2021年1月29日星期五

hemorrhoids and anal fissures,How much do you know about anal fistula?

    Anal fistula is also called "anorectal fistula". Most anal fistulas are formed by rupture of anorectal abscess or incision and drainage. The abscess gradually shrinks, but the contents of the intestine (including bacteria and feces) continue to enter the abscess cavity. In the process of healing and shrinking, a tortuous cavity is often formed, and the drainage is not easy to heal. There will be many scar tissues around the cavity after a long time. , The formation of chronic infectious channels. The granulomatous ducts around the anus formed by the rupture of the abscess around the rectum and the long-term unhealed. It occurs mostly in men and a small number of women aged 20-40. Anal fistula generally consists of a primary internal opening, a fistula, and a secondary external opening. The inner mouth is mostly located near the tooth line, mostly one, and the outer mouth is located on the skin around the anus, which can be one or more.

    Basic overview

    Anorectal fistula mainly invades the anal canal and rarely involves the rectum, so it is often called anal fistula, which is a granulomatous tube communicating with the skin of the perineum. The inner mouth is mostly located near the tooth line, and the outer mouth is located at the perianal and skin. The entire wall of the fistula is composed of thickened fibrous tissue with a layer of granulation tissue inside, which does not heal for a long time. The incidence is second only to hemorrhoids, and is more common in young men. It may be related to the strong secretion of sebaceous glands, one of the target organs of sex hormones in men.

    Once an anal fistula is formed, it cannot heal naturally and must be cured by surgical treatment. There are many treatment methods for anal fistula. The traditional surgery, laser, freezing, thread hanging, etc. are not ideal. Some are painful and have a long course, some are not completely easy to relapse, and some indications are difficult to grasp or have more complications. Adopting An's therapy to treat high-level complex anal fistulas using main focus incision and drainage to simplify the complex, and low-level treatment of high-level anal fistulas has become a new principle of safe treatment of anal fistulas.

    Clinical symptoms

    1. Pus discharge is the main symptom. The amount of pus is related to the length and length of the fistula. The new fistula discharges more pus, and the secretion irritates the skin and causes itching and discomfort. When the external mouth is blocked or pseudo-healed, pus accumulates in the fistula and local swelling Pain, even fever, the closed fistula ruptured later, and the symptoms disappeared. Due to poor drainage, the abscess recurs, and multiple external openings can also be ruptured. Larger and higher anal fistulas often have feces or gas discharged from the external mouth. During examination, the external opening is usually a papillary protrusion or a bulge of granulation tissue, and a small amount of pus is discharged from the extrusion, mostly a single external opening, near the anus. There are also multiple external openings, and the subcutaneous fistulas between the external openings are connected, and the skin becomes hard and shrinks. There are also multiple external openings on both sides. The fistulas are "horseshoe-shaped". In the digital rectal examination, induration or cords can be palpable in the lesion area, and there is tenderness. Explore upward with the cords, sometimes palpating the internal opening. If the outer mouth is irregular, not bulging, has a sneaking edge, granulation is gray-white or has thin cheese-like secretions, it should be suspected of tuberculous anal fistula.

    A small amount of purulent, bloody, and mucous discharge out of the fistula is the main symptom. Larger high anal fistulas, because the fistula is located outside the sphincter muscle and is not controlled by the sphincter muscle, feces and gas are often discharged. Due to the irritation of the secretions, the anus is moist and itchy, sometimes forming eczema. When the external mouth heals and an abscess is formed in the fistula, you may feel obvious pain, and may be accompanied by systemic infection symptoms such as fever, chills, and fatigue. After the abscess is punctured or incised and drained. The symptoms are relieved. The recurrence of the above symptoms is a clinical feature of fistula.

    2. Pain When the fistula is unobstructed without inflammation, there is often no pain, only local swelling and discomfort, which aggravate when walking. When the fistula is infected or the pus is not discharged smoothly and swells and becomes inflamed, it can cause pain. Internal fistula often feels burning and discomfort in the lower rectum and anus, and pain during defecation.

    3. Itching Because pus continuously stimulates the perianal skin, it often feels itching, moist and uncomfortable perianal, skin discoloration, epidermal shedding, fibrous tissue proliferation and thickening, and sometimes eczema.

    4. Poor defecation. Complex anal fistulas that do not heal for a long time can cause large fibrotic scars or ring-shaped cords to form around the anus and rectum, which affects the dilation and closure of the anus, and it is difficult to defecate, and there is a feeling of inexhaustible defecation.

    5. Systemic symptoms In the acute inflammation period and repeated attacks of complex anal fistulas, different degrees of fever may appear, or accompanied by long-term chronic wasting symptoms such as weight loss, anemia, and physical weakness.

    Most anal fistulas are caused by abscesses around the rectum and anal canal. Therefore, the internal opening is mostly at the anal sinus on the dentate line. The abscess ruptures on its own or forms an external opening on the perianal skin. Because the outer mouth grows faster. Abscesses often falsely heal, leading to repeated episodes of ulceration or incision, forming multiple fistulas and external openings. Make simple anal fistula become complex anal fistula. The fistula is surrounded by dense fibrous tissue, and the inflammatory granulation tissue near the lumen can be epithelialized in the later period. Tuberculosis, ulcerative colitis, Crohn's disease and other specific inflammations, malignant tumors, and anal canal trauma infections can also cause anal fistulas, but they are relatively rare.

    development process

    The formation of anal fistula is inseparable from the development of perianal abscess. The formation of anal fistula roughly goes through four stages:

    The first stage: infection and inflammation of anal crypts and anal flaps. At first, it is limited to local inflammation. If it is not treated in time, the inflammation can spread around the anus.

    The second stage: Inflammation starts from the local anal recesses and anal flaps, and gradually spreads to form perirectal inflammation. If the inflammation cannot be controlled, it may invade the tissue gaps with low disease resistance.

    The third stage: due to the decreased disease resistance of the tissues around the anorectal space, it becomes a place for germs to invade, spread, accumulate and multiply, causing the tissues here to be prone to infection and inflammation, which is invincible, and the formation of anorectal abscesses. If the anorectal abscess can be treated properly in the early stage, the abscess can often dissipate and heal without leaving any sequelae; if the early treatment is delayed or improperly handled, the tissue necrotic pus can spread along the local gap, making the condition aggravated and complicated. Surgical incision and drainage as soon as possible to excrete pus and control the development of inflammation.

    The fourth stage: The perianal abscess ruptures spontaneously or after treatment with incision, drainage and dressing, although the abscess cavity gradually shrinks, but the ulcer does not close for a long time. At this time, the cavity wall has formed a hard duct wall with connective tissue hyperplasia. The remaining space is the fistula. The pus often flows out of the fistula, with repeated infections and recurring attacks. It cannot heal itself for a long time and becomes a fistula.

    classification

    Classification of anal fistula

    1. According to the source of the disease

    Suppurative anal fistula and tuberculous anal fistula.

    2. According to the degree of disease

    ①Simple anal fistula

    a. Low-position simple anal fistula: a complete fistula with only one fistula, one internal opening and one external opening. The internal mouth is at the tooth line, and the pipe passes through the superficial part or below the superficial part of the external sphincter.

    b. High simple anal fistula: There is only one fistula, the internal mouth is above the tooth line or the tooth line, the pipeline runs above the deep layer of the external sphincter, or passes through the rectal mucosa without passing through the muscle (including internal blind fistula and total internal Fistula).

    ②Complex anal fistula

    a. Low complex anal fistula: the internal opening is at the tooth line, the duct is below the deep layer of the external sphincter, and there are branches and cavities, and two or more external openings and ducts.

    b. Highly complex anal fistula: There are more than two ducts or branches and cavities, the main duct passes through the deep layer of the external sphincter or through the rectal ring, and has one or more internal openings, and the internal opening is above the rectal ring. According to the extent of the lesion invading the anorectum, it can be further divided into three degrees, just like the low complex anal fistula.

    ③ Horseshoe anal fistula

    The fistula circulates, the outer mouth is on both sides of the anus, and the inner mouth is mostly at 6 or 12 o'clock in the lithotomy site. There are anterior, posterior, and anterior horseshoe-shaped anal fistulas.

    a. Anterior horseshoe-shaped anal fistula: the fistula circulates, and the outer mouth spreads to the perineum and vaginal fistula on both sides of the front of the anus. If the outer mouth is within 2.5cm of the anal edge, the inner mouth is on the opposite side. If it is more than 2.5cm, the inner mouth may be on the back side.

    b. Posterior horseshoe-shaped anal fistula: The fistula circulates and spreads to both sides of the back of the anus. It is far and deeper from the anal margin. There are many external openings and most of the fistula lumens are intertwined. The internal openings are mostly on the back of the anus.

    c. Anterior and posterior horseshoe-shaped anal fistula: The fistula circulates around the anal canal, and there are a few in the outer anal area, ranging from a few to dozens. Large areas are violated and the pipeline is complicated.

    Determine the inspection method of the internal opening of anal fistula:

    The internal opening of the anal fistula is the primary site of the lesion. Unclear positioning will inevitably lead to failure in treatment, because resection or incision of the internal opening is the key to curing anal fistula. The methods to find and determine the internal opening of anal fistula are:

    (1) Anoscopy   under direct vision, all the dentition lines can be seen. The internal mouth is often inflamed and inflamed with anal fistula with secretions. For suspicious anal crypts, silver round-tip probes can be used to penetrate them.

    (2) The probe is inserted into the anus first, and the silver round-tip probe is used to gently probe in the direction of the intestinal cavity from the outer mouth along the pipe. Complete anal fistula, the fingers in the intestinal cavity can be felt near the tooth line Use the probe to determine the inner mouth, and avoid blindly exerting force when exploring to avoid false pathways and spread the infection.

    (3) Dyeing inspection   Put dry gauze into the rectum, slowly inject 1~2ml of melanin from the outer mouth, and then pull out the gauze. If it is dyed, it proves that there is an inner mouth.

    (4) Surgical examination   incise the fistula and look for the internal opening along the fistula, which is generally easy to find.

    (5) Anal sinus hook examination: A speculum was inserted into the anus, and anal sinus with redness, swelling and inflammation was seen, and the internal mouth was mostly here. Check the anal sinus repeatedly with the anal sinus hook, and it is not difficult to find the internal opening. Avoid violence when exploring, so as not to pierce the normal anal sinus and cause new infection of the internal mouth.

    (6) Methylene Blue Mark   Place a moderate gauze cloth in the anus, and then inject 5% methylene blue aqueous solution into the fistula from the outer mouth, then gently pull the gauze out to observe the position of the inner mouth. Afterwards, use a speculum to open the anus. Near the dentate line, where the coloration is most noticeable, the anal sinus hook or probe is used to probe, and most of the internal openings can be found.

    (7) Other inspection methods, such as X-ray examination and anal canal pressure measurement, are seldom used and can also be used if conditions permit.

    In addition, anal fistula can be divided into:

    ①Subcutaneous or submucosal anal fistula a. Subcutaneous fistula refers to a superficial anal fistula with the primary internal opening in the anal sinus, the fistula under the skin of the anal canal or the skin around the anus, and the external opening is very close to the anus. b. Submucosal fistula means that the primary opening is in the anal sinus, the fistula is under the anal canal and rectal mucosa, and there is no opening outside the skin.

    ②Anal fistula between internal and external sphincter a. Low intermuscular fistula: refers to the anal fistula where the internal orifice is in the anal sinus, and the fistula passes through the gap between the internal and external anal sphincter muscles and through the skin of the external anal sphincter. The fistula that runs straight and has only one external opening is called simple low intermuscular fistula. However, those with curved and branched tubes are called complex low intermuscular fistulas. b. High intermuscular fistula: refers to an anal fistula that develops upward from the fistula to the internal and external sphincter muscles from the internal opening to the anal sinus.

    ③Inferior anal fistula of the levator ani muscle a. Low external muscular fistula: refers to an anal fistula in which the internal opening is in the anal sinus and the fistula passes through the superficial part of the external anal sphincter. The development of one side of the ischial space is called simple low external muscle fistula. It develops toward the ischi-rectal space on both sides, forming a horseshoe-like shape with external openings on both sides of the anus. It is called complex low external muscular fistula or low shoe-shaped anal fistula. b. High external muscular fistula: refers to an anal fistula with the internal opening in the anal sinus and the fistula passing through the deep part of the external anal sphincter. The development of one side of the ischiorectal space is called simple high external muscular fistula, and the development of both sides of the ischiorectal space is called complex high external muscular fistula, also called high shoe-shaped anal fistula.

    ④The upper anal fistula of the levator ani muscle refers to the internal orifice on the wall of the anal canal and rectum above the anal sinus or dentate line. The fistula enters the pelvic-rectal space from the muscle space and passes through the high anal fistula of the levator ani muscle.

    If there are external openings on the left and right sides of the anal canal, it should be considered as a "shoe-shaped" anal fistula. This is a special type of penetrating sphincter anal fistula, and it is also a high-position curved anal fistula. The fistula surrounds the anal canal and passes from one side of the ischiorectal fossa to the opposite side. It becomes a semi-ring shape, like a shoe iron, hence the name. There is an inner mouth near the tooth line, and the number of outer mouths can be multiple, scattered on the left and right sides of the anus, in which there are many branches, spreading around. Shoe-shaped anal fistula is divided into two types: front-shoe type and back-shoe type. The latter is more common, because the back tissue of the anal canal is looser than the front, and the infection is easy to spread.

    clinical diagnosis

    What checks should be done

    1. Digital examination.

    2. Staining inspection is methylene blue staining inspection.

    3. Probe inspection Use a probe to insert the tube through the outer port to determine the location of the fistula and the location of the inner port. This method is generally performed under anesthesia during the operation. If the operation is improper or unfamiliar with this method, it may cause false passages.

    4. Fistula angiography inject 30%-40% lipiodol from the external port. X-ray film can observe the distribution of fistula. It is mostly used for the diagnosis of high complex anal fistula and shoe-shaped anal fistula (Figure 6) Yang (1993) examined clinical suspected anal canal Rectal abscess or fistula in 17 cases, 6 cases were clinically suspected of abscess, and anal canal ultrasound AUS examination also showed abscess; another 82% (9/11) AUS found fistula and clinical routine

    5. Fibrocolonoscopy: It has diagnostic significance for fistulas caused by Crohn’s disease and ulcerative colitis; the examination failed to find.

    6. Anal canal ultrasound is sometimes valuable for the diagnosis of intersphincteric fistula but cannot diagnose external sphincteric fistula and transsphincteric fistula.

    7. MRI examination by Lunniss reported 35 cases of the results of this method and the results of the operation were consistent with the results: primary anal fistula (85.7%) secondary fistula and abscess (91.4%) hoof fistula (64.3%) fistula internal opening 80% Therefore, it is believed that the diagnosis of anal fistula position during MRI examination has extremely high accuracy. The correct use of MRI clinically can not only improve the success rate of the operation, but also monitor whether the complex anal fistula is completely healed.

    8. Surgical examination. Cut the fistula and look for the internal opening along the fistula, which is generally easy to find.

    Differential diagnosis of anal fistula

    There are also many fistulas around the anus and the sacrum, which are easily misdiagnosed as anal fistulas and should be identified.

    ①Perineal urethral fistula: It is mostly caused by urethral injury or stricture. The bulb of the urethra is connected to the skin, and urine flows out of the fistula during urination, and there is no fistula in the rectum.

    ② Anterior sacral fistula: It is formed by the abscess between the sacrum and the rectum punctured near the tailbone, without a fistula leading to the anus.

    ③ Congenital fistula: It is formed by the rupture of a sacrococcygeal cyst. The primary external opening is often at the midpoint of the gluteal sulcus and near the tip of the tailbone. Hair can be seen in the fistula, which occurs from embryogenesis.

    ④ Sacrococcygeal fistula: It is often caused by hip injuries, such as blows, kicks, and abrasions. Abscesses are formed in the sacrococcyx, thereby forming a fistula.

    ⑤ Hidradenitis suppurativa: The lesions are in the skin and subcutaneous tissues, with a wide range of lesions. There may be numerous sinus openings, nodular or diffuse, but the sinuses are shallow and do not communicate with the rectum. There is no abscess cavity after the sinus is cut. And fistula.

    ⑥ Tuberculous anal fistula: The internal and external opening is large, the edges are not neat, and the fistula is often not hardened.

    ⑦ Chronic colitis complicated by anal fistula (omitted).

    ⑧ Congenital rectal fistula: often opening in the perineum or vagina, the inner opening is on the wall of the anal canal, not near the anal sinus.

    ⑨Other: such as rectal urethral fistula, rectal bladder fistula, rectovaginal fistula, etc., it is easier to distinguish from anal fistula.

    The difference between complex anal fistula and high anal fistula

    The distinction between anal fistula is simple or complex, mainly based on the number or length of the fistula and whether it is bent.

    treatment

    Treatment principles

    The principle of treatment of anal fistula should be based on the mechanism of anal fissure and the anatomical structure of the anal fistula.

    ①Remove the internal ostium: During the operation, find the original internal ostium, and remove the infected anal sinus, anal glands and their ducts. This is the key to the treatment of anal fistula.

    ②Take care of the fistula, branch pipe, and dead space: clear the fistula’s pipe, branch pipe, and dead space to avoid recurrence after surgery.

    ③Retention of anorectal ring: During anal fistula surgery, the diagnosis should be made, the internal opening and the direction of the fistula should be identified, and the anorectal ring should be retained to maintain normal anal sphincter function.

    In the specific surgical operation, we must carefully find the internal opening and prevent cutting off the anorectal ring.

    treatment plan

    Anal fistula cannot heal itself. Without treatment, there will be recurrent abscesses around the rectal anal canal. Therefore, surgical treatment is necessary. The principle of treatment is to incise the fistula to form an open wound. Promote healing. There are many surgical methods. Surgery should be selected according to the position of the internal mouth, the relationship between the fistula and the anal sphincter. The key to surgery is to minimize the damage of the anal sphincter and prevent anal incontinence. At the same time avoid the recurrence of the fistula.

    One. Fistula incision is to cut open all the fistula. The method of wound healing by the growth of granulation tissue. Suitable for low anal fistula, because the fistula is deep below the external sphincter. After the incision is opened, only the subcutaneous and superficial parts of the external sphincter are injured, and postoperative anal incontinence will not occur. The operation is performed under sacral anesthesia or local anesthesia. The patient is in a lateral position or a lithotomy position. Firstly, methylene blue solution is injected from the outer mouth to determine the position of the inner mouth, and then a probe is inserted into the gall tube from the outer mouth. Understand the running of the fistula and its relationship with the sphincter. Under the guidance of the probe, cut the surface tissue on the probe to the inner opening. Scrape off the granulation tissue and necrotic tissue in the fistula, trim the edge of the skin, make the wound a V-shaped wound with a small inside and a large outside, and fill the wound with oil gauze to ensure that the wound grows from the bottom to the outside.

    The surgical steps of anal fistula incision:

    The principle of the operation is to cut the fistula completely, and fully remove the scar tissue on both sides of the incision to make the drainage flow smooth and the incision to heal gradually. This method is only applicable to low straight or curved anal fistulas. The operation method is as follows.

    1 Properly probe the inner mouth to find the inner mouth. The operation is the same as the thread-hanging therapy. After the inner mouth is detected, pull the probe out of the anus. If the fistula is bent or branched and the probe cannot penetrate the inner mouth, inject it from the outer mouth. 1 % Melanin solution is a little to determine the position of the inner mouth, and then probe from the outer mouth with a grooved probe, cut the pipeline gradually, and probe until it reaches the inner mouth. If the internal opening cannot be found after careful inspection, the anal sinus that is suspected of being diseased can be treated as the internal opening.

    2 Cut the fistula and fully cut the edge tissue. Cut all the superficial tissues of the fistula, from the outer mouth to the inner mouth and the corresponding anal sphincter fibers. After the fistula is cut, it should be checked whether there is a branch, and if found, it should also be cut. After the fistula is completely cut, the rotting granulation tissue will be scraped away. Generally, it is not necessary to remove the entire fistula to avoid excessive wounds. Finally, trim the edges of the wound so that the wound is in a "V" shape with a small bottom and a large mouth, which is convenient for deep wound healing.

    3 During the anal sphincterotomy, the relationship between the position of the probe and the anorectal ring should be carefully understood. If the probe enters below the anorectal ring, although all the fistulas and most of the external sphincter muscles and corresponding internal sphincter muscles are cut, due to preservation If the puborectalis muscle is removed, it will not cause anal incontinence. If the probe enters the rectum above the anorectal ring (such as superior sphincter anal fistula, external sphincter anal fistula), fistula incision should not be performed, and thread-attaching therapy or staging surgery should be performed. In the first stage, the fistula below the ring is incised or removed, and the fistula above the ring is hung with thick silk and tied tightly. In the second stage of surgery, after most of the external wounds have healed, the anorectal ring has been adhered and fixed, and then the anorectal ring is cut along the line.

    After the fistula is incised, the wall granulation tissue can be scraped off with a curette. Generally, it is not necessary to remove it to reduce bleeding and avoid damage to the posterior sphincter. Resection of fistula tissue should be sent for pathological examination.

    4 Wound treatment   Postoperative wound treatment is often related to the success or failure of the operation. The key is to keep the wound from healing from the base to the surface. Change the dressing once a day, preferably after defecation, and gradually reduce the filling dressing in the wound until the wound in the anal canal heals. Doing a digital rectal examination every few days can dilate the anal canal and prevent bridge adhesions to avoid false healing.

    two. Thread-hanging therapy is a method of slowly incising the anal fistula using the mechanical compression of rubber bands or corrosive medicinal thread. It is suitable for simple anal fistulas with low or high internal and external openings within 3-5cm from the anus, or as an adjuvant treatment for complex anal fistula incision and resection.The ligated muscle tissue has blood flow disorder, and gradually becomes necrotic and disconnected. However, fibrosis caused by inflammation makes the severed muscle adhere to the surrounding tissues. The muscle does not contract too much and gradually heals, thereby preventing anal incontinence caused by the retraction of the severed anorectal ring. The operation is performed under sacral anesthesia or local anesthesia, after inserting the probe from the external port. Follow the direction of the fistula and pass through the inner mouth, and tie a sterile rubber band or thick silk thread to the probe at the inner mouth. Guide through the entire fistula, incise the skin between the inner and outer mouth, and tie the thread tightly. After the operation, take a bath for each mouth and after the toilet to clean the area. If there is a lot of ligation, tie the thread again after 3-5 days. Generally 10-14 days after operation, the punctured tissue breaks by itself. 3. Anal fistula resection The fistula is cut and the bone wall of the fistula is completely removed to healthy tissue. The wound is not sutured; if the wound is large, it can be partially sutured and partially opened, filled with oil gauze, so that the wound grows from the bottom to heal. Suitable for low simple anal fistula.

    Anal fistula resection and primary suture

    This method is only suitable for simple or complex low-straight anal fistulas. If the fistula is hard cord-shaped, the effect will be better. Surgery points: ①The bowel should be prepared before surgery, antibiotics should be applied before and after surgery, and bowel movements should be controlled for 5 to 6 days after surgery. ②The fistula should be completely removed, leaving fresh wounds, and ensuring that no granulation tissue and scar tissue remain. ③The skin and subcutaneous fat cannot be removed too much, which is convenient for wound suture. Therefore, high curved anal fistula should not be sutured, because it has many branches, and it is often necessary to remove too much tissue to clean its branches. ④All layers of wounds should be completely sutured and aligned, leaving no dead space. ⑤ Strict aseptic operation during the operation to prevent contamination, such as cutting the fistula.

    The most common complications after anal fistula surgery are bleeding and urinary retention.

    ①Bleeding: Anal fistula surgery generally has larger wounds and deeper wounds. The local blood vessels are abundant, so there are more vascular injuries. Postoperative bleeding often occurs. For this reason, the obvious bleeding points must be ligated during the operation. For deep blood vessels that are not easy to ligate, electrocautery should be used to stop the bleeding. After checking if there is no bleeding, fill it with gauze and apply pressure to stop the bleeding. For those who still have bleeding, the wound should be opened to stop the bleeding again.

    ② Urinary retention: Urinary retention is rare after anal fistula. If urinary retention occurs, hot compress, acupuncture and other methods should be used for treatment. For those who have not urinated after various treatments, urinary catheterization should be used.

    Postoperative care

    Use conventional methods, routine dressing of postoperative incision, traditional Chinese medicine bath, topical medication, intravenous infusion of antibiotics, plus Kangfuxin liquid, soak the liquid with medical gauze and apply the affected area. The infected wound is first debrided and then rinsed with this product And use the soaked gauze of this product to fill or apply.

    Incision healing is generally divided into inflammation period, granulation tissue hyperplasia period, and scar period. Chinese medicine also divides the healing function into purulent removal and decay removal, removal of decay and muscle growth, and muscle closure. Kangfuxin Liquid is an ethanol extract from the dried worms of Periplaneta americana. It has the advantages of improving blood vessels, nourishing yin and producing muscles, so as to promote wound healing, shorten the course of disease, and reduce pain. It is worthy of promotion.

    Preventive health care

    1. Establish normal dietary habits, because the occurrence of anal fistula is related to damp and heat. For greasy diet, damp and heat can be generated internally, so it is not appropriate to eat more

    2. Eat more light and vitamin-rich foods, such as mung beans, radishes, winter melon and other fresh vegetables and fruits

    3. For chronic anal fistulas, it is mostly deficiency syndrome. Eat more protein-containing foods such as lean meat, beef, mushrooms, etc. in your diet.

    4. Treat anal sinusitis and anal papillitis in time to avoid perirectal abscess and anal fistula.

    5. If the anus is burning and uncomfortable, and the anus falls, the cause should be found out and treated in time.

    6. Prevention and treatment of constipation and diarrhea is of great significance to the prevention of perirectal abscesses in the anal canal, because dry stools are easy to scratch the anal sinus, coupled with bacterial invasion and infection. Most people with diarrhea have proctitis and anal sinusitis, which can further develop inflammation.

    7. Active treatment, not active treatment may cause systemic venereal diseases around anorectal abscess, such as ulcerative colitis and Crohn's disease.

    8. Develop good bowel habits, take a bath after defecation to keep the anus clean, which has a positive effect on preventing infection.

    Prevention and rehabilitation of anal fistula

    The onset of anal fistula is mostly because the perianal abscess ruptures spontaneously, or after incision and drainage, it is not completely healed. A few are caused by tuberculosis. The health care measures for anal fistula should start from two aspects:

    1. Preventive health care

    There is no better prevention method for anal fistula. Comprehensive measures should be adopted to improve local blood circulation, enhance cleanliness, frequent washing or bathing, and prevent constipation, diarrhea, and perianal abscess.

    2. Rehabilitation

    Once the anal fistula is formed, immediately carry out anti-infective treatment, and pay attention to bed rest and reduce activities. Eat light and easy to digest, avoid irritating food. Partially can be fumigated, bathed or hot compress. After the symptoms of anal fistula are discovered, they must be treated in time to prevent the development of the disease and bring difficulties to the treatment.

    How to prevent anal fistula in winter?

    The air is dry in winter, and constipation is one of the symptoms that are prone to occur in the dry winter, and frequent constipation is the main reason for the aggravation of hemorrhoids. Therefore, it is necessary to pay attention to daily protection in winter, and seek medical treatment in serious cases.

    Because the blood vessels in the anorectal part of the human have no venous flaps, it is easy to cause blood stasis in the anorectal part of the lower part of the human body. In addition, irregular stools, constipation, prolonged squatting, hard defecation, addiction to spicy food, such as peppers, raw onions, raw garlic , Drinking a lot of alcohol; irregular life, sitting for a long time, can cause varicose veins, tortuosity, hyperplasia and hemorrhoids in the anorectal area.

    Generally speaking, there are four types of people who are most prone to hemorrhoids, most of whom are 25-65 years old.

    One is people who stand for a long time, sit for a long time and have long-term constipation, such as drivers, mental workers, and white-collar workers;

    Second, in pregnant women, direct compression of the anus by the fetus will hinder the return of blood, coupled with prolonged exertion during childbirth, causing anal vein congestion;

    The third is people with irregular daily life, such as frequent overeating, eating spicy and stimulating things, and alcoholism;

    Fourth, people who have bad habits when defecate, such as people who squat in the toilet and like to read books and newspapers.

    Many people in life have become ill without knowing it, thinking that constipation and hemorrhoids are trivial things. In fact, hemorrhoids can be perceived and judged by yourself, especially for the above-mentioned special groups, and you must always pay attention to the condition of stool. If you feel pain when you defecate, it may be caused by anal fissure, inflammatory external hemorrhoids, anal sinusitis, etc.; if the redness and swelling cannot be touched, it may be a perianal abscess; if there is purulent discharge, it may be an anal fistula. If the anus is itchy Anal eczema is also accompanied by secretions; if bleeding during stool is likely to be internal hemorrhoids, but if the color of blood after the stool is dull, the number of stools per day is increased and the physical fitness is reduced, it may be rectal cancer. In addition, most people have soft skin tags on the anus. If the skin tags suddenly enlarge and become tender in a short time, it may be thrombotic external hemorrhoids or inflammatory external hemorrhoids.

    How to care for anal fistula during operation

    ① Hospitalized patients should be warmly received, and they should be introduced to the ward environment and hospital rules and regulations, so that they can become familiar with the hospitalization environment and enter the role of patients as soon as possible.

    ② Some patients feel shy and embarrassed. At this time, the nurse should tell the patient the relevant knowledge so that the patient can treat the disease.

    ③  Instruct patients to eat nutritious, digestible, non-spicy and irritating food.

    ④ Conscientiously implement the doctor's orders and make various preoperative preparations. When cleaning the enema, the nurse should explain to the patient clearly the purpose, meaning, and how the patient is required to cooperate. During the operation, proceed in the treatment room with proper cover. Pay attention to the lightness of the operation. Lubricate the anal canal with paraffin oil, which can talk to the patient and distract the patient's attention to reduce the pain caused by intubation.

    ⑤ Patients feel anxious and fearful, mainly because they are afraid of pain. Some are because the previous surgical treatment has failed, or they are worried about whether the operation is going well, and they are afraid that they will not be successful at once. Nurses should be caring about the patient, talk to the patient more, encourage the patient to ask questions, understand the cause of anxiety and fear, and then explain and actively guide the patient in every way to eliminate the patient's concerns and make the patient emotionally stable.

    ⑥ Organize the exchange of information among similar surgical patients to make them psychologically prepared. Introduce the condition of the surgical patient, the surgical process and the nursing measures to increase the patient's sense of security and make them feel relieved to undergo the operation.

    Common sense of postoperative nursing of anal fistula

    Postoperative treatment of anal fistula is very important, and it can even be said that the postoperative treatment has a direct impact on the pros and cons of the operation. Generally speaking, Vaseline gauze and other filling gauze from the wound are taken out 24 hours after the operation. If the wound is deeper and larger, it can be taken out after 48 hours. If the patient has a bowel movement, he should take a bath on the affected area after defecation. Dressing. Once a day, until the wound is completely healed. When changing the dressing, the wound should maintain a smooth flow, and the medicine cloth should be placed deep in the wound, that is, the bottom of the wound, covering the granulation tissue so that it grows from the deep part, but it should not be packed too tightly to avoid hindering healing. At the same time, check the wound condition to avoid adhesion of the external wound, early healing, and the formation of a new fistula. The granulation that grows faster on the outside should be cut frequently, and the external tissue that has healed in advance should be removed early, and the external drainage port should be enlarged to make the drainage smooth. When changing dressings, those who have the conditions should try to use Chinese medicinal ointments such as Shengji Yuhong Ointment to get rid of rotten flesh and promote wound healing.

    Anal fistula surgery must be changed daily in the early stage. It can be said that the importance of dressing change after anal fistula surgery is no less than or even higher than that of anal fistula surgery to some extent. Because the wounds after anal fistula surgery are often open, the following effects can be achieved through dressing changes after surgery:

    1) Remove secretions and feces from the surgical wound, keep the wound clean, and prevent contamination and infection;

    2) The drug gauze inserted into the wound during dressing change can not only drain smoothly, but also protect the wound surface;

    3) When changing the dressing, you can use some drugs that promote wound growth, such as Beifuji, etc.;

    4) Facilitate the discovery and treatment of unhealthy granulation tissue and promote wound healing;

    5) The filling of gauze can ensure that wound healing starts from the base and avoid bridge healing.

    Diet after anal fistula

    Patients with anal fistula should eat soft and digestible food with less residue at the beginning of the operation. On the one hand, postoperative consumption is large, bed rest time is long, and digestive function is reduced. The burden on the digestive tract should be reduced as much as possible; on the other hand, rough, dry stools should be avoided. Stimulates postoperative wounds and relieves pain. One week after surgery, the amount and variety of drinking can be increased, and getting out of bed can be increased. In the later stage of wound recovery, eat more high-protein and nutritious foods, such as lean meat soup, ribs soup, black fish soup, ham soup, pigeon soup, fresh chicken soup, turtle soup, etc., to increase nutrition and supplement sufficient protein. It is beneficial to promote wound healing. At this time, if you eat some seaweed, kelp, etc., you can tag and supplement trace elements, which is also beneficial to the patient.

    Causes of recurrence after anal fistula surgery

    The recurrence of anal fistula after surgery is not a rare phenomenon in clinical practice. The reasons are as follows:

    1) Improper handling of the inner mouth: most of the reasons are that the inner mouth is not accurately found, or the primary infection, that is, the inner mouth, is not completely removed;

    2) Improper handling of anal glands: According to recent studies, anal gland infection is an important cause of anal fistula. Therefore, the internal mouth must be removed, as well as the anal glands and ducts that are inflamed near the internal mouth;

    3) The fistula branch and its cavity are not completely removed: that is, if the necrotic tissue is not scraped or the branch is removed during the operation, it can lead to recurrence;

    4) Complicated internal orifice: When there are two or more internal orifices in the fistula, the search for the internal orifice is incomplete, leading to recurrence. In addition, some patients developed perianal abscesses due to anal gland infections, resulting in new anal fistulas;

    5) The dressing change is not in place after the operation, and the wound adheres prematurely, forming a false healing;

    6) Combined with systemic diseases, such as diabetic anal fistula, in addition to local treatment, the anal fistula of such patients must be treated with hypoglycemic treatment. Only in this way can it be possible to achieve good therapeutic effects.

    What is the cause of non-healing wound after anal fistula surgery

    After some patients with anal fistula undergo surgical treatment, the wounds will not heal for a long time, and the pus will continue, and the healing will be very unsatisfactory. There are many reasons for this situation. Common clinical reasons are:

    1. The internal ostium was not accurately found during the operation, or the internal ostium was handled incorrectly, resulting in a false internal ostium; or even though the internal ostium was accurately found, the infected anal sinus, anal gland and internal sphincter were not completely removed. It can also lead to poor healing.

    2. Urgent surgery when the sinus is not formed, the inflammation will spread and new sinus and abscess cavity will be formed, which will affect the healing.

    3. Due to the bending of the fistula, the false fistula or fistula is left during the operation, or the necrotic tissue in the fistula is scratched and not clean, causing the wound to be difficult to heal and recur.

    4. There is a gap or dead space when the wound is sutured, or the suture tension is too large.

    5. There are foreign bodies in the wound, such as thread, cotton wool, etc., which are embedded in the surrounding granulation tissue, which affects the normal growth and healing of the wound.

    6. The patient's physique is too weak or accompanied by chronic diseases such as diabetes, tuberculosis, leukemia or anemia, making it difficult for the wound to heal for a long time.

    In order to prevent the occurrence of the above situation, the lesion should be completely removed during the operation, and various factors that are not conducive to wound healing should be eliminated. To prevent wound infection after the operation, antibiotics can be used continuously for a week, while keeping the wound drainage smooth, and also pay attention to the general condition. Active treatment of underlying diseases can make the anal fistula heal smoothly

    For the problem of cancerous anal fistula,

    It can be explained clearly in three sentences. 1. Anal fistula is not directly related to cancer. Anal fistula is not a pre-cancerous lesion; 2. Chronic anal fistula does have cancerous cases due to long-term inflammatory stimulation or scar tissue mutation; 3. Chronic anal fistula cancerous Cases are very rare, and the probability of anal fistula becoming cancerous is very low. It can be said that carcinogenesis of anal fistula is very rare in clinical practice. Since Rosser first reported carcinogenesis of anal fistula in 1934, no more than 3 cases have been reported in each literature. In the 70 years from 1934 to the present, it has been reported worldwide. There are not many cases of anal fistula canceration. There is a saying that there are more than 150 cases of anal fistula canceration in foreign literature so far, and there are also hundreds of cases. In short, anal fistula canceration is very rare in clinical practice and can be said to be chronic. The probability of canceration of anal fistula is very low. According to statistics, the probability of canceration of anal fistula is 0.1%, so patients do not need to be too nervous. However, this does not mean that the anal fistula is a minor problem and it can be ignored. The hazard of anal fistula is still obvious. Especially in patients with repeated attacks, a simple fistula may develop into a complex fistula. Moreover, although the probability is very low, anal fistula is still Malignant changes are possible. At present, whether it is domestic or foreign, surgical treatment is the most reliable and effective way to cure anal fistula.

    How do patients with anal fistula self-care?

    Self-care of patients with anal fistula is particularly important. It can not only improve the stimulation of local adverse environment, but also provide a good foundation for treatment and rehabilitation. During the remission period, pay attention to the cleanliness of the anus. You should often use warm salt water to soak the anus. You can also use alum water to wash the area, or use potassium permanganate solution to clean the area. Wash at least once every night to clean the area. Hygiene can also improve local blood circulation, enhance resistance to diseases, and reduce inflammation. When the secretions of anal fistula increase, the underwear should be washed and changed frequently, and the secretions should not be accumulated in the affected part. During the attack period, the external mouth can be expanded surgically to drain the pus, which can relieve the pain and prevent the pus from spreading to other parts. In short, taking appropriate health care measures can control the development of the disease and reduce the suffering of patients.

    Will anal fistula heal by itself?

    Anal fistulas are rarely healed naturally. Surgery is the main treatment, which can often be cured, but there is a certain recurrence rate. For cases that are not suitable for surgery, non-surgical treatments can be used, which can generally relieve symptoms, prevent the fistula from spreading in depth, and control its development. Anal fistula, like paraanal abscess, is different from infections in other parts of the body. Because it occurs near the anus and rectum, there is a fixed source of infection in the anus or rectum, that is, the internal mouth. At the same time, the lesion is located in the anal sphincter. The relaxation and contraction of the sphincter will affect The discharge of pus. Therefore, once anal fistula and paraanal abscess occur, no matter how serious they are, there is no possibility of self-healing. Drug treatment only relieves symptoms. Clinically, only surgery (including thread hanging) can achieve the purpose of cure. In the past, many people tried to use various methods other than surgery, but they all ended in failure. To say the least, no non-surgical method has been found to cure anal fistula.

    Regarding the treatment of anal fistula, experts suggest that it is best to use anal fistula surgery in the early stage, because anal fistula is generally difficult to heal by itself, so it is necessary to choose an effective method for treatment in time. What to do if you have an anal fistula is the anxious voice of every patient. In fact, you don't need to be too nervous, as long as you suspect that you have anal fistula symptoms, go to the hospital for diagnosis in time and treat as soon as possible. So what should I do if I have anal fistula?

    The principle of treatment of anal fistula should be based on the mechanism of anal fissure and the anatomical structure of anal fistula.

    ①Remove the internal ostium: During the operation, find the original internal ostium, and remove the infected anal sinus, anal glands and their ducts. This is the key to the treatment of anal fistula.

    ②Take care of the fistula, branch pipe, and dead space: clear the fistula’s pipe, branch pipe, and dead space to avoid recurrence after surgery.

    ③Retention of anorectal ring: During anal fistula surgery, the diagnosis should be made, the internal opening and the direction of the fistula should be identified, and the anorectal ring should be retained to maintain normal anal sphincter function.

    In short, in the specific treatment of anal fistula operation, we must carefully find the internal opening and prevent cutting off the anorectal ring. Because anal fistula cannot heal itself, surgical treatment is necessary. The principle of surgical treatment is to cut the fistula completely, and if necessary, remove the scar tissue around the fistula at the same time, so that the wound will gradually heal from the base up. Depending on the depth and straightness of the fistula, thread hanging therapy, anal fistula incision or resection can be used.

    Conservative treatment of anal fistula is generally used for patients with elective surgery, the purpose is to reduce symptoms and reduce attacks. ①Regulate defecation: keep the stool unobstructed, prevent diarrhea or constipation, so as to reduce the irritation of stool to the internal opening of anal fistula. ②Clean the anus: Take a bath with warm saline or potassium permanganate solution 1 to 2 times a day. And change underwear frequently. ③Appropriate medication.

    Anorectal experts once again reminded patients with anal fistula to go to a professional hospital for the treatment of anal fistula for diagnosis, and choose an effective treatment for anal fistula according to the condition.

    Note for dressing replacement:

    ① Sitz bath and flushing: Sit bath should be taken every day after the operation, especially after the toilet can not be ignored. Make sure the wound is clean and speed up healing. Wound irrigation should be performed on large wounds, first with warm normal saline or antibiotic solution for wound irrigation. Maintain a certain pressure when flushing so that the cleaning solution can reach every corner of the wound.

    ②Dressing: In-wound dressing can prevent adhesion of the wound surface (skin bridging), so the wound surface should be small at the bottom and have a large mouth, which can heal from bottom to top. If pus is found in the wound when the dressing is taken out, indicating a residual abscess cavity, the drainage should be expanded immediately, otherwise the wound will not heal.

    ③ Digital rectal examination: It can be found whether there is dead space and pus in the wound. In addition, it can also be found whether there is a tendency to anal stenosis. If there is, anal expansion should be performed regularly. Therefore, regular digital rectal examinations should be performed.

    Can acute anal fistula be operated without surgery

    ① General therapy: take a bath with potassium permanganate aqueous solution.

    ②Oral medication: Chinese medicine can be taken orally to make the stool soft and easy to pass. At the same time, general analgesics are used to relieve pain and promote wound healing.

    ③Injection closure therapy: Inject 0.5% procaine behind the anus, or seal it under the crack, which can quickly relieve pain. Local anesthetics can also be used to seal the acupoints of Changqiang, which also has a better analgesic effect.

    ④ Acupuncture therapy: take the Changqiang point and pierce it with a long needle for strong stimulation.

    ⑤Others: pay attention to proper rest and regular bowel movements; do not over-exhaust the diet; do not use severe diarrhea medicines, so as not to stimulate the cracks and form chronic anal fissures.

    Conservative treatment of anal fistula

    Conservative treatment of anal fistula is generally used for patients with elective surgery, the purpose is to reduce symptoms and reduce attacks.

    ①Regulate defecation: keep the stool unobstructed, prevent diarrhea or constipation, so as to reduce the irritation of stool to the internal opening of anal fistula.

    ②Clean the anus: Take a bath with warm salt water or potassium permanganate solution every day. And change underwear frequently.

    ③Appropriate medication: antibiotics can be used orally to control inflammation. It can also be used for topical application such as ointment or Chinese medicine for internal or external use.

    Exercise frequently to prevent anal fistula

    Many causes of anal fistula are related to bad habits:

    1. Reading books and newspapers when going to the toilet will cause prolonged squatting or defecation time, which will lead to congestion in the anorectum and induce diseases.

    2. Diarrhea and constipation are important factors of anorectal diseases. Constipation is the biggest culprit. Long-term retention of toxic substances in the rectum can not only induce rectal cancer, but also the accumulation of feces, which affects blood circulation. If the dry fecal mass is removed by force, it will inevitably put greater pressure on the anus, causing congestion, swelling, and mouth A series of pathological changes. Diarrhea is often a clinical manifestation of colon disease. Diarrhea can also increase the chance of local anal infection, resulting in anal sinusitis, inflammatory external hemorrhoids, perianal abscess and other diseases.

    3. People who drink alcohol for a long time or eat spicy foods, faintly mixed with spicy foods can stimulate the digestive mucosa, cause vasodilation, colon dysfunction, and the incidence of anorectal diseases will increase significantly.

    4. Standing or sitting for a long time. Due to the treatment or sitting posture, the anus and rectum lie in the lower part of the human body, and the hemorrhoid veins are not smooth.

    Therefore, to prevent anal fistula:

    Do not endure stool for a long time, avoid the formation of habitual constipation, and reduce the impact pressure and laceration caused by dry and hard stool on the anorectal canal. Usually eat more vegetables and fruits that contain more fiber, and eat less irritating foods, such as peppers, ginger, wine, etc., to reduce the irritation to the anorectal organs. It is not advisable to apply irritating chemicals in the anorectal canal to avoid congestion and swelling of the skin and mucous membranes, causing inflammation. Patients with sigmoid colon, rectum, anus and other diseases should adopt the right decubitus position when sleeping to reduce the pressure on the left colon and promote local blood circulation. People who are engaged in sedentary, standing, and squatting occupations often change their positions, increase activities appropriately, and participate in exercises between work (classes).

    Doing sit-ups can increase the strength of the abdominal muscles, which is very helpful for improving bowel function and can effectively prevent anal fistula.

    Common complications after anal fistula

    1. Bleeding: There is a large blood vessel rupture, and active bleeding points appear. At this time, silk thread should be used to ligate the bleeding points to stop bleeding.

    2. Urinary retention: Difficulty urinating for the first time after surgery, especially in elderly patients with enlarged prostate. Postoperative pain and excessive local anesthetics can also cause dysuria. Generally, massage or hot compresses on the lower abdomen, and listening to the sound of running water can be effective.

    3. False healing of wounds: often caused by untimely or inappropriate dressing changes, some of which are caused by the patient’s "physical factors". At this time, only need to re-open the falsely healed part to make drainage smooth, so drainage is smooth Very important.

    4. Infection: As long as the dressing is changed after the operation and the anus is cleaned after defecation, there will be no infection. If it is infected, the feces must have contaminated the wound. At this time, the wound should be debrided and antibiotics should be given intravenously to control the infection.

    Will anal fistula recur after surgery?

    In anorectal diseases, the recurrence rate after anal fistula surgery is relatively high, which mainly refers to high complex anal fistulas. It has been reported that the recurrence rate has reached 21% abroad, so the treatment of high anal fistula is still a recognized problem at home and abroad.

    The causes of recurrence after anal fistula surgery are complex. The main reason is the internal opening problem: either the real internal opening was not found, or there were two internal openings and only one was cut during the operation. Since the internal opening is the source of infection of anal fistula, as long as there is a remaining internal opening, after the operation It will relapse. Another reason for the recurrence of anal fistula after surgery is the complex condition, too many fistulas, and the direction is unknown. As a result, there are omissions during the operation, which causes postoperative recurrence.

    According to the comprehensive clinical situation: if it is a high complex anal fistula, about one in five people may recur after the operation; if it is a high simple anal fistula, most of the fistula can be cured after the operation, and very few people relapse; if it is low complexity Anal fistula should be cured after surgery, and the recurrence may be an undiscovered high fistula. Simple low anal fistula can be cured after surgery without recurrence.

    Why should it not be too early for patients with anal fistula to defecate?

    Generally speaking, it takes about 2-3 weeks after anal fistula surgery to heal gradually. If the postoperative bowel movement is too early and the fecal mass is too hard, it will not only contaminate the anal wound, but also easily be crushed by the hard fecal mass. Therefore, it is very important to properly control the time of defecation. Generally, it is more appropriate for 2 days after the operation, and you must take a bath after the defecation. At the same time, pay attention to local anal exercises to improve blood circulation and speed up recovery after anal fistula surgery.

    Do patients with anal fistula need to be taboo?

    Suffering from anal fistula, it is necessary to taboo in the daily diet. Eating disorder is the main cause of damp heat and poisonous fire in the body. Therefore, any food that can easily irritate the anus and cause infection or produce dampness and heat should not be eaten, and eat more foods that can clear away heat and dehumidify heat without irritating the anus. Fried foods, greasy foods, rice noodles, white wine, cigarettes, peppers, sausages, etc. are not suitable for eating. Foods that should not be eaten more include seafood, dog meat, beef and mutton, green onions, garlic, leeks, eggs, etc. Good to eat are grains, whole grains, standard flour, mung beans, soy products, winter melon, radish, loofah, bitter gourd, fungus, mushrooms, lean pork, chicken, lotus root, various green leafy vegetables and fruits such as apples, bananas, and pears.

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