RU2326604C1 - Method of rectal fistula treatment - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: pelvic topography type is determined. Rectum wall is repaired in area of inner sinus tract following surgical d-bridement of scar tissues within sinus tract. Within external edge of perineum operative wound inner portion of gluteus maximus muscle is free from cellular tissue and cut out for complicated U-shaped fasciomuscle graft based on primary branches of lower gluteal neurovascular beam. Muscular part of graft is penetrated into residual cavity, and fascial part of complicated graft is fixed to rectum wall through separate interrupted catgut suture at symphysis-petal pelvic topography angled 90° to pelvic horizontal axis. At sacropetal pelvic topography it is fixed angled 120° to pelvic horizontal axis.

EFFECT: enables to provide plastic area revasculization; prevents infiltrative inflammatory and suppurative complications; fixes internal opening; reduces possibility of fistula relapse.

2 ex

Description

The invention relates to medicine, namely to coloproctology, and can be used in the surgical treatment of patients with extrasphincteric and transsphincteric fistulas of the rectum.

Fistulas of the rectum - one of the most common coloproctological diseases, their frequency ranges from 15% to 30% [B. Zhukov, V. N. Shabaev, V. R. Isaev, N. A. Lysov Coloproctology. - Samara, Samara State Medical University, 1999, 132 p .; Rivkin V.L. et al. "Hemorrhoids and other diseases of the anal canal", M., 1994, - 238 p.].

Moreover, fistulous forms of paraproctitis are found in 28% of cases among all proctologic diseases [Zhukov B.N., Shabaev V.N., Isaev V.R., Lysov N.A. Coloproctology. - Samara, Samara State Medical University, 1999, 132 p .; Rivkin V.L. et al. "Hemorrhoids and other diseases of the anal canal", M., 1994, - 238 p.].

Depending on the location of the fistulous passage in relation to the external sphincter of the anus, intra-, trans- and extrasphincteric fistulas of the rectum are isolated [Vorobev G.I. The basics of coloproctology. - Rostov-on-Don: Phoenix, 2001, - 414 p.]. Extrasphincteric fistulas are high-level fistulas in which the course goes around the sphincter of the anus outside. Treatment of complex (extrasphincteric) fistulas remains an urgent task, since the fistulous course is high, it can occupy several cellular spaces with the formation of sagging, during surgery there is a danger of sphincter injury [Semionkin E.I. Coloproctology. - M.: Publishing House Medpraktika. - M., 2004, - 224 p.].

At the State Scientific Center of Coloproctology of the Ministry of Health of the Russian Federation, Yu.V. Dultsev and K.N. Salamov (1980) developed a classification of extrasphincteric fistulas of the rectum according to the degree of complexity: for the I degree of complexity of the extrasphincteric fistula, the internal opening is narrow without scars around it, there are no ulcers and infiltrates in fiber, the course is quite straight. At the II degree of complexity, there are scars in the area of the internal opening, but there are no inflammatory changes in the fiber. With III degree, extrasphincteric fistulas characterize a narrow inner opening without a scar process around, but there is a purulent-inflammatory process in the fiber. At the IV degree of complexity, fistulas have a wide internal opening surrounded by scars, with inflammatory infiltrates or purulent cavities in the cellular spaces [Dultsev Yu.V., Salamov K.N. Paraproctitis. - M .: "Medicine", 1981, - 208 p., Ill.].

A number of methods are known for the surgical treatment of rectal fistula. So, with extrasphincteric fistulas A.N. Ginger [Ginger A.N. Atlas of operations on the rectum and colon. M .: Medical manual, 1968] an operation was developed in which the fistulous course after staining is dissected from the perineum in the form of a strand to the wall of the rectum. After this, the prepared fistulous passage is cut off with scissors at the base. The remaining segment of the fistulous course, visible in the depths of the wound as a blue spot, is scraped out by a curved sharp spoon filled with 2% tincture of iodine.

After this, the surgeon, with a wound diluted with hooks, sews the remainder of the fistulous course with 2-3 catgut sutures in the depths of the curve with a small needle, bringing together the surrounding tissue. Sometimes it is possible to put 2 rows of catgut sutures. A rectal mirror is inserted into the intestinal lumen; the inner fistula opening is exposed. A posterior sphincterotomy is made through the inner opening of the fistula to a depth of 1.2-1.5 cm in men; in women, to a depth of 1 cm. The edges of the dissected internal opening are excised with long Cooper scissors.

In recent years, this operation is rarely used due to the high frequency of relapses. Low efficiency in some cases is associated with improper selection of patients, a pronounced cicatricial process in the tissues surrounding the fistula, but, according to Fedorov V.D. et al., the main reason is that leaving even a small segment of the fistulous course leads to relapse of the fistula [Clinical surgical coloproctology. A guide for doctors. Edited by Fedorov V.D. and others M., Medicine, 1994, S. 353-358].

Rivkin V.L. et al. [Rivkin V.L., Bronstein A.S., Fine S.V., An V.K. Guide to coloproctology. - M.: Publishing House Medpraktika. - M., 2004, - 488 S.] proposed their own version of radical surgery for extrasphincter fistula of the rectum. The surgeon marks the fistulous passage with vital dye and excises its outer part from the tissues “in the form of a cord”. Having reached the turn of the fistulous passage to the intestine, the surgeon cuts off the outer part of the fistula and probes its stump to once again determine its course and internal opening of the fistula in the anal canal. Further along the probe (or along the curved small clamp of Billroth), conducted into the lumen of the intestine, a distal part of the fistula is dissected through the internal opening, separated from the perineal wound by a triangular incision, as is done during the Gabriel operation. The probe is removed from the perineal wound, the stump of the fistula is scraped out with a sharp spoon, treated with iodine and sutured in the perineal wound with two rows of interrupted sutures.

According to G.I. Vorobyev et al., A comparison of the operation described by A.N. Ryzhikh and the version of V.L. Rivkin does not reveal any fundamental differences [Fundamentals of Coloproctology. Ed. Vorobyova G.I. - M .: Medical Information Agency LLC, 2006. - 432 p., Ill.]. This operation has the same drawbacks that were indicated during the operation proposed by A.N. Ryzhikh.

A known method of plastic surgery proposed by T.V. Abuladze [Abuladze T.V. Plastic surgery for fistulas of the rectum. - Surgery. - 1992. - No. 2, p. 70-65]. The method consists in the fact that with a pronounced cicatricial process after excision and cutting off the fistula from the perineum, its stump is sutured with a perlone and a polymer film is glued to it in the form of a patch up to 5-6 mm in size, the perineal wound is sutured with a chrome catgut to the skin. Separate silk sutures are applied to the skin. On the freshened surface of the inner opening of the fistula, MK-14 glue is applied and a patch of autofascation or synthetic film reinforced with lavsan is glued. The patch is additionally hemmed around the perimeter to the wall of the anal canal [Abuladze T.V. Plastic surgery for fistulas of the rectum. - Surgery. - 1992. - No. 2, p. 70-65].

Moreover, with complex fistulas, when the cicatricial process affects not only the external part of the fistulous course, but also captures its internal opening, T.V. Abuladze proposed an original modification of the above method. When the first part of the operation is carried out similarly, and after processing the internal opening and cryptectomy, the same patch is glued to its bottom, moreover, the implant is immersed deep into the anal canal, and the mucous membrane is sutured over it [Abuladze T.V. Plastic surgery for fistulas of the rectum. - Surgery. - 1992. - No. 2, p. 70-65].

The disadvantages of all of the above methods are.

1. The inability to control the adequate fixation of the patch with biological glue, as well as the need for additional hemming of the patch with threads with pronounced wick properties.

2. Compression of tissues in the region of the internal opening, which in conditions of ischemia and secondary infection leads to suppurative complications and relapse of the disease.

3. When using the method with complex fistulas, a residual cavity is formed, which increases the risk of purulent complications (infiltrates, abscesses and relapse of the fistula).

4. There is a risk of teething and implant migration with the development of cicatricial deformity of the intestine and, at the same time, the failure of the plastic stage.

5. The implementation of these methods using autofascation or synthetic polymers does not provide for revascularization of the plastic zone.

A known method of treating a rectal fistula by excising the fistulous passage with the movement of the mucous membrane of the distal rectum [Clinical surgical coloproctology. A guide for doctors. Edited by Fedorov V.D. and others M., Medicine, 1994, S. 353-358].

Dye is introduced into the external fistulous opening. A bordering incision is made on the perineal skin around the external fistulous opening. The fistulous course in the acute way is isolated in the form of a strand to the wall of the rectum and cut off. In the presence of a purulent cavity in the pararectal tissue, it is opened and the walls are completely excised within healthy tissues. A rectal mirror is inserted into the rectal lumen and a rectal sphincter divulsion is performed. In the submucosal layer of the rectum in the wall of the anal canal, corresponding to the location of the inner opening of the fistula, novocaine is administered. A lunar incision along the transitional fold of the anus separates the musculoskeletal flap 3-4 cm above the internal opening. The flap is removed in the opposite direction with Alice terminal. The inner hole in the intestinal wall is scraped with a Volkman spoon and two rows of catgut sutures are applied. Then, with a few catgut sutures, a mobilized musculoskeletal flap is sutured so that the needle sticks at the edge of the wound in the anterior fold and the puncture comes out from the mobilized flap. With a few rare sutures, the edges of the flap are fixed to the edge of the perianal skin, after which the former internal opening of the fistula in the mucous and muscular layer of the intestine is located outside the anal canal. The wound in the perineal region is partially sutured or left open and an ointment swab is placed in it. A tape with an antiseptic ointment and a vent tube are inserted into the rectum.

The disadvantages of this method include both intra-and postoperative complications.

1. A high probability of damage to the wall of the rectum at the inner opening of the fistula, which can lead to failure of the anal sphincter.

2. Perforation of the mobilized musculoskeletal flap; perforation of the wall of the ampulla of the rectum in cases where the fistula is combined with a purulent cavity in the pararectal tissue, and especially if these cavities are located close to the wall of the rectum above the anal canal.

3. The use of the method does not include plastic soft tissue of the residual cavity with autotissues, which increases the likelihood of the formation of non-purulent complications (infiltrates, abscesses and relapse of the fistula).

4. There is a risk of teething and implant migration with the development of cicatricial deformity of the intestine and, at the same time, the failure of the plastic stage.

5. The implementation of these methods using autofascation or synthetic polymers does not provide for any revascularization of the plastic zone.

6. Relapse of the fistula with flap necrosis or teething.

The prototype of the present invention as the closest in combination of features to the claimed method is the method proposed by A.M. Kuzminov et al. (RF patent No. 2186528). The method is as follows.

In the patient's position for lithotomy under regional anesthesia, the perianal skin, anal canal is examined, the fistulous passage is probed and its labeling with methylene blue solution. The fistulous passage located extrasphincterously is excised to the internal fistulous opening. Stained with methylene blue, scarred tissue is excised. Purulent streaks are additionally opened and drained. Using a hydraulic preparation, the mucus-muscular flap from the perianal skin to the lower ampullar part of the rectum is separated in an acute way (1.0-2.0 cm above the dentate line). This, as a rule, is enough to lower the mobilized flap to the level of the perianal skin so that the internal fistulous opening is located outside the area of the anal canal.

The authors consider the necessary condition for the operation to mobilize all layers of the rectum. At the same time, the external sphincter is skeletonized while maintaining the integrity of its structures.

After careful hemostasis, the mobilized segment of the intestine is reduced to the edge of the perianal skin over the skeletonized portion of the external sphincter, where it is fixed with nodal catgut sutures.

The implementation of this method has the following disadvantages.

1. This operation is not feasible in the presence of an active inflammatory process in pararectal tissue due to the high probability of inflammatory complications of the plastic phase.

2. There is a high likelihood of perforation of the mobilized flap, perforation of the wall of the ampulla of the rectum in cases where fistula in the pararectal tissue is combined with a purulent cavity, and especially if these cavities are located close to the wall of the rectum above the anal canal.

3. The implementation of this method does not provide for any revascularization of soft tissues in the plastic zone.

4. Necrosis of the mucus-muscular flap, teething sutures when performing this method inevitably lead to relapse of the fistula.

5. The operation and adequate closure of the internal opening of the fistula in this way is not feasible with cicatricial changes, covering more than the semicircle of the rectum.

6. No method provides for differences in the technique of surgery depending on the type of pelvic topography.

The objective of the invention is to prevent the development of insufficiency of the anal sphincter, local purulent-inflammatory complications and postoperative relapse of the disease.

EFFECT: increased efficiency of treatment of patients with complete extra- and transsphincter rectal fistulas due to prevention of recurrence of fistula and development of anal sphincter insufficiency by using a fascial-muscular transplant based on a medial portion of the gluteus maximus muscle with gluteal fascia immersed in the residual cavity of the surgical wound and fixed to the fascial case of the rectum, a combination of excision of the fistula with measures aimed at eliminating the residual cavity, stopping in scorched and revascularization plastic zone.

The task is achieved in that the U-shaped fascial-muscle transplant is cut out on the basis of the medial portion of the gluteus maximus muscle with the gluteal fascia located above it, and then the muscle part of the graft is immersed in the residual cavity with fixation of the fascial part of the graft to the fascial case of the rectum at an angle of 90 ° to the horizontal axis of the pelvis with a symphysopetal type of pelvic topography and at an angle of 120 ° to the horizontal axis of the pelvis with a sacropetal type of pelvic topography.

The method is as follows. Irrigography, defecography, endorectal ultrasound are performed. The type of pelvic topography is determined by the method of V. Moskalenko [Moskalenko V.V. et al. In the book: Materials of the typical anatomy of the pelvic organs in connection with drainage. M., 1941].

The following features are characteristic of the symphysopetal type of pelvic topography: the sagittal axis of the sciatic-rectum fossa is inclined posteriorly at an angle to the horizontal less than 113 °, the rectum is cylindrical, the long axis is inclined to the sacrum at an angle to the horizontal less than 113 °, the bottom of the bladder is above the pelvic horizontal. The following features are characteristic of the sacropetal type of pelvic topography: the sagittal axis of the sciatic-rectum fossa is inclined posteriorly at an angle to the horizontal greater than 113 °, the rectum is an ampoule type with a long axis inclined to the sacrum at an angle to the horizontal greater than 113 °, the bottom of the bladder is below the pelvic horizontal.

In the position of the patient on the back, the legs are bent at the knee and hip joints and laid on supports, under conduction anesthesia or intravenous anesthesia, a rectal mirror inserted into the rectum performs sphincter divisions. Dye is introduced into the external fistulous opening. A fringing cut of the skin of the perineum is made around the external fistulous opening. The fistulous course in the acute way is isolated in the form of a tubular strand to the wall of the rectum and excised. In the presence of a purulent cavity in the pararectal tissue, it is opened and the walls are completely excised within healthy tissues. The scar tissue surrounding the fistulous course and the edges of the inner fistula opening are excised. In the submucosal layer of the rectum in the wall of the anal canal, corresponding to the location of the inner opening of the fistula, novocaine is administered. A lunar incision along the transitional fold of the anus separates the musculoskeletal flap 3-4 cm above the internal opening. The flap is removed in the opposite direction with Alice terminal. The inner hole in the intestinal wall is scraped with a Volkman spoon and two rows of catgut sutures are applied. Then, with a few catgut sutures, a mobilized musculoskeletal flap is sutured so that the needle sticks at the edge of the wound in the anterior fold and the puncture comes out from the mobilized flap. With a few rare sutures, the edges of the flap are fixed to the edge of the perianal skin, after which the projection of the fistula’s internal opening in the muscular-muscular layer of the intestine is located outside the anal canal. In the outer edge of the perineal surgical wound, the inner portion of the gluteus maximus muscle is freed from the fiber and a complex U-shaped fascial-muscular transplant is made from it based on the 1st order branches of the lower gluteal neurovascular bundle, the muscle part of the graft is immersed in the residual cavity, and the fascial part of the complex transplant is fixed to the rectal wall with separate nodal catgut sutures with a symphysopetal type of pelvic topography at an angle of 90 ° to the horizontal axis of the pelvis, and with sacropetal type of pelvic topography - at an angle of 120 ° to the horizontal axis of the pelvis. Produce hemostasis control. The surgical wound is sutured in layers with separate interrupted sutures to the skin.

The method was tested in 12 patients in the coloproctology department of the clinic of Rostov State Medical University.

Examples of specific performance of the method.

Example 1. Patient I., 40 years old, medical history No. 3729/144, was admitted to the coloproctology department of the Rostov State Medical University on 05.16.05 with complaints of pain in the perineum, the presence of discharge from the external opening of the fistula. An objective study found: at 12 o’clock on the conditional dial there is an external fistulous opening 2 × 2 mm with edges covered with granulation tissue. Irrigography, endorectal ultrasound, anthropometric measurements of the pelvis and rectum were performed according to the method of V.V. Moskalenko et al. (1941). Based on the studies, a sacropetal type of pelvic topography was established. 05/18/05 the patient underwent surgery (protocol No. 127). In the position of the patient on the back, the legs are bent at the knee and hip joints and laid on supports, under an intravenous anesthesia, a rectal mirror inserted into the rectum performed sphincter divisions. Dye was introduced into the external fistulous opening. A fringing incision was made on the skin of the perineum around the external fistulous opening. The fistulous course in the acute way was isolated in the form of a tubular strand to the wall of the rectum and excised. The scar tissue surrounding the fistula and the edges of the fistula internal opening were excised. Novocaine was introduced into the submucosal layer of the rectum in the wall of the anal canal, corresponding to the location of the internal opening of the fistula. A lunar incision along the transitional fold of the anus separates the mucus-muscular flap 3-4 cm above the internal opening. The flap was removed in the opposite direction with Alice's terminal. The inner hole in the intestinal wall was scraped with Volkman's spoon and two rows of catgut sutures were placed. Then, with a few catgut sutures, a mobilized musculoskeletal flap was sutured so that the needle was injected at the edge of the wound in the anterior fold, and the puncture was attached to the mobilized flap. With a few rare sutures, the edges of the flap were fixed to the edge of the perianal skin, after which the projection of the fistula’s internal opening in the muscular-muscular layer of the intestine was located outside the anal canal. In the outer edge of the perineal surgical wound, the inner portion of the gluteus maximus muscle was freed from fiber and a complex U-shaped fascial-muscular transplant was made from it based on the 1st order branches of the lower gluteal neurovascular bundle. To isolate the plastic zone, the fascial part of the complex transplant was fixed with separate nodal catgut sutures to the wall of the rectum above the internal opening of the fistula at an angle of 120 ° to the horizontal axis of the pelvis. The muscle part of the complex graft was filled with a residual cavity. Made a control hemostasis. The surgical wound was sutured in layers with separate interrupted sutures to the skin. The postoperative period was uneventful, without complications. Healed postoperative wounds up to 9 days. 05/26/05 was discharged from the department with recovery. At the control examination after 3, 6 and 12 months, the patient did not show complaints. The sphincter tone is preserved, with rectoscopy of mucosal defects not detected. There is no data for relapse of the fistula.

Example 2. Patient A., 36 years old, medical history No. 4883/187, was admitted to the coloproctology department of the Rostov State Medical University on 06.27.05 with complaints of unpleasant sensations in the anal area arising from sitting, the presence of purulent discharge from the fistula. An objective study found: in the perianal region to the left 5-7 cm from the anus with a transition to the perineum, there is an arched postoperative scar 10 cm, up to 5 mm wide, elastic without the effects of infiltration and hyperemia. At the anterior and posterior extremities of the scar there were two external openings of the fistulous course, 2 × 3 mm in size with dense edges, hypergranulations. Irrigography, endorectal ultrasound, anthropometric measurements of the pelvis and rectum were performed according to the method of V.V. Moskalenko et al. (1941). Based on the studies, it was found that the type of pelvic topography is symphysopetal. 06/29/05 the patient underwent surgery (protocol No. 171). In the position of the patient on the back, the legs are bent at the knee and hip joints and laid on supports, under an intravenous anesthesia, a rectal mirror inserted into the rectum performed sphincter divisions. Dye was introduced into the external fistulous opening. A fringing incision was made on the skin of the perineum around the external fistulous opening. The fistulous course in the acute way was isolated in the form of a tubular strand to the wall of the rectum and excised. The scar tissue surrounding the fistula and the edges of the fistula internal opening were excised. Novocaine was introduced into the submucosal layer of the rectum in the wall of the anal canal, corresponding to the location of the internal opening of the fistula. A lunar incision along the transitional fold of the anus separates the mucus-muscular flap 3-4 cm above the internal opening. The flap was removed in the opposite direction with Alice's terminal. The inner hole in the intestinal wall was scraped with Volkman's spoon and two rows of catgut sutures were placed. Then, with a few catgut sutures, a mobilized musculoskeletal flap was sutured so that the needle was injected at the edge of the wound in the anterior fold, and the puncture was attached to the mobilized flap. With a few rare sutures, the edges of the flap were fixed to the edge of the perianal skin, after which the projection of the fistula’s internal opening in the muscular-muscular layer of the intestine was located outside the anal canal. In the outer edge of the perineal surgical wound, the inner portion of the gluteus maximus muscle was freed from fiber and a complex U-shaped fascial-muscular transplant based on the 1st order branches of the lower gluteal neurovascular bundle was stolen from it. To isolate the plastic zone, the fascial part of the complex transplant was fixed with separate nodal catgut sutures to the wall of the rectum above the internal opening of the fistula at an angle of 90 ° to the horizontal axis of the pelvis. The muscle part of the complex graft was filled with a residual cavity. Made a control hemostasis. The surgical wound was sutured in layers with separate interrupted sutures to the skin. The postoperative period was uneventful, without complications. Marked healing of the postoperative wound up to 10 days. 07/07/05 was discharged from the department with recovery. At the follow-up examination after 3, 6 and 12 months, the patient did not complain, the sphincter tone was preserved, and rectal examination of the mucous membrane revealed no defects. There is no data for relapse of the fistula.

Thus, in comparison with the prototype, the method has the following advantages.

1. The use of fascial-muscle non-free flap allows to achieve subsequent revascularization of the plastic zone.

2. Elimination of the residual cavity prevents infiltrative-inflammatory and suppurative complications.

3. Additional reinforcement of the internal opening reduces the likelihood of relapse of the fistula.

4. The application of the method takes into account the individual characteristics of the pelvic topography in relation to the operation technique.

Claims (1)

A method for surgical treatment of rectal fistulas, comprising excising a stained fistula with surrounding scar tissue and plastic restoration of the rectal wall in the area of the internal fistulous opening, characterized in that the U-shaped fascial-muscular transplant is cut out on the basis of the medial portion of the gluteus maximus muscle located above it gluteal fascia, and then immerse the muscle part of the graft in the residual cavity with fixation of the fascial part of the graft to the fascial case direct to shki at 90 ° to the horizontal axis of the pelvis simfizopetalnom type pelvic topography and an angle 120 ° to the horizontal axis of the pelvis during hip sakropetalnom type topography.