RU2366370C2 - Anal fissure surgery technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to colorectal surgery. A fissure is excised. Under epidural-sacral anaesthesia, within 5-8 minutes balloon divulsion of anal sphincter is carried out. Therefor, parent diametre of anal canal is evaluated. Divulsion is performed with the balloons of diametre 4.1, 4.5, 4.8, 5.1 cm considering the parent diametre of anal canal. It is ensured with using the balloon made of thin rubber and packed in a hardwearing cylindrical cloth pocket. The balloon is stretched to external diametre. The offered method presents pathogenetically grounded, less traumatic and simple intervention, provides prevention of disease recurrence, and allows improving functional clinical effect of treatment.

EFFECT: offered method allows eliminating sphincterotomy, reducing postoperative pain syndrome; it represents an operation of choice for treatment of chronic anal fissure with anal sphincter muscle spasm.

1 ex

Description

The invention relates to medicine, namely to colorectal surgery, and can be used to treat anal fissures.

The following methods of treating anal fissures are known.

1. There is a method of treating anal fissures by excision and transcranial dosage sphincterotomy, in which the wound is not sutured (Aminev A.M., 1979).

The disadvantage of this method is:

- long-term healing of postoperative wounds (within 21-30 days),

- the risk of developing anal sphincter failure,

- the possibility of forming a rough deforming anus of the postoperative scar.

2. A known method of treating anal fissures by balloon divulsion. One of the first publications is dated 1914, when the author (Hirschman L.J. 1914) inflated the balloon in the anal canal without anesthesia and pressure control in the balloon. In recent publications (Nielsen MB et al. 1993; Renzi A. et al. 2005; Sohn N. et al. 1992; Sohn N. 1997; Walfisch S. 1998), the authors used a balloon with a diameter of 30-40 mm, inflated it in anal canal up to 1.4 atmospheres and withstood exposure for up to 6 min (A. Renzi et al. 2005). It should be noted that the authors did not dissect the anal fissure. In addition, the manipulation took place only under local anesthesia.

The disadvantage of this method is:

- the development of relapses was observed in 6-8% of patients (Renzi A. et al. 2005; Sohn N. et al. 1992: Walfisch S. 1998), up to 22% (Sohn N. 1997).

- weakness of the anal sphincter develops in 6-8% of patients (Nielsen M.B. 1993; Renzi A. 2005).

Prototype Characterization

A known method of treating anal fissures by excising them with lateral subcutaneous sphincterotomy (Parks A. Management of fissure in ano. // Hosp. Med., 1967, No. 1, p. 737).

Criticism of the prototype.

Significant disadvantages are:

- In the early postoperative period, the formation of hematomas and abscesses in the area of sphincterotomy is possible. In the distant postoperative period, the formation of rectal fistulas was noted in 0.2-1.6%. It should be emphasized that in 0.6-19.6% of patients, the weakness of the sphincter of the anus persists, of which I degree of incontinence is recorded in 0.6-11.6% of cases, and II degree in 6-8%. Relapse of the disease develops in 0.6-11.1% of patients (Shelygin Yu.A. et al. 2005; Poletov N.N. et al. 2003; Tocchi A. 2004).

The purpose of the invention: Improving the results of surgical treatment of patients with anal fissure.

The technical result of this work lies in the fact that the proposed method of balloon divulion of the anal sphincter with excision of the anal fissure allows us to consider it as the operation of choice for the treatment of chronic anal fissure with spasm of the anus sphincter.

The proposed method is a pathogenetically substantiated, less traumatic intervention; after the operation, special use of narcotic painkillers is not required. The pneumodivulsion method can significantly reduce postoperative pain (2-4 points on a 10-point analogue scale) and significantly reduce the number of postoperative complications, since there is no need for sphincterotomy. Rehabilitation of patients is 1-4 days, which significantly reduces the time of patient disability and does not require hospitalization or hospitalization for no more than one to two days. The method is convenient and easy to use, its methodological development by coloproctologists requires a short training course. In this regard, the use of this treatment method is possible on an outpatient basis or in a one-day hospital.

Technique of operation: Under epidural-sacral anesthesia, a gradual balloon sulphide anal sphincter balloon is produced using an engineered balloon consisting of thin rubber placed in a durable cloth pouch in the form of a cylinder, the diameter of which is from 4.1 to 5.1 cm. The balloon along with the manometer and pear make up a single closed system. By injecting air to 0.6-0.8 atmospheres, the balloon expanded completely to its maximum diameter and for 5-8 minutes the anal sphincter was sabotaged until the spasm of the internal sphincter was completely relieved. Depending on the initial diameter of the patient’s anal canal, which was determined by a simple device in the form of a cone with marks on it, the sabotage was carried out with four sizes of cylinders with a diameter of 4.1, 4.5, 4.8 and 5.1 cm. After the sabotage, economical excision of the anal fissure together with the “watchdog” tubercles with a radio wave scalpel, or an electrocoagulation loop. It should be noted that balloon diversion is performed with a gradual increase in pressure, under epidural-sacral anesthesia, which ensures complete relaxation of the anal sphincter evenly over the entire circumference.

Clinical example: Case history No. 2063, 2006

Patient Bulkina I.V., 36 years old, was admitted with complaints of severe pain in the anus during and after defecation, lasting about 3 hours, the release of scarlet blood, and stool fear. Considers herself a patient for 1 year, exacerbation due to increased pain in the last 2 weeks.

Locally: when diluting the edges of the anus at 6 o’clock, there is a mucosal defect of about 1.0 × 0.4 cm in length with dug callous edges, a whitish bottom, and a hypertrophied papilla. On finger examination, there is a pronounced spasm, painful anal fissure.

Profilometry: pressure in the anal canal at rest amounted to: 89.6 mm water before surgery. Art. (at the norm - 52.2 ± 8.2 mm of water. Art.), on the 7th day after the operation - 45.4 mm of water. Art. and 30 days after surgery - 49.7 mm of water. Art.

Diagnosed with chronic posterior anal fissure with sphincter spasm.

On September 11, 2006, the patient underwent surgery: pneumodilation of the anal sphincter with excision of the anal fissure.

Under epidural-sacral anesthesia, a cone-shaped device was inserted into the anal canal with marks on it (the initial diameter of the anal canal was 4.8 cm). After removing the cone, the corresponding balloon with a diameter of 4.8 cm is introduced into the anal canal. Balloon sulphure was performed for 8 minutes. After removing the balloon, the anal fissure was excised. The duration of the operation was 15 minutes (along with balloon divulia). The postoperative period was uneventful. There was no pain. 6 hours after the operation, she was discharged for outpatient aftercare. On the first and second days I took ketanes of 1 table. for pain. P / o the wound healed on the 20th day after surgery. With stool, the patient did not note the above complaints.

According to this technique, 253 patients were operated on. In no case of weakness of the anus sphincter was revealed. Relapse was detected in 2 cases.

The proposed method in comparison with the known methods of surgical treatment of anal fissures makes it possible:

- significantly reduce postoperative pain;

- reduce postoperative hospital bed to 1 day;

- reduce the incidence of postoperative complications and relapses;

- improve the functional results of treatment.

Bibliography

1. Aminev A.M., Guide to proctology, t.4, 1979, p.57.

2. Ulanovsky I.N., SU copyright certificate 1149944, IPC АВВ 17/00, BI No. 14, 1985.

3. Parks A.G. The management offissure-in-ano. - British Journal of Hospital Medicine, 1967, 1. P.737-739.

4. Shelygin Yu.A., Zharkov E.E., Orlova L.P. et al. Long-term results of excision of an anal fissure in combination with lateral subcutaneous sphincterotomy // Actual problems of coloproctology. - Moscow, 2005, - p. 141-142.

5. Flights N. N., Podmarenkova L. F., Orlova L. P. et al. Long-term results of excision of a chronic anal fissure with lateral subcutaneous sphincterotomy, mechanisms for the return of the disease and the development of insufficiency of the anal pulp. // Actual issues of coloproctology. Thes. doc. I Congress of Coloproctologists of Russia with international participation. - Samara. 2003 .-- pp. 112-113.

6. Tocchi A., Mazzoni G., Miccini M., Cassini D., Bettelli E., Brozzetti S .. Total lateral sphincterotomy for anal fissure // International Journal of Colorectal Disease. - 2004. - V.19, N.3. - P.245-249.

7. Hirschman L.J. Handbook of diseases of the rectum. // St. Louis: CB, 1914. Nielsen M. B., Rasmussen O., Pedersen J.F. et al. Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano: an endosonographic stady. // Dis Colon Rectum. - 1993. - V.36. - N.7. - P.677-680.

8. Parks A. Management of fissure in ano. // Hosp. Med., 1967, No. 1, p. 737.

9. Renzi A., Brusciano L., Pescatori M. et al. Pneumatic ball dilatation for chronic anal fissure: a prospective, clinical, endosonographic and manometric stady. // Dis Colon Rectum - 2005 .-- V.48. - N.1. - P.121-126.

10. Sohn N., Eisenberg M.M., Weinstein M.A. et al. Precise anorectal sfincter dilatation - its role in the therapy of anal fissures. // Dis Colon Rectum. - 1992. - V.35. - N.4. - P.322-327.

11. Sohn N., Weinstein M.A. Anal dilatation for anal fissure. // Semin colon rectal surgery. - 1997; 17-23.

12. Walfisch S., Silberstein E. Balloon anal dilatation for anal fissure. // Tech Coloproctol. - 1998; 2; 73-5.

Claims (1)

A method of surgical treatment of anal fissures, including excision of the fissure, characterized in that a balloon divulsion of the anal sphincter is carried out for 5-8 minutes under epidural-sacral anesthesia, for which the initial diameter of the anal canal is determined, the sulphurization is carried out with cylinders with a diameter of 4.1, 4 , 5, 4.8, 5.1 cm, depending on the initial diameter of the anal canal, using a balloon made of thin rubber placed in a durable cloth bag in the form of a cylinder, expanding to its maximum diameter.