肛周子宫内膜异位症临床资料分析及文献研究

发布时间：2018-10-12 07:35

【摘要】：目的:回顾性分析肛周子宫内膜异位症的病因病机、发病特点、鉴别诊断、治疗方法及预后等相关因素,以探讨肛周子宫内膜异位症的诊治方法,以期为临床提供参考。方法:收集南京市中医院2006年1月至2016年1月肛肠外科诊治的17例肛周内异症患者的病例资料并进行随访;计算机检索有关肛周异位症的文献,发表年限为2000年1月～2016年12月。通过纳入和排除标准然完成初筛,去除重复报道,然后进一步分析文献中的数据,决定文献是否纳入。数据资料主要为病例的一般情况、临床特点、治疗及随访预后。所有数据均采用描述性汇总分析。结果:11例术前临床诊断为肛周内异症,6例分别诊断为肛周脓肿和肛瘘,术后病理均证实为肛周内异症。术前11例病灶未累及肛门括约肌者予以手术全切除,术后随访未复发;6例病灶累及肛门括约肌(其中4例合并肛瘘),未合并肛瘘的2例患者予以完全切除病灶(包括部分括约肌),术后继续口服避孕药3月,随访未复发;4例合并肛瘘患者在保护肛门功能的情况下尽量切除病灶,病理诊断为肛周内异症后予以促性腺激素释放激素(GnRH-a)治疗3月,停药后3例病灶复发,1例拒绝再次手术予以口服避孕药控制症状,2例予以再次手术切除病灶,术后继续予GnRH治疗3月,随访未见复发。研究中共纳入67篇相关文献,共767例患者,95.7%的患者临床症状典型,4.3%的患者临床症状不典型;文献中仅有8.5%(65/767)患者行血清CA-125检查;手术或超声下发现59.2%的病灶表现为单发,9.7%表现多发,病灶平均直径为2.64cm±0.97cm;所有患者均采用手术治疗,其中病灶涉及肛门括约肌者占18.1%(138/767),手术治愈率为85.9%(659/767),失访率为1.7%(13/767),术后复发率约为6.0%(46/767),40.4%(310/767)患者接受药物治疗。结论:1、肛周内异症临床发病率低,可能与经阴道分娩时会阴侧切(或者撕裂伤)、产时合并宫腔和(或)会阴部手术操作以及侧切口愈合不良等因素有关。其他相关因素可能有年龄、产后月经复潮时间以及产后母乳喂养时间等。2、肛周内异症症状典型者易确诊,症状不典型者易需结合其他辅助检查,如盆腔超声、MRI或穿刺细胞学等检查,有助于明确诊断。3、肛周内异症目前主要治疗方式是手术完全切除,病灶累及肛门括约肌多术前或术后联合药物治疗,药物治疗主要为雌孕激素治疗,其他还有中药口服或保留灌肠、针刺疗法等方法。4、肛周内异症的复发可能与术前诊断不明确有关,以致病灶切除不完全,复发再次手术时注意评估患者的肛门功能,避免出现大便失禁。
[Abstract]:Objective: to analyze the etiology, pathogenesis, characteristics, differential diagnosis, treatment and prognosis of perianal endometriosis, so as to explore the diagnosis and treatment of perianal endometriosis. Methods: from January 2006 to January 2016, 17 patients with perianal heterosis were collected and followed up in Nanjing Hospital of traditional Chinese Medicine from January 2006 to January 2016. The publication period is from January 2000 to December 2016. Through the inclusion and exclusion of the criteria to complete the initial screening, remove repeated reports, and then further analysis of the data in the literature to determine whether the literature included. The data were mainly general case, clinical features, treatment and follow-up prognosis. All data were analyzed by descriptive summary. Results: 11 cases were diagnosed as perianal heterosis, 6 cases as perianal abscess and anal fistula. Total resection of anal sphincter was performed in 11 patients who had no involvement of anal sphincter before operation. 6 patients with anal sphincter involved anal sphincter (4 patients with anal fistula), 2 patients without anal fistula underwent complete resection (including partial sphincter), and continued to take contraceptive orally for 3 months after operation. 4 patients with anal fistula were treated with gonadotropin releasing hormone (GnRH-a) for 3 months. After stopping the treatment, 3 cases recurred, 1 case refused to take contraceptive to control the symptoms again, 2 cases were resected again. The patients were treated with GnRH for 3 months. No recurrence was found in the follow-up. A total of 67 related articles were included in the study, including 767 patients, 95.7% of them had typical clinical symptoms, 4.3% of them had atypical clinical symptoms, only 8.5% (65 / 767) of the patients had CA-125 examination in serum. Under surgery or ultrasound, 59.2% of the lesions showed single lesions, 9.7% showed multiple lesions, and the mean diameter of lesions was 2.64cm 卤0.97 cm. All the patients were treated by operation. Among them, 18.1% (13.8 / 767) of the lesions involved anal sphincter, 85.9% (65.9 / 767) of the patients were cured, 1.7% (13 / 767) of the patients were lost, the recurrence rate was about 6.0% (46767), and 40.4% (310 / 767) patients received drug treatment. Conclusion: 1. The clinical incidence of perianal heterosis is low, which may be related to lateral perineal incision (or laceration) during vaginal delivery, intrauterine and / or perineal operation during labor, and poor healing of lateral incision. Other related factors may include age, postpartum menstrual regurgitation and postpartum breast-feeding time, etc. 2. Those with typical symptoms within anus are easy to be diagnosed, and those with atypical symptoms need to be combined with other auxiliary examinations. For example, pelvic ultrasound, MRI or puncture cytology are helpful in the diagnosis of perianal heterosis. At present, the main treatment for perianal heterosis is complete resection of the tumor and the involvement of the anal sphincter before or after the operation. Drug therapy is mainly estrogen and progesterone therapy, other methods include oral or reserved enema of Chinese medicine, acupuncture therapy and so on. 4. The recurrence of perianal heterosis may be related to the unclear diagnosis before operation, resulting in incomplete excision of the lesion. Care should be taken to evaluate anus function during recurrent reoperation to avoid fecal incontinence.
【学位授予单位】：南京中医药大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.1

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