few papers reported on the use of IDUS and MRI to diagnose recurrent anal fistula. Conclusion: The diagnosis of an anal fistula was primarily based on

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1 Sponsored by: Nanjing Municipal Hospital of Chinese Medicine (www. Njszyy.cn) and Nanjing Public Health Bureau ( International Union for Difficult-to-treat-Diseases ( Review Comparison of the diagnosis and treatment of anal fistula in China and out of China Hao Chen 1 #, Qiang Leng 1 #, Xiaofeng Wang 1, Alexander Stojadinovic 2, Itzhak Avital 3, Heiying Jin 1 1 National Center of Colorectal Surgery, the 3rd affiliated Hospital of Nanjing University of Traditional Chinese Medicine, 1 Jinling Road, Nanjing , China. 2 Inernational Union for Difficult-to-treat-Diseases, MD, USA 3 Department of Surgery, Saint Peter s University Hospital, Rutgers University New Brunswick NJ, USA (#: These authors contributed equally to this work) Chinese Approaches for Difficult Diseases 2016; 3:32-39 Corresponding author: Heiying Jin, MD., PhD National center of colorectal Disease The 3rd affiliated Hospital Nanjing University of Traditional Chinese Medicine Nanjing , China jinheiying@hotmail.com This is an open-access article distributed under the terms of the International Standard Serial Number ( ) and the International Union for Difficult-to-treat-Diseases ( Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited. Received: ; Accepted: ; Published: Abstract Objective: To better understand the current diagnosis and treatment of anal fistula in China and out of China. Methods: The medical databases were searched for reports on the treatment of anal fistula, published from January 2009 to December The methods used for diagnosis and treatment, were analyzed. Results: A total of 500 Chinese documents and 53 English documents were collected. Most of the documents on the diagnosis of anal fistula relied on clinical symptoms and physical inspection. Only a few papers described using IDUS or MRI for the diagnosis. For diagnosis criteria, only 14 documents (2.8%) used Parks classification in Chinese document, while the others used China s anal fistula diagnosis and treatment guidelines. But for documents out of China, Twenty-nine documents (54.7%) used Parks classification. During the treatment of anal fistula, documents in China mainly showed the use of traditional methods such as fistulotomy or cutting seton. Documents out of China showed that the rate of sphincter-saving surgery was increasing (69.3%). During postoperative follow-up, clinical symptoms and physical inspection were mainly used to treat relapsing anal fistulas. Only a 综述 国内外肛瘘诊疗现状的对比与启示 陈豪 1 # 冷强 1 1 # 王晓峰 Alexander Stojadinovic 2 Itzhak Avital 3 1, 金黑鹰 1 南京中医药大学第三附属医院全国肛肠中心, 南京, 21001, 中国 2 国际抗难治疾病联盟, 马利兰州, 美国 3 外科系,Saint Peter 大学附属医院,Rutgers 大学, New Brunswick, 新泽西州, 美国 (#: 二作者对本项目的贡献相当 ) 中医药抗疑难症 2016: 5: 通讯作者 : 金黑鹰, 医学博士全国肛肠中心第三附属医院南京中医药大学南京,21001, 中国电子邮箱 :jinheiying@hotmail.com 本刊为网上杂志, 国际标准序列号为 本刊为国际抗疑难杂症联盟 ( 的学术刊物. 在保证如实完整反映本刊所发论文的前提下, 任何个人与非商业团体可免费下载任一文章的全文或章节 收稿 : ; 接受 : 发表 : 摘要目的 : 调查目前国内外肛瘘诊治的具体情况, 了解国内外肛瘘诊治的现状及发展方向 方法 : 本实验自医学数据库中检索了 2009 年 1 月至 2013 年 12 月期间国内外发表的关于肛瘘治疗的相关文献, 对肛瘘诊疗过程中的方法和效果进行分析 结果 : 共获得中文文献 500 篇, 英文文献 53 篇 对肛瘘的诊断大多数文献仍依靠临床症状和临床物理检查为主, 仅少部分文献描述采用腔内超声或 MRI 进行诊断 就诊断标准而言, 在中文文献中, 仅 14(2.8%) 采用 Park 的分类方法, 其他则采用中国的肛瘘的诊断方法和冶疗指南 然而, 在中国以外的地区,29 篇文献 (54 7%) 使用 Park 的分类方法 在肛瘘的治疗中, 中文文献主要采用传统的肛瘘切开切除或切割挂线治疗, 而英文文献在使用传统治疗方法的同时, 保留括约肌的肛瘘手术比例明显增大 (69.3%) 术后随访过程中, 仍主要依靠临床症状和物理检查对复发肛瘘进 Page 32

2 few papers reported on the use of IDUS and MRI to diagnose recurrent anal fistula. Conclusion: The diagnosis of an anal fistula was primarily based on doctors' experience in China and out of China; inadequate attention was paid to objective forms of diagnosis. More research is needed to determine whether this affects treatment results. Foreign documents classified anal fistulas mainly using Parks method. Documents in China and out of China use different classification methods, which makes them difficult to compare. In terms of treatment methods, treatment out of China was based on sphincter-saving surgery, while treatmentin China was based on fistulotomy and Cutting seton, which potentially caused more harm to sphincters. Postoperative follow-up in China and out of China paid attention to recurrence rate. However, less attention was paid to the incontinence rate, especially the long-term rate of postoperative incontinence. Key words: Anal fistula; Diagnosis; Treatment; outcome Introduction Anal Fistula is an ancient diagnosis. According to historical records, as early as the 5th century BC, Hippocrates had used horsehair to treat anal fistulas as noted by Seton [1, 2]. With the understanding of the pathogenesis of anal fistula, pelvic anatomy and its physiology, great progress has been made in the classification of anal fistula and related treatment methods. In order to understand the current status of anal fistula and the differences between international peers, we analyzed the documents related to anal fistula published in the last five years. Simultaneously, we compared the documents and analyzed the treatment course and effects, in order to better understand the diagnosis and treatment of anal fistulas in China and out of China. 1. Research Methods 1.1. Retrieval Methods At Chinese databases ( and ( anal fistula was used; at the international database ( anal fistula, perianal fistula and anorectal fistula were used as keywords to retrieve all documents related to the diagnosis and treatment of anal fistula published between January 2009 and December If a given document in the English literatures was published by a Chinese doctor or researcher, the data was included as a Chinese document. The study was approved by the ethic committee of the 3rd affiliated Hospital of Nanjing University of 行诊断, 仅少部分采用腔内超声或 MRI 进行诊断 结论 : 无论在中国或者是其他国家, 对于肛瘘的诊断多根据医生个人的经验诊断为主, 而对于肛瘘的客观诊断均重视不够 这一共同倾向是否影响肛瘘的治疗结果, 尚需进一步研究 国外文献肛瘘以 Park 分类方法为主 然而, 中国大陆以及大陆以外的地区则采用不同的分类方法, 极难进行对照比较 关于肛瘘的治疗方法, 中国以外的国家和地区以括约肌保留手术为主 而中国仍以对括约肌损伤较大的传统手术为主 无论在中国或者是其他国家, 对治疗结果随访主要关注复发率 ; 对于失禁率 特别是对术后远期失禁率关注不够 关键词 : 肛瘘 ; 治疗现状 ; 调查 导言肛瘘是一种古老的疾病, 早在公元前 5 世纪, 就有希波克拉底采用马鬃进行挂线治 疗肛瘘的历史记载 [1,2] 随着对肛瘘发病机理 及肛门解剖和生理的了解, 目前对肛瘘的分类 及治疗手段都有了巨大的进步 为了了解我国 肛瘘诊疗的现状, 了解与国际同行之间的差 异, 我们对近 5 年来国内发表的关于肛瘘的文 章进行了调查, 并与近 5 年来国际发表的文章 进行比较, 对肛瘘的诊治过程及结果进行分 析, 以了解目前国内外肛瘘诊治的现状及发展 方向 1.1. 检索方法 1. 研究方法 在中文 ( 和 ( 数据库中, 以 肛瘘 为关键词 ; 在外文数据库 Pubmed ( 中, 以 anal fistula perianal fistula 和 anorectal fistula 为关键词, 检索自 2009 年 1 月到 2013 年 12 月期间发表的所有关于肛瘘治疗的文献 中国医生或科研人员发表在外文期刊上的文献, 统归为中文文献目下 此实验的开展获南京中医药大学第三附属医院, 全国肛 Page 33

3 Traditional Chinese Medicine Inclusion and Exclusion Criteria All randomized controlled trials (RCT), retrospective or prospective research and case reports on the treatment of anal fistula were included in this study. The anal fistulas associated with Crohn s disease and AIDS were excluded Data Collection Two investigators collected all documents. They focused on research methods, cases, diagnostic methods, and classification of anal fistula, as well as surgical methods, follow-up (time and method), postoperative recurrence rate of anal fistula and anal incontinence. 2. Results 2.1. General resource of documents Five hundred Chinese documents and 53 English documents were included in this study. Among the Chinese documents, 157 were prospective RCT, 91 were retrospective controlled trials, and 252 were case reports, including 43,301 cases in total. Among the English documents, 2 were RCT, 2 were prospective controlled trials, 5 were retrospective controlled trials, and 44 were case reports, including 3,231 cases in total Diagnosis and Classification Methods In terms of the diagnosis of the anal fistula in the Chinese documents, 464 documents (92.8%) failed to describe the specific methods used for diagnosis; 1 document (0.2%) showed that the investigators used physical examination; 33 documents (7.0%) showed that IDUS and MRI were used for the diagnosis. In terms of classification of the anal fistula, only 14 documents (2.8%) used Parks classification, while the others used China s anal fistula diagnosis and treatment guidelines. For the English documents, there were 4 papers (7.5%) that used IDUS and MRI for diagnosis, 1 document (1.9%) used clinical physical examination, and the other documents failed to describe the methods used for diagnosis. Twenty-nine documents (54.7%) used Parks classification Treatment methods and effects The treatment methods for anal fistula in the Chinese documents included the following: 330 documents (66.0%) with 肠中心论理委员会批准 1.2. 纳入及排除标准所有关于肛瘘治疗的随机对照研究 回顾性或前瞻性对照研究以及病例报道均纳入本研究 对于 Crohn 病相关性肛瘘及 AIDS 相关性肛瘘均排除本研究 1.3. 数据采集纳入的文献由两位作者对研究方法 病例 数 肛瘘诊断方法 肛瘘分类 手术方法 随访时间 随访方法以及术后肛瘘复发率及 肛门失禁率进行采集 2. 结果 2.1. 文献一般资料共纳入中文文献 500 篇, 英文文献 53 篇 在中文文献中前瞻性对照研究 157 篇 回 顾性对照研究 91 篇 病例报道 252 篇, 总病 例数 例 ; 在英文文献中随机对照研究 2 篇 前瞻性对照研究 2 篇 回顾性对照研究 5 篇 病例报道 44 篇, 总病例数 3,231 例 2.2. 诊断与分类方法在中文文献中, 对肛瘘的诊断,464 篇 (92.8%) 文献未描述具体的诊断方法,1 篇 (0.2% ) 依靠体格检查诊断, 33 篇 (7.0%) 采用腔内超声或 MRI 诊断 对肛瘘 的分类仅 14 篇 (2.8%) 进行 Parks 分类, 其 余文献均根据我国肛瘘诊治指南对肛瘘进行 分类 在英文文献中, 有 4 篇 (7.5%) 文献使用了腔内超声或 MRI 进行诊断,1 篇 (1.9%) 采用临床体格检查诊断, 其余文献均未描述诊断方法 29 篇 (54.7%) 文献对肛瘘进行 Park 分类 2.3. 治疗方法与效果在中文文献中, 对于肛瘘治疗方法的选择,330 篇 (66.0%) 文献报道了肛瘘切开 Page 34

4 fistulotomy; 225 (45.0%) with cutting seton; 19 (3.8%) with the loose Seton method. The reported number of documents using fibrin glue, LIFT, anal fistula plug, and advanced skin flap were 9 (1.8%), 11 (2.2%), 26 (5.2%), and 6 (1.2%) respectively. These papers reported different rates of cure. In anal fistula incision or resection, the postoperative recurrence rate ranged from 0~22.1% and the anal incontinence rate ranged from 0~31.3%; in cutting seton surgery, the postoperative recurrence rate ranged from 0~27.5% and the incontinence rate ranged from 0~22.6%; in the loose Seton surgery, the postoperative recurrence rate ranged from 0~8.1% and the incontinence rate ranged from 0~14.1%. For the application of biological fibrin glue, the postoperative recurrence rate ranged from 0~20.8% and the incontinence rate ranged from 0~12.2%; in LIFT, the postoperative recurrence rate ranged from 0~7.7% and the incontinence rate was 0; using an anal fistula plug, the postoperative recurrence rate ranged from 0~27.5% and the incontinence rate ranged from 0~18.6%. With regard to advanced skin flap surgery, the postoperative recurrence rate ranged from 0~12% and the incontinence rate ranged from 0~8.3%. Regarding the choice of treatment of anal fistula in the English documents, 8 documents (15.1%) reported anal fistula incision or resection methods; 4 documents (7.5%) reported cutting seton; 5 documents (9.4%) reported using the loose Seton. The number of documents using biological fibrin glue, LIFT surgery, anal fistula plug, advanced skin flap or other methods were 2 (3.8%), 15 documents (28.3%), 13 (24.5%), 6 (11.3%) and 6 ( 11.3%) respectively. Regarding to outcomes, in anal fistula incision or resection, the recurrence rate ranged from 0~ 32% and the incontinence rate ranged from 0~ 20%; for cutting using Seton surgery, the postoperative recurrence rate ranged from 3~9% and incontinence rate from 0~2%; in loose Seton surgery, the recurrence rate ranged from 0~ 19% and incontinence rate from 0~ 3.8%. With regard to biological fibrin glue, the recurrence rate ranged from 26~35% and the incontinence rate was 0%; for LIFT, the recurrence rate ranged from 5~60% and the incontinence rate ranged from 0-7.1%. Use of an anal fistula plug was associated with a recurrence rate of 22.1~ 86.7% and an incontinence rate of 0~1.8%. For the advanced skin flap surgery, the postoperative recurrence rate ranged from 6.5~ 28% and the incontinence rate ranged from 0~55%. With regard to other methods including anal fistula resection under endoscopic view, stem cell treatment and high ligation, the recurrence rates ranged from 12.9%~62.7%, and the rates of incontinence were reported to be unknown. (See Table 1) 或切除法,225 篇 (45.0%) 报道了切割挂线 法,19 篇 (3.8%) 报道了引流挂线法, 采用 生物蛋白胶 LIFT 肛瘘栓和推移皮瓣的文献 数量分别为 9 篇 (1.8%) 11 篇 (2.2%) 26 篇 (5.2%) 和 6 篇 (1.2%) 在治疗效果 上, 各文献报道结果不一 肛瘘切开或切除术 后肛瘘复发率为 0~22.1%, 肛门失禁率为 0~31.3% ; 切割挂线术后肛瘘复发率为 0~27.5%, 失禁率为 0~22.6%; 引流挂线术后 肛瘘复发率为 0~8.1%, 失禁率为 0~14.1%; 使用生物蛋白胶术后肛瘘复发率为 0~20.8%, 失禁率为 0~12.2% ; LIFT 术后复发率为 0~7.7%, 失禁率为 0%; 使用肛瘘栓术后复发 率为 0~27.5%, 失禁率为 0~18.6%; 推移皮瓣 术后复发率为 0~12%, 失禁率为 0~8.3% 在英文文献中, 对于肛瘘治疗方法的选择,8 篇 (15.1%) 文献报道了肛瘘切开或切除法,4 篇 (7.5%) 报道了切割挂线法,5 篇 (9.4%) 报道了引流挂线法, 采用生物蛋白胶 LIFT 手术 肛瘘栓 推移皮瓣或其他方法的文献数量分别为 2 篇 (3.8%) 15 篇 (28.3%) 13 篇 (24.5%) 6 篇 (11.3%) 和 6 篇 (11.3%) 在治疗效果上, 肛瘘切开或切除术后 肛瘘复发率为 0~32%, 肛门失禁率为 0~20%; 切割挂线术后肛瘘复发率为 3~9%, 失禁率为 0~2%; 引流挂线术后肛瘘复发率为 0~19%, 失禁率为 0~3.8%; 使用生物蛋白胶 术后肛瘘复发率为 26~35%, 失禁率为 0%; LIFT 术后复发率为 5~60%, 失禁率为 0~7.1% ; 使用肛瘘栓术后复发率为 22.1~86.7%, 失禁率为 0~1.8%; 推移皮瓣术 后复发率为 6.5~28%, 失禁率为 0~55%; 其他 方法包括内镜下肛瘘切除 干细胞治疗及肛瘘 高位结扎等, 术后肛瘘复发率为 12.9~62.7%, 失禁率报道不详 ( 见表 1) Page 35

5 Table 1. Statistics of the data included in the documents reviewed 表 1. 纳入文献数据统计 Therapies 治疗方法 Incision or resection 肛瘘切开切除 Incision Seton 切割挂线 Drainage Seton 引流挂线 Biological fibrin glue 生物蛋白胶 LIFT 提起 Anal fistula plug 肛瘘栓 Advanced skin flap 推移皮瓣 other methods 其他方法 Chinese documents ( 中文文献 ) English documents ( 英文文献 ) Document Cases Recurrence % Incontinence % Follow-up/Y Document Cases Recurrence % Incontinence % Follow-up/Y 文献数 病例数 复发率 % 失禁率 % 随访时间 文献数 病例数 复发率 % 失禁率 % 随访时间 y y y y y Unknown Follow-up In the Chinese documents, the postoperative follow-up was from 2 weeks to 10 years; 449 documents (99.8%) did not show the follow-up methods, and only one paper described using MRI to assess the operation performed. In the out of China documents, the postoperative follow-up phase was from 3 months to 7 years; among them, only 11 documents (20.8%) described using IDUS and MRI, and other documents did not show the follow-up methods (See Table 1). 3. Discussion Anal fistula is a common medical problem. Most of the associated characteristics are obvious. However, only 48% anal fistula can be diagnosed by medical history and physical examination [3]. Around 5% of anal fistulas have multi-fistula content or the fistula is located above the anal straight ring. Without sufficient assessment before surgery, it is easy to confuse a fistula with a focus of infection; this is the major reason for recurrence[4,5]. In recent years, with the usage of IDUS and MRI, the treatment has changed from traditional experience with regard to diagnosis to objective imaging diagnosis. Currently, MRI has been the gold standard used for the treatment of anal fistulas [6]. Having an IDUS and MRI examination before surgery is helpful for fistulas difficult to find [7,8], three-dimensional ultrasound or MRI imaging of the fistula helps with the accuracy of the diagnosis [9, 10] and is associated with a decrease in the recurrence rate of anal fistulas. However, the results of this study showed that the diagnosis on anal fistula prior to surgery relied on personal experience and physical examination. Less than 10% used IDUS and/or MRI 随访在中文文献中, 术后随访时间持续 2 周至 10 年不等, 其中 499 篇 (99.8%) 未描述 随访方法, 仅 1 篇文献描述随访中采用 MRI 进行术后评估 在英文文献中, 术后随访时间 持续 3 个月至 7 年不等, 其中 11 篇 (20.8%) 描述使用腔内超声或 MRI 进行随访, 其余未 描述随访方法 ( 见表 1) 3. 讨论肛瘘是一种常见疾病, 大多数肛瘘表 现明显, 然而通过病史和简单的物理检查仅 48% 的肛瘘能够得到准确诊断 [3] 约 5% 的肛 瘘含有多个瘘管或瘘管位于肛直环上方, 术前 评估不充分导致手术中瘘管或隐匿感染灶的残 留是术后肛瘘复发的主要原因 [4,5] 近年来随 着腔内超声 MRI 的使用, 对于肛瘘的诊断已 由传统的经验诊断逐步向客观影像学诊断过 渡, 到目前 MRI 已经成为术前诊断肛瘘的金 标准 [6] 术前腔内超声或 MRI 的检查能够有 助于隐匿瘘管的发现 [7,8], 尤其是三维超声或 MRI 瘘管成像能够进一步提高肛瘘诊断的准确 性 [9,10], 减少肛瘘术后的复发率 然而本研 究显示目前国内外在术前对肛瘘的诊断仍主要 依靠个人的经验及体格检查, 采用腔内超声或 MRI 比例不超过 10% Page 36

6 In terms of the classification, Parks [11] relied on the relationship between the fistula and anal sphincter to develop a classification that has been widely used since The results of our study showed that the traditional method is currently used in a much simpler form. There was no additional information of the relationship between the fistula and anal sphincter. In addition, the classification methods differed. The comparability among the documents was poor. In non-chinese documents, the number of cases using Parks classification was higher than in Chinese documents. However, the detailed classification using Parks accounted for 47.2% of the total. An ambiguous diagnosis not only affects the cure rate, it also makes it difficult to assess the effectiveness of different methods for diagnosis and treatment. There was no unified standard for the treatment of anal fistulas. However, total sphincter preservation procedure seems to be preferred [12]. In recent years, sphincter-saving surgery such as advanced flap surgery, biological fibrin glue, anal fistula embolization, and LIFT have been preferred for treating complex anal fistulas [13]. The success rate of these treatment methods differs in different countries. However, compared with the traditional anal fistula surgery, the sphincter-saving surgery is preferred because it protects the anal functions [14]. Currently, in western countries, the rate of maintaining the anal sphincter during surgery continues to grow [15]. In this study, the out of China papers showed that the rate of sphincter-saving surgery, during the recent 5 years accounted for 69.3% of cases, while the rate was only 7.2% in China. Most clinicians prefer fistulotomy or cutting seton. Although these methods play an important role in the treatment of anal fistulas, these operations may lead to irreversible harm to anal functions. Thus, keeping the whole sphincter intact is preferred and reduces the rate of incontinence [16]. On the hand, the traditional fistulotomy or cutting seton may lead to irreversible structural damages to the sphincter and consequently results in a significantly higher incontinence rate [17,18]. Therefore these traditional approaches should be avoided to be the first choice of the treatment. The follow-up period was similar in China and out of China. For a simple anal fistula, the rate of cure by fistula incision or removal can reach 95% [19]. However, the recurrence rate of complex anal fistulas was still high. Thus, in terms of the assessment of rates of cure, attention to the recurrence rate, as well as anal function is important; especially 10 years after surgery. In addition, the judgment of anal fistula relapse relied on the typical clinical symptoms. During the follow-up period, when some 在肛瘘的分类上,Parks [11] 于 1976 年 根据瘘管与肛门括约肌之间的关系对肛瘘进行 了详细的分类并得到广泛应用 本研究显示, 目前国内主要还是根据传统的方法进行简单分 类, 未充分了解瘘管与肛门括约肌的关系, 而 且分类方法不统一, 文献之间可比性差 在英 文文献中, 采用 Parks 分类的比例明显高于中 文文献, 但是有详细 Parks 分类的病例仅占总 数的 47.2% 不明确的诊断不仅影响到治疗效 果, 同时对各种治疗方法的有效性的评估带来 困难 对于肛瘘的治疗, 国内外仍没有形成形成统一的标准 但肛瘘外科治疗重点应注重肛门功能的保护 尽可能施行微创治疗已经达成共识 [12]. 近年来, 保留括约肌手术, 如推移黏膜瓣或皮瓣术 生物蛋白胶封闭术和肛瘘栓塞术 LIFT 术等正逐步成为复杂性肛瘘的治疗选择 [13 对于这些方法的治愈率, 各个研究报道不一, 但与传统的肛瘘手术方法相比, 保留括约肌手术能更好地保护肛门功能 [14] 目前西方国家在肛瘘的治疗过程中选择使用保留肛门括约肌的手术方法的比重逐年增多 [15] 本研究中显示, 近 5 年的英文文献中, 采用保留括约肌手术的比例占到 69.3%, 而国内该比例仅占 7.2%, 绝大多数作者仍是采用传统的瘘管切开切除或切割挂线方法, 虽然这些方法在肛瘘的治疗中占有重要作用, 但是这些手术可能对病人造成不可逆的肛门功能损害 因此, 全括约肌保留手术作为肛瘘治疗新的方向, 能降低术后肛门失禁的几率 [16], 应作为肛瘘治疗的首选技术, 而传统的切割挂线法瘢痕组织多, 易损伤括约肌, 造成肛门功能障碍 [17,18], 作为肛瘘治疗的最后一步, 应尽量避免使用 国内外在随访时间上类似 国内外的文献均没有关注肛瘘术后数十年以后的肛门功能 肛瘘治疗的目的是瘘管的治愈, 对于简单的肛瘘, 瘘管切开或切除后治愈率可达 95%[19], 而复杂性肛瘘术后复发率仍较高 因此, 在治疗结果评估方面, 除了重视对肛瘘复发率的评估以外, 肛瘘术后肛门功能, 特别是肛瘘术后数十年以后的肛门失禁风险应作为 Page 37

7 symptoms were present in patients, a complete examination did not necessarily follow in a vast majority of the cases. The results of our current study showed that in only 1 paper among all the Chinese documents was MRI used for patient evaluation. Similarly, in the English documents, the rate of use of the IDUS or MRI accounted for only 20.8% of the cases. It remains to be determined whether it is beneficial to use IDUS or MRI to evaluate patients without symptoms during the follow-up. However, it is apparent that, for patients with recurrent lesions, the use of IDUS and MRI can not only help with diagnosis and treatment, but also assist the evaluation of the anal functions[20]. In conclusion, our study showed that the diagnosis and treatment of anal fistulas in China and out of China was mainly based on doctors' experience with little attention to objective diagnosis. More research is needed to determine if this affects treatment results. Foreign documents classified anal fistula based mainly on Parks method, but classification methods differed in China, which made comparisons difficult. With regard to treatment methods, foreign treatment was based on sphincter-saving surgery, whilst domestic treatment was based on traditional fistulotomy or cutting seton, which damages the anal sphincter. Postoperative follow-up in China and out of China paid more attention to recurrence rate, but less attention to the incontinence rate, especially to the long-term rate of postoperative incontinence. 一个重要评估指标 此外, 对于术后肛瘘复发的判断主要依靠典型的临床症状, 在随访过程中或病人出现症状之前, 较少采用辅助检查进行确认 本研究调查显示在随访过程中, 在国内文献中仅 1 篇描述了采用 MRI 检查, 而外文文献中采用 MRI 或腔内超声的比例也仅为 20.8% 对于无症状患者在随访过程中是否需要行腔内超声或 MRI 检查仍待讨论 但对于复发肛瘘行腔内超声或 MRI 检查不仅能够了解瘘管的情况, 更能够评估肛门括约肌缺损情况, 对肛门功能进行评估 [20] 总之, 从文献调查的结果来看, 国内 外对于肛瘘的诊断多以医生经验诊断为主, 对 于肛瘘的客观诊断均重视不够 这一共同倾向 是否影响肛瘘的治疗结果尚需进一步研究 国 外文献肛瘘以 parks 分类方法为主, 但是国内 文献分类方法不统一, 可比性差 ; 关于治疗方 法, 国外以括约肌保留手术为主而国内仍以对 括约肌损伤较大的切割挂线手术为主 ; 国内外 对治疗结果随访更关注复发率, 对于失禁率 特别是对于手术后远期失禁率关注不够 References ( 参考文献 ) 1. Jin HY, Zhang B. The new points of view on treating anal fistula. Shanghai, China: Second Military Medical University Press; Malik AI, Nelson RL. Surgical management of anal fistulae: a systematic review. Colorectal Dis. 2008; 10: of deep postanal space abscess in the treatment of posterior horseshoe fistula 3. Inceoglu R, Gencosmanoglu R. Fistulotomy and drainage. BMC Surg. 2003; 3: Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, Khubchandani IT. Is simple fistula in ano simple? Dis Colon Rectum. 1994; 37: Zimmerman DD, Delemarre JB, Gosselink MP, Hop WC, Briel JW, Schouten WR. Smoking affects the outcome of transanal mucosal advancement flap repair of transsphincteric fistulas. Br J Surg. 2003; 90(3): Shi LJ. The progress of radiology and pathology in anal fistula [J]. Medical Theory and Practice. 2013; 26(4): Lindsey I, Humphreys MM, George BD, Mortensen NJ. The role of anal ultrasound in the management of anal fistulas. Colorectal Dis. 2002; 4: Beets-Tan RG, Beets GL, van der Hoop AG, et al. Preoperative MRI of anal fistulas: Does it really help the surgeon? Radiology. 2001; 218: Page 38

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