RU2492801C1 - Method of predicting encopresis after anorectoplasty in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to paediatric surgery, and can be used for predicting results of operative treatment of rectum and anus atresia in children. Anorectal area is examined by methods of laser Doppler flowmetry, optic tissue oxymetry and laser fluorescence in not less than 4 points. In each of the points determined are: index of microcirculation - I_mi, volume of blood filling - V_bi, index of blood oxygenetion - SO_2i; intensity of radiation of collagen and elastin fluorescence - I_fki, I_f"э"i and intensity of diffused laser radiation I_li. Specific consumption of oxygen by tissue, as ratio SO_2i/V_bi, ratio of index of microcirculation to volume of blood filling- I_mi/V_bi are calculated and coefficient of fluorescent contrast of fraction of tissue proteins η_fi is determined by means of computer processing. All obtained values on 4 points are averaged to obtain average values of SO₂/V_b; η_f, and if values SO₂/V_b ⁼0.01-2, I_m/V_b=0.01-1; η_t=0.01-1, prediction is estimated as favourable.

EFFECT: method makes it possible to estimate change of blood flow, hypoxia and disorganisation of intercellular components of connective tissue of anorectal area in a reliable way and make prognostic conclusions as to selection of individual treatment.

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Description

Anomalies in the development of the anorectal region currently continue to be one of the most difficult problems in childhood surgery. Over the past 10 years, the number of children with atresia of the rectum and anus has increased more than 2.5 times. Correction of this pathology is possible only surgically.

The results of surgical correction of this pathology are not always favorable: some of the children subsequently experience anal incontinence associated with congenital insufficiency or damage to the muscular structures of the obturator. In accordance with this, a preliminary study of the state of the anorectal region (the state of its muscle tissue, the degree of its sclerosis) is necessary.

The basis of this invention is spectrophotometric studies of tissue using the apparatus LAKK-M. The use of non-invasive methods of laser Doppler flowmetry, optical tissue oximetry and laser fluorescence of the main tissue fluorophores makes it possible to assess changes in blood flow in microvessels, hypoxia and disorganization of intercellular components of connective tissue.

These studies will allow to predict the result of anarectoplasty, to choose the right treatment tactics and the terms of surgical treatment.

A known method for predicting the results of surgical treatment of atresia of the rectum and anus in children by examining the external sphincter of the anus using the X-ray method (A.N. Smirnov et al. X-ray assessment of the colon in patients with functional disorders in the long term after correction of anorectal anomalies. (Actual problems of pediatric surgery, resuscitation and anesthesiology. Collection of scientific, works under the editorship of the academician of the Academy of Medical Sciences of the USSR, professor Yu.F. Isakov. M., 1989, p.

In this method, the assessment of a favorable prognosis is carried out according to the height of the atresia level and the presence of a direct anorectal angle.

The disadvantage of this method is the low reliability of prediction, due to the fact that in some patients, even with direct anorectal angle after surgery, encoporesis is observed.

Closest to the proposed is a method for predicting encopresis after anorectoplasty in children, including a study of the anal area (Pat RF No. 2132152, class A61B 5/04, 1999). In this method, concentric needle electrodes are introduced into the muscle of the external sphincter of the anus, the frequency, amplitude and Wilson coefficient are determined, based on which the position of the sphincter is judged.

This technique is invasive, its implementation in children of the first year of life is associated with the need for anesthesia due to the pain of the procedure. It is also possible bleeding from the introduction of needle electrodes, as in children of the first month of life, bleeding of tissues is increased.

In addition, the functionality of this method is limited. So, for example, it cannot be used in the absence of muscles of the external and / or internal sphincter. This is usually determined visually during surgery. In addition, anal incontinence is also associated with the process of sclerosis in the postoperative area of the sphincter apparatus, which is generally not taken into account in this method.

In accordance with the foregoing, the authors set a task aimed at eliminating these shortcomings and creating a non-invasive method for studying the anorectal region in children with wide functional capabilities.

To solve this problem, in the method for predicting encopresis after anorectoplasty in children, including the study of the anorectal region, it is proposed to study the anorectal region using laser Doppler flowmetry, optical tissue oximetry and laser fluorescence, with at least 4 points of the anorectal region around the anus using a laser source with a wavelength of 370 nm, excite tissue fluorescence, then at each point determine the microcirculation index - I _mi , volume blood filling volume - V _bi , blood oxygenation index - SO _2i, collagen and elastin fluorescence emission intensity - I _fKi, I _fei at a wavelength of 420-460 nm and scattered laser radiation intensity I _li at a wavelength of 370 nm, then calculate specific oxygen consumption tissue, as the ratio SO _2i / V _bi , the ratio of the microcirculation index to the volume of blood supply - I _mi / V _bi , using computer processing to determine the coefficient of fluorescence contrast of the tissue protein fraction η _fi , to average all the obtained values over 4 points to obtain I mean SO ₂ / V _b ; I _m / V _b ; η _f and when the value of SO ₂ / V _b = 0,01-2, I _m / V _b = 0,01-1; η _f = 0.01-1 evaluate the forecast as favorable

The method is as follows.

Spectrophotometric studies of the tissue are carried out using the LAKK-M apparatus using laser Doppler flowmetry, optical tissue oximetry and laser fluorescence of the main tissue fluorophores. Using these methods allows us to assess changes in blood flow in microvessels, hypoxia and disorganization of the intercellular components of connective tissue.

It has been experimentally established that the anal region of the child, as a rule, is not equally affected in all its areas. The presence of scars, adhesions located on the test surface dramatically changes the quantitative value of the intensity of the reflected radiation of collagen and elastin. In this regard, as criteria for assessing the condition of the anal region, it is necessary to determine the intensity of the reflected radiation of collagen and elastin at least 4 points around the anus, which allows to determine the disorganization of the intercellular components of the connective tissue, as well as the change in blood flow in microvessels, and the presence of hypoxia in this area, will significantly increase the reliability of assessing the condition of the anal area.

All diagnostic tests are carried out indoors at normal room temperature of 20-22 ° C. The patient is lying on the couch, legs are bent at the knees and brought to the stomach. The study of the anal area is carried out at least 4 points located around the anus. Tissue fluorescence is excited in each of the points sequentially using a laser radiation source with a wavelength of 370 nm, then at each of the points i = 1-4, the microcirculation index - I _mi , blood volume - V _bi , blood oxygenation index - are recorded using a sensor SO _2i (the intensity of the fluorescence emission of collagen and elastin - I _fki , I _fei at a wavelength of 420-460 nm and the intensity of scattered laser radiation I _li at a wavelength of 370 nm, then determine the specific oxygen consumption of the tissue as the ratio SO _2i / V _bi , mik index ratio otsirkulyatsii to the volume of blood filling - I _mi / V _bi, via computer processing coefficient determined fluorescent contrast tissue protein fraction η _fi, by the known formula

, $${\eta }_{ƒi}=\frac{I_{ƒki}+I_{ƒi\mathrm{uh}}-I_{li}}{I_{ƒki}+I_{ƒi\mathrm{uh}}+I_{li}}+\mathrm{one}$$

,

then find the value of the relations SO _2i / V _bi , I _mi / V _bi and the coefficients η _fi according to obvious formulas from 4 points:

$$S{O}_2/V_b=\frac{\mathrm{one}}{\mathrm{four}}{\displaystyle \sum _{i=\mathrm{one}}^{i=\mathrm{four}}S{O}_{2i}/V_{bi}}$$

$$I_m/V_b=\frac{\mathrm{one}}{\mathrm{four}}{\displaystyle \sum _{i=\mathrm{one}}^{i=\mathrm{four}}{I}_{mi}/V_{bi}}$$

$${\eta }_{ƒ}=\frac{\mathrm{one}}{\mathrm{four}}{\displaystyle \sum _{i=\mathrm{one}}^{i=\mathrm{four}}{\eta }_{ƒi}}$$

and with a value of SO ₂ / V _b = 0.01-2; I _m / V _b = 0.01-1; a η _f = 0.01-1 evaluate the prognosis as favorable.

Specific examples of the method

Example 1

Kesareva V., 1 year 3 months, No. 24129 was born with atresia of the anus, rectovestibular fistula. Was in DRL MONICA in September 2009, a month ago, anterior sagittal anorectoplasty by Rizzolli was performed. Before the subsequent surgical treatment, the closure of the sigmostomy, using the LAKK-M apparatus, a study was performed using laser Doppler flowmetry, optical tissue oximetry and laser fluorescence of the main tissue fluorophores. After excitation of fluorescence using a laser source with a wavelength of 370 nm, tissue fluorescence is excited at 4 points around the anus, then the microcirculation index is recorded using a sensor at each point — I _m1 , I _m2 , I _m3 , I _m4 = 11, 8 , 14, 17 blood supply volume - V _b1 , V _b2 , V _b3 , V _b4 = 11, 19, 17, 19; blood oxygenation index - SO ₂₁ , SO ₂₂ , SO ₂₃ , SO ₂₄ = 11, 20, 17, 15, specific oxygen consumption by the tissue, as the ratio SO _2i / V _bi = 1, 0.9, 1, 0.8, the ratio of the microcirculation index to the volume of blood supply - I _mi / V _bi = 1, 0.4, 0.8, 0, 9 fluorescence emission intensity ollagena and elastin - I _fki, I _fei in wavelength 420-460 nm _{= I fk1, I fk2, I} fk3, I fk4 = 10; 5; 9; 2.1; I _fe1 , I _fe2 , I _fe3 , I _fe4 = 12, 4, 6, 18, respectively, and the intensity of the backscattered laser radiation I ₁₁ , I ₁₂ , I ₁₃ , I ₁₄ at a wavelength of 370 nm = 156; 160; 92; 67. According to the data obtained using computer processing, the coefficient of fluorescence contrast of the tissue protein fraction was determined η _fi = 0.25; 0.1; 0.28; 0.35, all data were averaged over 4 points, as a result of which received: SO ₂ / V _b = 0.93; I _m / V _b = 0.78; η _f = 0.24. Therefore, the forecast is favorable. After closure of the stoma, there is no fecal incontinence.

Example 2

Murashov I., 17 years old, No. 2885, was born with an atresia of the anus, a sigmostoma was applied during the neonatal period, perineal proctoplasty was performed at the age of 3 years. Was in DRL MONICA in January 2009. Received to address the issue of prompt closure of the sigmostomy. A study of the proposed method in order to predict the results of the operation. When examining the anorectal region, SO ₂ / V _b = 2.7; I _m / V _b = 1.45; η _f = 1,2. Therefore, the prognosis is poor. Conducting conservative treatment courses is not enough. A transplant in the tissue of the anal area of the bone marrow with stem cells is shown.

Creating a simple, non-invasive method of research will reliably assess the condition of the anorectal region in the child and make prognostic conclusions regarding the choice of individual treatment.

Claims (1)

A method for predicting encopresis after anorectoplasty in children, including the study of the anorectal region, characterized in that the study of the anorectal region is carried out using laser Doppler flowmetry, optical tissue oximetry and laser fluorescence, with at least 4 points of the anorectal region around the anus using a source laser radiation with a wavelength of 370 nm excite tissue fluorescence, then at each of the points determine the microcirculation index - I _mi ;, the volume is blood-filled Ia - V _bi, blood oxygenation index - SO _2i, the fluorescence emission intensity of collagen and elastin - I _fki, I _fei wavelength 420-460 nm and intensity of scattered laser radiation I _li at a wavelength of 370 nm, then calculating the specific oxygen consumption of cloth as the ratio of SO _2i / V _bi, microcirculation index ratio to the volume of blood filling - I _mi / V _bi, via computer processing coefficient determined fluorescent contrast tissue protein fraction η _fi, all the obtained values are averaged on 4 points to obtain the average value Nij SO ₂ / V _b; I _m / V _b ; η _f and when the value of SO ₂ / V _b = 0,01-2, I _m / V _b = 0,01-1; η _f = 0.01-1 evaluate the prognosis as favorable.