本文详细报道了一例2岁2个月男性患儿复杂性肛瘘的诊疗过程。患儿因“反复肛旁肿痛流脓1年半,加重1月”入院,其肛瘘情况特殊,瘘管多达3根,通过全面的术前检查,包括血常规、生化、凝血四项、感染标志物、直肠肛门彩超及电子肠镜等,明确诊断并排除炎症性肠病。手术采用肛门瘘管切除术 + 肛瘘挂线术,术后给予常规抗感染、补液及切口局部清洁消毒等治疗。文章深入讨论了该病例在诊断、治疗方式选择以及术后护理等方面的特点与难点,旨在为临床医生在处理幼儿复杂性肛瘘时提供参考,强调个性化诊疗和术后护理的重要性。This article reports in detail the diagnosis and treatment process of a 2-year-old and 2-month-old male child with complex anal fistula. The child was admitted to the hospital due to “recurrent perianal swelling, pain, and pus discharge for 1 and a half years, aggravated for 1 month”. The condition of the anal fistula was special, with up to 3 fistulas. Through comprehensive preoperative examinations, including blood routine, biochemistry, coagulation, infection markers, rectal and anal ultrasound, and electronic colonoscopy, the diagnosis was confirmed and inflammatory bowel disease was ruled out. The surgery adopts anal fistula resection and anal fistula suture, and postoperative treatment includes routine anti infection, fluid replacement, and local cleaning and disinfection of the incision. The article deeply discusses the characteristics and difficulties of the diagnosis, treatment method selection, and postoperative care of this case, aiming to provide reference for clinical doctors in dealing with complex anal fistula in young children, emphasizing the importance of personalized diagnosis and postoperative care.
