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中华结直肠疾病电子杂志 ›› 2023, Vol. 12 ›› Issue (05) : 353 -362. doi: 10.3877/cma.j.issn.2095-3224.2023.05.001

解剖与手术专栏

肛周坏死性筋膜炎感染路径浅析
张臣熊, 吴雨凝, 谭皓, 续菡, 张迪, 孙锋()   
  1. 401120 重庆市渝北区中医院肛肠科;510405 广州,中医药大学第一临床医学院
    510405 广州,中医药大学第一临床医学院
    510655 广州,中山大学附属第六医院肛肠外科
    510405 广州中医药大学第一附属医院肛肠科
  • 收稿日期:2023-08-29 出版日期:2023-10-25
  • 通信作者: 孙锋
  • 基金资助:
    国家自然科学基金面上项目(82074442)

Analysis of infection path of perianal necrotizing fasciitis

Chenxiong Zhang, Yuning Wu, Hao Tan, Han Xu, Di Zhang, Feng Sun()   

  1. Department of Proctology, Yubei Hospital of Traditional Chinese Medicine, Chongqing 401120, China; First Clinical School of Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
    First Clinical School of Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
    Department of Coloproctology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
    Department of Colorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
  • Received:2023-08-29 Published:2023-10-25
  • Corresponding author: Feng Sun
引用本文:

张臣熊, 吴雨凝, 谭皓, 续菡, 张迪, 孙锋. 肛周坏死性筋膜炎感染路径浅析[J]. 中华结直肠疾病电子杂志, 2023, 12(05): 353-362.

Chenxiong Zhang, Yuning Wu, Hao Tan, Han Xu, Di Zhang, Feng Sun. Analysis of infection path of perianal necrotizing fasciitis[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2023, 12(05): 353-362.

肛周坏死性筋膜炎(PNF)是一种特殊类型的感染,一般由多种细菌(包括厌氧菌和需氧菌)混合感染而发病。PNF感染可沿着肛周、会阴的浅筋膜扩散,上至腹壁,下达下肢,同时感染还可能向深部蔓延,到达肛提肌上间隙、膀胱周围间隙、直肠后间隙等盆腔腹膜外间隙,甚至进一步蔓延至腹膜后间隙。这些感染常常是沿着筋膜、筋膜间隙进行播散,同时还可以沿着血管神经穿行孔进行蔓延。尽管目前医疗水平有了极大的提升和发展,但临床医生在PNF的诊断及治疗方面仍然面临巨大的挑战。本研究旨在通过大体解剖资料、病例资料、既往文献回顾性分析肛周会阴、盆腔、腹膜后筋膜及间隙解剖知识,以及PNF的感染蔓延播散途径,以期为该病的诊断及手术治疗提供参考。

Perianal necrotizing fasciitis (PNF) is a special type of infection that typically involves mixing infection with a variety of bacteria, including anaerobic and aerobic bacteria. PNF infection can spread along the superficial fascia of the perianal and perineum, up to the abdominal wall and down to the lower extremities. Meanwhile, the infection may also spread deep to the pelvic extraperitoneal space such as the superior levator anal space, the peribladder space, the retrorectal space, and even further spread to the retroperitoneal space. These infections often spread along the fascia, the fascial space, and can also spread along the vascular and nerve crossing foramen. Although the current medical level has been greatly improved and developed, clinicians still face great challenges in the diagnosis and treatment of perianal necrotizing fasciitis. The purpose of this study was to retrospectively analyze the anatomical knowledge of perianal perineum, pelvic cavity, retroperitoneal fascia and space, as well as the infection spread and dissemination route of PNF through gross anatomical data, case data and previous literature, in order to provide reference for the diagnosis and surgical treatment of PNF.

图1 男性会阴部浅层解剖图(图片来源于参考文献[8])
图2 男性会阴部深层解剖图(图片来源于参考文献[8])
图3 后侧盆壁筋膜(图片来源于孙锋团队解剖)
图4 盆筋膜(图片来源于孙锋团队解剖)
图5 盆腔腹膜外间隙(图片来源于孙锋团队解剖)
图6 腹壁浅筋膜(图片来源于孙锋团队解剖)
图7 腹膜后间隙(图片来源于参考文献[28])7A:轴位示意图。腹膜后间隙有3个:肾周间隙,包绕双侧肾脏、肾上腺和近端输尿管(图中显示为直接包绕肾脏的脂肪);肾旁前间隙(APS),其内有胰腺(P)、升结肠(AC)、降结肠(DC)、和部分十二指肠(DU),位于肾周间隙前方;肾旁后间隙(PPS),深达腹横筋膜,肾周间隙后方。腹膜后3个筋膜平面:肾旁前间隙与肾周间隙的肠系膜后平面(RMP);肾周间隙与肾旁后间隙的肾后平面(RRP);外侧锥平面(LCP),与这两个其他平面横向通信的潜在空间。在图中,外侧锥形平面和肾旁前间隙的最内线代表壁层腹膜。7B:矢状位示意图。腹膜后间隙向下,肠系膜后平面(RMP)和肾后平面(RRP)融合形成筋膜间联合平面(CIP)
图8 一例仅累及肛周的PNF,8A为术前;8B为术后15天(图片来源于张臣熊)
图9 一例被误诊为肛周脓肿的PNF,在外院行肛周脓肿切开引流术后,感染进一步从肛周、会阴部蔓延至阴囊、右侧腹股沟及右下腹壁。9A为第二次手术术前;9B为第二次手术术后第三天(图片来源于张迪、张臣熊)
图10 PNF向肛提肌上间隙、直肠后间隙蔓延示意图(孙锋绘制)
图11 一例累及膀胱前间隙的PNF盆腔MRI。11A:轴位显示括约肌间、右侧坐骨直肠窝有游离气体及脓液存在;11B:轴位显示感染进一步向上蔓延,并突破肛提肌平面;11C:矢状位显示除了肛周间隙有游离气体外,在膀胱前间隙也有游离气体存在;11D:冠状位显示感染累及右侧坐骨直肠窝,并沿着盆膈进一步向上蔓延(图片来源于张臣熊)
图12 一例累及直肠后间隙、膀胱前间隙的PNF盆腔核磁,在直肠后间隙(12A)、膀胱前间隙(12B)有游离气体及脓液的存在(图片来源于张臣熊)
图13 一例累及盆腔、腹壁腹膜外组织的PNF。13A:冠状位MRI显示肛管、盆腔周围软组织肿胀,局部积气、积液,经肛提肌上间隙蔓延至膀胱前间隙,并继续沿腹股沟向上蔓延。CT影像:13B矢状位、13C冠状位提示盆腔积气、积液明显,并沿膀胱前间隙蔓延至腹壁腹膜外组织(图片来源于孙锋团队)
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