Anorectal Infection: Abscess–Fistula
肛門直腸感染：膿腫-瘺管

EPIDEMIOLOGY  流行病學

ETIOLOGY OF ANAL SEPSIS
肛門膿毒症的病因

Anorectal abscess is believed to originate from an infection in the anal glands. In 1880, Hermann and Desfosses demonstrated branching of the anal glands within the internal sphincter, submucosa, and opening into the anal crypts.¹³ They were the first to suggest that infection in the anal glands results in extension of sepsis through the intersphincteric space to the perianal tissues.¹³ Tucker and Hellwig demonstrated definitively that anal sepsis originated in the anal ducts, which allows the infection to extend from the anal lumen into the wall of the anal canal.¹⁴ Eisenhammer in 1956 ascribed almost all anal fistulas to anal intermuscular gland infection.¹⁵ The infection may extend between the internal and external sphincter, reach the anal verge to become a perianal abscess. Or it may rupture through the external sphincter and become an ischiorectal abscess. If the abscess extends cephalad in the rectal wall a high intermuscular abscess will result and extension of abscess above the levators will produce a supralevator abscess. A deep postanal abscess may extend to either or both ischiorectal fossae resulting in a horseshoe abscess (Figs. 1 and 2).
肛門直腸膿腫被認為起源於肛門腺感染。1880 年，Hermann 和 Desfosses 證明瞭肛門腺在內括約肌、粘膜下層的分支，並打開到肛門隱窩中。¹³ 他們首先提出肛門腺感染導致敗血症通過括約肌間隙擴展到肛周組織。¹³ Tucker 和 Hellwig 明確證明，肛門敗血症起源於肛管，這使得感染從肛管延伸到肛管壁。¹⁴ Eisenhammer 在 1956 年將幾乎所有的肛瘺都歸因於肛門肌間腺感染。¹⁵ 感染可能延伸到內括約肌和外括約肌之間，到達肛緣，成為肛周膿腫 。或者它可能通過外括約肌破裂並變成坐骨直腸膿腫 。如果膿腫在直腸壁中向頭側延伸，則會導致高位肌間膿腫 ，膿腫延伸到提肌上方將產生提肌上膿腫 。肛門后深膿腫可能延伸至一側或兩側坐骨直腸窩，導致馬蹄形膿腫 （圖 1）。1 和 2）。

There are rare causes of supralevator abscess, which result from a pelvic sepsis due to appendicitis, diverticulitis, or gynecologic sepsis. These may extend into the rectum or spread downward through the levators into the ischiorectal fossa. Crohn disease of the anorectal region may extend transmurally into the perirectal or perianal space. Similarly, suppuration may occur with perforation of the anorectum from impacted chicken or fish bones, from externally penetrating trauma (stab or gunshot wounds), low rectal cancer or cancer originating in the anal glands. Specific infections related to oxyuris vermicularis, tuberculosis, or fungal infections are relatively uncommon and of historic interest.
提肌上膿腫的病因很少見，由闌尾炎、憩室炎或婦科膿毒症引起的盆腔膿毒癥引起。這些可能延伸到直腸或通過提肌向下擴散到坐骨直腸窩。肛門直腸區域的克羅恩病可能經壁延伸至直腸周圍或肛周間隙。同樣，化膿也可能發生在肛門直腸穿孔時，由受影響的雞骨或魚骨、外部穿透性創傷（刺傷或槍傷）、低位直腸癌或起源於肛門腺的癌症。與蠕蟲、結核病或真菌感染相關的特異性感染相對少見，具有歷史意義。

Anorectal fistulas arise from a preexisting abscess in the majority of cases. A previously drained abscess may heal permanently, heal and recur in the same location, or remain unhealed draining intermittently or continuously. In both latter cases, a diagnosis of anal fistula is almost certain. In a study of 100 recurrent anorectal abscesses, an underlying fistula was demonstrated in 68% of the patients.¹⁶ Fistulas may occur with much less frequency from trauma, iatrogenic perforation, posthemorrhoidectomy, infected episiotomy or repair of a fourth-degree sphincter tear during delivery, infected anal fissure, or Crohn disease.
在大多數病例中，肛門直腸瘺是由先前存在的膿腫引起的。先前引流的膿腫可能會永久癒合，在同一位置愈合併復發，或者保持未癒合，間歇性或持續引流。在後兩種情況下，幾乎可以確定肛瘺的診斷。在一項對 100 例復發性肛門直腸膿腫的研究中，68% 的患者存在潛在的瘺管。¹⁶ 瘺管的發生頻率可能要低得多，原因包括外傷、醫源性穿孔、后痢切除術、會陰切開術感染或分娩過程中四度括約肌撕裂修復術、肛裂感染或克羅恩病。

In a study of 1023 patients Ramanujam et al found 219 intersphincteric, 75 supralevator, 437 perianal, 233 ischiorectal, and 59 high intermuscular variants. The incidence of fistula in these abscess subsets was 47.4%, 42.6%, 24.5%, 25.3%, and 15.2%, respectively. With unroofing and primary fistulotomy, when deemed safe, the incidence of recurrent infection was only 3.7%.⁶
在對 1023 名患者的研究中，Ramanujam 等人發現了 219 個括約肌間變異、75 個肛上變異、437 個肛周變異、233 個坐骨直腸變異和 59 個高位肌間變異。這些膿腫亞群中瘺管的發生率分別為 47.4% 、 42.6% 、 24.5% 、 25.3% 和 15.2%。在認為安全的情況下，使用去頂和原發性瘺管切開術，復發感染的發生率僅為 3.7%。⁶

CLASSIFICATION OF FISTULAS
瘺管的分類

Throughout the years many classifications have been proposed (low vs high, simple vs complex, with or without extension). Nowadays, the classification of Park, Gordon, and Hardcastle is the one commonly used because not only does it describe accurately the anatomic track of the fistula, but it is also important in predicting the complexity of the operation, the need for varying degree of sphincterotomy, and the potential for continence disturbance.¹⁷ Intersphincteric fistulas begin at the dentate line and end at the anal verge, tracking between internal and external sphincters. Transsphincteric fistulas track through the external sphincter into the ischiorectal fossa. Suprasphincteric fistulas originate at the anal crypt and circle the entire sphincter mechanism before ending at the ischiorectal fossa. Extrasphincteric fistulas are usually very high in location, traverse the entire sphincter mechanism as well as the levators, and may originate anywhere in the anorectum—not solely from an anal crypt. Each of these types of fistulas may be associated with an adjacent communicating high blind tract (Fig. 3).
多年來，已經提出了許多分類（低與高、簡單與複雜、有或沒有擴展）。如今，Park、Gordon 和 Hardcastle 的分類是常用的分類，因為它不僅準確描述了瘺管的解剖軌跡，而且在預測手術的複雜性、不同程度的括約肌切開術的需要以及失禁障礙的可能性方面也很重要。¹⁷ 括約肌間瘺從齒狀線開始，到肛緣結束，在內括約肌和外括約肌之間跟蹤。 經括約肌瘺通過外括約肌進入坐骨直腸窩。 括約肌上瘺起源於肛隱窩，環繞整個括約肌機構，最後止於坐骨直腸窩 。 括約肌外瘺通常位置非常高，穿過整個括約肌機構和提肌，並且可能起源於肛門直腸的任何部位，而不僅僅是肛門隱窩。這些類型的瘺管中的每一種都可能與相鄰的交通性高位盲道有關（圖 D）。3）.

DIAGNOSIS  診斷

The principle symptom of anorectal abscess is pain. As such, it has to be differentiated from other causes of anal pain including anal fissure, thrombosed hemorrhoids, levator spasm, sexually transmitted disease, proctitis, and cancer. Low (intersphincteric, perianal, and ischiorectal) abscesses are usually associated with swelling, cellulites, and exquisite tenderness, but few systemic symptoms. High (submucosal, supralevator) abscesses may have few local symptoms, but significant systemic (fever, toxicity) symptoms. If an abscess is suspected, but cannot be diagnosed with certainty due to patient's resistance, examination under anesthesia (EUA) must be arranged as soon as possible. Rarely, imaging is needed to diagnoses an acute abscess.
肛門直腸膿腫的主要癥狀是疼痛。因此，必須將其與肛門疼痛的其他原因區分開來，包括肛裂、血栓性痔瘡、提肌痙攣、性傳播疾病、直腸炎和癌症。低位（括約肌間、肛周和坐骨直腸）膿腫通常伴有腫脹、橘皮組織和輕微壓痛，但很少有全身癥狀。高位（黏膜下、提肌上）膿腫可能幾乎沒有局部癥狀，但有明顯的全身性（發熱、中毒）癥狀。如果懷疑膿腫，但由於患者的抵抗力而無法確定診斷，則必須儘快安排麻醉下檢查 （EUA）。極少數情況下，需要影像學檢查來診斷急性膿腫。

A clinically draining fistula is easily diagnosed and anoscopy should be performed looking for the internal opening. Goodsall's rule is still applicable unless the anatomy has been distorted with prior operations and fibrosis.¹⁸ Probing the fistula tract in the office is painful and unnecessary. If intraoperatively a primary opening cannot be easily identified, injection of a dilute hydrogen peroxide solution with or without a few drops of methylene blue is often helpful. If one or more EUAs have not resulted in identification of the internal opening, anal fistulography, endoanal ultrasound with injection of peroxide, computed tomography (CT), or magnetic resonance imaging (MRI) may be utilized.
臨床引流瘺管很容易診斷，應進行肛門鏡檢查以尋找內部開口。Goodsall 規則仍然適用，除非解剖結構因先前的手術和纖維化而變形。¹⁸ 在辦公室探查瘺管是痛苦且不必要的。如果在術中不容易識別原發性開口，注射稀釋的過氧化氫溶液，加或不加幾滴亞甲藍通常有説明。如果一個或多個 EUA 未導致識別內部開口，則可以使用肛瘺造影、注射過氧化物的肛門內超聲、計算機斷層掃描 （CT） 或磁共振成像 （MRI）。

In patients with long-standing fistulas there is a risk of developing cancer. In one study, six cancers were found in fistulas which had been present for an average of 13.8 years.¹⁹ No intraluminal tumor was found in any of the six patients. This condition must be differentiated from perforating cancer causing secondary fistulas.
長期瘺管患者有患癌症的風險。在一項研究中，在平均存在 13.8 年的瘺管中發現了 6 種癌症。¹⁹ 6 例患者中均未發現腔內腫瘤。這種情況必須與導致繼發性瘺的穿孔癌相鑒別。

OBJECTIVES IN MANAGEMENT
管理目標

TREATMENT OF ANORECTAL ABSCESS
肛門直腸膿腫的治療

An anorectal abscess requires a surgical procedure for early, adequate, and dependent drainage. A superficial abscess may be amenable to drainage in the office or emergency room, however, a more complex ischiorectal abscess needs to be examined under anesthesia and drained appropriately. General or regional anesthesia allows the surgeon to adequately examine the patient, identify the entire extent of the abscess, and provide wide, dependent drainage. Even if a large abscess has drained spontaneously, EUA and wide drainage is still indicated, because so often the thick proteinaceous abscess content will plug the small opening and the abscess will continue to smolder.
肛門直腸膿腫需要外科手術進行早期、充分和依賴性引流。淺表膿腫可能適合在辦公室或急診室引流，但是，更複雜的坐骨直腸膿腫需要在麻醉下檢查並適當引流。全身麻醉或區域麻醉使外科醫生能夠充分檢查患者，確定膿腫的整個範圍，並提供寬泛的獨立引流。即使大膿腫已自發引流，仍需進行 EUA 和寬引流，因為厚厚的蛋白質膿腫內容物通常會堵塞小開口，膿腫將繼續冒煙。

There is no place for antibiotic therapy alone as “conservative” management of an anorectal abscess. The abscess wall contains occluded and necrotic blood vessels and the antibiotic will never penetrate into the abscess cavity. The old technique of incision of abscess, curettage, and instillation of antibiotics and primary closure advocated in the 1950s by Goligher^19a has long been abandoned. Antibiotics in addition to adequate drainage are indicated in diabetic patients, those with morbid obesity or immunosuppression (e.g., human immunodeficiency virus, acquired immunodeficiency syndrome, chemotherapy, posttransplant surgery, etc.). If a patient remains febrile, continues to have signs and symptoms of cellulitis or persistent elevated white blood cell count, the patient should be returned to the operating room to search for undrained pus rather than continuing with the same or a newer regimen of antibiotics.
單獨的抗生素治療不能作為肛門直腸膿腫的“保守”治療。膿腫壁包含閉塞和壞死的血管，抗生素永遠不會滲透到膿腫腔中。Goligher¹⁹⁵⁰ 年代倡導的膿腫切開、刮宮術、滴注抗生素和一期封堵術的舊技術早已被放棄。除了充分引流外，抗生素也適用於糖尿病患者、病態肥胖或免疫抑制患者（例如，人類免疫缺陷病毒、獲得性免疫缺陷綜合征、化療、移植后手術等）。如果患者仍然發熱，繼續有蜂窩織炎的體征和癥狀或白細胞計數持續升高，則應將患者送回手術室尋找未排出的膿液，而不是繼續使用相同或更新的抗生素方案。

A large abscess should be drained with multiple counter incisions rather than a long incision, which will create a step-off deformity and delay wound healing. Packing is not recommended due to severe pain inflicted on the patient during its removal, unless there is continuous oozing of blood from the depth of the wound, which is difficult to control directly, but stops with packing and compression. Similarly, horseshoe abscesses should be drained with counter incisions on both sides rather than a long curved incision connecting the two sides. It is preferable to make as many incisions as necessary to drain a large abscess, leaving the intervening skin intact and encircling it with a Penrose drain sutured onto itself to avoid premature extrusion. The drains will delay the healing of superficial tissues allowing the abscess to fill in and close from the depth. The drains can be removed in an outpatient setting 2 to 3 weeks later as the surgeon sees fit.
大膿腫應通過多個反向切口引流，而不是長切口，否則會產生階梯狀畸形並延遲傷口癒合。不建議進行填塞，因為在取出過程中會給患者帶來劇烈的疼痛，除非傷口深處有血液持續滲出，這很難直接控制，但會隨著填塞和壓縮而停止。同樣，馬蹄形膿腫應在兩側使用反向切口引流，而不是使用連接兩側的長彎曲切口進行引流。最好根據需要做盡可能多的切口來引流大膿腫，保持中間皮膚完整，並用縫合到自身上的 Penrose 引流管將其包圍，以避免過早擠出。引流管會延遲淺表組織的癒合，使膿腫從深處填充和閉合。2 至 3 周后，如果外科醫生認為合適，可以在門診機構移除引流管。

Should a surgeon search for a fistula at the time of the initial incision and drainage (I & D) of an abscess? This is controversial. McElwain and McLean reported 1000 primary fistulotomies during drainage of an abscess with no adverse results.²⁰ However, this report preceded the advent of anal physiologic studies and endoanal ultrasonography to determine the extent of the sphincter injury and its consequences. Others have reported a good success rate with primary fistulotomy.⁶ If the surgeon is not familiar with anorectal anatomy or pathology, anal fistula should not be searched for. However, an experienced surgeon may probe the corresponding anal crypt gently, looking for a fistula. If a fistula is identified and is quite superficial, primary fistulotomy may be attempted.⁶ If the surgeon is not certain of the thickness of the sphincter muscle involved in the fistula, a loose seton of braided, nonabsorbable suture should be inserted into the fistula tract, tied loosely to act as a drain as well as a marker for future fistula surgery.²¹
外科醫生是否應該在膿腫的初始切口和引流（I & D）時尋找瘺管？這是有爭議的。McElwain 和 McLean 報告了膿腫引流期間的 1000 例原發性瘺管切開術，無不良結果。²⁰ 然而，這份報告早於肛門生理學研究和肛門內超聲檢查的出現，以確定括約肌損傷的程度及其後果。其他患者報告了原發性瘺管切開術的成功率很高。⁶ 如果外科醫生不熟悉肛門直腸解剖學或病理學，則不應尋找肛瘺。但是，經驗豐富的外科醫生可能會輕輕探查相應的肛隱窩，尋找瘺管。如果發現瘺管並且非常淺表，則可以嘗試一期瘺管切開術。⁶ 如果外科醫生不確定瘺管所涉及的括約肌的厚度，則應將鬆散的編織、不可吸收的縫合線插入瘺管中，鬆散地系扎以作為引流管以及未來瘺管手術的標誌。²¹

In horseshoe abscesses, the deep postanal space should be unroofed. The abscess on either side is drained and a Penrose drain is inserted and secured on either side for prolonged drainage. If a midline posterior fistula is identified, a seton can be placed and tied loosely to be addressed in the future.
在馬蹄形膿腫中，應揭開肛門后深間隙。引流兩側的膿腫，並在兩側插入並固定 Penrose 引流管以延長引流時間。如果發現中線後瘺，可以放置掛線並鬆散地系紮，以備將來處理。

Anorectal abscess in patients with Crohn disease should be drained as close to the anal canal as possible while avoiding an incision in the external sphincter. This will result in a shorter rather than longer fistula track subsequently and makes the future management of the patient easier.
克羅恩病患者的肛門直腸膿腫應盡可能靠近肛管引流，同時避免在括約肌外切口處引流。這將導致隨後的瘺管路徑更短而不是更長，並使患者的未來管理更容易。

An alternate method of drainage of abscess popular at the Cleveland Clinic was to place a mushroom catheter in the abscess, keeping it for as long as necessary for prolonged drainage. The catheter can be used for a sinogram or a contrast CT examination. If the abscess is considered complex or recurrent, imaging might be helpful to provide a road map for subsequent operations.
克利夫蘭診所流行的另一種膿腫引流方法是在膿腫中放置一根蘑菇導管，只要需要長時間引流，就可以保持它。導管可用於鼻竇造影或造影劑 CT 檢查。如果認為膿腫複雜或復發，影像學檢查可能有助於為後續手術提供路線圖。

Prolonged drainage from an I & D site of an abscess beyond 2 to 3 months should raise suspicion of a fistula. Similarly, if an abscess heals and recurs at the same location a fistula should be strongly suspected. Prolonged therapy with the same or different antibiotics and cauterization of a fistula track is usually fruitless and delays the inevitable need for reexploration. The appearance of an abscess on the opposite side should alert the surgeon of the presence of a horseshoe abscess–fistula originating in the midline, most commonly posterior midline. Confirmation of diagnosis with CT, endoanal ultrasound (with or without peroxide injection), or MRI is usually unnecessary. Fistulography has been replaced by modern imaging techniques especially MRI, which can be a very accurate diagnostic tool in experienced hands.
從膿腫的 I & D 部位長時間引流超過 2 到 3 個月應引起對瘺管的懷疑。同樣，如果膿腫在同一位置愈合併復發，則應強烈懷疑瘺管。使用相同或不同的抗生素進行長期治療和瘺管軌道燒灼通常沒有結果，並且延遲了不可避免的重新探查需求。對側膿腫的出現應提醒外科醫生存在起源於中線的馬蹄形膿腫——瘺管，最常見的是后中線。通常不需要通過 CT、肛門內超聲（伴或不伴過氧化物注射）或 MRI 來確認診斷。瘺管造影已被現代成像技術，尤其是 MRI 所取代，在有經驗的人中，MRI 可以成為非常準確的診斷工具。

TREATMENT OF ANORECTAL FISTULA
肛門直腸瘺的治療

If a drainage site of an abscess does not heal in 2 to 3 months or breaks down after healing, a fistula should be strongly suspected and the patient should be reexplored under anesthesia. Imaging studies can be utilized for complex or recurrent cases, but is often unnecessary and quite costly.
如果膿腫的引流部位在 2 至 3 個月內未癒合或在癒合后破裂，則應強烈懷疑瘺管，並應在麻醉下重新探查患者。影像學檢查可用於複雜或復發的病例，但通常是不必要的且相當昂貴。

Preoperatively a fistula can be diagnosed by gentle palpation of the tract connecting the external opening to the anal canal. A lubricated gloved finger should be able to detect the fistula track (like the extensor tendons of the hand). In the operating room with the patient under anesthesia or monitored anesthesia care, the secondary opening is probed with a blunt tipped fistula probe and the corresponding area of the dentate line inspected through an operating anoscope. Compression of the fistula tract might yield a droplet of pus from the primary opening. Lateral traction on the external opening will help straighten the fistula tract and facilitate probing. If this proves ineffective, a dilute solution of plain hydrogen peroxide or with a few drops of methylene blue should be injected gently into the external opening with an angiocath and following the Goodsall's rule, the dentate line is inspected for leakage of the injected solution. More than a century since its original description, the Goodsall's rule is still a very reliable guide for identification of the internal opening of the fistula, unless the anatomy has been distorted with previous operations and scarring.¹⁸
術前可以通過輕輕觸診連接外部開口和肛管的通道來診斷瘺管。戴著手套潤滑的手指應該能夠檢測到瘺管軌跡（如手的伸肌腱）。在手術室中，患者處於麻醉狀態或監測麻醉護理下，用鈍頭瘺管探針探查二次開口，並通過手術肛門鏡檢查齒狀線的相應區域。瘺管受壓可能會從原發性開口產生膿液滴。外開口的橫向牽引有助於拉直瘺管並便於探查。如果證明無效，則應將普通過氧化氫的稀釋溶液或含幾滴亞甲藍的溶液輕輕注射到帶有血管導管的外部開口中，並按照 Goodsall 規則，檢查齒狀線是否洩漏注射溶液。自最初描述以來一個多世紀，Goodsall 規則仍然是識別瘺管內部開口的非常可靠的指南，除非解剖結構因先前的手術和疤痕而變形。¹⁸

Once the fistula is identified, the surgeon must decide what to do with it. In general, the goal of fistula surgery is primary healing. If the surgeon is too aggressive, the fistula may be cured at a cost of incontinence or worse, yet a false passage may be created that further complicates the clinical picture. Nevertheless, being conservative and doing less harm to the sphincter contributes to the persistence or recurrence of a fistula.
一旦確定了瘺管，外科醫生必須決定如何處理它。一般來說，瘺管手術的目標是初次癒合。如果外科醫生過於激進，瘺管可能會以失禁或更糟的代價治癒，但可能會產生假通道，使臨床情況進一步複雜化。然而，保守治療和對括約肌的傷害較小有助於瘺管的持續存在或復發。

When treating a fistula the classification proposed by Parks, Gordon, and Hardcastle (Fig. 3) is invaluable not only to assess the complexity of the fistula, but also to predict the ease or the difficulty of the operation, risk of recurrence, or incontinence. These issues must be discussed with the patient preoperatively. If the risks versus benefits of surgery have not been discussed with the patient, it is appropriate to abort the procedure and postpone definitive surgery until the patient understands the risk and benefits of a proposed operation and is able to decide and give informed consent. If the surgeon is not confident or certain about the nature and complexity of a fistula, a second opinion from an experienced colorectal surgeon should be sought.
在治療瘺管時，Parks、Gordon 和 Hardcastle 提出的分類（圖 .3） 不僅對於評估瘺管的複雜性，而且對於預測手術的難易程度、復發風險或失禁也很有價值。這些問題必須在術前與患者討論。如果尚未與患者討論手術的風險與益處，則最好中止手術並推遲確定性手術，直到患者瞭解擬議手術的風險和益處，並能夠決定並給予知情同意。如果外科醫生對瘺管的性質和複雜性沒有信心或確定，則應尋求經驗豐富的結直腸外科醫生的第二意見。

Intersphincteric fistulas are amenable to a simple distal internal sphincterotomy much like lateral internal sphincterotomy done for anal fissure, this procedure results in minor disturbance of continence (5% or less).
括約肌間瘺適用於簡單的遠端內括約肌切開術，就像為肛裂所做的外側內括約肌切開術一樣，該手術會導致輕微的節制干擾（5% 或更少）。

Extrasphincteric fistulas, though rare, are too complex to be treated with fistulotomy and may need diversion and complicated procedures to close the primary opening of the fistula.
括約肌外瘺雖然罕見，但太複雜，無法用瘺管切開術治療，可能需要改道和複雜的手術來閉合瘺管的主要開口。

Transsphincteric and suprasphincteric fistulas are difficult when it comes to the choice of procedures to be used in treatment. In general, two types of operations can utilized for these fistulas: those employing sphincterotomy and those without sphincterotomy.
在選擇用於治療的手術時， 經括約肌和括約肌上瘺是困難的。一般來說，這些瘺管可以使用兩種類型的手術：採用括約肌切開術的手術和沒有括約肌切開術的手術。

FISTULOTOMY WITH SPHINCTEROTOMY
瘺頭切開術聯合括約肌切開術

Only low (distal) transsphincteric fistulas involving the distal one third to one half of the external sphincter are amenable to sphincterotomy. This will definitely cause some disturbance of continence, which can be estimated based on the amount of external sphincter divided to be in the range of 17 to 33%.²²
只有累及外括約肌遠端 1/3 至 1/2 的低位（遠端）經括約肌瘺管適合進行括約肌切開術。這肯定會引起一些失禁障礙，這可以根據 17% 到 33% 的外括約肌的數量來估計。²²

A partial external sphincterotomy can be utilized as a definitive procedure for low transsphincteric fistulas.
部分括約肌外切開術可用作低位經括約肌瘺的確定性手術。

A staged fistulotomy implies that a portion of the sphincter mechanism is divided at the first operation, a marking (loose) seton is placed around the remaining portion of the external sphincter involved in the fistula. After 6 to 8 weeks, the patient is reexamined in the operating room and if the initial fistulotomy incision is healed by fibrosis, the remainder of the sphincter is divided, removing the seton. In a study of 480 patients, Ramanajam et al reported good results with staged fistulotomy with minimal impairment of continence.²¹ However, this report preceded the anal physiologic studies and availability of endoanal ultrasound.
分期瘺管切開術意味著在第一次手術時將括約肌機構的一部分分開，在瘺管所涉及的外括約肌的剩餘部分周圍放置一個標記（鬆散的）掛線。6 至 8 周後，患者在手術室進行複查，如果最初的瘺管切開切口通過纖維化癒合，則括約肌的其餘部分被分開，去除掛線。在一項對 480 名患者的研究中，Ramanajam 等人報告了分期瘺管切開術的良好結果，節制損害最小。²¹ 然而，本報告先於肛門生理學研究和肛門內超聲的可用性。

Using a cutting seton, the skin overlying the fistula is removed, fibrotic tissue, if any, is excised and a rubber band is inserted around the external sphincter and tied loosely to produce additional drainage.²² After the suppuration has subsided, the rubber band is tightened with serial sutures or a hemorrhoidal ligator every 2 weeks until the rubber band Seton cuts through the muscle completely.²³ In a small series, a cutting seton was associated with low recurrence rates (0.8%) and minor incontinence (2–6%) and major incontinence of 5–10%.²⁴
使用切割掛線 ，去除覆蓋在瘺管上的皮膚，切除纖維化組織（如果有），並在外括約肌周圍插入橡皮筋並鬆散地系紮以產生額外的引流。²² 化膿消退後，每 2 周用連續縫合線或痔瘡結紮器收緊橡皮筋，直到橡皮筋 Seton 完全穿過肌肉。²³ 在一個小型系列研究中，切割掛線與低復發率 （0.8%） 和輕度尿失禁 （2-6%） 以及 5-10% 的重度尿失禁相關。²⁴

Using a chemical seton, a seton coated with latex is impregnated with Kshara, an alkaline compound, and is introduced in the fistula tract and tightened progressively, allowing the chemical to cut through the fistula and allowing the tissue to reunite behind the cutting seton. In a comparison of 237 patients with fistulotomy compared with 265 treated with Kshara sutra, the healing time was faster in the fistulotomy group (4 vs 8 weeks), the recurrence rate was lower (4% vs 11%) and the incontinence rate was similar.²⁵
使用化學掛線 ，塗有乳膠的掛線浸漬鹼性化合物 Kshara，並引入瘺管並逐漸收緊，使化學物質能夠切開瘺管並允許組織在切割掛線後面重新結合。在 237 名瘺管切開術患者與 265 名 Kshara sutra 治療的患者中，瘺管切開術組的癒合時間更快（4 周對 8 周），復發率較低（4% 對 11%），尿失禁率相似。²⁵

TREATMENT OF FISTULA WITHOUT SPHINCTEROTOMY
不做括約肌切開術的瘺管治療

To preserve continence, different methods have been designed in the last two decades to close the fistula tract without sphincterotomy. The problem with all of these techniques is that they have a variable success rate averaging 40 to 70% and the surgeon and the patient trade cure for preservation of continence and the need for further and often multiple operations.
為了保持節制，在過去的二十年中設計了不同的方法來閉合瘺管，而不進行括約肌切開術。所有這些技術的問題在於，它們的成功率各不相同，平均為 40% 到 70%，外科醫生和患者用治癒來保持節制，並需要進一步的、通常是多次的手術。

A loose seton placed at the time of original drainage of abscess or in a “high” fistula in ano, provides drainage, prevents recurrence of abscess, and acts as a marker for future fistula surgery, e.g., two-stage fistulotomy procedures.²⁶
在膿腫原始引流時或肛門瘺的“高位”瘺管中放置鬆散的掛線 ，提供引流，防止膿腫復發，並作為未來瘺管手術的標誌物，例如兩期瘺管切開術。²⁶

The fibrin sealant technique originally entailed using an autologous material that has now been replaced with a commercially available sealant. The fistula opening is cannulated with a double-channel catheter from a secondary opening toward the primary opening. The injection of fibrinogen through one arm and thrombin through the other results in the production of a pearly clot at the internal opening. The catheter is then gradually withdrawn through the fistula tract and fibrin sealant is injected continuously until the tract is completely sealed and a similar clot is seen at the external opening. The wound is covered with Vaseline gauze and the patient is followed on a biweekly basis until either the fistula closure occurs or failure is documented beyond 12 weeks. Early enthusiasm with this technique with a report of 80% has dwindled to 30 to 40% success rates.²⁷ The advantage of fibrin sealant is that it may be repeated and the salvage procedure increases the success rate by an additional 10 to 15%.²⁸ This technique is more suitable for longer fistula tracks. Rectovaginal fistula due to the short straight track is especially unsuitable for fibrin sealant.²⁷
纖維蛋白密封劑技術最初需要使用自體材料，現已被市售密封劑取代。瘺管開口用雙通道導管從次級開口向初級開口插管。通過一隻手臂注射纖維蛋白原，通過另一隻手臂注射凝血酶，導致在內部開口處產生珍珠狀凝塊。然後通過瘺管逐漸拔出導管，並連續注射纖維蛋白封閉劑，直到導管完全密封並在外部開口處看到類似的凝塊。用凡士林紗布覆蓋傷口，每兩周對患者進行一次隨訪，直到瘺管閉合或 12 周後記錄到衰竭。早期對這種技術的熱情（報告為 80%）已經下降到 30% 到 40% 的成功率。²⁷ 纖維蛋白密封劑的優點是可以重複進行，並且挽救程式將成功率額外提高了 10% 至 15%。²⁸ 這種技術更適合較長的瘺管軌跡。由於直腸陰道瘺程短，特別不適合使用纖維蛋白封閉劑。²⁷

An anal fistula plug (AFP) is an acellular porcine submucosal collagen designed to allow growth of fibroblasts into its scaffolding, resulting in closure of fistulas. Originally, success rates of up to 80 to 85% were reported; however, more recent reports have lowered the success to 30 to 50%.²⁹ As in fibrin sealant, failed cases can be subjected to a salvage procedure using AFP. There is evidence from a consensus conference that placing a seton for 2 to 3 months allowing the fistula tract to mature improves success rates.³⁰ A newer fistula plug made of PTFE is under investigation and long-term results are not yet available.
肛瘺栓 （AFP） 是一種脫細胞豬粘膜下膠原，旨在允許成纖維細胞生長到其支架中，從而閉合瘺管。最初，據報導成功率高達 80% 至 85%;然而，最近的報告將成功率降低到 30% 到 50%。²⁹ 與纖維蛋白密封劑一樣，失敗的病例可以使用 AFP 進行挽救程式。來自共識會議的證據表明，放置掛線 2 至 3 個月，讓瘺管成熟可以提高成功率。³⁰ 一種由 PTFE 製成的新型瘺管塞正在研究中，尚未獲得長期結果。

An endorectal advancement flap (ERAF), originally designed for low rectovaginal or anoperineal fistulas secondary to obstetric injury have also been utilized for anorectal fistulas. In this procedure, a flap of rectal wall including mucosa, submucosal, and superficial smooth muscle is raised cephalad. The primary opening of the fistula is closed and the flap is brought down and sutured to the anoderm. The fistula tract is drained with a size #10–12 mushroom catheter for 10 to 14 days. If the internal opening of the fistula is too distal, ERAF will result in ectropion and a “wet anus,” which will be interpreted as incontinence by the patient. ERAF is suitable for fistulas in the lateral or anterior quadrant, but it is difficult to raise a posterior midline flap due to the acute angulation of the rectum rendering the proximal extent of the flap relatively inaccessible. If the rectal mucosa is normal, ERAF can be used in Crohn fistulas as well.³¹
最初為繼發於產科損傷的低位直腸陰道或肛門會陰瘺設計的直腸內推進皮瓣 （ERAF） 也被用於肛門直腸瘺。在該手術中，直腸壁的皮瓣（包括粘膜、粘膜下層和淺表平滑肌）被抬高到頭側。瘺管的主要開口閉合，皮瓣被拉下並縫合到肛門皮膚上。用 #10-12 號蘑菇導管引流瘺管 10 至 14 天。如果瘺管的內部開口太遠，ERAF 將導致瞼外翻和“肛門濕潤”，這將被患者解釋為尿失禁。ERAF 適用於外側或前象限的瘺管，但由於直腸的急性成角，使得皮瓣的近端範圍相對難以接近，因此很難抬起后中線皮瓣。如果直腸粘膜正常，ERAF 也可用於克羅恩瘺。³¹

A dermal island flap anoplasty (DIFA) is a procedure for resurfacing the anal canal in low anal strictures. Nelson and colleagues modified the procedure to cover the primary opening of the fistula after it was closed with absorbable sutures. The raised dermal flap is then advanced in the anal canal and sutured to the lower rectal wall with full-thickness bites. The procedure can be done in all quadrants and even in Crohn fistulas as long as the low rectal mucosa is normal. Recurrence/persistence is always seen early (6–18 months) and may be addressed with a repeat (salvage) flap. A success rate as high as 80% was reported by Nelson et al.³²
真皮島狀皮瓣肛門成形術 （DIFA） 是一種在低位肛門狹窄中重塑肛管表面的手術。Nelson 及其同事修改了該程式，以覆蓋用可吸收縫合線閉合瘺管後的主要開口。然後將凸起的真皮瓣推進到肛管中，並用全層咬合縫合到直腸下壁。只要直腸低位粘膜正常，就可以在所有象限甚至克羅恩瘺中進行該程式。復發/持續總是在早期 （6-18 個月） 出現，並且可以通過重複（挽救）皮瓣來解決。Nelson 等人報告的成功率高達 80%³²

Ligation of the intersphincteric fistula tract (LIFT) is the most recent attempt in closure of transsphincteric fistula tracts. An incision is made parallel to the anal verge and deepened, separating the internal and external sphincters until the fistula tract is encountered. An indwelling probe facilitates identification of the tract. The tract is then encircled, ligated at both the proximal and distal ends with absorbable sutures, and the fistula tract is divided. A segment of the tract can be excised (similar to a vasectomy procedure). The external end of the tract is left alone if short and can be drained with a small mushroom catheter if it is long. Although this is a relatively new procedure, success rates of 57% and 89% have been reported.^33,34 Long-term follow-up is needed to validate these results, but this operation makes sense as a definitive method of closure of transsphincteric fistulas without sphincterotomy.
括約肌間瘺束結紮術 （LIFT） 是經括約肌瘺管閉合的最新嘗試。平行於肛緣切開並加深，將內括約肌和外括約肌分開，直到遇到瘺管。留置探針有助於識別腸道。然後將瘺管束包圍，用可吸收縫合線在近端和遠端結紮，並分開瘺管。可以切除一段尿道（類似於輸精管切除術）。如果束的外端短，則保持獨立，如果長，可以用小蘑菇導管引流。雖然這是一個相對較新的手術，但據報導成功率分別為 57% 和 89%。³³³⁴ 需要長期隨訪來驗證這些結果，但這種手術作為無需括約肌切開術的經括約肌瘺管閉合的確定性方法是有意義的。

The York–Mason Procedure is an operation that allows an excellent exposure of the midrectum. The procedure, originally designed for rectoprostatic urethral fistula, may be utilized for extrasphincteric fistulas with or without covering colostomy. The advantage of this approach, despite its complexity, is that it puts the surgeon in virgin territory, especially after multiple prior failed operations.
York-Mason 手術是一種可以很好地暴露直腸中部的手術。該手術最初設計用於直腸前列腺尿道瘺，可用於有或沒有覆蓋結腸造口術的括約肌外瘺管。儘管這種方法很複雜，但其優勢在於它使外科醫生處於處女地，尤其是在之前多次手術失敗之後。

CONCLUSION  結論

An anal fistula is an affliction that tests the patience of the surgeon and the patient alike. Approaching the fistulas with the intent to cure, the surgeon must always keep in mind the fine balance between an aggressive approach resulting in cure and incontinence and a conservative approach, preserving continence and resulting in recurrence or persistence and the need for additional operative procedures. Respecting the classic adage of “primum non nocere,” the surgeon must be familiar with all available alternatives in treating a fistula and try to tailor the operation to the patient and not vice versa. In these litigious times, recurrence or persistence of a fistula is surely preferable to incontinence.
肛瘺是一種考驗外科醫生和患者耐心的疾病。以治癒為目的接近瘺管時，外科醫生必須始終牢記導致治癒和失禁的積極方法與保守方法（保持節制並導致復發或持續）以及需要額外的手術程序之間的微妙平衡。尊重“primum non nocere”的經典格言，外科醫生必須熟悉治療瘺管的所有可用替代方案，並嘗試為患者量身定製手術，而不是相反。在這個訴訟時代，瘺管的復發或持續肯定比失禁更可取。