RU2597320C1 - Method of treating postradiation rectovaginal fistulas - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and surgery. Carry out treatment of postradiation rectovaginal fistulas. From non-irradiated areas of the patient's body by means of vacuum liposuction take away the lipoaspirate. It is cleared of a supranatant and infranatant. Stromal-vascular fraction is allocated. Enter lipoaspirate the fan-retrograde at 0.1-0.2 ml per one pass of the cannula with diameter 1.0-1.2 mm, length 70 mm through skin punctures in deep layers of the rectovaginal septum. Stromal-vascular fraction in the form of suspension using a needle with diameter 0.2-0.4 mm is introduced the into mucosal and submucosal layers, using papule method, along the whole surface of the rectum.

EFFECT: method allows to improve tissue homeostasis and healing of postradiation rectovaginal fistula, due to engraftment in the irradiated zones of the healthy stem cells triggering regenerative process.

1 cl, 2 ex, 2 dwg

Description

The invention relates to medicine and can be used in surgery, coloproctology, gynecology.

Rectovaginal fistula is a pathological course that communicates the lumen of the rectum and vagina. Most often, the disease is acquired in nature, less often - congenital. In most cases, the causes of the development of acquired rectovaginal fistulas are complicated births, injuries, unsuccessful gynecological or proctological operations. The only way to radically treat non-healing rectovaginal fistulas, regardless of their origin, is surgery (Viatcheslav Vasilyev. Rectovaginal fistula. - Internet site http: // iurs / org / ua / ru / pacientam / zabolevaniya / rektovaginanyj-svish /. A separate group consists of postradiation rectovaginal fistulas arising from radiation or combined treatment of cervical cancer.The formation of the fistula begins with the appearance of an ulcer on the front wall of the rectum, followed by its deepening and penetration into the vaginal lumen.

The authors of the proposed method has been studied an array of patents for inventions of the Russian Federation relating to methods of surgical treatment of rectovaginal fistula. The most acceptable for postradiation fistula is, in their opinion, the method of surgical treatment of rectovaginal fistula according to the patent of the Russian Federation No. 2369337 (IPC АВВ 17/00, priority 07.07.2008). According to the known method, a rectovaginal fistula is excised, then a full-layer segment of the vaginal wall is isolated and mobilized in a caudal direction by incision of the posterior vaginal wall, it is folded back, then the rectovaginal septum is cleaved, then the anterior sphincterole-plasty is performed, then the anterior canal plasticity is formed and the anterior duct is plastic and By hemming the flap with separate sutures to the skin, the vagina is sutured in the longitudinal direction.

The disadvantage of this method are: the need for anesthesia, the complexity of the operation itself, associated with high morbidity, a long rehabilitation period, as well as a high risk of postoperative complications.

The authors of the proposed method, not finding a suitable surgical treatment for postradiation rectovaginal fistula, turned to methods of treating trophic ulcers, the nature of which is close to ulcers that cause the appearance of postradiation rectovaginal fistula.

A known method of treating trophic ulcers (RF patent No. 2528973, IPC A61K 35/12, C12N 5/077, A61P 17/02, convention priority 07.08.2003, US 60/493000). The method includes adipose tissue autotransplantation - lipofilling with a lipoaspiration cannula up to 1.2 mm in diameter from subcutaneous fat of the anterior abdominal wall, which is washed with a 5% glucose solution; the resulting fat fraction is diluted with a 5% glucose solution in a ratio of 1: 1 - glucose - fat, shaken and get a suspension, through the punctures on the skin up to 1.5 mm into the soft tissue around the ulcer and directly under the ulcer defect injected cannula up to 1.2 mm in diameter with a blunt end, carry out to the end of each marked beam and introduce the resulting suspension at the exit, gradually removing the cannula by simultaneously pressing the syringe on the piston; up to 5 injections of suspension from one puncture are made fan-shaped, creating a perifocal roller up to 0.7 cm thick; the distance between the beam-channels should not exceed 2-3 mm.

The known method leads to the healing of trophic ulcers of external localizations. In the case of treatment of such a trophic ulcer, there is convenient access to it from all sides and from the bottom with the introduction of lipoaspirate into soft tissues. Compared with trophic ulcers of external localizations, rectovaginal fistula has differences in surgical access and anatomical structure: the surface layer is represented by a thin mucous membrane, and the submucosal and muscle layers form deep tissues. Lipoaspirate, which is administered with thick cannulas up to 1.2 mm, cannot technically be introduced into the mucous and submucosal layers, but only into the muscle layer, as a result of which the mucous layer does not heal, and therefore, the rectovaginal fistula is not epithelized.

A known method of treating trophic ulcers, in which adipose tissue is collected from a patient by lipoectomy (excision) of a section of subcutaneous fat in the umbilical region or along the inner surface of the upper third of the thigh (Treatment method using autologous mesenchymal stem cells from adipose tissue in patients with trophic ulcers , approved by the Ministry of Health of the Republic of Belarus on November 18, 2011, registration No. 093-0911, Instructions for use - see the websites http://celltech.by/index.php/lechenie-troficheskikh-yazv-konechnostej and www.bsmu.by/downloads/vrachu/instrukcii/093-0911.pdf). The resulting lipoaspirate is transported to the laboratory, where it is purified from the supranatant and poured into a nutrient medium to accumulate a homogeneous cell suspension. After careful research, cellular biomass is transported to a specialized clinic for transplantation. First, a homogeneous cell suspension is applied to the central surface of the wound with a micropipette, and then intradermal introduction of cellular material to a depth of 2-4 mm along the periphery of the wound surface is performed.

The disadvantage of this method is that it is expensive, requiring large financial costs and a large number of specialists in the cultivation of a homogeneous suspension from autologous mesenchymal stem cells of the stromal-vascular fraction. In addition, the accumulation of a pure population of stem cells occurs due to their multiple division, which increases the risk of overgrowing them into malignant cells.

Despite the above disadvantages, the method according to Registration Instructions No. 093-0911, of the Republic of Belarus, is the closest in technical essence and the achieved effect to the claimed method of treatment of postradiation rectovaginal fistula, therefore, it is selected as a prototype.

The objective of the proposed method is to increase the effectiveness of the treatment of postradiation rectovaginal fistula and complete rehabilitation of this category of patients with restoration of intestinal continuity.

The technical result of treatment according to the claimed method is that as a result of injection transplantation, healthy stem cells take root in the irradiated zones and take on the function of maintaining tissue homeostasis, starting the tissue regeneration process.

This problem is solved due to the fact that in the method of treating postradiation rectovaginal fistula, including the adipose tissue of a patient, purification of the obtained lipoaspirate from the supranatant, isolation of the stromal-vascular fraction from it and introduction of the latter into the surrounding tissue fistula, according to the invention, lipoaspirate is taken from non-irradiated parts of the body through vacuum liposuction, additionally clean it from the infranatant, after which, through fan-shaped tunnels, retrogradely introduced through prok the skin on the skin into the deep layers of the rectovaginal septum cannula with a diameter of 1.0-1.2 mm, a length of 70 mm, 0.1-0.2 ml in one pass of the cannula, then the stromal-vascular fraction is injected as a heterogeneous suspension with a needle with a diameter of 0 , 2-0.4 mm papular over the entire surface of the rectum into the mucous and submucosal layers.

The lipoaspirate is injected through punctures made on the skin of the rectovaginal septum, in an amount of three to five, and two to three additional punctures in the cranial semicircle of the fistula wall.

Studies on patent and scientific and technical sources of information indicate that the proposed method for the treatment of postradiation rectovaginal fistula is not known and should not be explicitly studied from the prior art, and therefore meets the criteria of "novelty" and "inventive step".

The inventive method of treatment of postradiation rectovaginal fistula can be carried out in specialized clinics and rehabilitation centers using well-known medical materials and equipment.

Thus, the claimed method of treatment of postradiation rectovaginal fistula meets the criterion of "industrial applicability".

The proposed set of essential features allows us to solve the problem.

The inventive method is based on the ability to convert multipotent mesenchymal stromal cells (MMSCs) into other types of cells and tissues. MMSCs are present in various tissues of the human body, including adipose tissue. In accordance with the proposed method of treatment, the intake of lipoaspirate is carried out from unirradiated parts of the body by means of vacuum liposuction. This manipulation is minimally invasive, easily tolerated by the patient and has a low risk of complications with strict adherence to surgical techniques, as well as general surgical and oncological canons. When injecting autologous transplantation of adipose tissue, the cell mass is transferred in its natural microenvironment, providing a higher survival rate of the transplanted material. Adipose tissue through punctures of the donor region is infiltrated with a liposuction solution and then vacuum aspirated, followed by centrifugation. After centrifugation, adipose tissue is cleaned of supra and infranatant. From the purified lipoaspirate, a cell heterogeneous suspension, the stromal-vascular fraction, is isolated. To achieve the maximum therapeutic effect, both lipoaspirate and a heterogeneous cell suspension are used. This is due to the fact that the introduction of lipoaspirate into the external mucous layers of the vagina and rectum is technically impossible. However, the use of lipoaspirate is advisable in order to regenerate their inner muscle layers. The lipoaspirate is injected through punctures on the skin into the deep layers of the rectovaginal septum with cannulas 1.0-1.2 mm in diameter, 70 mm long, 0.1-0.2 ml in one pass of the cannula retrograde, that is, a linear tunnel forms during puncture, which evenly filled on the reverse stroke of the needle. Three to five injections of lipoaspirate are made from one puncture at the same level, through fan-shaped tunnels. Less than three punctures are not enough to evenly distribute along the irradiated tissues, and with more than five, the risk of general surgical complications (infection, bleeding, excessive tissue trauma) increases. The size of the cannula, as well as the amount of lipoaspirate administered, was determined experimentally. The following punctures are carried out on the second, third, etc. levels of deep tissues of the rectovaginal septum and again through the fan-shaped tunnels, lipoaspirate is administered. The multi-tunnel technique of introducing lipoaspirate ensures filling of the tunnels created by the cannula with fat, allowing to distribute the lipoaspirate as evenly as possible among the blood-supplying tissues of the deep layers of the rectovaginal septum. This is done by creating from each puncture 20-30 tunnels in various directions and planes. In addition, two to three punctures are made in the cranial semicircle of the fistula wall. With this retrograde, fan-shaped, multi-tunnel technique, a sufficient amount of lipoaspirate is introduced, which allows the deep tissues of the rectovaginal septum to be effectively restored. At the end of the lipoaspirate administration, a heterogeneous suspension of the stromal-vascular fraction is introduced, which easily passes through a needle 0.2-0.4 mm in diameter, papular throughout the surface of the rectum into the mucous and submucosal layers, without injuring them. Places of deposition of stromal cells that trigger the regeneration of the mucous membrane are everywhere created.

Thus, the proposed method consists in the injection of lipoaspirate - adipose tissue, purified from supranatant and infranatant, and heterogeneous cell suspension isolated from it into all layers of the rectovaginal septum.

Compared with the prototype, in the proposed method, an adequate ratio of the simplicity of the method and the effectiveness of the results was found, which ensures an increase in the effectiveness of the treatment of postradiation rectovaginal fistula up to the complete rehabilitation of this category of patients with restoration of intestinal continuity.

The method is illustrated by drawings, which depict on:

FIG. 1 - the location of the internal organs near the rectovaginal fistula;

FIG. 2 is a diagram of fan-shaped tunnels in the deep tissues of a rectovaginal fistula.

The name of the leader in FIG. one:

1 - rectovaginal fistula; 2 - the uterus; 3 - bladder; 4 - the urethra; 5 - the inner muscle layer of the rectovaginal septum, where the lipoaspirate is introduced; 6 - the vagina; 7 - anus; 8 - the rectum; 9 - the outer mucous layer of the rectovaginal septum, where the stromal-vascular fraction is introduced.

The name of the leader in FIG. 2:

1 - rectovaginal fistula; 10 - syringe for injection of lipoaspirate; 11 - puncture; 12 - fan-shaped tunnels; 13 - cranial semicircle of the fistula wall.

The method is as follows.

A method for the treatment of postradiation rectovaginal fistula includes the collection of lipoaspirate from non-irradiated areas of the patient’s body, which is cleaned of the supranatant and infranatant, the stromal-vascular fraction is extracted from it, and then retrogradely, through tunnels fan-shaped from one puncture, they are injected through punctures on the skin into the deep layers of the rectaginal tract cannula with a diameter of 1.0-1.2 mm, length 70 mm, 0.1-0.2 ml per one cannula pass, then the stromal-vascular fraction is injected in the form of a heterogeneous suspension with a diameter needle rum 0.2-0.4 mm papular over the entire surface of the rectum into the mucous and submucosal layers. The number of punctures on the skin of the rectovaginal septum can be from three to five, as well as two to three additional punctures in the cranial semicircle of the fistula wall.

Let us consider in more detail the process of taking lipoaspirate (adipose tissue). In the subcutaneous fat layer of the non-irradiated region, through the punctures in 2.5 mm, the adipose tissue is infiltrated with a liposuction solution containing physiological saline, lidocaine, adrenaline: the ratio depends on the specific clinical situation. The fence is produced by a cannula 2.5 mm in diameter with 14 holes. Then the lipoaspirate obtained from the patient is subjected to centrifugation for 2 minutes at 3000 rpm, after which the lipoaspirate is purified from the supranatant (triglycerides) and infranatant (liquid fraction), in order to obtain the most concentrated adipose tissue.

The isolation of a heterogeneous suspension of the stromal-vascular fraction is carried out in a known manner (see A Novel and Effective Strategy for the Isolation of Adipose-Derived Stem Cells: Minimally Manipulated Adipose-Derived Stem Cells for More Rapid and Safe Stem Cell Therapy / Edoardo Raposio, MD, Ph, Ph .D. Giorgia Caruana, MD Sabrina Bonomini, MD Guido Libondi, MD Plast. Reconstr. Surg. 133: 1406, 2014).

The lipoaspirate is placed in a test tube and washed twice in a buffer by adding Dulbecco's phosphate-buffered saline solution, as a result of which the contents of the tube are divided into 2 parts: a buffer with red blood cells remains at the bottom of the tube, and a lipoaspirate at the top. The red blood cell buffer is removed with a pipette. A 0.15% collagenase type 2 solution is added to a test tube with washed lipoaspirate, periodically shaken once every 5-10 minutes for 30 minutes at 37 ° C, while incubation is carried out. Collagenase is then inactivated by adding Dulbecco's phosphate-buffered saline to lipoaspirate in a ratio of 1: 1. The suspension obtained after inactivation of collagenase is first passed through a cell filter of the CellStrainers type with a pore diameter of 100 μm, and then centrifuged for 5-7 minutes, at 300 g at 22 ° C. At this stage, an aliquot is selected to count the number of nucleated cells in the hemocytometer, in order to control the qualitative and quantitative composition of the final product.

The resulting cell pellet was resuspended by adding Dulbecco's phosphate-buffered saline and centrifuged again for 5-7 minutes, 300 g at 22 ° C. The supernatant is drained, and the cell pellet is resuspended in 2-3 ml of Dulbecco's phosphate-buffered saline with the addition of an antibiotic. The result is a heterogeneous cell suspension, ready for use.

Lipoaspirate is injected through punctures on the skin into the deep layers of the rectovaginal septum by cannula with a diameter of 1.0-1.2 mm and a length of 70 mm. The introduction of retrograde, through a fan-shaped direction from one puncture of the tunnels of 0.1-0.2 ml in one pass of the cannula. The number of punctures on the skin of the rectovaginal septum can be from three to five, and another two to three additional punctures are performed in the cranial semicircle of the fistula wall.

A heterogeneous suspension of the stromal-vascular fraction is injected with a needle 0.2-0.4 mm in diameter papularly over the entire surface of the rectum into the mucous and submucosal layers.

Description of the clinical case 1.

Patient Α., 76 years old, was admitted to the surgical department of the Moscow City Clinical Hospital No. 8 in Chelyabinsk in September 2014. It is known from her anamnesis that in 1984 she underwent radiation therapy for cervical cancer. For 30 years, the patient did not seek medical help. In May 2014, complaints appeared about the excretion of feces from the vagina, and the patient was referred for consultation with a coloproctologist. During sigmoidoscopy, 3-4 cm above the dentate line along the anterior semicircle, a rectovaginal septum defect of up to 1.5 cm in diameter was detected (freely passes the index finger). The edges of the defect are scarred, tumor tissues are not detected. Colonoscopy revealed signs of radiation proctitis with the formation of a fistula in the lower ampullar part of the rectum. A histological examination revealed morphological signs of chronic purulent-granulating inflammation of the edges of the fistulous defect of the rectal wall. An MRI of the pelvic organs was performed. Conclusion: the condition after radiation treatment of cervical cancer, MR-signs of the vaginal-rectal fistula, adhesions of the pelvis, involutive changes in the uterus, appendages.

Upon admission to the hospital, the condition is satisfactory. The abdomen is soft, painless on palpation. With a digital examination of the rectum, as well as rectoscopy up to 16 cm: the perianal region is not changed, the sphincter is tonic, the digital examination is painless. At a height of 3-4 cm above the dentate line, an oval-shaped rectovaginal septum defect is determined up to 1.5 cm in diameter with cicatricial changes in the edges of the defect, red in color, increased contact vulnerability. The rectal mucosa is dull, hyperemic, "rough", elasticity is reduced, the vascular pattern is smeared. No changes were detected in laboratory analyzes. The patient underwent a comprehensive clinical and instrumental examination. With endoscopic endoscopy, no pathological changes were detected. Ultrasound of the abdominal cavity and retroperitoneal space revealed diffuse changes in the liver, cholelithiasis, chronic calculous cholecystitis.

Given the data from a comprehensive examination, a suspicion of malignant rectal formation was excluded. September 20, 2014 was imposed anuspraeternaturalis.

A month later, the patient underwent microinjection autotransplantation of adipose tissue into the rectovaginal septum and the edges of the fistula from the side of the vagina and rectum under spinal anesthesia. The operation was carried out according to the following procedure. Adipose tissue was taken using cannulas with a diameter of 2.5 mm with 18 holes with a diameter of 1 mm by aspiration syringe liposuction with preliminary tissue infiltration with a modified Klein solution. The right flank region, which was not exposed to radiation therapy, was used as a donor zone. The resulting lipoaspirate was centrifuged at an acceleration of 1250 g for 3 min in sterile plastic tubes. After removal of the supra and infranatant, 50 ml of purified adipose tissue was obtained. Of this amount, 30 ml were transferred to the laboratory to isolate the stromal-vascular fraction. The remaining 20 ml of adipose tissue was inserted into the deep tissue through three punctures on the skin of the rectovaginal septum and two additional punctures in the cranial semicircle of the fistula wall. For injection, an injection cannula with a diameter of 1.0 mm and a length of 70 mm and a 1 ml luer-lock syringe were used. The introduction was carried out by means of fan-shaped tunnels, retrograde in small amounts of 0.1-0.2 ml per one passage of the cannula with the aim of uniform distribution of adipose tissue in the recipient area. The stromal-vascular fraction resuspended in 10 ml of physiological saline was injected with a 0.4 mm papular needle into the mucous and submucosal layers along the entire surface of the rectum. No seams were placed on the inlet openings in the donor and recipient zones.

The postoperative period was uneventful, the patient received antibacterial and symptomatic therapy. The hospitalization time was 7 days. Control examinations were carried out with a frequency of 1 time per month. The clinical picture in dynamics was characterized by a thickening of the rectovaginal septum and a gradual decrease in the diameter of the rectovaginal fistula. No side effects were observed during the observation period. After 3 months, the rectovaginal septum defect was completely epithelized. Control colonoscopy 6 months after surgery.

In May 2015, control fibrocolonoscopy was performed. According to the FCC: cicatricial deformity of the anterior wall of the lower ampullar part of the rectum in the projection of the former rectovaginal fistula.

Microscopic examination revealed structural changes characteristic of young connective tissue: moderately represented diffusely located elements of polymorphic cell infiltrate, characteristic of granulation tissue, are universally determined. In the predominant productive tissue reaction, lymphocytes, macrophages, fibroblasts prevail, few plasmocytes and single neutrophilic granulocytes are found among the abundance of full-blooded vessels of the capillary and arteriolar type with proliferating endotheliocytes. In some places, stasis phenomena with foci of myxoidization and moderate local edema of the intercellular matrix are recorded.

The patient underwent extraperitoneal closure of the sigmostoma (restoration of intestinal continuity). On the fourth day, the patient had a chair. In satisfactory condition, the absence of complaints from the rectum and a regular act of defecation, the patient was discharged home on the tenth day.

Description of the clinical case 2.

Patient N., 59 years old, was admitted to the surgical department of MBUZ GKB No. 8 06/03/2015. From the anamnesis it is known that in October 2014 she underwent a course of radiation therapy for cervical cancer. In December 2014, there were complaints of severe pain in the rectum while sitting, standing, and at night lying down. The patient noted an abundant discharge of dark blood from January 2015 and an increase in bowel movements up to 10 times a day. Since December 2014, the patient has repeatedly sought help from an oncologist, gastroenterologist and general practitioner.

No treatment has been performed. 06/01/15, the patient filed a previous complaint with a coloproctologist. During sigmoidoscopy, 4 cm above the dentate line along the anterior semicircle, a ulcerative defect of up to 40 mm in diameter was visualized, covered with fibrinous plaque against the background of infiltration of the surrounding mucosa with intramucous hemorrhages and with severe bleeding of surrounding tissues. The edges of the defect are scarred. Colonoscopy revealed signs of postradiation proctitis and a postradiation ulcer of the lower ampullar rectum. A histological examination of a tissue fragment from the edge of a rectovaginal septal ulcer revealed structural changes characteristic of chronic nonspecific purulent-granulating inflammation with a predominance of exudative-necrotic tissue reaction with the onset of granulation maturation and the formation of post-radiation fibrosis of the rectal mucosa.

Upon admission to the MBUZ GKB No. 8, the state of moderate severity. The abdomen is soft, painless. With a digital examination of the rectum, as well as rectoscopy up to 20 cm: the perianal region is not changed, the sphincter is tonic, the size of the defect is the same, the ulcer is covered with fibrinous deposits against the background of infiltration of the surrounding mucosa with intramucous hemorrhages and with severe bleeding of the surrounding tissues. In depth, the defect extended to ¾ of the thickness of the rectovaginal septum, which was regarded as a preperforative state. The edges of the defect are scarred, contact vulnerability is increased. The rectal mucosa is dull, “rough,” elasticity is reduced, the vascular pattern is smeared. Inspection sharply painful. In a general blood test, hemoglobin is 61 g / l. In a biochemical blood test, a decrease in total protein to 60 g / l was noted. The patient underwent a comprehensive clinical and instrumental examination. With esophago-gastro-duodenoscopy, pathological changes were not detected. Ultrasound of the abdominal cavity and retroperitoneal space revealed diffuse changes in the liver. 06.06.15, the patient was transfused with 460 ml of red blood cell mass.

06.06.15, microinjection autologous transplantation of adipose tissue (MAJT) was performed into the rectovaginal septum and submucosal injection of the stromal-vascular fraction of its own adipose tissue into the edges and bottom of the ulcer under spinal anesthesia. The operation was carried out according to the following procedure. Adipose tissue was taken using cannulas with a diameter of 2.5 mm with 18 holes with a diameter of 1 mm by aspiration syringe liposuction with preliminary tissue infiltration with a modified Klein solution. As the donor zone, the lower parts of the anterior abdominal wall, not exposed to radiation therapy, were used. The resulting lipoaspirate was centrifuged at an acceleration of 1250 g for 3 min in sterile plastic tubes. After removal of the supra and infranatant, 50 ml of purified adipose tissue was obtained. Of this amount, 30 ml were transferred to the laboratory to isolate the stromal-vascular fraction. The remaining 20 ml of adipose tissue was introduced into the deep tissue through 3 punctures on the skin of the rectovaginal septum and two additional ulcers in the cranial semicircle. For injection, an injection cannula with a diameter of 1.0 mm and a length of 70 mm and a 1 ml luer-lock syringe were used. The introduction was carried out by means of fan-shaped tunnels, retrograde, in small amounts of 0.1-0.2 ml per one cannula pass with the goal of uniform distribution of adipose tissue in the recipient zone. The stromal-vascular fraction resuspended in 10 ml of physiological saline was injected with a 0.4 mm papular needle into the mucous and submucosal layers along the entire surface of the rectum. No seams were placed on the inlet openings in the donor and recipient zones.

The postoperative period was uneventful, the patient received antibiotic therapy in the form of metronidazole 1 tablet 3 times a day for 5 days, analgesia - non-steroidal anti-inflammatory drugs as needed. The hospitalization time was 6 days. Control examinations were carried out with a frequency of 1 time per month with the collection of histological material from the edges and bottom of the ulcer. The clinical picture was characterized by a thickening of the rectovaginal septum and a gradual decrease in the diameter of the ulcer defect. No side effects were observed during the observation period. At the follow-up examination after 1 month, the patient noted: the general condition is satisfactory. There was no pain symptom, there was no pathological discharge from the intestine, the number of bowel movements decreased to 2 times a day. After 3 months, the ulcer defect in the lower ampullar part of the rectum completely epithelized. During the histological study of the biopsy specimen from the zone of the preceding rectal wall defect, growths of maturing granulation tissue were registered with the predominance of a productive tissue reaction. Moreover, among the elements of polymorphic cell infiltrate lymphocytes, histiocytes, and fibroblasts prevailed among the numerous arteriolar vessels with moderately proliferating endothelium. In most fields of vision, progressive epithelization of maturing granulations was observed.

Recommended follow-up examination after 6 months.

As can be seen from the examples, the method allows to achieve effective treatment of postradiation rectovaginal fistula and restoration of intestinal continuity.

The advantage of the proposed method for the treatment of postradiation rectovaginal fistula is the use of the patient’s own adipose tissue with minimal manipulation. This approach removes the problems with the logistics of the material to a remote laboratory, its sterility and the number of procedures. For a short time, you can perform liposuction at the operating table, prepare a lipoaspirate in a special way, purify it and isolate a heterogeneous suspension of the stromal-vascular fraction and immediately use the resulting material to treat the patient. This is very technological and fast, in contrast to the use of external laboratories, special equipment and a staff of specialists involved in the preparation of a homogeneous suspension of the stromal-vascular fraction.

Claims (2)

1. A method of treating postradiation rectovaginal fistula, including taking adipose tissue from a patient, purifying the obtained lipoaspirate from the supranatant, isolating the stromal-vascular fraction from it and introducing the latter into the surrounding tissue fistula, characterized in that the lipoaspirate is taken from unirradiated parts of the body by vacuum liposuction , additionally clean it of the infranatant, after which, through fan-shaped tunnels, retrograde, injected through punctures on the skin into the deep layers of rectovaginal the cannula septum with a diameter of 1.0-1.2 mm, a length of 70 mm, 0.1-0.2 ml per one cannula pass, then the stromal-vascular fraction is injected as a heterogeneous suspension with a needle with a diameter of 0.2-0.4 mm papular over the entire surface of the rectum into the mucous and submucosal layers. 2. The method according to p. 1, characterized in that the lipoaspirate is administered through punctures made on the skin of the rectovaginal septum, in an amount of three to five, and two to three additional punctures in the cranial semicircle of the fistula wall.

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