RU2559936C1 - Method of treating pilonidal cyst - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: pilonidal cyst is excised. A full-time vacuum therapy according to the schedule starts 24 hours after a surgical intervention. For the first 8 days at an initial negative pressure of 50 mm Hg every 2 minutes and a final negative pressure of 125 mm Hg every 5 minutes. For the following 12 days: at an initial negative pressure of 75 mm Hg every 7 minutes and a final negative pressure of 125 mm Hg every 2 minutes. A drain dressing and an antiseptic dressing are changed every 4 days as the vacuum therapy continues.

EFFECT: method increases the clinical effectiveness in pilonidal cyst, reduces the length of full wound healing and the risk of postoperative complications by the vacuum therapy and the integrated treatment of pilonidal cyst.

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Description

The invention relates to medicine, namely to coloproctology, and can be used for complex treatment of epithelial coccygeal passage.

The epithelial coccygeal passage (ECC) is a narrow canal lined with epithelium, containing hair follicles, sebaceous glands and opening on the skin of the intergluteal folds with one or more pinholes (Shelygin Yu.A., Grateful L.A. Coloproctology Handbook. M .: Litterra, 2014.S. 135).

ECH is a fairly common disease and accounts for 1-2% of all surgical diseases. The disease manifests itself, as a rule, in people of the most active working age, while the incidence peak occurs at the age of 15 to 30 years with a predominance of males in a ratio of 3: 1. Despite the many ways of treating ECX, their results cannot be called completely satisfactory due to the long term healing of wounds of the sacrococcygeal region, which, according to the literature, lasts up to 80 days, a high rate of relapse of the disease from 2 to 40% and postoperative complications from 2.5 to 53% (Clinical recommendations for the diagnosis and treatment of adult patients with epithelial coccygeal passage. - M., 2013, p. 12). Therefore, the development of new highly effective methods of treating ECC is an urgent problem of modern coloproctology.

Conducted research on the medical-scientific and patent literature found various ways of treating ECH.

There is a method of radical surgical treatment of ECC, consisting in excision of the ECC without suturing the wound with its further open management (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M .: Medicine, 1988, P. 92-94).

A significant drawback of this method is the need for long-term treatment. The healing time of a wound defect can reach several months. According to the literature, this period is from 9 to 10 weeks (Lavreshin P.M., Nikulin D.Yu., Korablina S.S. Diagnosis and treatment of epithelial coccygeal passage \\ Medical Bulletin of the North Caucasus, No. 4, 2011, С, 100 )

The well-known "Method of complex treatment of epithelial coccygeal passage" (RF patent No. 2444304, published on 03/10/2012). The method includes excision of the coccygeal passage, bringing the edges of the wound to the bottom of the wound and partial suturing of the wound with single U-shaped sutures without tension, antibiotic therapy. Before bringing the edges of the wound to the bottom of the wound on its lateral surface from the side of subcutaneous fat, linear cuts are made over the entire length of the wound at a distance of 0.5 cm from the skin surface with a depth of 0.5 cm. At a distance of 1.0-1.5 cm from the edges of the postoperative wound at the bottom of the wound, symmetrically on both sides, install polyvinyl chloride (PVC) tubes equal to the length of the wound, with holes on the side surface located every 2 cm. For immunotherapy, a patient is taken for blood, centrifuged to separate it mass. The erythrocyte mass is returned to the patient. The remaining cell mass is cultured with 500,000 IU of interleukin-2 for 60 minutes at a temperature of 37 ° C, centrifuged with the release of the supernatant. The supernatant containing a complex of autologous cytokines is injected through tubes in a volume of 5 ml for every 2 cm of the length of the wound on the first and third days after surgery.

The disadvantage of this method is the possibility of secondary infection, as well as the duration of wound healing, the terms of which can be from 4 to 12 weeks. Predisposing factors for infection of the wound is the presence of two PVC tubes, as a gateway for infection.

Also known is a method of treating ECX proposed by Duxbury and colleagues (Duxbury MS, Finaly IG, Butcher M., Lambert AW Use of a vacuum assisted closure device in pilonidal disease \\ J. Wound Care. 2003; 12 (9): 355), including excision of the ECX. 48 hours after excision of the ECC, a removable drainage dressing is applied and round-the-clock vacuum therapy is carried out in a constant mode of operation with a negative pressure of 125 mm Hg. A change in the drainage bandage is subsequently performed every 3 days. The course of vacuum therapy is 6 weeks, and the period of complete healing of the wound is 8 weeks.

A known method of treating ECX using vacuum therapy described by Benderwald F.P. and colleagues (Farrell D., Murphy S. Negative Pressure Wound Therapy for Recurrent Pilonidal Disease. A Review of the Literature \\ Wound Ostomy Continence Nurs. 2011; 38 (4): 373-378), providing for excision of ECC, application of replaceable drainage dressings, conducting round-the-clock vacuum therapy in a constant mode of operation with a negative pressure of 125 mm Hg Change of drainage dressings is performed every 2 days. The course of vacuum therapy is from 4 to 9 weeks. Vacuum therapy is stopped after the wound is completely filled with granulations; while the period of complete healing of the wound is from 9 to 22 weeks.

The disadvantage of the above methods of treatment is the long healing time of the wound, which is from 8 to 22 weeks, as well as the possibility of developing postoperative complications in the form of divergence of the edges of the wound and its infection.

The closest technical solution, selected as a prototype, is a method of treating ECH, described by Banasiewicz Y. and colleagues (Banasiewicz T., Bobkiewicz A., et al. Portable VAC therapy improve the results of the treatment of the pilonidal sinus - randomized prospective study \\ Polski Przeglad Chirurgiczny. 2013, 85, 7, 371-376). The method includes excision of the ECC, the application of a removable drainage dressing by laying in a wound dressing-sponge, installing wound drainage and gluing a film coating. The drainage tube is connected to the apparatus for therapy under controlled negative pressure and conduct round-the-clock vacuum therapy in a variable mode of operation according to the scheme: 3-8 minutes with a negative pressure of 100-130 mm Hg and 1-3 minutes without vacuum. Changing the drainage dressing is performed if necessary in case of violation of its tightness. The duration of vacuum therapy is 12 days.

The disadvantages of the prototype are: the possibility of developing postoperative bleeding due to the fact that vacuum therapy is started immediately after excision of the ECX, long terms for complete healing of the wound, since after 12 days of vacuum therapy, complete healing of an unhealed wound, as a rule, cannot to happen. At the same time, the results of a retrospective analysis of 18 case histories of patients treated according to the method described in the prototype in the surgical department of the clinic of Rostov State Medical University (Rostov State Medical University) showed that the average healing time for these patients is 31 days.

The task of the invention is to develop a highly effective method for the treatment of epithelial coccygeal passage.

The technical result of the proposed method, objectively manifested during its implementation, is to increase the effectiveness of the method of treatment of ECX by reducing the time of complete healing of the wound and eliminating the possibility of postoperative bleeding.

The technical result is achieved as follows. The ECC is excised, a removable drainage bandage is applied, for which a bandage-sponge is placed in the wound, wound drainage is installed, the bandage with an antiseptic is laid, and then a film coating is glued. Connect the drainage tube to the apparatus for therapy, controlled by negative pressure, and conduct round-the-clock vacuum therapy in a variable mode of operation. Round-the-clock vacuum therapy begins to be performed 24 hours after the operation of excision of the ECC according to the scheme: during the first 8 days at an initial negative pressure of 50 mm Hg with an interval of 2 minutes and a final negative pressure of 125 mm Hg with an interval of 5 minutes. Over the next 12 days, round-the-clock vacuum therapy is performed according to the scheme: at an initial negative pressure of 75 mm Hg. with an interval of 7 minutes and a final negative pressure of 125 mm Hg with an interval of 2 minutes. Changing the drainage dressing and dressings with an antiseptic is performed every 4 days after the start of vacuum therapy.

Detailed description of the method.

Treatment of the epithelial coccygeal passage is carried out in the patient's position according to Depage (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M .: Medicine; - 1988, p. 75) under spinal anesthesia. Radical excision of the coccygeal passage is performed according to the standard procedure (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M .: Medicine, 1988, P. 92-94). The operation is completed by thorough hemostasis with bipolar electrocoagulation and tamponing the wound with a dressing with ointment, for example, Levomekol.

24 hours after the excision, the ECC is ligated: tampons with Levomekol ointment are removed from the wound, and a removable drainage dressing is applied to the wound, for example, from the Suprasorb CNP kit of Lohmann & Rauscher (Germany) for applying drainage dressings. Put a bandage-sponge in the wound, install wound drainage, put a sterile bandage, for example, Kerlix with an antiseptic company AMD (USA). A film coating is glued, for example, from a Suprasorb CNP kit from Lohmann & Rauscher (Germany). The drainage tube is connected to a device for controlled negative pressure therapy, for example, to a Suprasorb CNP P2 device from Lohmann & Rauscher (Germany) for outpatient treatment of “mobile” patients. Immediately after this, they begin to perform round-the-clock vacuum therapy according to the scheme: during the first 8 days at an initial negative pressure of 50 mm Hg. with an interval of 2 minutes and a final negative pressure of 125 mm Hg with an interval of 5 minutes. Over the next 12 days, vacuum therapy is performed according to the scheme: at an initial negative pressure of 75 mm Hg. with an interval of 7 minutes and a final negative pressure of 125 mm Hg with an interval of 2 minutes. Changing the drainage dressing and dressings with an antiseptic is performed every 4 days after the start of vacuum therapy.

The practical feasibility of the claimed method for the treatment of ECX is illustrated by examples from clinical practice.

Example 1: patient G., 17 years old, was hospitalized in the surgical department No. 1 with a diagnosis of epithelial coccygeal passage in the stage of purulent fistula.

Patient G. complained of a fistulous opening in the sacrococcygeal region with purulent discharge, constant soiling of linen and discomfort. Sick for 6 months, when she first noticed the appearance of painful swelling, pain, redness in the sacrococcygeal region and an increase in temperature to 38.0 ° C. An outbreak and drainage of the abscess of the coccygeal region was performed on an outpatient basis, the wound healed by secondary intention. Patient G. subsequently formed a fistulous passage with constant purulent discharge.

Status localis: when examining the sacrococcygeal region on the right buttock at a distance of 1.5 cm from the midline, a longitudinal postoperative scar 4 cm long, indented and light, is noted. In the middle third of this scar there is a fistulous opening 0.5 × 0.5 cm in size with hypergranulations available for probe investigation; the latter passes 1.5 cm in depth, while there is a purulent discharge in moderation. Palpation: from the outer opening of the fistula down and to the midline, a tight cord is determined. Study per rectum: the message of the fistulous course with the intestine is not determined.

Patient G. was treated with ECX according to the claimed method. In the position of patient G. according to Depage under spinal anesthesia, a radical excision of the coccygeal passage was performed according to the standard method (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M: Medicine, 1988, P. 92-94). The operation was completed by careful hemostasis with bipolar electrocoagulation and tamponing the wound with a dressing with Levomekol ointment. 24 hours after the ECC excision operation, ligation was performed, tampons with Levomekol ointment were removed from the wound, and a removable drainage dressing from the Suprasorb CNP kit of Lohmann & Rauscher (Germany) was applied to the wound for applying drainage dressings. A sponge dressing was placed in the wound, wound drainage was installed, a sterile Kerlix dressing with an AMD antiseptic (USA) was placed, after which a film coating from the Suprasorb CNP kit of Lohmann & Rauscher (Germany) was glued. The drainage tube was connected to a Suprasorb CNP P2 negative pressure therapy device from Lohmann & Rauscher (Germany) for outpatient treatment of “mobile” patients. Immediately after this, a round-the-clock vacuum therapy was started according to the scheme: during the first 8 days at an initial negative pressure of 50 mm Hg. with an interval of 2 minutes and a final negative pressure of 125 mm Hg with an interval of 5 minutes. Over the next 12 days, vacuum therapy was carried out according to the scheme: at an initial negative pressure of 75 mm Hg. with an interval of 7 minutes and a final negative pressure of 125 mm Hg with an interval of 2 minutes. A change in the drainage bandage and the antiseptic dressing was performed every 4 days after the start of vacuum therapy.

Patient G. on the 9th day was discharged from the hospital for outpatient treatment in satisfactory condition with a clean, actively granulating wound. Complete wound healing in patient G. was recorded on the 23rd day during the follow-up examination. There was no postoperative bleeding in patient G. In the remote postoperative period, there was no relapse of the disease, a good cosmetic effect was noted.

Example 2: patient K., 19 years old, was hospitalized in the surgical department No. 1 with a diagnosis of epithelial coccygeal passage in the stage of purulent fistula.

Complaints about the presence of a fistulous opening in the sacrococcygeal region with purulent discharge. She became ill 2 months ago when she noticed the appearance of painful swelling, pain, redness in the sacrococcygeal region and a temperature increase of up to 38.0 ° C, the abscess opened on its own. It was treated independently, however, a fistulous passage with a constant purulent discharge was formed.

Status localis: when examining the sacrococcygeal region in the intergluteal fold at a distance of 7 cm from the anus, a fistulous foramen of 0.5 × 0.5 cm with hypergranulations is determined, accessible by probe examination; the latter extends 1.5 cm in depth. There is a purulent discharge in a moderate amount. A palpation from the outer opening of the fistula down towards the primary openings of the course is determined by a tight cord. Study per rectum: the fistulous passage with the intestine is not determined, there is no pathology at the height of the finger, there are light brown stool marks on the glove.

Patient K. was treated with ECX according to the claimed method. In the position of patient G. according to Depage under spinal anesthesia, a radical excision of the coccygeal passage was performed according to the standard method (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M .: Medicine, 1988, P. 92-94). The operation was completed by careful hemostasis with bipolar electrocoagulation and tamponing the wound with a dressing with Levomekol ointment. 24 hours after the ECC excision operation, ligation was performed, tampons with Levomekol ointment were removed from the wound, and a removable drainage dressing from the Suprasorb CNP kit of Lohmann & Rauscher (Germany) was applied to the wound for applying drainage dressings. A sponge dressing was placed in the wound, wound drainage was installed, a sterile Kerlix dressing with an AMD antiseptic (USA) was placed, after which a film coating from the Suprasorb CNP kit of Lohmann & Rauscher (Germany) was glued. The drainage tube was connected to a Suprasorb CNP P2 negative pressure therapy device from Lohmann & Rauscher (Germany) for outpatient treatment of “mobile” patients. Immediately after this, a round-the-clock vacuum therapy was started according to the scheme: during the first 8 days at an initial negative pressure of 50 mm Hg. with an interval of 2 minutes and a final negative pressure of 125 mm Hg with an interval of 5 minutes. Over the next 12 days, vacuum therapy was carried out according to the scheme: at an initial negative pressure of 75 mm Hg. with an interval of 7 minutes and a final negative pressure of 125 mm Hg with an interval of 2 minutes. A change in the drainage bandage and the antiseptic dressing was performed every 4 days after the start of vacuum therapy.

Patient K. on the 11th day was discharged from the hospital for outpatient treatment in satisfactory condition with a clean, actively granulating wound. Complete wound healing in patient K. was recorded on day 25 during the follow-up examination. There was no postoperative bleeding in patient K. In the remote postoperative period, there was no relapse of the disease, a good cosmetic effect was noted.

In the surgical department of Rostov State Medical University, according to the claimed method, ECC was treated in 8 patients: 5 men and 3 women, aged 17 to 32 years. All patients did not have any bleeding in the postoperative period; the terms of complete wound healing averaged 24 days.

Thus, the proposed method in comparison with the prototype can significantly reduce the time of complete healing of the wound and to exclude cases of postoperative bleeding.

Claims (1)

A method for treating the epithelial coccygeal passage (ECC), including excision of the ECC, applying a removable drainage dressing by putting a bandage on the wound, installing wound drainage and applying a film coating, connecting the drainage tube to a controlled negative pressure therapy device and conducting round-the-clock vacuum therapy in variable operating mode, characterized in that after installing wound drainage, an additional bandage with an antiseptic is placed on it, and round-the-clock vacuum therapy is started lnyat 24 hours after excision operation ECx scheme: during the first 8 days with an initial negative pressure of 50 mm Hg with an interval of 2 minutes and a final negative pressure of 125 mm Hg with an interval of 5 minutes, over the next 12 days - at an initial negative pressure of 75 mm Hg with an interval of 7 minutes and a final negative pressure of 125 mm Hg with an interval of 2 minutes; change of drainage dressings and dressings with an antiseptic is performed every 4 days after the start of vacuum therapy.