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
First massage the anal
opening with the front
of the anoscope
e
5 Common Methods ofExamination forAnal Fistula
55
The direction of the lens should be facing the
navel rst and then facing the sacral tail after
passing through the anal canal. After reaching the
ampulla of rectum, the core should be pulled out
to observe whether there is adhesive mucus or
blood on the top of the core. After adjusting the
light to directly illuminate the visual eld in the
tube, carefully observe the color of the mucosa at
the lower end of the rectum, whether there are
tumors, polyps, ulcers, foreign bodies, secretions,
etc. Then, slowly withdraw the mirror body from
the anus, and observe whether there are internal
hemorrhoids, anal nipple hypertrophy, anal sinusitis, or anal stula opening near the dentate line.
Below the dentate line, look for cracks, growths,
etc. (Fig. 5.11). In order to observe the lesion
Remove the anoscope core
Fig. 5.11 Anoscopy method
Insert the anoscop
towards the
umbilicus
carefully, it is sometimes necessary to insert the
lens several times. Note: during the examination,
if further observation is required or the rotating
mirror body is required, the core must be inserted
again before operation to prevent injury to the
anal canal and rectal mucosa.
In patients with anal stula, there is often congestion and swelling in the internal opening in
the dentate line, or there are red, inamed pits
and protruding nodules. Because the anal canal is
dilated, the stula wall is compressed; sometimes, pus can be seen owing from the internal
opening to the intestinal cavity. At this time, if
methylene blue is injected from the external
opening of stula, the overow of methylene
blue from the internal opening can be seen, or the
gauze placed in the anus will have methylene
blue.
Leaf Anoscope
Before anoscopy, ask the patient to empty his
stool. The surgeon should hold the handle of the
anoscope in his left hand, close all the leaves of
the leaf anoscope, smear parafn oil on them,
insert them into the anus, and then open them up.
The lesion is observed by using the space between
the leaves (Fig.5.14). Note: during the examination, do not suddenly pull up the leaf anoscope to
prevent the injury of intestinal mucosa and do not
force to push in order to prevent stabbing the
intestinal wall.
5.1.2.5 Inspection ofAnal Crypt Hook
Crypt hook examination is an important method
to examine the internal opening. There are two
kinds of hooks commonly used: the hooks are
0.5cm and 1.0 cm, respectively. When using the
crypt hook probe, rst take the small hook, probe
the suspicious lesion area of the anus under the
microscope, and then slowly explore the rest of
the anal stula along the dentate line. If necessary, take the hook to explore again. In general,
the normal crypt can be probed by the crypt hook,
but the hook is shallow. If the hook is deep, the
location of the internal opening should be highly
suspected; if the direction of the hook is consistent with the direction of the anal stula, the location of the internal opening can be claried. The
56
Fig. 5.12 Staining examination of anal stula
lower stula is then inserted with a probe from
the external opening. If the two meet and touch, it
indicates that the explored internal opening and
stula are interlinked, and the anal crypt is where
the internal opening is.
5.1.2.6 Methylene Blue Staining Examination
The staining agent is injected into the stula from
the external opening of the anal stula to stain the
wall of the stula so as to show the position of the
internal opening and determine the range, course,
morphology, and number of stula (Fig.5.12).
The commonly used staining agent is 2% methylene blue or 2% methylene blue mixed with 1%
hydrogen peroxide. Specic examination methods are as follows:
Fill theGauze Roll intheAnus
Take the anus mirror and apply lubricant and
insert it into the anus, extract the lens core, and
then put the rolled yarn roll into the anus, and
then slowly take out the anus mirror so that the
gauze roll is placed in the anal canal. During the
operation under anesthesia, the gauze can be
directly put into the anus.
Dye Injection
Use a 5-ml syringe to extract 2–4ml of methylene blue, cut off the needle of the scalp needle
hose, connect the syringe to the scalp needle
hose, insert the hose through the external opening
into the stula for more than 1–2 cm, and press
R. Shi and L. Liu
on the external opening to prevent methylene
blue from spilling out of the external opening.
Inject methylene blue slowly. After infusion, continue to press the external opening to prevent
methylene blue from spilling out, and then lightly
press and knead the stula for observation.
Observation ofStaining Area
The observation of the internal opening staining
area can be divided into direct observation and
indirect observation. At the same time as injecting the liquid, direct observation is made by
opening the anus and looking directly at the colored spot, while indirect observation is made by
identifying the colored area of the yarn coil.
When the anal plug gauze rolls out, rst observe
whether there is any color or not. If there is staining, it indicates that the internal and external
opening of stula is on the same path. The position of the internal opening can be determined by
observing the position of the shading area, and
the corresponding area of the shading area is the
position of the internal opening. However, when
the internal opening is large, the stain will overow more, and it is difcult to accurately identify
the location of the internal opening. In the case of
internal opening atresia, although no staining
agent is spilled from the anus, sometimes blue
dye can be seen in the anal mucosa, so the location of the internal opening can also be
determined.
In addition, the anoscope can also not be
removed during the staining examination to
observe whether the dye spills from the internal
opening. This method is often used for intraoperative examination of the internal opening.
5.2 Auxiliary Examination
ofFistula
5.2.1 Ultrasonic Examination
Ultrasound examination is a method to diagnose
diseases by utilizing the information generated
by the interaction between the physical characteristics of ultrasound and the acoustic characteristics of human organs and tissues and by
l
anal sphincter
5 Common Methods ofExamination forAnal Fistula
57
receiving, amplifying, and processing the information to form graphics, curves, or other data.
Because it is painless, inexpensive, and portable
equipment, it is widely used in the clinic.
5.2.1.1 Equipment
There are two types of transanal ultrasound: linear and radial. The radial examination function
can observe the pathological changes of the anus
within a range of 360°, and the whole perianal
image can be better displayed by using the urethra as the 12-point position (Fig.5.13). However,
it is difcult to understand the longitudinal information of anal canal. If the inspector is familiar
with the normal anatomic structure of anus during ultrasonic examination, he or she can make
up for this deciency. During the examination,
the ultrasonic probe inserted into the anus is
moved up and down for several times to observe
the anatomical relationship between the location
of the primary lesion, the course of stula, and
the anal sphincter and anal levator ani muscles
surrounding the stula.
5.2.1.2 Examination Methods
According to the method of ultrasound echo display, there are two methods. (1) The twodimensional section diagnostic method
(abbreviated as B-mode ultrasound) is the most
widely used ultrasound diagnostic method in
clinics at present. In the anorectal department, it
is often used for abdominal and perianal examinations. The real-time two-dimensional ultrasound tomography of human soft tissue organs is
obtained by linear scanning. (2) Color Doppler
ow imaging (CDFI) is a method of using autocorrelation technology on a two-dimensional
ultrasound section to quickly obtain all echo
information in a larger chamber or pipeline and
then color coding and overlapping in the corresponding area of the same two-dimensional grayscale image. This can reect the blood ow
movement situation inlocal tissues. According to
the path of examination, it can be divided into the
body surface ultrasonography and the endoluminal ultrasound. Anal stula is usually examined
by endoluminal ultrasound. Because transanal
ultrasound examination is specialized, it has
great clinical signicance for anal stula and
other diseases. This chapter mainly introduces
the transanal ultrasound examination method.
Transanal ultrasonography
The enema should be given with 100ml of glycerol in advance, and the left lateral position
should be taken. The ultrasonic probe should be
inserted through the anus, and the urethra should
be rstly scanned to mark the position of 12
o’clock. Then move the ultrasonic probe up and
down to conrm the internal sphincter, external
Fig. 5.13 Image of
radiant ultrasound
system
Superficial
external
anal sphincter
Deep externa
58
R. Shi and L. Liu
sphincter, and levator ani muscles as diagnostic
targets and observe the presence of lesions and
the direction of expansion. In order to locate the
dentate line, a crypt hook can be placed in the
dentate line when combined with high intersphincteric lesions.
When the ultrasound probe is inserted from
the anus, the lower part of the external sphincter
is located at the supercial part of the lower part
of the anus and shows low echo and round around
the anus. The sphincter muscle bundle is weaker
in females than in males, especially in the front of
the anus. According to the contraction of the
anus, the voluntary contraction of the muscle can
be observed, and this indicates that the muscle
bundle is striated muscle.
The supercial part of the external sphincter
and the subcutaneous part of the circular external
sphincter have obvious shape differences and
show low echo. The supercial part of the external sphincter is the largest, longest, and strongest
muscle bundle in the external sphincter. It shows
three forms on ultrasound, but all three of them
x the anus in the back from the left or right
sphincters. When contracting the anus, random
contraction of the muscle is observed, indicating
that the muscle bundle is striated muscle. On the
inner side of the supercial external sphincter, we
can see that the deep external sphincter, which is
described as a low echo, is circular around the
deep anal sphincter as the subcutaneous part of
the external sphincter. However, this muscle bundle is anatomically tightly attached to the posterior puborectalis muscle, and in many patients, it
cannot be clearly scanned.
The levator ani muscle can be divided into
three parts: puborectalis muscle, pubococcygeal
muscle, and iliac coccygeal muscle according to
its course. However, there is no clear demarcation between the three parts, so it is difcult to
completely differentiate them in the ultrasonographic images. Because the internal sphincter is
thin, in many patients it cannot be clearly
described.
Endoscopic Ultrasonography
Endoscopic ultrasonography is simple, rapid, and
easily accepted by patients. During operation, the
patient takes the left lateral position or the prone
position, the probe is gently inserted into the distal rectum, and the lens is retreated outward while
the examination is performed.
There are three criteria for nding the internal
opening under endoscopic ultrasonography: ①
the internal sphincter is detected through the
intersphincteric stula (positive predictive value:
80%); ② obvious defect of internal sphincter
(positive predictive value: 79%); and ③ clear subepithelial stula with localized sphincter defect
(positive predictive value: 94%). The overall sensitivity of these three signs in combination is
94% (specicity: 87%, positive predictive value:
81%).
5.2.1.3 Normal Anatomy ofTransanal
Ultrasound Examination
The images of internal sphincter, external sphincter, and levator ani muscle are recorded by preoperative ultrasonography. The muscles are exposed
during the operation. Ultrasound examination is
to be performed. If it is consistent with the preoperative ndings, the muscles are identied as certain muscles. In addition, cases of internal
hemorrhoids and anal ssure are also examined
by ultrasound. Through the above efforts, the
normal ultrasound anatomy of anal canal can be
mastered.
1. Internal sphincter
On ultrasound, it appears to be the innermost region, circular around the anus, and
appears to be hypoechoic. Due to the thin
layer, many cases cannot be scanned.
2. The subcutaneous part of the external
sphincter
Close to the outside of the internal sphincter, a clear circular hypoechoic image is easily
found (Fig.5.14).
3. Supercial external sphincter
When the ultrasonic probe is moved
upward from the trace to the subcutaneous
part of the external sphincter, the image is the
supercial part of the external sphincter, and
its shape is signicantly different from that of
the subcutaneous part of the external sphincter (Fig.5.15). The supercial appearance of
Internal anal sphincter
l
anal sphincter
5 Common Methods ofExamination forAnal Fistula
Fig. 5.14 Ultrasonic
images of the
subcutaneous and
internal sphincter of the
external sphincter
Fig. 5.15 Ultrasound
images of the supercial
and deep parts of the
external anal sphincter
59
External Anal Sphincter
the external sphincter in the vast majority of
cases is described as any of the three patterns
shown in Fig.5.16, a distinct low echo.
4. Deep external sphincter
At the same height as the supercial part of
the external sphincter, the inner part of the
supercial part of the external sphincter is
round around the anus and also presents as
hypoechoic, but the deep image of the external sphincter in many cases is not clear.
5. Levator ani muscle
At the height of the probe, it should be
scanned from the superficial and deep
parts of the external sphincter; moving the
probe upward, there is a low muscle echo
image that is U-shaped around the anus
(Fig.5.17).
6. Dentate line
Under normal conditions, it is impossible
to locate the dentate line by ultrasonic examination. Therefore, a liquid should be used to
better characterize the characteristics of
ultrasonic wave in the dentate line, i.e., with
0.5% serucaine E (0.5 ml) for local injection
of about 5 places. This can accurately determine the position of the dentate line. It is also
possible to position the dentate line by placing
a crypt hook at the dentate line portion.
5.2.1.4 Ultrasonic Characteristics
When meeting specic cases in the clinic, doctors should compare the results of palpation
Superficial
external
anal sphincter
Deep externa
ofDierent Types ofPerianal
Abscesses andAnal Fistulas
60
a
b
c
Subcutaneous external
Urethra
Fig. 5.16 Three forms
of the supercial part of
the external sphincter.
The three pictures A/B/C
on the left show the
ultrasound images of the
supercial part of the
external sphincter
muscle traced at
different positions
A/B/C in the right
picture
R. Shi and L. Liu
Puborectalis Muscle
Deep external anal sphincter
a
b
Coccyx
c
Internal anal sphincter
Fig. 5.17 Ultrasonic
image of the levator ani
muscle
Superficial external
anal sphincter
anal sphincter
Postanal Space
Levator Ani M.
with the ultrasound images and the intraoperative ndings so as to determine the ultrasound
images of various types of perianal abscess and
anal stula and grasp the characteristics of the
lesions.
Intersphincteric Abscess, Intersphincteric Fistula (II Type)
On the ultrasonographic images, the intersphincteric lesions present as a hypoechoic mass in the
medial external sphincter. The abscess is cystic,
External Anal Sphincter
External Anal
5 Common Methods ofExamination forAnal Fistula
61
and the anal stula is a mass with approximately
the same echo density as the sphincter. The high
intersphincteric stula (II H) or low intersphincteric stula (II L) can be distinguished by locally
injecting serucaine E into the dentate line to
locate the dentate line.
Case 1: II HA, II LA (Figs.5.18 and 5.19)
In Fig. 5.18, the supercial external sphincter
appears as a U-shaped hypoechoic layer surrounding the anus. The intersphincteric lesion
presents as a 6-point hypoechoic mass.
Figure5.19 is the image of the ultrasonic probe
Fig. 5.18 Ultrasound
image of high
intermuscular abscess
being pulled outward. The subcutaneous part of
the external sphincter appears as a round
hypoechoic layer around the anus. II LA and II
HA also show the sphincter within 6-point inside
the low echo. Therefore, a diagnosis of II HA II
LA is made.
Case 2: II Hs (Fig.5.20), II Ls (Fig.5.21)
The circular hypoechoic layer surrounding the
anus in Fig. 5.20 is the supercial part of the
external sphincter. At six o’clock, the masses at
the same level as the supercial part of the external sphincter can be seen, showing as II Hs. In
Fig. 5.19 Ultrasound
image of low
intermuscular abscess
IIHA
(Superficial)
IILA
Sphincter
(Superficial)
62
External Anal Sphincter (Subcutaneous)
Fig. 5.20 Ultrasound
image of high
intermuscular stula
R. Shi and L. Liu
Fig. 5.21 Ultrasound
image of low
intermuscular stula
External Anal
Sphincter
(Superficial)
IILs
IIHs
Fig. 5.21, the subcutaneous part of the circular
external sphincter can be seen, and the lesion of
II Ls can be seen at six o’clock. According to the
above characteristics, the case is diagnosed as II
Hs, II Ls.
Ischioanal Abscess, Ischioanal Fistula (Type III)
Because the gap behind the anus is full of pus, the
ischioanal abscess shows a cystic shape in the
gap behind the anus on ultrasonic examination,
and the pus is discharged simultaneously when
pressing on the supercial part of the external
sphincter. Ischioanal abscess needs to be differentiated from intersphincteric abscess. It is very
difcult to identify by palpation, but it can be
easily identied by ultrasound.
In the case of ischioanal stula, the purulent
uid in the posterior anal space decreases, and
the inner cavity becomes smaller, presenting as a
low-echo mass extending along the supercial
part of the external sphincter to the horseshoe-
IIHA
(Superficial)
5 Common Methods ofExamination forAnal Fistula
63
shaped masses on both sides. Most cases of
ischiorectal space lesions are associated with
intersphincteric lesions (mostly II H).
When Takano Masahiro studied the formation
pattern of ischioanal abscess by ultrasonic
examination, he found something very interesting: in the production process of ischioanal
abscess, an intersphincteric abscess was formed
rst, and then the intersphincteric abscess bursts
through the external sphincter and extends deep
into the posterior anal space, and then forms the
ischioanal rectal abscess. When ultrasound examines the posterior anal space, there is no posterior
anal space near the outside of the internal sphincter at the supercial height of the external sphincter. On the outside of the internal sphincter, there
is a deep part of the external sphincter, and the
outside of the deep part of the external sphincter
has a deep postanal space. Therefore, the infection
of the anal gland between the internal and external sphincter does not directly spread to the deep
space but rst forms the intersphincteric abscess.
In some cases, the intersphincteric abscess ruptures the deep external sphincter and spreads to
the deep space, forming ischiorectal abscess and
ischiorectal stula (Case 3).
When observing the lesions of the ischioanal
abscesses with ultrasonic examination, the
lesions in the deep space were rst seen, the
abscess is presented as a cystic shape, while the
anal stula presented as a mixed echo mass.
Almost all cases are accompanied by low echo
masses (intersphincteric lesions) on the inside of
the external sphincter, and it is necessary to properly treat the lesions here during surgery (Case 3,
Case 4).
Case 3: III BA (Fig.5.22), II HA, II LA
(Fig.5.23)
In Fig.5.22, II HA can be seen at six o’clock, and
deep external sphincter can be seen behind it. The
deep part of the external sphincter ruptured at six
o’clock, and the lesion spread to the posterior
anal space. In Fig.5.23, we can see the subcutaneous part of the sphincter round around the
anus, in which II LA can be seen. According to
the above ndings, the diagnosis of this case is III
BA, II HA, and II LA.
Case 4: III Bs, II Hs (Fig.5.24)
Unlike in the abscess stage, in the posterior anal
space at 6 points, brin in the pus precipitates
after a long period of development and becomes a
horseshoe-shaped lesion with a mixture of strong
echo and low echo, and is expressed as III Bs. The
hypoechoic mass, II Hs, can be seen in the inner
side of the internal sphincter at 6 points. Therefore,
the disease is diagnosed as III Bs, II Hs.
Fig. 5.22 Ultrasonic
images of ischiorectal
fossa abscess and high
intermuscular abscess
External Anal
Sphincter
(Deep)
External Anal
Sphincter
Postanal Space
III BA
64
Fig. 5.23 Ultrasonic
images of pus species
and low intermuscular
abscess in ischiorectal
fossa
Fig. 5.24 Ultrasonic
images of ischiorectal
fossa stula and high
intermuscular stula
External Anal
Sphincter
(Subcutaneous)
R. Shi and L. Liu
IILA
IIIBA
Pelvirectal Abscess, Pelvirectal Fistula (Type IV)
As with the ischiac rectum lesion, except for the
result of Crohn’s disease and foreign body, it is
rare for individuals to have multiple intersphincteric lesions and ischiac rectum lesions.
IIHs
External Anal
Sphincter (Deep)
IIIBs
It is believed that it is caused by the upward
spread of the high intersphincteric lesions (II
H) or the upward spread of the ulceration of
levator ani muscle in ischiorectal fossa lesions
(III). Therefore, pelvic rectal lesions are mostly
associated with intersphincteric lesions and