| Backround Anorectal fistula was the kind of chronic inflammatory abnormal communications between anorectum and around the skin. Dominant clinical manifestations of long time unhealed anorectal fistula include reccurent anorectal infection, liquid secretion, suppuration or anorectal malignancy in the late stage. Irregular diet or low resistance state were the common reasons in anorectal fistula. The disease can only be managed by surgery. Or else, it likely results in abscess formation or further complications. Up to now, there was no gold standard treatment and standard management efficacy evaluation system to surgical method in the world. Nowadays comlex fistula is the hot research topic in the world. Because the same disease can be manifestated in different ages, especially in infants and adults, it is necessary to further explore the onset, related etiology and exact diagnostic difference between infant's and adult's anorectal fistula. These differences may take important role in clinical management, and can provide theoretical basis to further clinical research.Nowadays there were numbers of surgical methods used to anorectal fistula. However, recurrence and fecal incontinence are two important unsolved problems after surgery. Difficulty of detection to main fistula tract and its branchs, improper treatment and insufficiency on fistula tract resection were most important reasons of recurrence. To the contrary, total resection of sphincter around the anus and rectum can result in fecal incontinence after surgery. Although Open incision or endorectal advancement flap have good efficiency to anorectal fistula, however, the diversity in different country could not take this method for granted. Seton surgery can preserve the anorectal sphincter function. However, repeated stringing can cause severe pain to patients after surgery. Therefore, sphincter-preseving techniques such as minimized fistula plug may improve patients life quality. However, up to now, there were no standard management efficacy evaluation system before and after surgery. Ultrasound and Magnetic Resonance Imaging can not provide dynamic states of anorectal sphincter although it has morphological basis. Williams Score System and fecal Incontinence Severity Index have subjectivity. They can be influenced by occupation, social degree, environmental conditions and psychological states of patients. The anorectal manometric study can evaluate the efficieny in different management methods of anorectal fistula.Traditional surgery is the efficient way in the closure of fistula internal openings. But, postoperatitve incontinence was the disadvantage of it. Fibrin glue was the painless and simple sphincter preserving procedure. But, its report has regional disparity. Insufficiency of endepidermis and granulation tissue resection are the important reasons of postoperative complication. Therefore, it is essential to explore the better management method in order to improve anorectal fistula patient's life quality, and to protect normal sphincteric function of anorectal fistula patients which are the two main goals in this study.Objective Management of anorectal fistula was the difficult point in anorectal surgery. Simple fistulectomy can result in postoperative recurrence. Sphincter resction can cause fecal incontinence. Uo to now, there were no standard management efficacy evaluation systems in the world before and after anorectal surgery. The efficacy of anorectal fistula management is closely associated with characteristics of different age and different surgical method. Anorectal fistula in infants have more difference in these characteristics and management efficacy compared with adults fistula. First part of this series study, we dominantly compare features and surgical management of anorectal fistula in infants and adults in order to find the better method of management using retrospective comparative way. The purpose of the second part of this study was to find the better diagnostic instruments which can reflect the recovery on anorectal sphincter function by using the anorectal manometric pressure changes before and after anal fistula surgery and to find the relation between anorectal manometric changes and Williams score system. The aim of the third part was to compare the efficacy and safety of Acellular Dermal Matrix bioprosthetic material and conventional fistulectomy combined with endorectal advancement flap in the treatment of anorectal fistula. This randomized controlled trial can also observate occurrence rate and patients life quality of minimized material patients.Methods In the first part,102 pediatric anorectal fistula patients less than 2 years of age from January 2000 to September 2009 and 84 adults anorectal fistula from January 2007 to September 2008 in First Teaching Hospital of Xinjiang Medical University were reviewed retrospectively according to age, gender, physical finding, classification of fistula, postoperative occurrence and fecal incontinence, management method. In the second part,138 anorectal fistula patients and 100 healthy volunteers received anorectal manometry. Technological indexes of anal fistula patients before and after surgery were comparatively analyzed compared with that of healthy subjects. We also recorded all patients Williams anorectal incontinence severity score before and after surgery in order to compare subjective and objective parameter of these indexes. In the third part,90 consecutive in-hospital patients with complex anorectal fistulas from September 2008 through December 2009 were prospectively enrolled in randomized into two groups. Subjects were blinded about the treatment. We compared our outcomes for minimized Accellular Dermal Matrix anal fistula material and fistulectomy combined with advancement flap closure in the aspect of success rate, fecal incontinence rate, anorectal deformity rate, pain score, closure time and life quality score. Success was difined as closure of all external openings, abseence of drainage without further intervention, and absence of abscess formation. Follow-up examinations were performed at 2 days,2,4,6, and 12 weeks, and 5months after surgery.Results hi retrospective study,98 patients in infant group were male when other 4 cases were female with mean age of 9.5 months.97 cases have the history of previous anorectal abscesses.100 infants fistulas were single which two of them were complex. Their origins in the crypts were clearly identified in 91 cases (89.22%). All patients received surgical management. No recurrences were observed after surgical treatment in infants group. In adults group,9 patients (10.71%) have fecal incontinence and rectoanal disorders in different stages after surgery, and 5 cases (5.95%) recured of anorectal fistula. In the second part of the study, anorectal reflexes of postoperative anal fistula patients weaken vary in grade. The weaking extent in hilar fistula group was obvious compared with that of lower fistula group and normal healthy subjects. Rectal resting pressure, anal resting pressure and anal squeeze pressure in hilar fistula patients were obviously lower than that of lower fistula group and normal healthy subjects. All of these indexes in lower fistula patients were obviously lower than normal healthy subjects. There were 14 cases which occurred fecal incontinence after surgery inner 138 fistula patients.9 cases inner the 14 fecal incontinence were hilar fistula (5 cases were in grade B on anal function, 2 cases were in grade C, other 2 were in grade D),and 5 of them were lower fistula (in grade B). Anorectal manometric findings fit with their corresponding Williams index scores. All manomertic abnormal patients have lower Williams index score. In the third randomized controlled trial part, the overall success rate of minimized Accellular Dermal Matrix material after 5.7 months was 37 of 45 (82.22%). Four patients (8.89%) had a plug dislodgement, and other treatments were performed. One patients had abscess formation, two fistulas recurred. Four experiment patients lost to follow up. Thirteen of 45 in controls recurred.5 patients (11.11%) received surgical drainage because of abscess formation in controls. There was significant difference in Acellular Dermal Matrix than in advancement flap closure in the aspects of success rate, pain score and closure time (?<0.05), especially in high transsphincteric fistula. However, there were no statistical differences between them in the aspect of fecal incontinence rate and anorectal deformity rate.Conclusion There were distinct differences between different ages, especially in infants and adults in anorectal fistula. These differences were manifestated of anatomical, clinical, and classificational aspects. Simple type was dominant in infant's anal fistula, and fistulotomy was the effective method to them. However, for adults, simple resection can result in high occurence rate. Sphincter splitting fistulotomy in adults can result in fecal incontinence. Therefore, surgeons should guarantee normal anorectal sphincter function to use minimized surgical options in operation. Understanding of these differences between infants and adults can provide a direction to anorectal fistula management.In the second part, we can aome to the conclusion that anorectal manometry could provide a useful objective tool for evaluating anal sphincter function before and after anal fistula surgery, it has important diagnostic significance to the clinical management of anorectal fistula surgery. In the final part, closure of the primary opening of a fistula tract using Acellular Dermal Matrix plug is an effective method of treating anorectal fistulas. The success rate for Acellular Dermal Matrix for the treatment of complex anal fistula was 82.22 percent, which is much higher than conventional fistulectomy combined with endorectal advancement flap procedure. Given the plug dislodgement was associated with the procedure. Acellular Dermal Matrix should be considered as a first line treatment for patients with complex anorectal fistula. Further randomized controlled multicenter clinical trials are needed to elucidate the efficacy to high transsphincteric anorectal fistula. |
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