RU2397713C2 - Method of surgical release of lengthy stricture of anus and rectum with rectourethral fistulae in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applicable for release of lengthy stricture of anus and rectum with rectourethral fistula in children. Cicatrically modified posterolateral wall of rectum and cicatrical tissue of adrectal space are exsected keeping the anterior wall of rectum. Defect in the urethra is sutured with own tissues, muscular layer of the rectum front wall. Channel is formed and overlying colon is taken down through it.

EFFECT: method enables to reduce risk of fistula recurrence.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of extended stricture of the anus and rectum with rectourethral fistula in children.

It is known that anorectal abnormalities in children can be corrected by posterior sagittal access developed by PENA A. in 1982 (Peña A, de Vries P. Posterior sagittal anorectoplasy. Important technical considerations and new applications. J. Pediatr. Surg. L7: 796- 881, 1982).

Method no PENA A. lies in the fact that the patient is placed on the operating table face down with a raised pelvis. The incision begins from the middle of the sacrum and continues to the center of the external sphincter. The parasagittal fibers of the external sphincter, the levator and the muscular complex are separated strictly along the midline. At the end of the separation of all muscle structures, the rectum is visible in the wound.

Silk sutures are placed on the back wall of the rectum on both sides of the midline, after which the intestine is opened in the center and the incision is continued strictly along the midline down to the site of the fistula. Separate the anterior wall of the rectum from the common with the urethral wall. Carry out plastic urethra. The intestine is secreted around the entire circumference to such a depth that it can be freely lowered to the perineum. After the reduction, the perineum is reconstructed.

It is also known that in cases of a high form of atresia of the anal canal and rectum with rectourethral fistula, intrarectal peritoneal-perineal proctoplasty according to Ramualdi-Rebeyn is used (Lenyushkin A.I. Children's Coloproctology. - M .: Medicine. - 1990. - 116 p.) . Produce median laparotomy. Mobilize the mesentery of the sigmoid colon, while maintaining good blood supply to the site to be reduced to replace the rectum. The sigmoid colon is intersected between the two clamps a few centimeters above the transitional fold of the peritoneum. The peripheral end of the intestine is demucozed, trying to bypass from all sides the mucous membrane of the fistula and bandage it.

Transferring the patient to a lithotomy position, an incision is made on the perineum. The anal canal is made in a natural place and connected to the rectal one, perforating the blind “sac” from the side of the abdominal cavity so that the tunnel passes in the center of the pubic-rectal muscle and the entire muscle holding complex. The end of the mobilized intestine is lowered to the perineum, where the anus is formed, hemming the edge of the intestine to the edge of the skin incision behind the mucous membrane.

It is also known that Lenyushkin A.I. with recurrent rectourethral fistula performs perineal access if the fistula is located in the membranous part of the urethra or on the border with the prostatic (Lenyushkin AI Children's Coloproctology. - M .: Medicine. - 1999. - 342 p.). At the same time, in the patient’s lithotomy position, the bladder is opened with an epicystostomy incision and a catheter is inserted antegradely into the urethra. Then the arcuate incision of the skin of the perineum between the sciatic tubercles 2-2.5 cm above the mucocutaneous transition exposes the site of the anastomosis and allocates it from all sides. This stage of the operation is the most responsible and difficult, since it is necessary to manipulate in scar tissue. Immediately near the wall of the intestine, the fistula cross, open the defects of the intestinal wall and urethra. Under the control of a finger inserted into the rectum, the front wall of the intestine is mobilized so that its defect can be sutured with two rows of immersion sutures. Depending on the size of the defect, different methods of urethral plasty are used. The wound on the perineum is sutured in layers.

When using the above methods, the percentage of complications, unfortunately, remains high. The removal of anastomosis from the perineal access is extremely difficult due to the pronounced cicatricial process both in the wall of the rectum and in the tissues surrounding it. With the combination of stricture of the rectum with a fistula, mobilization of the anterior wall of the rectum under the control of a finger is extremely difficult. Suturing of the urethral defect only with its own tissues, often with scarred edges, leads to frequent relapses of the fistula of this localization.

The Romualdi-Rebeyn operation is practically impossible with an extended stricture of the rectum and anus, since from the laparotomic approach, given the small size of the pelvis in children, it is impossible to accurately resect the altered tissues.

The purpose of the invention is the radical elimination of extended stricture of the anus and rectum with rectourethral fistula in children.

For the first time, this goal is achieved by the fact that after preliminary demucosis of the mucosa by the posterior-sagittal approach, the scar-changed posterolateral walls of the rectum and cicatricial tissues of the rectal space are preserved with preservation of the anterior wall of the rectum, the urethral defect is sutured with its own tissues, the muscular layer of the anterior rectal wall, and the channel is formed for subsequent reduction of the overlying colon, abdominal-perineal access through the formed channel in excess reduces the overlying colon noses, thereby covering the urethral defect with three layers of tissue.

The method is illustrated by the following examples of its implementation:

Example 1

N. Vladislav, 5 years old (medical history No. 3396).

Diagnosis: Relapse of rectourethral fistula. Long cicatricial stricture of the anus and rectum. Megacolon. Chronic constipation, fecal incontinence. Condition after proctoplasty for atresia of the anus and rectum with rectourethral fistula.

Anamnesis: at the age of 3 days, was operated on for atresia of the anus and rectum and rectourethral fistula. Perineal proctoplasty with sagittal access was performed. In the postoperative period, constipation was noted. Bougienage was carried out to No. 14 (no effect).

In our department, it has been observed since 2002. According to the survey, cicatricial stricture of the anus and rectum was revealed.

09/25/2002, the operation was performed: colostomy. The course of the postoperative period was smooth.

The anus and rectum were bougienaged to bougie No. 12-14.

A year later (October 10, 2003), an operation was performed: closure of the colostomy. In the long-term postoperative period, the child was disturbed by constipation, subsequently, calomazie. During the last month, leakage of urine through the anus during the act of urination is noted.

On admission: general condition of moderate severity for the underlying disease. When viewed from organs and systems without features.

Inspection of the perineum: anus - located typically, deformed by scars. Per rectum - the rectal ampoule is stenosed, digital examination of the rectum is difficult. A pocket-shaped recess of up to 1.5 cm is defined along the front wall.

Examination:

Irrigography: The colon is filled to the dome of the cecum. When filling, a low colonic reflux is determined. The anal canal is narrowed. The folds of the mucous membrane in the anal canal are located spirally. The sigmoid colon is dilated, the haustration is poorly expressed. Overlying departments are not treason.

Cystoscopy: Bladder mucosa not changed. The mouth of the ureters is typically located, tightly closed. There is a rectourethral fistula with a diameter of about 0.5 cm on the posterior wall of the bulbous urethra, directly below the pelvic diaphragm. The fistula is catheterized. The outlet is located on the front wall of the intestine at a distance of 2.5 cm from the mucocutaneous transition.

Treatment:

April 9, 2007 - operation: Abdominal-sacral proctoplasty, cystostomy. Posterior sagittal skin incision from the coccyx to the anus, while maintaining the integrity of the fibers of the external anal sphincter. Tissues are acutely and bluntly dissected to the posterior wall of the rectum. To expand the surgical field, a resection of the last coccygeal vertebra was performed. During the audit of the rectum, a rectourethral fistula was found that passes between the preserved rectal mucosa and the full-layer reduced intestine. Using hydropreparation, demucosis of the rectal mucosa was performed. Cicatricial walls of the rectum were excised, leaving its anterior wall. The urethra was made using its own tissues (VAT 4/0) on a catheter.

A rectal canal is formed. A silicone tube is left in the rectal canal. The sacral wound is sutured in layers, with the restoration of the integrity of the muscular complex.

Then the patient was transferred to a lithotomy position. A median laparotomy was performed with excision of the old postoperative scar, and the abdominal cavity was opened in layers. The distal colon was mobilized due to the dissection of the parietal peritoneum and ligation of the branches a. colica sinistra. The mobilized gut is fixed on a silicone tube and relegated to the perineum. The intestine is stitched to the perianal skin with interrupted sutures (PDS 3/0). A silicone tube was inserted into the lumen, fixed to the intestine. In the abdominal cavity, the integrity of the peritoneum is restored. Hemostasis. Layered seams on the wound. Iodine. Aseptic dressing.

In the postoperative period, the child received infusion, antibacterial, stimulating therapy. The postoperative period is smooth.

04/23/2007 (after 2 weeks) - operation: cutting off the reduced bowel.

The postoperative period is smooth. Received uroseptics (5-NOC, furagin). 05/04/2007 cystostomy drainage removed, urinates independently, urine control tests are within normal limits. Sutures removed, healing by first intention.

At re-examination after 1 month (medical history No. 6313).

The condition is satisfactory. When examining the perineum: the anus is usually located. Anus area without inflammation. On finger examination, the anastomotic area is passable. Urination is free, painless, arbitrary. There is no leakage of urine through the anus.

Control sigmoidoscopy: the endoscope is inserted freely. In the area of the anastomosis, single granulations are determined, the zone of the anastomosis is passable, diameter up to 2 cm. The colon without features.

Treatment: prophylactic bougienage of the anastomosis with bougie No. 13 was performed, cleansing enemas, microclysters with chamomile, anti-inflammatory suppositories. Anastomosis freely pass. Granulation decreased.

Control examination after 6 months.

The condition of the child is satisfactory.

When examining the perineum: the anus is usually located. Anus area without inflammation. A rectal examination revealed no pathology, the anastomosis zone is freely passable for bougie No. 14. Urination is free, painless, arbitrary. There is no leakage of urine through the anus.

The advantage of the claimed method for surgical removal of an extended stricture of the rectum and anus with rectourethral fistula in children is the radical elimination of scar-altered tissues of the rectum and pararectal space, optimal access to the rectourethral fistula with the possibility of its reliable overlapping with its own tissues, the muscular wall of the rectum and the full-layer reduced colon. Preservation of the demucosal anterior wall of the rectum eliminates injury to the urethra and allows its tissue to be used for urethral plastic surgery. Radical excision of scar tissue in the rectal canal creates adequate conditions for blood supply to the colon that has been reduced to the perineum. The use of this method eliminates the recurrence of bowel stenosis and rectourethral fistula.

All operated patients are under clinical supervision. The observation periods of up to a year or more are convincing in order to assert with full confidence that the method we developed for the surgical removal of an extended stricture of the anus and rectum with rectourethral fistula in children is effective and incomparably better than previously known surgical methods of treatment.

The claimed method is not obvious to specialists - pediatric surgeons.

It should be noted that such surgical interventions are feasible only in specialized clinics, highly professional pediatric colorectal surgeons.

Our method of surgical removal of an extended stricture of the anus and rectum with rectourethral fistula in children significantly improves the results of surgical treatment of this complex pathology.

Claims (1)

A method of surgical removal of an extended stricture of the anus and rectum with rectourethral fistula in children, characterized in that after preliminary demucosis of the mucosa by the posterior-sagittal approach, the rumen-modified posterolateral walls of the rectum and cicatricial tissues of the rectal space with preservation of the anterior rectal wall are excised, the urethral defect is sutured with their own tissues, the muscle layer of the anterior wall of the rectum, form a channel for subsequent reduction of the overlying colon, abdominal ezhnostnym access via the channel formed with excess degrade the overlying large intestine, thereby urethral defect cover three layers of tissue.