RU2268754C1 - Method for endovascular treatment of chronic hemorrhoid - Google Patents

Abstract

FIELD: medicine, proctology.

SUBSTANCE: one should perform dearteriolyzation of internal hemorrhoids. Moreover, occlusion should be fulfilled endovascularly superselectively due to introducing nonlyzing roentgenocontrast emboli - metal spirals into area of the mouths of distal branches of the upper rectal artery. Moreover, for vascular contrasting it is necessary to nonionic contrast substances. The innovation suggested enables to exclude post-embolization acute rectal ischemia.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to general proctology, and can be used to treat chronic hemorrhoids.

Hemorrhoids is one of the most common diseases, in the treatment of which various methods are used - from conservative therapy to radical surgery [1-9, 12]. A very large number of scientific works have been devoted to the problem of treating hemorrhoids, but so far there is no universal method of treatment, since patients seeking help vary in age, size of hemorrhoids, their macromorphological structure, complications, concomitant and associated diseases of the anorectal region [1].

Known drug treatment of acute and exacerbations of chronic hemorrhoids, aimed at eliminating certain symptoms of the disease. Therapy involves a comprehensive medical treatment. The basis of conservative therapy is the normalization of bowel function and bowel movements (plant fiber, heavy drinking, drugs to regulate stool). Against this background, derivatives of flavonoids (Detralex), local drugs (anti-inflammatory suppositories and ointments, painkillers, vasotropic drugs) are used [1, 9].

The disadvantage of conservative treatment of hemorrhoids is its palliativeness. The effect is noted only during therapy itself and for a short period after it. From a socio-economic point of view, drug treatment leads to the loss of a large number of working days and excludes the possibility of persistent labor rehabilitation of these patients.

Known instrumental (semi-surgical) methods of treating chronic hemorrhoids: injection sclerotherapy, WD-II electrotherapy, cryotherapy, infrared photocoagulation, latex ligation of hemorrhoidal nodes. The most complete analysis of the results of using the above minimally invasive methods of treating chronic hemorrhoids is given in the work of L. A. Blagodarny [1]. These treatment methods are mainly used in outpatient practice, both monotherapy and in various combinations.

The disadvantages of instrumental methods of treatment are still frequent complications: bleeding requiring surgical intervention or blood transfusion therapy (1-3%), purulent-inflammatory complications (1-2%), anal pain syndrome (5-35%). In addition, semi-surgical interventions do not sufficiently possess the necessary radicalism, and favorable results are recorded in 30-90% of cases. The need for other treatment methods arises in 10-70% of patients [1, 9].

Finally, the surgical treatment of hemorrhoids is known - the Milligan-Morgan operation, which until recently was the main radical method of treating hemorrhoids in Russian clinics practically without taking into account the stage of the process [1, 3, 5, 6].

However, with a sufficiently high radicalism, this method of treatment has a number of significant drawbacks. The duration of hospitalization is from 4 to 8 days, the period of disability is up to 21-28 days. Patients are exposed to pain and drugs, postoperative stress due to the presence of pain (in 100% of cases). In addition, with this method of treatment, the spectrum of early and late postoperative complications is most fully represented. Bleeding due to slipping of the ligature from the vascular pedicle of the node is recorded in 1-2% of cases, purulent-inflammatory complications (suppuration of postoperative wounds, paraproctitis) - in 2%, reflex urinary retention - in 5-15%, cicatricial stenosis of the anal canal - in 1 %, anal incontinence - in 2%.

Recently, in foreign and domestic publications, there have been reports of methods of treating chronic hemorrhoids that provide access to the distal rectum and the terminal branches of the superior rectal artery: Longo method, suture donation of hemorrhoidal arteries under the control of dopplerometry [2, 12]. The rationale for such methods is determined by the basic principles of the pathogenesis of hemorrhoids: the imbalance between the arterial inflow to the hemorrhoidal nodes and venous outflow, dystrophy and weakening of their ligamentous apparatus. This leads to hypertrophy of the cavernous tissue, bleeding and prolapse of hemorrhoids from the anus. The proposed methods are aimed specifically at these pathogenetic factors: eliminate arterial nutrition of the cavernous tissue, fix the falling out internal hemorrhoidal nodes in the anal canal. At the same time, the nodes remain practically intact and continue to some extent fulfill their physiological role in anal retention [2, 4, 9, 10, 12].

The drawbacks of these methods are determined by transanal access with a certain share of invasion, therefore, they are characterized by traditional postoperative complications. In the literature there are references to intra- and postoperative bleeding, purulent-inflammatory complications in the intervention zone, reflex urinary retention. The problem of postoperative anal pain and discomfort remains unresolved; according to indications, narcotic and non-narcotic analgesics are used [2, 12].

The closest to the technical solution was chosen as the method of x-ray endovascular embolization of the upper rectal artery (REVE BPA), which consists in the dearterization of the branches of the upper rectal artery with Teflon fibers through endovascular access [11]. The procedure begins with catheterization of the inferior mesenteric artery (NBA) according to Seldinger. The catheter is then inserted selectively into the superior rectal artery (BPA). Synthetic material (Teflon fibers) is used for embolization. The delivery of emboli to the vessel is carried out hydraulically. For occlusion of the main trunk of the BPA, emboli with a diameter of up to 0.6 mm are introduced in an amount of from 40 to 120 pieces. Thus, dearterialization of BPA eliminates blood flow through its distal branches to the cavernous tissue of the rectum, causing desolation and sclerosis of the internal hemorrhoids. Manipulation is carried out under local anesthesia. Full activation of patients after manipulation is possible within 12 hours after the intervention. Preparing the gut for manipulation is not required. Discharge patients from the hospital on the 5th day after the intervention. The period of incapacity for work is 7 days. This method of treating chronic hemorrhoids was implemented by the author in clinical practice in 12 patients [11]. All patients were examined up to 1 year after treatment - no complaints were presented, the clinic of the disease was absent.

However, with the accumulation of clinical experience, a number of disadvantages of this method were identified. Some patients showed signs of ischemia of the rectosigmoid colon and proximal rectum, which were manifested by pain in the lower floor of the abdominal cavity of varying intensity. This required the implementation of infusion antispasmodic, disaggregant and rheological therapy, the appointment of analgesics and dynamic monitoring, extended the length of hospital stay of patients. In one case, ischemia acquired an irreversible character with the outcome in the stricture of the rectosigmoid colon. The use of Teflon fibers for embolization lengthens the time of intervention (40-50 min). Thereby, it increases the risk of unintentional (fatal) arterial thrombosis (prolonged regional catheter hypotension, slowing down the blood flow velocity). In addition, Teflon is not radiopaque, which requires a large consumption of contrast to control the progress and result of the REVE VRA. And the use of urographin (an amidotrizoate group) can aggravate ischemia, causing a toxic reaction, accompanied by blockage of the smallest vessels as a result of agglutination of red blood cells, followed by the development of necrosis.

The objective of the invention is to achieve a stable clinical recovery of patients with chronic hemorrhoids, reducing the time of medical manipulation and hospitalization, eliminating the risk of developing post-embolization acute rectal ischemia, fatal thrombosis.

The task is achieved due to the fact that occlusion is carried out endovascularly superselectively by introducing into the region of the mouths of the distal branches of the superior rectal artery non-lysable radiopaque emboli - metal spirals, using non-ionic contrast agents to contrast the vessels.

The method is as follows. The manipulation is carried out using the angiographic complex "PHILIPS BV-212" (Holland), vascular catheters of the company "COOK" and "CORDIS" are used, emboli are metal spirals with a diameter of 0.1 to 0.3 mm, non-ionic contrast agents (omnipack, ultra-vist )

Manipulation begins with selective catheterization of the inferior mesenteric artery (NBA) through the femoral artery according to Seldinger under local anesthesia. After installing a catheter guide at the mouth of the NBA, lower mesentericography is performed by introducing 5-10 ml of contrast medium. After evaluating the angiogram by a catheter guide, a manipulation catheter is brought to the BPA bifurcation or trifurcation. Through it, the distal branches of BPA and the blood supply to them cavernous tissue (internal hemorrhoidal nodes) contrast, assessing their number and position. Metal spirals are delivered to the occlusion site (in the distal branches of the BPA) via a manipulation catheter. Occlusion of the distal branches of the BPA usually requires 10 to 12 metal emboli. The adequacy of occlusion and its level are controlled by the position of the radiopaque emboli and the contrast of the vessels on the monitor screen. Occlusion is stopped with a decrease in contrast or a complete cessation of the contrast of the distal branches of the BPA and cavernous tissue. Research and control over the manipulation is carried out in direct projection. After the end of medical manipulation and catheter extraction, a pressure bandage is applied to the site of the femoral artery puncture and bed rest is prescribed for 12 hours. No chemotherapeutic treatment is required. After a day, the patient is discharged under the supervision of an outpatient coloproctologist. The hospitalization period is 3 days, the period of incapacity for work is 5 days.

The method of superselective x-ray endovascular embolization of the distal branches of the upper rectal artery (SS REVE BPA) in the treatment of chronic hemorrhoids was implemented in clinical practice in 30 patients: in stage I-III (with a predominance of the symptom of recurrent bleeding of varying intensity up to severe profuse) - in 21 patients; with contraindications for surgical treatment - in 2; with relapse of the disease after surgical treatment - in 5; with the ineffectiveness of conservative therapy and minimally invasive treatment methods used earlier - in 2. All patients were examined in a period of 3 to 6 days and from 1 to 12 months after the manipulation. Sclerosis of hemorrhoids occurred within 1 month. The phenomena of acute rectal ischemia were not observed in any case. In addition, the dopplerometry data on hemorrhoidal nodes and on the mucosa in the interstitial spaces convincingly testify to the efficiency of cavernous tissue embolization without disturbing the microcirculation of the distal rectal mucosa. An almost 2-fold decrease in the volume of blood flow in hemorrhoidal nodes was observed 1 day after the manipulation (from 109.5 ± 9.2 ml / min / 100 g to 60.2 ± 4.4 ml / min / 100 g). The last parameter does not significantly differ from that one month after manipulation (59.6 ± 4.3 ml / min / 100 g) and practically corresponds to the volume of blood flow in the interstitial space (59.4 ± 4.1 ml / min / 100 g) at the same time of the examination. Morphometric studies of the rectal mucosa in the period from 6 to 12 months after occlusion of the distal branches of BPA did not reveal morphological changes in the inflammatory, atrophic, and dysregenerative nature of the latter in the long-term postembolism period. Electromyography data indicate the absence of a negative effect of SS REVE BPA on the contractility of the obturator apparatus of the rectum. The background and arbitrary electrical activity of the muscles of the external sphincter after SS REVE BPA did not significantly differ from normal indicators: 41.0 ± 2.6 μV and 184.0 ± 7.1 μV, respectively. The anal reflex did not suffer, which indicates the preservation of the neuro-reflex regulation of the obturator apparatus of the rectum. 1 year after the manipulation of complaints, the patients did not present, the disease was not clinically determined: the rectal mucosa is pink, shiny, macroscopically without signs of atrophy; internal hemorrhoids are sclerotic, up to 0.5 cm in size, painless, do not fall out during bowel movements; there are no phenomena of anal incontinence.

Example

Patient V., 60 years old, medical history No. 2168, was admitted to the department of coloproctology of the Road hospital st. Krasnoyarsk with a diagnosis of chronic hemorrhoids, II century, complicated by recurrent bleeding. Suffers from hemorrhoids 20 years. Over the past year, notes a deterioration. After the act of defecation, a small amount of blood discharge is observed in drops. He considers the cause of the disease constipation. However, after the examination, which excluded the organic pathology of the colon, and the course of therapy, which normalized the act of defecation, rectal bleeding continued. Upon admission, the patient's condition is satisfactory. Somatic status without features. On local examination: external hemorrhoidal nodes are not detected. In the anal canal at 3.7 and 11 hours there are internal hemorrhoidal nodes enlarged to 1 cm in diameter, painless, with an eroded surface, and contact bleed. After clinical examination, without special preparation of the colon, angiography of the lower mesenteric artery (NBA) and upper rectal (BPA) was performed. Result: enrichment of the peripheral bed of BPA, tortuosity and expansion of its distal branches. In the parenchymal phase, intense contrasting of hyperplastic cavernous tissue (internal hemorrhoidal nodes) was noted.

12 metal coils with a diameter of 0.1-0.3 mm were superselectively introduced into the distal branches of the BPA. On the control roentgenogram, radiopaque emboli are determined in the area of the mouths of the distal branches of the BPA, the absence of contrast of the internal hemorrhoidal nodes. The post-embolization period - without features, there is no pain in the pelvic or abdominal cavity, stool - the next day without blood impurities. Discharged on the 3rd day from the moment of receipt in satisfactory condition. On examination after 6 months: the rectal mucosa is pale pink, with no signs of atrophy, sclerosed internal hemorrhoids up to 0.5 cm in size, the surface is not eroded, there is no contact bleeding. Stool on the background of a plant diet 1 time in 2-3 days, feces sometimes solid consistency. The function of the sphincter of the rectum is preserved.

Using the method allows you to:

- to cure or significantly reduce the symptoms of chronic hemorrhoids (I-III century) with a predominance of recurrent bleeding of various frequencies and intensities;

- become one of the methods of choice for contraindications to surgical treatment - hemorrhoidectomy, for relapse of the disease after surgical treatment, with the ineffectiveness of conservative therapy and minimally invasive treatment methods used earlier;

- reduce the length of hospital stay to 3 days, the duration of disability - up to 5 days, reduce the cost of treatment;

- possess atraumaticity directly in the pathological zone, namely: the preservation of the rectal mucosa, the integrity of the epithelium of the anal canal and perianal skin (there is no wound surface, which is the source of postoperative bleeding, the entrance gate for infection and the reason for anal pain); completely eliminate the possibility of strictures of the anal canal, as well as postoperative pulp insufficiency;

- Do not resort to any pain medication or other therapy in the post-embolization period;

- have minimal invasiveness (super-selective catheterization and occlusion of the distal branches of the BPA, supplying exclusively hyperplastic cavernous tissue of the rectum - internal hemorrhoidal nodes);

- do not cause ischemia of the mucous-submucous layer of the rectum, exclude the possibility of developing fatal thrombus formation, postembolization necrosis of the proximal rectum;

- not violate the morphological and functional state of the mucosa of the distal rectum and anal canal;

- not to violate the function of the sphincter of the rectum, and the preservation of sclerotized internal hemorrhoidal nodes to a certain extent provide their role in the function of maintaining feces;

- to promote, against the background of sclerosis of the cavernous tissue of the rectum and distal branches of BPA, the return of internal hemorrhoidal nodes (to a certain extent) to their initial anatomical position, eliminate not only the symptom of bleeding, but also create conditions for the prevention of prolapse of nodes;

- have good aesthetic results;

- be a highly comfortable method of treatment for the patient;

- exclude preoperative preparation of the colon.

The method of endovascular treatment of chronic hemorrhoids has an inventive step, since the implementation of superselective occlusion of the branches of the upper rectal artery (BPA) in the treatment of chronic hemorrhoids by introducing into the region of the mouth of the distal branches of the BPA non-lysable radiopaque emboli - metal spirals and using non-ionic contrast agents for contrasting vessels known from the level of medicine. Descriptions of this method of treating hemorrhoids in the available medical and patent literature have not been found.

The invention is industrially applicable, as it can be used in healthcare in coloproctological institutions and research institutes of the Russian Federation in the treatment of chronic hemorrhoids.

Information sources

1. Grateful L.A. Clinical and pathogenetic substantiation of the choice of a method for the treatment of hemorrhoids // Abstract. Dis. ... doctor of medical science. - M., 1999;

2. Vorobiev G.I., Shelygin Yu.A., Titov A.Yu., Kanametov M.Kh. Experience in the treatment of hemorrhoids by suture ligation of hemorrhoidal arteries under the control of dopplerometry // Diseases of the colon. Issues of organizing proctological care. Abstracts IV Republican Scientific and Practical Conference with international participation in proctology: Functional and inflammatory diseases of the colon - surgical and therapeutic aspects. New in coloproctology. - Minsk, 2001. - P.21-23;

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7. Milligan E.T.C., Morgan C.N., Jones L.E., Officez R. Surgical anatomy of the anal and the operative of the heamorroid // Lancet. - 1937. - Vol. 2. - P.1119-1124;

8. Stelzner F. Heamorroids // Dtsch. - Med.wschr. - 1963. - Bd. 88. S.689-696;

9. Godeberge P., Kontou J.F. Atlas of Hemorrhoids // Les Laboratoires Sender. - 1998. - P. 48;

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Claims (1)

A method for the treatment of chronic hemorrhoids, including dearteriolization of internal hemorrhoidal nodes, characterized in that the occlusion is carried out endovascularly superselectively by introducing into the mouth of the distal branches of the upper rectal artery non-lysable radiopaque emboli - metal spirals, using non-ionic contrast agents to contrast the vessels.