Elsevier

International Journal of Surgery
國際外科雜誌

Volume 40, April 2017, Pages 130-134
第 40 卷 ，2017 年 4 月，第 130-134 頁
International Journal of Surgery

Original Research  原創研究
Transanal opening of intersphincteric space (TROPIS) - A new procedure to treat high complex anal fistula
經肛門括約肌間隙開放 （TROPIS） - 一種治療高度複雜肛瘺的新手術

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Highlights  突出

  • •
    The satisfactory treatment of high complex fistula-in-no still eludes us.
    我們仍然無法令人滿意地治療高複雜瘺管。
  • •
    The sepsis/tract in intersphincteric space is like a small abscess in a closed space.
    括約肌間隙的膿毒症/膿毒癥束就像封閉空間中的小膿腫。
  • •
    The sepsis in intersphincteric space plays a pivotal role in the pathogenesis of most complex fistula-in-ano.
    括約肌間隙膿毒症在大多數複雜肛瘺的發病機制中起關鍵作用。
  • •
    The sepsis in intersphincteric space needs to be drained and the space kept open so that it heals with secondary intention.
    括約肌間隙的膿毒症需要引流，並保持空間開放，以便它以次要目的癒合。
  • •
    This is done by transanal opening of intersphincteric Space (TROPIS).
    這是通過經肛門括約肌間隙 （TROPIS） 開放來完成的。
  • •
    TROPIS is a simple new sphincter sparing procedure which is quite effective in treating high complex fistula-in-ano.
    TROPIS 是一種簡單的新型保留括約肌手術，對治療高度複雜肛瘺非常有效。
  • •
    TROPIS is also very effective in supralevator and horseshoe fistula and fistula with multiple tracts.
    TROPIS 對提上瘺和馬蹄瘺以及多束瘺也非常有效。

Abstract  抽象

Background  背景

The sepsis in intersphincteric space has important role in pathogenesis of most complex fistula-in-ano. This sepsis is like a small abscess in a closed space. This closed space needs to be drained adequately and then kept open for the fistula-in-ano to heal properly. The aim was to lay open and drain the intersphincteric space through internal opening via transanal approach. This has been tried in submucosal and intersphincteric rectal abscesses but has never been tried in complex fistula-in-ano.
括約肌間隙膿毒症在大多數複雜肛瘺的發病機制中起重要作用。這種膿毒症就像一個封閉空間里的小膿腫。這個封閉的空間需要充分引流，然後保持開放，以便肛瘺管正常癒合。目的是通過經肛門入路通過內部開口打開和引流括約肌間隙。這已在粘膜下和括約肌直腸膿腫中嘗試過，但從未在複雜肛瘺中嘗試過。

Materials and methods  材料和方法

All consecutive patients of complex high (involving >1/3 of sphincter complex) fistula-in-ano who were operated were included in the prospective cohort study. Preoperative MRI scan was done in all the patients. Transanal laying open of the intersphincteric space (TROPIS) was done through the internal opening. The external sphincter was not cut. The tracts in the ischiorectal fossa were curetted and cleaned. The incontinence scores were measured.
所有連續接受手術的複雜高位 （涉及括約肌復合體 >1/3） 肛瘺患者均被納入前瞻性佇列研究 。所有患者均進行術前 MRI 掃描。經肛門打開括約肌間隙 （TROPIS） 是通過內部開口完成的。外括約肌未被切斷。坐骨直腸窩中的束被刮除和清潔。測量失禁評分。

Results  結果

61 patients with high complex fistula-in-ano were included (follow-up:6–21 months). Male/Female:59/2, age-42.3 ± 9.5 years. 85.2% (52) were recurrent, 83.6% (51) had multiple tracts, 36.1% (22) had horseshoe tract, 34.4% (21) had supralevator extension and 26.2% (16) had associated abscess. 95.1% (58) were posterior fistula out of which 90.2% (55) were in posterior midline. Nine patients were excluded (due to tuberculosis, lost to follow-up). Fistula healed completely in 84.6% (44/52) and didn't heal in 15.4% (9/52). 4/9 of these were reoperated and fistula healed in three patients. Thus overall healing rate was 90.4% (47/52). There was no significant change in incontinence scores.
納入 61 例高複雜肛瘺患者 （隨訪時間：6-21 個月）。男/女：59/2，年齡 42.3 ± 9.5 歲。85.2% （52） 為復發性，83.6% （51） 為多路，36.1% （22） 為馬蹄形束，34.4% （21） 為提肌上延伸，26.2% （16） 為相關膿腫。95.1% （58） 為後瘺， 其中 90.2% （55） 位於後中線。排除了 9 例患者 （由於肺結核，失訪）。84.6% （44/52） 的瘺管完全癒合，15.4% （9/52） 的瘺管未癒合。其中 4/9 患者再次手術，3 例患者瘺管癒合。因此，總體癒合率為 90.4% （47/52）。失禁評分沒有顯著變化。

Conclusions  結論

TROPIS is a simple effective sphincter sparing procedure to treat high complex fistula-in-ano including supralevator and horseshoe fistula.
TROPIS 是一種簡單有效的保留括約肌手術，用於治療高度複雜肛瘺，包括提上瘺和馬蹄形瘺。

Keywords  關鍵字

Fistula
Intersphincteric
Sepsis
Supralevator
Incontinence
Fistula-in-ano
Anal

肛瘺
括約肌間
膿毒症
肛
瘺上性尿
失禁
肛瘺

1. Introduction  1. 引言

The role of intersphincteric space in pathogenesis of most complex fistula-in-ano is increasingly being recognized [1], [2]. The deep postanal space (DPAS), which was first described by Courtney [3] as “posterior sub-sphincteric space”, was postulated to play a key role in pathogenesis and spread of posterior fistula-in-ano especially horseshoe fistulas. Based on this concept, modified Hanley procedure was innovated [4] in which the sepsis in DPAS was eradicated through the posterior midline incision which involved cutting of both internal and external sphincters. However, further research highlighted that posterior deep intersphincteric space (DPIS) was far more often involved in complex posterior cryptoglandular fistula than DPAS [1], [5]. Therefore, the focus seems to be shifting to treating sepsis in intersphincteric space (DPIS) rather than DPAS [1], [5], [6]. This sepsis in the intersphincteric space is akin to an abscess in a closed space. This closed space needs to be adequately drained and then kept open so that sepsis is eradicated and the fistula can heal properly. Isolated attempts to close internal opening without eradicating intersphincteric sepsis (as in anal fistula plug, OTSC clip, VAAFT etc) could lead to recurrence of fistula [7], [8]. This could explain high recurrence rates in complex fistula after such procedures [7], [8].
括約肌間隙在大多數複雜肛瘺發病機制中的作用越來越得到認可 [1]， [2]。Courtney [3] 首先將深肛後間隙 （DPAS） 描述為“後括約肌下間隙”，據推測在肛門後瘺（尤其是馬蹄瘺）的發病機制和擴散中起關鍵作用。基於這一概念，創新了改良的 Hanley 手術 [4]，其中 DPAS 中的膿毒症通過後中線切口根除， 涉及切割內括約肌和外括約肌。然而，進一步的研究強調，后深括約肌間隙 （DPIS） 比 DPAS 更常參與複雜的后隱腺瘺 [1]、[5]。 因此，重點似乎正在轉向治療括約肌間隙 （DPIS） 膿毒症，而不是 DPAS [1]、[5]、[6]。 這種發生在括約肌間隙的膿毒症類似於封閉空間內的膿腫。這個封閉的空間需要充分引流，然後保持開放，以便根除膿毒症，瘺管可以正常癒合。孤立地嘗試關閉內部開口而不根除括約肌間膿毒症（如肛瘺栓、OTSC 夾、VAAFT 等）可能導致瘺管復發 [7]、[8]。 這可以解釋此類手術后複雜瘺管的高復發率 [7]、[8]。
In this study, the intersphincteric space was drained and laid open through the transanal route. The intersphincteric space was not closed and kept open so that it healed by secondary intention. The aim of this step was eradication of sepsis and healing of fistula. Since the external sphincter was not cut or damaged, the risk to incontinence was expected to be minimal. This simple procedure, transanal opening of intersphincteric space (TROPIS) through the internal opening, was done in complex high fistula-in-ano.
在這項研究中，括約肌間隙通過經肛門途徑引流並打開。括約肌間隙沒有關閉並保持開放，因此它通過次要意圖癒合。此步驟的目的是根除膿毒症和治癒瘺管。由於外括約肌沒有被割斷或損壞，因此預計尿失禁的風險很小。這種簡單的手術，即通過內部開口經肛門開口括約肌間隙 （TROPIS），是在複雜的高位肛管中完成的。

2. Methods  2. 方法

A prospective study was carried out in which all the consecutive patients operated in a referral institute between January 2015 to July 2016 were included. The approval from the hospital ethical committee was taken before the start of the study. An informed verbal and written consent in two languages (English and a native language) was taken from every patient. The principle behind the procedure and the associated risks were explained to the patients.
進行了一項前瞻性研究，其中納入了 2015 年 1 月至 2016 年 7 月期間在轉診機構進行手術的所有連續患者。在研究開始之前獲得了醫院倫理委員會的批准。每位患者都以兩種語言（英語和母語）獲得知情的口頭和書面同意。向患者解釋了手術背後的原理和相關風險。

2.1. Inclusion criteria  2.1. 納入標準

  • -
    High cryptoglandular fistula-in-ano (involving more than one-thirds of the sphincter complex as assessed on MRI scan and intraoperative examination under anesthesia)
    高位隱腺肛瘺（根據 MRI 掃描和麻醉下術中檢查評估，涉及超過三分之一的括約肌複合體）
  • -
    Horseshoe fistula
    馬蹄瘺
  • -
    Supralevator fistula  提肌上瘺

2.2. Exclusion criteria  2.2. 排除標準

  • -
    Low fistula (involving less than one-third of the sphincter complex)
    低位瘺管（累及不到 1/3 的括約肌複合體）
  • -
    Fistula-in-ano with Crohn's disease
    患有克羅恩病的肛瘺

2.3. Principle behind the procedure
2.3. 程式背後的原則

The sepsis in fistula-in-ano is different from other sinus/fistula as it has some component/tract in intersphincteric plane (which can vary in different patients). The sepsis in this intersphincteric tract is bound by muscles on both sides (internal sphincter inside and external sphincter outside). For fistula to heal completely, this intersphincteric tract needs to be opened up. This opening can either be from outside through ischiorectal fossa by cutting the external sphincter or from inside the rectum by cutting the mucosa and internal sphincter. The former would involve a bigger cut and would damage external sphincter, which is more vital to continence. On the other hand, the opening from inside would involve a smaller cut and would not lead to cutting of external sphincter at all.
肛瘺中的膿毒症與其他鼻竇/瘺管不同，因為它在括約肌間平面上有一些成分/束（在不同患者中可能有所不同）。該括約肌間束中的膿毒症被兩側的肌肉（內括約肌內側和外括約肌外側）束縛。為了使瘺管完全癒合，需要打開這個括約肌間束。這個開口可以通過切開外括約肌從外部穿過坐骨直腸窩，也可以通過切開粘膜和內括約肌從直腸內部切開。前者會涉及更大的傷口，並且會損壞外括約肌，而外括約肌對節制更為重要。另一方面，從內部開口會涉及較小的切口，根本不會導致外括約肌的切割。
Therefore in TROPIS procedure, the tract in intersphincteric space is ‘deroofed’ or opened from inside the anal canal. For this, the mucosa and internal sphincter over the intersphincteric tract is incised with electrocautery. This not only destroys the infected crypt gland but also opens the tract in intersphincteric space which is then allowed to heal by secondary intention.
因此，在 TROPIS 手術中，括約肌間隙的束被“去頂”或從肛管內打開 。為此，用電烙術切開括約肌間束上的粘膜和內括約肌。這不僅會破壞受感染的隱窩腺，還會打開括約肌間隙的束，然後通過繼發性意圖使其癒合。
The main aim of this procedure is to achieve fistula healing without doing any damage to external sphincter. This is achieved by removing sepsis on both sides of the external sphincter so that both sides heal well. Sepsis eradication is done by transanal opening up of fistula tract ‘inside the external sphincter’ and curetting the tract ‘outside the external sphincter’. Postoperatively, both sides are kept clean till complete healing happens. Inadequate cleaning of one side would lead to passage to infected fluid from this side to the other side leading to non-healing of both the sides. Therefore both the steps are crucial for the success of operation.
該程式的主要目的是在不對外括約肌造成任何損傷的情況下實現瘺管癒合。這是通過去除外括約肌兩側的膿毒症來實現的，這樣兩側都能很好地癒合。膿毒症根除是通過經肛門打開瘺管“外括約肌內”和刮除瘺管“外”瘺管來完成的。術后，保持兩側清潔，直到完全癒合。一側清潔不充分會導致受感染的液體從一側流向另一側，導致兩側不癒合。因此，這兩個步驟對於作的成功都至關重要。
The internal opening is widened by electrocautery only at mucosal and internal sphincter level. It is of paramount importance that the opening/tract though the external sphincteric is not widened. The electrocauterized wound in rectum (opened intersphincteric space) heals quite well in 15–20 days. Once this is achieved, the cleaning of external tract is gradually reduced and then stopped.
電烙僅在粘膜和內括約肌水平通過電烙擴大內部開口。最重要的是，通過外括約肌的開口/束不要擴大。直腸電灼傷口（打開的括約肌間隙）在15-20天內癒合得很好。一旦實現這一點，外尿路的清潔就會逐漸減少，然後停止。

2.4. Procedure  2.4.作步驟

Preoperative MRI scan was done in all the patients. Based on the MRI, the fistula tracts were mapped in detail and a schematic diagram of the fistula (Fig. 1) was made after a discussion between the radiologist and the surgeon (PG).
所有患者均進行術前 MRI 掃描。根據 MRI，對瘺管進行了詳細映射，並在放射科醫生和外科醫生 （PG） 討論後製作了瘺管示意圖（ 圖 1）。
Fig. 1
  1. Download: Download high-res image (799KB)
    下載： 下載高解析度圖片 （799KB）
  2. Download: Download full-size image
    下載： 下載全尺寸圖像

Fig. 1. A 57 year old man with complex high Horseshoe fistula treated by TROPIS procedure with complete healing demonstrated on follow-up MRI scan. Extreme left: Pre-operation MRI scans -Coronal section (upper) Axial (lower). Middle left: Schematic diagram of Fistula-in-ano- Coronal section (upper) Axial (lower). Middle right- Operative photographs- Preoperation (upper), Immediately after surgery (lower). Extreme right: Post-operation Follow-up MRI scans of healed fistula-Coronal section (upper) Axial (lower).
 圖 1.一名 57 歲男性，患有複雜的高位馬蹄瘺，接受 TROPIS 手術治療，隨訪 MRI 掃描顯示完全癒合。最左：術前 MRI 掃描 - 冠狀面（上） 軸向（下）。左中：肛瘺-冠狀切片示意圖（上） 軸向（下）。右中 - 手術照片 - 手術前（上），手術后即刻（下）。最右：術后隨訪 癒合的瘺管-冠狀動脈切片（上部）軸向（下部）。

The patient was given spinal anesthesia (saddle block) and then placed in lithotomy position. An oral dose of antibiotics, Ciprofloxacin-500 mg and Ornidazole-500 mg was given 6 h before the surgery. The internal opening was confirmed by injecting povidine iodine solution through the external opening and noticing its egress inside the anal canal. A curved artery forceps was inserted through the internal opening into the intersphincteric part of the fistula tract. The mucosa and the internal sphincter over the artery forceps was cut with electrocautery. The intersphincteric portion of the fistula tract was thus laid open on the medial (luminal) side (Fig. 1). The incision was usually curvilinear but could also be oblique, depending upon the direction of the intersphincteric tract. The incision started from the internal opening, which was mostly at the dentate line. In case of horseshoe fistula, the incision extended on both sides of the midline posterior internal opening. In case of an additional supralevator opening of the fistula in the rectum, the incision was extended from the midline posterior internal opening up to the supralevator rectal opening. Perfect hemostasis was achieved. The external opening/openings were slightly widened (up to 1 cm). All the tracts were thoroughly curetted as per the findings of MRI scan. The scrapings and pus was sent for histopathology and polymerase chain reaction (PCR) for Mycobacterium Tuberculosis.
患者接受脊髓麻醉 （鞍塊），然後置於截石位。手術前 6 小時口服抗生素環丙沙星 500 mg 和奧硝唑 500 mg。通過外部開口注射聚維定碘溶液並注意其從肛管內流出來，確認內部開口。將彎曲的動脈鑷子通過內部開口插入瘺管的括約肌間部分。用電烙術切開粘膜和動脈鉗上的內括約肌。因此，瘺管的括約肌間部分在內側（管腔）打開（ 圖 1）。切口通常是曲線的，但也可能是傾斜的，具體取決於括約肌間束的方向。切口從內部開口開始，主要位於齒狀線處。在馬蹄形瘺的情況下，切口延伸到中線后內開口的兩側。如果直腸瘺管有額外的提肌上開口，切口從中線后內開口延伸到提肌上直腸開口。實現了完美的止血。外部開口略微加寬（高達 1 釐米）。根據 MRI 掃描的結果，所有尿道都進行了徹底刮除。刮片和膿液送去進行組織病理學和結核分枝桿菌聚合酶鏈反應 （PCR）。
The patient was discharged the next day of surgery and was advised to resume normal activities after the discharge. The curetted tracts were cleaned and kept empty twice a day with cotton swab mounted on an artery forceps [9]. The incontinence was assessed by objective scoring [10] before the surgery and at 3 months after the surgery. The six parameters assessed in the scoring were incontinence to gas, liquid and solid, alteration in lifestyle, need to wear a pad, need to take constipating medicines and ability to defer defecation for 15 min. The perfect continence would have a zero score and total incontinence would be a score of 24.
患者在手術第二天出院，並被建議在出院后恢復正常活動。清潔刮除的束，每天用安裝在動脈鉗上的棉簽保持空腹 2 次 [9]。 在手術前和手術后 3 個月通過客觀評分 [10] 評估尿失禁。評分中評估的 6 個參數是氣體、液體和固體失禁、生活方式改變、需要戴護墊、需要服用便秘藥物和延遲排便 15 分鐘的能力。完美失禁的分數為零，完全失禁的分數為 24。
Fistula was taken to be healed when all the tracts healed completely and there was no pus discharge from any of the tracts or the anus. Pus discharge from even a single tract was considered as failure of the treatment.
當所有束完全癒合並且沒有任何束或肛門流出膿液時，瘺管被認為是癒合的。即使從單個通道流出膿液也被認為是治療失敗。

2.5. Statistical analysis
2.5. 統計分析

Comparison of categorical variables was performed by chi-squared analysis or Fisher's exact test, where appropriate. The continuous variables were assessed by t-test or ANOVA. The significant cut off point was set at p < 0.05.
分類變數的比較在適當的情況下通過卡方分析或 Fisher 精確檢驗進行。通過 t 檢驗或方差分析評估連續變數。顯著截斷點設置為 p < 0.05。

3. Results  3. 結果

61 patients with high complex fistula-in-ano with operated. The median follow-up was 9 months (range- 6–21 months). The ratio of male/female was 59/2, and the mean age was 42.3 ± 9.5 years. 85.2% (52) patients had recurrent fistula, 83.6% (51) had multiple tracts, 36.1% (22) had horseshoe tract, 34.4% (21) had supralevator extension and 26.2% (16) had an associated abscess. 95.1% (58) were posterior fistula out of which 90.2% (55) were in posterior midline. Nine patients were excluded from the analysis. (Six tested positive for Mycobacterium Tuberculosis, two were lost to follow-up and one patient was excluded as the procedure couldn't be completed due to intraabdominal extension of the fistula tracts). Fistula healed completely in 84.6% (44/52) and didn't heal in 15.4% (9/52) patients. 4/9 of the patients with failed procedure were operated again with the same procedure and the fistula healed in three patients. Thus the overall healing rate was 90.4% (47/52).
61 例高複雜肛瘺患者接受手術。中位隨訪時間為 9 個月 （範圍 - 6-21 個月）。男女比為 59/2，平均年齡為 42.3 ± 9.5 歲。85.2% （52） 患者有復發性瘺管，83.6% （51） 有多條瘺，36.1% （22） 有馬蹄形束，34.4% （21） 有提肌上延伸，26.2% （16） 有相關膿腫。95.1% （58） 為後瘺，其中 90.2% （55） 位於後中線。9 例患者被排除在分析之外。（6 例結核分枝桿菌檢測呈陽性，2 例失訪，1 例患者因瘺管腹內延伸而無法完成手術而被排除在外）。84.6% （44/52） 患者的瘺管完全癒合，15.4% （9/52） 的患者瘺管未癒合。4/9 的手術失敗患者再次使用相同的手術，3 例患者的瘺管癒合。因此，總治癒率為 90.4% （47/52）。
In 21 patients in whom the fistula had supralevator extension, there was additional supralevator opening in the rectum in six (28.6%) patients. In these cases, the incision was extended from the midline posterior internal opening up to the supralevator rectal opening. This was possible as supralevator extension was in intersphincteric plane in all the cases [11]. The six patients who tested positive for Mycobacterium Tuberculosis were started on anti-tubercular therapy (ATT). Five out of six patients completed the six months anti-tubercular therapy regimen. Four became alright and one was lost to follow-up. One patient is still on ATT.
在 21 例瘺管有提肌上延伸的患者中，6 例 （28.6%） 患者的直腸有額外的提肌開口。在這些病例中，切口從中線后內開口延伸到提肌上直腸開口。這是可能的，因為在所有病例中，提肌上伸展都在括約肌間平面 [11]。6 例結核分枝桿菌檢測呈陽性的患者開始接受抗結核治療 （ATT）。6 例患者中有 5 例完成了為期 6 個月的抗結核治療方案。4 例沒事，1 例失訪。一名患者仍在接受 ATT。
All patients were discharged from the hospital within 24 h of the admission. There was no significant change in the objective incontinence scores. Pre-operative incontinence scores were 0.19 ± 0.4 and post surgery incontinence scores after 3 months were 0.32 ± 0.6 (p = 0.20, unpaired t-test). There was no major complication of the procedure. One patient had bleeding from the anal wound three days after the surgery. The bleeding was controlled with the transanal application of manual pressure.
所有患者在入院后 24 小時內均出院。客觀失禁評分無顯著變化。術前尿失禁評分為 0.19 ± 0.4，術后 3 個月尿失禁評分為 0.32 ± 0.6 （p = 0.20，未配對 t 檢驗）。手術沒有重大併發症。1 例患者術后 3 天肛門傷口出血。通過經肛門手動加壓控制出血。

4. Discussion  4. 討論

In spite of innovation of several new procedures, the treatment of high complex fistula-in-ano remains a big challenge. Conventional methods like fistulotomy and cutting seton carries a high risk of incontinence in these fistula [12]. The newer methods are relatively safe but have a low success rate in complex fistula-in-ano [7]- [8]. These methods focus primarily on closing the internal opening. This is done either at mucosal level with a synthetic device [Anal fistula Plug (AFP) [13], OTSC clip [8] or Video assisted anal fistula treatment (VAAFT) [14]] or in intersphincteric plane by ligating the tract in intersphincteric plane as in LIFT (Ligation of intersphincteric tract) procedure [15]. Dismal results of all these procedures in complex fistula-in-ano indicate that some pivotal aspect of proper management was being overlooked.
儘管有幾種新手術進行了創新，但高複雜性肛瘺的治療仍然是一個巨大的挑戰。 瘺管切開術和切割掛線等傳統方法在這些瘺管中具有很高的尿失禁風險 [12]。 較新的方法相對安全，但在複雜肛瘺中成功率較低 [7]- [8]。 這些方法主要側重於關閉內部開口。這可以通過合成裝置 [肛瘺栓 （AFP） [13]、OTSC 夾 [8] 或視頻輔助肛瘺治療 （VAAFT） [14]] 在粘膜水準完成，也可以通過在括約肌間平面結紮肛瘺在括約肌平面上完成，如 LIFT（括約肌間束結紮）手術 [15].在複雜肛瘺中，所有這些手術的慘澹結果表明，正確管理的一些關鍵方面被忽視了。
The results of the study highlighted that Transanal laying open of the intersphincteric space (TROPIS) procedure was quite effective (overall healing rate of 90%) in curing high complex fistula-in-ano including horseshoe fistula (Fig. 1), fistula with multiple tracts (Fig. 1), fistula with associated abscess (Fig. 1) and supralevator fistula.
研究結果強調，經肛門括約肌間隙開放 （TROPIS） 手術在治癒高度複雜肛瘺方面非常有效（總體癒合率為 90%），包括馬蹄形瘺（ 圖 1）、多束瘺（ 圖 1）、瘺管伴相關膿腫（ 圖 1）和提肌上瘺。
An aspect of fistula-in-ano which differentiates it from fistula in other parts of the body is the sepsis in the intersphincteric plane. This sepsis is akin to an abscess in a closed space. The basic treatment fundamentals applicable to a closed abscess are also pertinent in fistula-in-ano management. These fundamentals entail two steps- adequate drainage of the cavity and keeping it open till the cavity heals by secondary intention. In context of sepsis in the intersphincteric plane, none of the procedures (AFP [13], OTSC [8], VAAFT [14], advancement flap [16], fibrin glue [16], Filac Laser [17]) addresses these two steps. LIFT procedure though takes care of the first step but it falls short of addressing the second step [15]. Only fistulotomy takes care of both the steps (the intersphincteric space is drained as well as kept open) and hence it has a high success rate in fistula-in-ano treatment [18]. Unfortunately, fistulotomy cannot be done in high and complex fistulas.
肛瘺與身體其他部位的瘺管區分開來的一個方面是括約肌間平面的敗血症。這種膿毒症類似於封閉空間中的膿腫。適用於閉合性膿腫的基本治療基礎也與肛瘺管理相關。這些基本原理包括兩個步驟——充分引流空腔並保持開放，直到空腔通過二次意圖癒合。在括約肌間層面膿毒症的情況下，沒有任何程式（AFP [13]、OTSC [8]、VAAFT [14]、前移皮瓣 [16]、 纖維蛋白膠 [16]、絲狀鐳射 [17]）涉及這兩個步驟。LIFT 手術雖然負責第一步，但它沒有解決第二步 [15]。 只有瘺管切開術可以完成這兩個步驟（括約肌間隙被引流並保持開放），因此它在肛瘺治療中具有很高的成功率 [18]。 不幸的是，瘺管切開術不能在高位和複雜的瘺管中進行。
Transanal opening of intersphincteric space (TROPIS) procedure, by deroofing the intersphincteric space from the luminal side, addresses both the above issues in a satisfactory manner. The deroofing not only adequately clears all the pus but also converts a closed intersphincteric cavity into a saucer shaped open wound which heals quite well by secondary intention. Unlike other procedures which intend to heal the internal opening by primary intention, TROPIS aims to do the same by secondary intention. It is an established fact that in the presence of infection, healing by secondary intention is better than primary intention.
經肛門括約肌間隙開放 （TROPIS） 手術，通過從管腔側去除括約肌間隙的屋頂，以令人滿意的方式解決了上述兩個問題。去頂不僅充分清除了所有膿液，而且還將封閉的括約肌間腔轉化為碟形開放性傷口，通過二次意圖癒合得相當好。與其他旨在通過主要意圖治癒內部開口的程式不同，TROPIS 旨在通過次要意圖來做同樣的事情。一個既定的事實是，在存在感染的情況下，次要意圖的癒合比最初的意圖要好。
Transanal drainage of rectal abscesses (submucosal and intersphincteric) has been described in the literature [19]. But utilizing this concept (laying open the intersphincteric space through transanal route) to treat complex fistula-in-ano has never been described before.
文獻中已經描述了直腸膿腫（粘膜下和括約肌間）的經肛門引流 [19]。 但是利用這個概念（通過經肛門途徑打開括約根間隙）來治療複雜的肛瘺以前從未被描述過。
The observations made by Kurihara et al. [5] and Zhang et al. [1] that most anal fistulas especially the posterior complex fistula have sepsis in intersphincteric plane has been corroborated in the present study. Detailed analysis of MRI scans in all the patients helped significantly to track the fistula tracts in intersphincteric plane. Even most transsphincteric fistulas were found to have some intersphincteric tracts on MRI scans (Fig. 1). However some transsphincteric fistulas do join anal canal without any intersphincteric component. In such fistula, routine procedures (AFP, OTSC, VAAFT, advancement flap, fibrin glue, Filac laser) may also be effective. However, in cases, where intersphincteric component/tract is there, these procedures would perhaps fail as they don't address the problem of intersphincteric sepsis.
Kurihara 等 [5] 和 Zhang 等 [1] 的觀察結果表明，大多數肛瘺，尤其是後複合瘺，在括約肌間平面有膿毒症，在本研究中得到了證實。對所有患者的 MRI 掃描進行詳細分析有助於顯著跟蹤括約肌間平面的瘺管。甚至大多數經括約肌瘺在 MRI 掃描中也發現有一些括約肌間束（ 圖 1）。然而，一些經括約肌瘺確實在沒有任何括約肌間成分的情況下加入肛管 。在此類瘺管中，常規手術（AFP、OTSC、VAAFT、推進皮瓣、纖維蛋白膠、Filac 鐳射）也可能有效。然而，在存在括約肌間成分/束的情況下，這些程式可能會失敗，因為它們沒有解決括約肌間膿毒症的問題。
LIFT (ligation of intersphincteric fistula tract) procedure also entails tackling of intersphincteric tract but the results of TROPIS procedure are better than LIFT [15]. There could be several possible reasons for this. First, in LIFT it is difficult to keep the intersphincteric space open for sufficient period to ensure healing with secondary intention. Second, LIFT would be difficult and technically demanding in very high fistula. Third, in fistula with an additional internal opening high up in the rectum as in supralevator fistula, managing this internal opening would be quite difficult with LIFT procedure. Therefore, LIFT has inferior results as compared to TROPIS in managing high fistulas with intersphincteric tracts.
LIFT（括約肌間瘺束結紮術）手術也需要處理括約肌間束，但 TROPIS 手術的效果優於 LIFT [15]。 這可能有幾個可能的原因。首先，在 LIFT 中，很難保持括約肌間隙開放足夠的時間以確保繼發性意圖的癒合。其次，在非常高的瘺管中，LIFT 將很困難且技術要求很高。第三，在直腸高處有一個額外內部開口的瘺管中，如提升肌瘺管，使用 LIFT 手術管理這個內部開口將非常困難。因此，與 TROPIS 相比，LIFT 在治療括約肌間束的高位瘺管方面的效果較差。
The MRI scan helped to accurately delineate the tract in the intersphincteric plane (Fig. 1). Preoperative mapping of the tracts facilitated the laying open of the intersphincteric tracts during the surgery (Fig. 1). Otherwise, accurate identification of all intersphincteric extensions might be difficult intraoperatively and there was always a risk of missing some tracts (Fig. 1). Since it was not always possible to predict complexity of fistula on history and physical examination, we had a policy of getting MRI scan in all the patients [20]. This practice, though added to the cost of the treatment but it helped to accurately identify intersphincteric tract and extensions in almost all the patients. MRI scan was also done in few post operative cases to confirm the complete healing of fistula (Fig. 1).
MRI 掃描有助於準確描繪括約肌間平面的束（ 圖 1）。術前神經束標測有助於在手術過程中張開括約肌間束（ 圖 1）。否則，術中可能難以準確識別所有括約肌間延伸部分，並且總是存在遺漏某些束的風險（ 圖 1）。由於並不總是能夠通過病史和體格檢查預測瘺管的複雜性，因此我們制定了對所有患者進行 MRI 掃描的政策 [20]。 這種做法雖然增加了治療成本，但它有助於準確識別幾乎所有患者的括約肌間束和延伸。少數術后病例也進行了 MRI 掃描，以確認瘺管完全癒合 （ 圖 1）。
To conclude, the success rate of transanal opening of intersphincteric space (TROPIS) procedure in over 90% of high and complex fistula is quite impressive. In the present cohort, more than 80% had multiple tracts and recurrent fistula and more than one-third patients had horseshoe tracts and supralevator extension. The significant aspect was that external sphincter was not cut or damaged in this procedure due to which the risk to continence was minimized. The technique was simple, easy to reproduce, associated with little pain and early resumption of normal activities. However, the long term results in larger number of patients are awaited.
總而言之，超過 90% 的高位複雜瘺管經肛門開口括約肌間隙 （TROPIS） 手術的成功率令人印象深刻。在本佇列中，超過 80% 的患者有多條束和復發性瘺管，超過 1/3 的患者有馬蹄束和提肌上延伸。重要的方面是在此過程中沒有切斷或損壞外括約肌，因此將失禁的風險降至最低。該技術簡單，易於複製，疼痛小，可及早恢復正常活動。然而，有待於更多患者的長期結果。

Presentation  介紹

The abstract has been.  摘要已經結束了。
  • Presented at European Society of Colo Proctology (ESCP)Annual Meeting, Milan, Italy, 28–30 September 2016
    2016 年 9 月 28 日至 30 日在義大利米蘭舉行的歐洲結腸直腸學會 （ESCP） 年會上發表
  • Invited for presentation at American Society of Colon Rectum Surgeons (ASCRS), Seattle, WA, USA, 10–14th June, 2017
    受邀於 2017 年 6 月 10 日至 14 日在美國華盛頓州西雅圖舉行的美國結腸直腸外科醫師協會 （ASCRS） 上發表演講

Ethical approval  倫理認證

Indus Hospital Ethics Committee.
Indus 醫院倫理委員會。
Indus Superspeciality Hospital.
Indus 超級專科醫院。
Mohali, INDIA.  印度莫哈裡。
Judgement's reference number.
判決書的參考編號。
Indus hospital/EC/03-12.  印度河醫院/EC/03-12。

Sources of funding  資金來源

NIL.  零。

Author contribution  作者貢獻

Pankaj Garg- concept, designed study, acquisition of data, analysis of data, drafting, revising, final approval of the draft, submission of manuscript.
Pankaj Garg - 概念、設計研究、數據採集、數據分析、起草、修改、草稿的最終批准、手稿提交。

Conflicts of interest  利益衝突

NIL.  零。

Research registration unique identifying number (UIN)
研究註冊唯一標識號 （UIN）

researchregistry2160.  研究註冊表2160。

Guarantor  保證人

Dr Pankaj Garg.  Pankaj Garg 博士。

Acknowledgements  確認

Nil.  尼羅河。

References  引用

Cited by (0)

  • Is fistulotomy still the gold standard in present era and is it highly underutilized?: An audit of 675 operated cases

    2018, International Journal of Surgery
    Citation Excerpt :

    The assessment of sphincter involvement was done by MRI and by doing examination (palpation of the sphincter after putting a probe in the fistula tract) under anesthesia before starting the surgery. When fistulotomy was not possible (high and supralevator fistulas), sphincter sparing procedures- TROPIS (transanal opening of intersphincteric space) [8,9] and PERFACT (proximal superficial cauterization of internal opening, emptying regularly of fistula tracts and curettage of tracts) [10,11]- were done. Based on the MRI, the fistula tracts were mapped in detail and a schematic diagram of the fistula was made before starting the surgery [8].

  • Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? A Retrospective Cohort Study

    2017, International Journal of Surgery
    Citation Excerpt :

    Grade III, IV & V are high complex fistulas and fistulotomy should not be attempted in these fistulas (Table 5, Figs. 3–5). The newer procedures which spare the sphincter such as FPR (Fistulectomy with primary sphincter reconstruction) [10], LIFT (Ligation of Intersphincteric fistula tract) [11], VAAFT (Video assisted anal fistula treatment) [12], AFP (Anal fistula plug) [13], TROPIS (Transanal opening of intersphincteric tract) [14], OTSC (Over-the-scope-clip proctology) [15] and FiLac laser [16]. The importance of preoperative MRI to correctly classify the fistula cannot be overemphasized.

  • Transanal Opening of Intersphincteric Space for Fistula-in-Ano

    2022, American Surgeon

  • Transanal opening of the intersphincteric space: a novel sphincter-sparing procedure to treat 325 high complex anal fistulas with long-term follow-up

    2021, Colorectal Disease

  • Current concepts in the pathogenesis of cryptoglandular perianal fistula

    2021, Journal of International Medical Research

  • Management of complex cryptoglandular anal fistula: Challenges and solutions

    2020, Clinical and Experimental Gastroenterology
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