| Objective1 To explore the clinical efficacy of different transanal surgery in the treatment of benign anorectal stenosis and to provide reference for reasonable selection and clinical application.2 To analyze the effectiveness and safety of different types of advancement flap anoplasty in the treatment of benign anal stenosis and clear the surgical indication,operative points and perioperative management strategies to provide theoretical guidance for further clinical application.3 To explore the advantages of TCM thread-drawing method in the treatment of benign anorectal stenosis,and to regulate and optimize the operative points.Through introducting the medicated thread of "clearing away dampness and toxic materials,invigorating the blood circulation and preventing the fibrosis”for surgical treatment,we will analyze the different hanging materials and off-line time on the release degree of stenosis,in order to reduce the incidence of perioperative complications,improve clinical efficacy and reduce the recurrence rate furtherly.Methods1 The first part is the literature research.Collecting and organizing the clinical literatures related with advancement flap anoplasty in the treatement of benign anal stenosis by searching China National Knowledge Infrastructure(CNKI),Wanfang Data Knowledge Service Platform,Weipu Chinese Journal Service Platform,Pubmed,Embase databases respectively from January 1985 to December 2016.According to the included and excluded criterias,useful information is exreacted including the literature title,author's name,magazine's name,year of publication,flap type,the number of surgery,postoperative complications,the period of follow-up and clinical efficacy.2 The second part is the prospective randomized controlled clinical study.Sixty patients with benign anorectal stenosis,who visited the departmentof proctology in Guang' anmen hospital,China Academy of Chinese Medical Sciences and department of general surgery in TCM hospital of Beijing huairou from October 2014 to September 2016,are divided into three groups randomly.20 cases underwent the operation of stricture being incised directly,20 cases got the thread-drawing procedure with ordinary rubber band and the other 20 cases got the thread-drawing procedure with medicated thread.Following information is evaluated including clinical efficacy,the changes of stenosis caliber,the degree of perioperative defecation,postoperative adverse reactions such as pain,bleeding,infection,and the anorectal function damage,the time of operation,the amount of intraoperative blood loss,correlation between off-line time and the release degree of stenosis,stenosis recurrence rate and the improvement of bowel obstruction symptoms score and the gastrointestinal quality of life gastrointestinal index at the postoperative two months and six months.All data is statistically analyzed by SPSS 18.0,bilateral test.Results1 Literature research1.1 Twenty-six articles,fourteen Chinese and twelve English ones,are brought into our final analysis.The total number of surgical cases is 639 and the main flap types include:Y-V advancement flap,V-Y advancement flap,rhomboid advancement flap,house advancement flap and lateral mucosal advancement flap.1.2 Ten articles,five English and five Chinese ones,recording Y-V advancement flap anoplasty in the treatment of benign anal stenosis are selected.The number of surgical cases is 178 and 160 cases are cured,effective in 18 cases and invalid in 0 case.The total cure rate is 89.89%.Perioperative complications include flap ischemia in 7 cases,suture dissection in 5 cases,incomplete anal incontinence in 4 cases,urinary infection in 3 cases,urinary retention in 3 cases,and perianal itching in 1 case.1.3 Four Chinese articles recording V-Y advancement flap anoplasty in the treatment of benign anal stenosis are selected.The number of surgical cases is 57 and 44 cases are cured,effective in 12 cases and invalid in I case.The total cure rate is 77.19%.Perioperative complication only is found in one case of postoperative mild anal incontinence with perianal itching.1.4 Eleven articles,six English and five Chinese ones,recording diamond advancement flap anoplasty in the treatment of benign anal stenosis are selected.The number of surgical cases is 129 and 115 cases are cured,effective in 10 cases and invalid in 4 cases.The total cure rate is 89.15%.Perioperative complications include flap ischemia in 4 cases,suture dissection in 4 cases and urinary infection in 1 case.1.5 Seven articles,three English and four Chinese ones,recording house advancement flap anoplasty in the treatment of benign anal stenosis are selected.The number of surgical cases is 117 and 107 cases are cured,effective in 10 cases and invalid in 0 case.The total cure rate is 91.450%.Perioperative complications reported in the literature are not clear,so cannot be accurately estimated.1.6 Three English articles recording lateral mucosal advancement flap anoplasty in the treatment of benign anal stenosis are selected.The number of surgical cases is 158 and 135 cases are cured,effective in 10 cases and invalid in 13 cases.The total cure rate is 85.44%.Perioperative complications include incomplete anal incontinence in 3 cases,perianal itching in 2 cases and wound infection in 1 case.2 Clinical research2.1 Comparison of clinical efficacy.15 cases(75%)are cured in the group of stricture being incised directly,17 cases(85%)are cured in the group of getting thread-drawing procedure with ordinary rubber band,and 18 cases(90%)are cured in the group of getting thread-drawing procedure with medicated thread.There is no significant difference among this three groups being compared with the Fisher's exact test(P>0.05).2.2 Comparison of postoperative digital rectal examination.The whole index finger can pass through in 15 cases in the group of stricture being incised directly at postoperative 2 months,while 18 cases in the group of getting thread-drawing procedure with ordinary rubber band and 20 cases in the group of getting thread-drawing procedure with medicated thread.There is no significant difference among the three groups being compared with the Fisher's exact test(P>0.05).The whole index finger can pass through in 12 cases in the group of stricture being incised directly at postoperative 6 months,while 14 cases in the group of getting thread-drawing procedure with ordinary rubber band and 17 cases in the group of getting thread-drawing procedure with medicated thread.There is no significant difference among the three groups being compared with the Fisher's exact test(P>0.05).2.3 Comparison of modified ODS scores.According to the bivariate repeated measurement data on the overall analysis,there is statistical significant difference(P<0.05)in the comparison of goups,time and the group interaction with time among the three groups.It is suggested that the great changes of modified ODS scores with the trend of time is affected by group.Independent-samples T test is used to compare the modified ODS at different time points among three groups.There is statistical significant difference(P<0.05)among the three different groups at postoperative 2 months.But there is no significant difference(P>0.05)between the group of stricture being incised directly and the group of getting thread-drawing procedure with ordinary rubber band at postoperative 6 months,while there is statistical significant difference(P<0.05)between the group of stricture being incised directly and the group of getting thread-drawing procedure with medicated thread,the group of getting thread-drawing procedure with ordinary rubber band and with medicated thread.The data shows that the improvement of modified ODS scores are significantly better in the group of getting thread-drawing procedure with medicated thread than the other two groups at postoperative 2 and 6 months.Paired samples T test is used to compare the modified ODS at different time points in three groups.There is statistical significant difference(P<0.05)before and after surgical treatment in three groups.There is no significant difference(P>0.05)in the group of stricture being incised directly and in the group of getting thread-drawing procedure with medicated thread between postoperative 2 months and 6 months.But there is statistical significant difference(P<0.05)in the group of getting thread-drawing procedure with ordinary-rubber band between postoperative 2 months and 6 months.The data shows that the modified ODS scores at postoperative 6 months in the group of getting thread-drawing procedure with ordinary rubber band are higher than at postoperative 2 months.2.4 Comparison of the degree of postoperative defecation.According to non-parametric Kruskal-Wallis test,there is statistical significant difference(P<0.05)among three groups when the first to the third bowel movement after surgery.The data shows that the group of stricture being incised directly is better than the other two groups.But there is no significant difference(P>0.05)among three groups on the 10th day after surgery.2.5 Comparison of operative time and intraoperative blood loss.According to non-parametric Kruskal-Wallis test,there is statistical significant difference(P<0.05)among three groups in terms of operative time.The data shows that the group of getting thread-drawing procedure with ordinary rubber band and the group with medicated thread are shorter than the group of stricture being incised directly while there is no significant difference between two groups of getting thread-drawing procedure(P>0.05).According to non-parametric Kruskal-Wallis test,there is statistical significant difference(P<0.05)among three groups in terms of intraoperative blood loss.The data shows that the group of getting thread-drawing procedure with ordinary rubber band and the group with medicated thread are less than the group of stricture being incised directly while there is no significant difference between two groups of getting thread-drawing procedure(P>0.05).2.6 Comparison of postoperative anal pain.According to non-parametric Kruskal-Wallis test,there is no significant difference(P>0.05)among three groups on the first day after surgery,while there is statistical significant difference(P<0.05)among three groups on the third,fifth and seventh day after surgery.The data shows that the group of getting thread-drawing procedure with medicated thread is slighter than the other two groups on the third,fifth and seventh postoperative day.2.7 Comparison of perioperative complications.According to the Fisher's exact test,there is statistical significant difference(P<0.05)among three groups.The data shows that the number of patients in the group of getting thread-drawing procedure with medicated thread is less than the other two groups.2.8 The correlation analysis between the off-line time and the release degree of stenosis at the postoperative 2 months.According to bivariate correlation analysis,there is a significant correlation(P<0.05)during two groups of getting thread-drawing procedure.The data shows that the longer time the rubber band falls off,the more fully the stenosis releases.2.9 Comparison of postoperative recurrence.The cases of recurrence are 5 in the group of stricture being incised directly at postoperative 2 months,while 2 cases in the group of getting thread-drawing procedure with ordinary rubber band and 0 case in the group of getting thread-drawing procedure with medicated thread.According to the Fisher's exact test,there is no significant difference(P>0.05)among three groups.The cases of recurrence are 8 in the group of stricture being incised directly at postoperative 6 months,while 6 cases in the group of getting thread-drawing procedure with ordinary rubber band and 3 cases in the group of getting thread-drawing procedure with medicated thread.According to the Fisher's exact test,there is no significant difference(P>0.05)among three groups.While the data shows that the number of stenosis recurrence is less in the group of getting thread-drawing procedure with medicated thread than the other two groups at postoperative 2 months and 6 months.2.10 Comparison of GIQLI scores.According to the bivariate repeated measurement data on the overall analysis,there is statistical significant difference(P<0.05)in the comparison of goups,time and the group interaction with time among the three groups.It is suggested that the great changes of GIQLI scores with the trend of time is affected by group.Independent-samples T test is used to compare the GIQLI scores at different time points among three groups.There is statistical significant difference(P<0.05)between the group of stricture being incised directly and the group of getting thread-drawing procedure with ordinary rubber band or and the group with medicated thread at postoperative 2 months and 6 months.While there is no significant difference(P>0.05)between two groups of getting thread-drawing procedure.The data shows that the improvement of GIQLI scores are significantly better in two groups of getting thread-drawing procedure than the group of stricture being incised directly at postoperative 2 and 6 months.Paired samples T test is used to compare the GIQLI scores at different time points in three groups.There is statistical significant difference(P<0.05)in the three groups respectively.The data shows that the GIQLI scores of the three groups after surgery raise at various degree,while they are lower at postoperative 6 months than at postoperative 2 months.ConclusionBased on two aspects of literature and clinical research,clinical and surgical guidance is provided for the transanl treatment of benign anorectal stenosis.Combined with the results of research,the following conclusions are drawn.1 Advancement flap anoplasty is one of the effective methods for the treatment of benign anal stenosis.The average cure rate is above 80%.We can select Y-V advancement flap,V-Y advancement flap,rhomboid advancement flap,house advancement flap or lateral mucosal advancement flap properly according to the location,degree and range of stenosis.The key to the success of the operation lies in choosing the type of flap reasonably,ensuring the adequate blood supply,sufficient flap freedom,controlling infection strictly,protecting the anal function,in order to improve the clinical curative effect to the greatest extent.2 Three kinds of operative methods including stricture being incised directly,getting thread-drawing procedure with ordinary rubber band,or getting thread-drawing procedure with medicated thread are the effective methods for treating the benign anorectal stenosis.There is no significant difference in the comparison of clinical efficacy,digital rectal examination and recurrence at postoperative 2 months and 6 months.While the group of getting thread-drawing procedure with medicated thread is more than the other two groups in term of the number of cured cases and less in term of the number of recurrence cases.3 Stricture being incised directly can relieve obstruction symptoms,expand stricture caliber and it has advantages of relieving the degree of defecation within 1 week after surgery.However it also has some disadvantages of postoperative bleeding,wound infection and anal function injury.4 Thread-drawing procedure has some advantages of operating easily,shortening operation time,reducing intraoperative bleeding and protecting the anus function.Getting thread-drawing procedure with medicated thread can significantly decreased the incidence of perioperative complications such as anal pain,postoperative bleeding and anal bulge and it also has certain advantages in improving the modified ODS score and GIQLI score.5 There is a certain correlation between the off-line time and the release degree of stenosis.The longer time the rubber band falls off,the more fully the stenosis releases.So the clinical efficacy can be guaranteed furtherly to extend the postoperative off-line time as far as possible and combined with the treatment concept of“deep hanging,slow and multipoint cutting,applying medicated thread". |
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