept for 1 week. Avoid
premature defecation, and take a bath with 1:5000
potassium permanganate solution after
defecation.
According to foreign reports, the success rate
of Musset in the treatment of rectal vaginal stula
is 87–100%. Shen Zhen etal. used this method to
treat 20 cases of rectal vaginal stula. All patients
underwent surgery successfully. The operation
time of the whole group was 30–50 min. Six
patients had perineal incision redness and purulent exudation. Healing and physiotherapy healed
well; hospitalization time was 10–15 (average
12.1) days. All patients were followed up for outpatient and telephone follow-up, with an average
follow-up of 7.0 ± 2.6 months; no recurrence
occurred.
In 2011, Hull et al. retrospectively analyzed
87 patients with rectal vaginal stula and found
that the success rate of perineal rectal incision
and rectal valvuloplasty was similar, but postoperative sexual function and control in patients
with perineal rectal incision was signicantly
improved.
Transanal Endoscopic Minimally Invasive (TEM) Surgery
Transanal endoscopic minimally invasive (TEM)
surgery is a new method for repairing rectal vaginal stula. It has the advantages of being minimally invasive, having clear visual eld and
accurate mouth recognition. The disadvantage is
that it is difcult to conduct the operation and its
application range is limited. It is limited to the
rectal mucosal ap. Covering the endoscopic
operation of the repair, some of this still needs to
be done manually.
Synthetic Materials Repair Spells
Since 2004, more and more research groups have
reported the use of biological patches in recto-
Fig. 10.6 Transperineal repair of congenital rectovaginal
stula
Fig. 10.7 After transperineal repair of congenital rectovaginal stula
212
R. Shi and F. Liu
vaginal stulas. The decellularized dermal graft
patch retains the biological scaffold mainly composed of collagen and extracellular matrix by
removing the antigen component. After being
implanted into the body, due to the reticular
framework structure, the host cells can be induced
and promoted to grow on the scaffold, and the
degradation products of the host are absorbed by
the normal tissues, thereby completing the regenerative reconstruction of the defect tissue. In
2006, Shelton and Welton reported that the use of
acellular dermal patch for reoperation of two
patients with recurrent rectal vaginal stula was
successful. Other repair methods, such as brin
glue closure and Surgisis Biodsign stula, have
been gradually applied to the treatment of rectal
vaginal stula since the 1990s, but due to the limited number of studies, the failure rate is high, and
currently, it is almost not used as the rst line of
treatment for rectovaginal stula.
10.3.4.2 Preoperative Management
Preoperative bowel preparation: 3 days before
surgery, patients should halt the intake of food,
oral laxatives, and no slag diet 1 day before surgery. Oral parenteral antibiotics should be taken
to keep the intestinal tract relatively clean after
surgery, delaying postoperative formation of
feces, and ensuring there is no high pressure and
high tension in the early rectal area.
Postoperative management: patients should
stay in bed after surgery, indwelling catheterization, and maintaining a slag-free diet for about 1
week to avoid increasing the traction in the
operating area. It is recommended to inject
intravenous metronidazole and cephalosporin
antibiotics on the rst day before surgery and
change oral antibiotics or antibiotics after surgery. Avoid constipation and sexual life within 3
months after surgery.
10.3.4.3 Others
There has been a great deal of controversy about
the role of proximal colostomy in the repair of
rectal vaginal stula. In 2016, Lambertz et al.
found through retrospective studies that proximal
colostomy did not help to improve the recurrence
rate after rectal vaginal hernia repair, which coin-
cided with the views of Jones et al. However,
Corte etal. performed a total of 286 surgical procedures on 79 patients with rectal vaginal stula
and found that temporary fecal diversion surgery
signicantly improved the success rate of repair.
Peng Hui and others believe that for the lower
rectal vaginal stula with good general condition
and small wound inammatory reaction, the fecal
diversion ostomy should not be routinely performed. However, if the diameter of the stula is
larger and the position is higher, multiple repair
failures have occurred, and for rectal vaginal stulas with difcult to control inammatory
responses, or those with poor general tumors,
radiotherapy, and Crohn’s disease rectal vaginal
stula, the suggestion is a proximal colostomy to
control infection. Denitive repair surgery is performed on the basis of nutritional support.
The stoma is usually performed after clearing
when the rectal vaginal stula has healed for 3
months. There are also studies that do not make a
stoma by extending the fasting time, total parenteral nutrition support, etc.
10.4 Tuberculous Anal Fistula
The rectal anus is prone to getting stulas. Before
the discovery of modern anti-tuberculosis drugs,
most anal stulas were caused by tuberculous.
Since the widespread use of anti-tuberculosis drugs
in recent times, tuberculous stulas have been
greatly reduced. At present, tuberculous anal stula
accounts for 3–4% of extrapulmonary tuberculosis,
which is the sixth most common infection point of
extrapulmonary tuberculosis. The disease is more
common in men and is often associated with tuberculosis. At present, it is relatively rare in clinical
practice, and there are many atypical cases that are
easy to misdiagnose and mistreat.
10.4.1 Cause
Tuberculous anal stula is a specic infection
formed by Mycobacterium tuberculosis around
the anus. The traditional classication of tubercu-
10 Diagnosis andTreatment ofSpecial Anal Fistula
213
losis is a type of skin cavity. It is thought to be a
tuberculosis lesion inside the body or tissue, or
ingested with bacteria or sputum, so that
Mycobacterium tuberculosis is brought to the
skin near the cavity through the natural cavity to
form an infection. Mycobacterium tuberculosis
can also enter the bloodstream and reach the anus
through blood circulation, causing tuberculosis.
Skin and mucosal trauma can also be followed by
primary inoculation of mycobacteria.
Chinese medicine believes that the occurrence of tuberculous anal stula forms mostly
due to patients’ diet, heat and heat endogenous,
damage to the lung and spleen, blockage of the
large intestine or anus, or due to anal damage,
meridian obstruction, or blood stasis. The syndrome type is mostly yin deciency internal
heat, or both humid and hot blockage and lack of
blood owing smoothly.
10.4.2 Clinical Manifestations
The typical local manifestations of tuberculous
anal stula are special. Redness and swelling in
the attack period are not obvious, local pain is not
severe, and ulceration is long-term. Pus is the
main symptom, it is more dilute, and the mouth is
not closed for a long time. Skin lesions begin
with brown-red papules, which can then develop
ulcerative plaques called tuberculous sputum.
There are many external mouths, irregular, with
large openings, fusiform shape, often curled at
the edges or subcutaneously, and the surrounding
skin is dark. The granulation tissue is pale and
swollen and slightly ooded. There are many
branches of the stula, pus is thin, the color is
yellowish, or there are rice water and cheese-like
secretions. The wall of the tube is soft, the lumen
is large, and the inner port is larger than the common stula. Most tuberculous anal stulas do not
follow Goodsall’s laws. Local lymph nodes often
have swelling. If it is not diagnosed as tuberculous anal stula before surgery, the wound will
not heal for a long time after surgery.
Typical tuberculous anal stula patients often
have more or less systemic manifestations of
Mycobacterium tuberculosis infection, such as
long-term persistent low fever, sometimes even
high fever, night sweats, cough, hemoptysis,
chest pain, fatigue, irritability, anorexia, etc.
At present, atypical tuberculous anal stula is
more common, and its symptoms are similar to
those of nontuberculous abscess or anal stula.
Douglas’s research shows that most patients with
tuberculous anal stula do not have convincing
symptoms of systemic tuberculosis. Because
there is no systemic tuberculosis, missed diagnosis and misdiagnosis are likely to occur.
According to Wang Zhigang and Lu Weijian,
the current clinical features of tuberculous anal
stula are the following: (1) patients are more
likely to be young and middle-aged men, and
they occur more often because of perianal
abscess, pain, or stool with blood. (2) The symptoms of the respiratory system and tuberculosis
poisoning are often not obvious. Patients can
often nd tuberculosis after a chest X-ray examination. (3) Laboratory examination: the positive
rate of acid-fast staining of sputum and purulent
secretions is higher. (4) There is a long history of
misdiagnosis. Because the anal stula does not
heal, tuberculosis is usually found only after
repeated diagnosis. (5) Compared with the clinical symptoms of other nonspecic infectious anal
stulas, tuberculous perianal abscess is softer in
texture, but the tenderness is not obvious, and
there is a sense of uctuation. After the formation
of anal stula, there is often a depression in the
outer mouth, which is a cylinder mouth, no induration, irregular, not fresh, easy to bleed, and at
the same time, the surrounding skin is often dark
purple, granulation tissue is grayish-white, and it
can be seen as cheese-like necrosis. The pus is
usually thin, is pale yellow in color, and quite like
the water after washing rice.
10.4.3 Inspection andDiagnosis
The early diagnosis and correct treatment of
tuberculous anal stula are difcult, and doctors
need a certain level of experience and high vigilance against this disease. When the anal stula is
not healed for a long time, a biopsy should be
performed and pathological examination and
214
R. Shi and F. Liu
bacterial culture should be performed to exclude
tuberculosis infection.
Tuberculous anal stula needs to rely on
biopsy and tuberculosis culture to diagnose.
Biopsy tissue acid-fast staining (Ziehl–Nielsen
staining) found that mycobacteria, or positive
guinea pig vaccination, or skin-like pathologically visible caseous necrotic granuloma, all contribute to the diagnosis of tuberculosis. Since the
culture takes 4 weeks, some new methods are
more useful such as PCR amplication to detect
bacterial DNA, which takes only 48h.
However, many times, sputum secretions were
taken for acid-fast staining, and no mycobacteria
were found. The chest X-ray, PPD test, and erythrocyte sedimentation test were also found to be
normal. When this happens, the stula tissue is
used for disease detection, and Xerox staining to
nd acid-fast bacilli is an effective diagnostic
method. Pathological examination can conrm
the diagnosis. However, it is not easy to obtain
tuberculosis lesions in brosis, and small lesions
of varying depths and typical tuberculosis lesions
can only be found inlocal lymph nodes.
Colonoscopy does not help the diagnosis of
tuberculosis because the morphology of the
mucosa and mucosal biopsy lack specic performance, making it difcult to rule out other
lesions. However, if the biopsy pathology has
tuberculosis, it can be diagnosed.
Patients with tuberculous anal stula must be
diagnosed with or without tuberculosis. The
methods for diagnosing tuberculosis include the
following: (1) sputum smear for tuberculosis: it is
simple, fast, and inexpensive, and the results are
available on the same day, but the type of bacteria
cannot be distinguished; the sensitivity is low,
usually 5000–10,000 and the bacteria/ml can
obtain positive results; the specicity is poor, and
various acid-fast bacilli can be colored, and further tests are needed to determine whether it is
tuberculosis. (2) Tuberculosis culture of sputum
is a reliable method for identifying live bacteria
and is known as the “gold standard.” The shortcoming is that it takes a long time, it takes several
days to 2 weeks to report results, and the sensitivity is low. Only about 80% of the smear-positive
specimens are culture-positive; the specicity is
poor, and various mycobacteria can grow, and a
drug sensitivity test needs to be combined.
Identication of mycobacterial species can determine whether it is tuberculosis. (3)
Mycobacterium species identication: based on
the physicochemical properties of different
mycobacteria, mainly biochemical methods.
Different strains of mycobacteria can be accurately identied, but the operation is complicated,
and the drugs used in individual tests have certain
risks. (4) Chest X-ray or video and CT examination. Tuberculosis of the lungs can often be
found. (5) Tuberculin skin test positive is more
common, has a certain reference signicance, but
there are also false-positive or false-negative
cases. (6) T-SPOT test: there are specic effector
T lymphocytes in the infected patients, and the
effector T lymphocytes secrete various cytokines
(IFN-γ) when stimulated by the antigen again.
Therefore, examination of effector T lymphocytes can be used for the diagnosis of tuberculosis or potentially infected persons with
tuberculosis. That is to say, the cytokine secreted
by the cells in the culture is captured by the antibody and expressed by enzyme-linked spot color
development. The T-SPOT assay is a C-interferon
release assay that uses TLR to detect T cells that
respond to 6 kD early secreted target antigens
and 10kD cultured lter protein–peptide pools to
diagnose tuberculosis infection. It has high sensitivity and specicity and is not affected by the
immunity of the body and BCG vaccination.
According to US FDA data, its sensitivity is
95.6%, and the sensitivity of domestic clinical
data report is 95.3%. There is a high rate of detection in patients with extrapulmonary tuberculosis. A negative result suggests that there are no
effector T cells specic for Mycobacterium
tuberculosis in the patient. Negative results may
be related to different stages of infection, a small
number of patients with immune system dysfunction or disease, and abnormal operation of the
experiment. Negative results suggest that there
are effector T cells specic to Mycobacterium
tuberculosis in the patient, and the patient has
tuberculosis infection. However, whether it is
active tuberculosis, it is necessary to combine
clinical symptoms and other examinations and
10 Diagnosis andTreatment ofSpecial Anal Fistula
215
examination indicators to comprehensively judge
the situation. When M. kansasli, M. szulgai, M.
marinum (sea), and M. gordonae (Gordon) are
infected with four environmental mycobacteria,
the T-SPOT test also has certain false positives.
This test method is used by more and more
researchers to identify active tuberculosis and
latent tuberculosis infections and to predict the
risk of tuberculosis.
Tuberculous anal stula needs to be differentiated from Crohn’s disease, actinomycosis, anal
stula, gelatinous carcinoma, sarcoidosis, and
other skin diseases. It should be noted that tuberculosis is rarely considered in the differential
diagnosis of perianal ulcers. Some tuberculous
anal stulas were initially diagnosed as Crohn’s
disease, so attention should paid to the medical
history and to whether the patients have had contact history such as epidemic areas. In the absence
of evidence of tuberculosis, at least for Crohn’s
disease, the stula should not be easily diagnosed
and treated, but a tuberculin test and long-lasting
ulcer tissue should be rst cultured.
10.4.4 Treatment
Once tuberculous anal stula is diagnosed, regular anti-tuberculosis treatment should be done
promptly. After anti-tuberculosis treatment for a
period of time, if necessary, surgery should be
performed. Surgical treatment should be performed after the local and systemic symptoms
have subsided, and the symptoms will continue to
alleviate for several months. If the incision does
not heal for a long time after surgery, the tuberculous anal stula should be diagnosed after an
examination, and anti-tuberculosis drugs should
be treated as soon as possible. Local antituberculosis drugs can be used to help the sore
surface healing.
10.4.4.1 Anti-tuberculosis Treatment
The Principle ofTreatment
The key to anti-tuberculosis treatment is to control systemic and local tubercle bacilli infection.
A reasonable and regular chemotherapy regimen
must have two or more bactericidal drugs, a reasonable dose, a scientic method of use, a sufcient course of treatment, and a standard and
early medication to cure tuberculosis. In order to
thoroughly treat tuberculosis, we must follow the
above ve principles: early, joint, appropriate,
standardized, and full-course. We must ensure
that the rule must be ruled out, and the rule must
be thorough. The lack of any of the above components can lead to treatment failure.
1. Early
Early treatment can help the lesions absorb
and dissipate without leaving traces.
2. Combination
Patients with initial treatment or re-
treatment should be combined with drugs, and
the cause of clinical failure is often refractory
to single medication. Combination therapy
must be combined with two or more drugs to
prevent or delay the development of drug
resistance and can improve the sterilization
effect. There are both intracellular bactericidal drugs and extracellular bactericidal
drugs, as well as bactericidal drugs suitable
for acidic environments so that the chemotherapy regimen achieves the best effect. This
can also shorten the course of treatment and
reduce unnecessary waste of resources.
3. Moderate
Be sure to use appropriate doses under the
guidance of a specialist. If the dose is too
large, the blood drug concentration is too
high, and it may cause a large toxic side reaction in the digestive system, nervous system,
or urinary system, especially to the liver and
lung. When the dose is insufcient, the blood
concentration is low, and the antibacterial
effect is not achieved. Sterilization is therefore not achieved, and it is easy to develop
drug resistance.
4. Specication
Because tuberculosis is a stubborn bacteria
with a long split cycle, slow growth, and
reproduction, it is difcult to kill. In treatment, the medication must be standardized. If
the medication is improper, symptom relief
will not be achieved, which will inevitably
216
R. Shi and F. Liu
lead to the occurrence of drug resistance,
resulting in treatment failure, and it will be
more difcult to treat in the future. Therefore,
medication must be strictly regulated.
5. Full course
One course of treatment is for 3 months.
The full course of treatment is 1 year or 1 and
a half years. Short-term treatment should not
be less than 6 or 10 months.
It should be noted that the drug resistance of
tuberculosis has increased year by year. The
WHO 2008 report showed that the global tuberculosis total resistance rate was 20%, and the
multidrug resistance rate was 5.3%. China is one
of 27 countries with high MDR-TB and highdrug- resistant tuberculosis. The treatment of
severe drug-resistant tuberculosis is more complicated. At present, in addition to standard treatment, chemotherapy, intervention, and immune
treatment have been gradually adopted.
Traditional Chinese medicine plays an important role in the treatment of tuberculosis. Chinese
medicine treatment of tuberculosis is mainly
aimed at the body’s own resistance, by strengthening the body’s immune function and resistance,
to achieve the role of inhibition of tuberculosis.
At the same time, in the treatment of tuberculosis, traditional Chinese medicine can also inhibit
and reduce the side effects of western medicine
on the stomach, liver, and kidney.
Medication Plan
This is generally divided into the intensive treatment phase (intensive phase) and consolidation
therapy phase (consolidation phase). Standard in
the intensive chemotherapy regimen is four drugs
in combination for 2 months, while that in the
consolidation phase is two or three drugs in combination for 4 months.
1. Recommended treatment plan for initial treat-
ment of dysentery and/or vaginal
tuberculosis
2HRZE/4HR (H: isoniazid, R: rifampicin,
Z: pyrazinamide, E: ethambutol).
The intensive phase should be treated with
the HRZE regimen for 2 months and contin-
ued with the HR regimen for 4 months. The
course of treatment is generally 6 months. For
patients with severe disease or comorbidities
that affect prognosis, the course of treatment
may be extended appropriately.
2. Recommended treatment plan for retreatment
of tuberculosis
2SHRZE/6HRE or 3HRZE/6HRE (S:
streptomycin, H: isoniazid, R: rifampicin, Z:
pyrazinamide, E: ethambutol).
The intensive phase should be treated with
the SHRZE regimen for 2 months, and the
duration of treatment with the HRE regimen
for 6 months, or the intensive phase with the
HRZE regimen for 3 months, and the extended
phase with the HRE regimen for 6 months.
After obtaining the results of the patient’s
anti-tuberculosis drug sensitivity test, a reasonable treatment plan should be selected
according to the drug resistance spectrum and
the history of previous treatment. The course
of treatment is generally 8 months. For
patients with severe disease or comorbidities
that affect prognosis, the course of treatment
may be extended appropriately.
3. Recommended treatment plan for multidrugresistant tuberculosis
6 Z Am(Km,Cm)Lfx(Mfx)Cs (PAS)Pto/18
Z Lfx(Mfx)Cs(PAS )Pto Scheme (Lfx: levooxacin, Mfx: moxioxacin, Am: amikacin,
Km: kanamycin, Cm: capreomycin, Pto: prothionamide, PAS: p-aminosalicylic acid, Cs:
cycloserine).
The Z Am (Km, Cm) Lfx (Mfx) Cs (PAS)
Pto regimen should be used for 6 months during the boost period and continued for 18
months using the Z Lfx (Mfx) Cs (PAS) Pto
regimen (alternative medicines in brackets).
The course of treatment is generally 24
months. For patients with severe disease or
comorbidities that affect prognosis, the course of
treatment may be extended appropriately. For
special patients, such as children, the elderly,
pregnant women, those on immunosuppression
drugs, and those with adverse drug reactions,
doctors can adjust the drug dose or drug based on
the above program.
10 Diagnosis andTreatment ofSpecial Anal Fistula
217
10.4.4.2 Surgical Therapy
After regular anti-tuberculosis treatment, after
reviewing tuberculosis, the patient should then be
treated with surgery. By this time, the surgical
treatment is the same as that for common anal
stula.
10.4.4.3 Topical Treatment
For postoperative tuberculous anal stula, rifampicin and some topical anti-tuberculosis drugs
can be used at the same time as systemic antituberculosis treatment.
10.5 AIDS Associated with Anal Fistula
Acquired immunodeciency syndrome (AIDS)
is a sexually transmitted disease (STD) caused by
human immunodeciency virus (HIV) infection
and characterized by severe immunodeciency.
Patients often contract lymphadenopathy,
anorexia, chronic diarrhea, weight loss, fever,
fatigue, and other systemic symptoms, and
opportunistic infections or secondary tumors can
gradually develop and ultimately lead to death. In
recent years, the number of patients with AIDS
complicated with anorectal diseases has gradually increased. According to the survey, the incidence of anorectal diseases in AIDS patients is
92.7% (204/220), including 179 cases of acne
(87.7%) and 15 cases of perianal eczema
(7.4%)—18 cases of anal papilloma (accounting
for 8.8%), 5 cases of anal condyloma acuminata
(2.5%), 3 cases of perianal folliculitis (1.5%), 4
cases of anal ssure (2.0%), and 6 cases of anal
stula (2.9%). Some patients had two or more
anorectal diseases. There was no signicant correlation between the incidence of anorectal diseases in AIDS patients and gender, age, ethnicity,
drug use, and CD4+ T cell count. It indicates that
the incidence of anorectal diseases in AIDS
patients is high and the diseases are diverse.
Therefore, AIDS patients should pay attention to
regular anorectal examinations for early diagnosis and treatment of anorectal diseases.
10.5.1 Diagnosis
Regular anorectal disease screening is important
for AIDS patients, especially gay men. Moreover,
the screening method for anorectal diseases is
more convenient. More than 90% of anorectal
diseases can be found through anal examination,
anal nger examination, and anal microscopy.
The method is simple, and the patient spends
less, and it is easy to be clinically popularized.
During the AIDS treatment, clinicians should
strengthen the regular screening of patients with
anorectal diseases, so that early anorectal diseases, early diagnosis, early intervention, and
treatment can be found to improve the quality of
life of patients.
Anorectal surgeons should consider the possibility of HIV infection for severe, long-term
treatment, recurrent episodes of hemorrhoids,
perianal eczema, anal condyloma acuminata,
perianal folliculitis, anal ssure and anal stula,
or anorectal symptoms in high-risk groups. It is
necessary to screen all patients with anal stula
for HIV before surgery. If HIV infection is suspected, a further examination should be carried
out and reported to the local CDC.
10.5.2 Treatment
In the AIDS Prevention and Control Regulations,
China stipulates that medical institutions may not
refrain or refuse treatment of other diseases of
AIDS patients. In recent years, the number of
HIV/AIDS patients requiring surgery has
increased, and hospitals have encountered such
patients, but most hospital surgeons will shut out
such patients or push them to the so-called “specialized hospitals,” but some specialized hospitals do not have the conditions to carry out certain
operations of this disease.
HIV/AIDS is not an absolute contraindication
to surgery, and reasonable surgical treatment is
the only effective way to save some HIV/AIDS
patients. Medical staff should take a positive attitude toward the operation of HIV/AIDS patients
and conduct a comprehensive assessment and