RU2620755C1 - Method of treating internal hemorrhoids - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to surgery and proctology. In carrying out intronodal laser coagulation of internal hemorrhoids volume of hemorrhoid is preliminarily determined by formula V_hemorrhoid=1/2 V=1/2 (4/3*π*R1*R3), where V is volume of ellipsoid in cm³, R1 is 1/2 of its basis width in cm, R2 is index of hemorrhoid height in cm, R3 is 1/2 of hemorrhoid length in apical-caudal direction in cm, π=3,14. Hemorrhoid, located on 3 o'clock of conditional clock, is measured in position on the right side, hemorrhoid, located on 11 o'clock, is measured in position for lithotomy, hemorrhoid, located on 7 o'clock, is measured in knee-elbow position. Then estimation of necessary energy of laser influence on tissues is calculated by formula W=K*V_hemorrhoid, where K=50 J/cm³ is constant coefficient, V_hemorrhoid is preliminarily estimated volume of hemorrhoid in cm³. Then transmucosal installation of laser light-conductor with the following laser impact with laser with wavelength 980 nm, power 8 Wt and estimated for each specific hemorrhoid energy W, is performed.

EFFECT: method makes it possible to carry out inronodal laser coagulation of internal hemorrhoids in outpatient conditions without suture material, with minimal injuring effect on mucous membrane of internal hemorrhoids and internal sphincter.

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Description

The invention relates to medicine, in particular to surgery, namely to proctology, and can be widely used as a minimally invasive method for the treatment of stage 3 chronic hemorrhoids.

The arsenal of a modern proctologist surgeon has a large number of means of physical impact on the tissues of the anorectal region: electrosurgical devices, a plasma scalpel, an ultrasonic dissector, various devices - emitters of quantum and thermal energy. Various publications, training and teaching aids widely cover all their advantages and disadvantages.

In the available literature, the number of reports on the use of minimally invasive methods of treatment, including laser coagulation in chronic internal hemorrhoids increased in the last decade. The high efficiency of transmucosal laser destruction of hemorrhoidal nodes with a minimal number of complications when using the water-absorbing and absorbing part of the laser spectrum in an outpatient setting is indicated in various reviews of specialized literature. The clinical effect of laser radiation is manifested in the normalization and improvement of microcirculation, a decrease in muscle tone, a decrease in the intensity of the pain syndrome, relief of inflammatory processes, stimulation of reparative processes and immunity.

So, in 2005, a group of Chinese proctologists published a report on the use of laser coagulation for stage III chronic hemorrhoids in 46 patients [Effect of diode laser coagulation treatment on grade IIIinternalhemorrhoids / D. Wang [etal.] // ZhonghuaWeiChangWaiKeZaZhi. - 2005 Jul. - Vol. 8, No. 4. - P. 325-327], while the high-intensity laser radiation of a diode laser with a wavelength of 810 nm, applied to the hemorrhoidal nodes outside, allows, according to the authors, to coagulate internal hemorrhoidal nodes, which significantly reduces their prolapse. Among the main advantages of the technique are reduced pain after surgery, quick rehabilitation, the ability to use the technique in an outpatient setting.

Fundamental experimental work was presented by a group of Brazilian scientists, in which, with laser irradiation of hemorrhoids of anthropoid apes with a 810 nm diode laser with a low power of 2 W, the effects of laser irradiation were studied, destructive changes in stromal and vascular elements of the node with vasospasm, accompanied by impaired pathological circulation in the cochlear system, were detected arteries and the beginning of connective tissue degeneration of the node tissue [A new method for hemorrhoid surgery: intrahemorrhoidal diodelaser, doesitwork? / H. Plapleretal. // PhotomedLaserSurg. - 2009 Oct. - Vol. 27, N5. - P. 819-823]. Paolo Giamundo and Raffaele Salfi, together with colleagues, proposed the use of a special ultrasonic Doppler sensor built into the proctoscope to perform laser coagulation of the terminal branches of the superior rectal artery ("HeLP ™ procedure") [The hemorrhoid laser procedure technique vs rubber bandligation: arandomizedtrialcomparing 2 miniinvasivetreatfor -degreehemorrhoids / P. Giamundo [et al.] // DisColonRectum. - 2011 Jun. - Vol. 54, No. 6. - P. 693-98]. For coagulation, the authors used pulsed laser radiation from a Biolitec diode apparatus with a wavelength of 980 nm and 1 μm, a power of 12 W, a pulse duration of 1.2 seconds, and an inter-pulse interval of 0.6 seconds. Five pulses of such radiation are able to carry out the necessary thermal effect to a depth of 5 mm at a distance of 3 cm above the dentate line, where in most cases the terminal branches of the superior rectal artery are located.

An experimental substantiation of the choice of the wavelength of high-intensity laser radiation for minimally invasive surgical treatment of chronic hemorrhoids is described (S.V. Shakhrai, Yu.M. Gain, M.Yu. Gain et al. // Kazan Medical Journal, 2013, vol. 94, No. 2, p. 271-277). In the experiment, morphological changes from the side of the rectum wall were evaluated under the influence of laser radiation with a wavelength of 970 and 1560 nm in order to choose the optimal wavelength for laser destruction of hemorrhoidal nodes. The essence of the intervention was to use high-intensity laser radiation as a source of devitalization of hemorrhoidal tissue with the development of the effect of "white denaturation" and subsequent sclerosis of the lesion. In this case, the fiber of the laser apparatus was immersed in the tissue of the hemorrhoidal node or acted on it contact (in any case, the laser radiation was not used as a scalpel to cut off the hemorrhoidal nodes). In developing the methodology, the most important technological issue was the choice of the wavelength of laser radiation.

The experience of using combined surgical treatment of stage III-IV hemorrhoids: submucous laser destruction of cavernous bodies in combination with transanal deserterization of hemorrhoidal arteries under ultrasound control (Nemenov E.G., Kochurkov N.V., Tolstoy BC et al. // Bulletin of the National Medico Surgical Center named after N.I. Pirogov, 2013, v. 8, No. 1, pp. 32-35). To perform surgical intervention, the authors used the Angiodin-Procto proximal suture ligation apparatus (ZAO NPF BIOSS, Russia) and the semiconductor laser LSP "IRE Polyus" with a wavelength of 0.97 microns and a power of 6 watts. (CJSC POLYUS, Russia). The technique for performing the surgical intervention was as follows: under an intravenous anesthesia, a Bioss anoscope was inserted into the anal canal with a diameter of 35 mm, with the help of a dopplerometry sensor installed on the latter, the location of the branches of the upper rectal artery to be ligated was determined. After ligation of the arteries, submucous, punctured, a laser fiber was drawn in two or three radial directions along the entire thickness of the cavernous tissue of the hemorrhoid. When the fiber was traction from the inside out, laser tissue destruction was performed, while the volume of the internal node was reduced by 3-4 times, after which the mucosa was lifted and mucopexyed with a continuous suture using a Dexon 2/0 thread with a 5/8 circle needle and a 27 mm needle length ( Covidien, USA) from the proximal portion to the distal part, not reaching the dentate line. In a similar way, lifting was performed along the entire perimeter of the intestine, mainly at 3, 7, and 11 hours.

Intronodal laser coagulation (INLK) of internal hemorrhoidal nodes in the treatment of chronic hemorrhoids is one of the youngest methods used in minimally invasive proctology, and the prospects for its implementation are directly related to the development of laser equipment and widespread use in other branches of medicine.

The technique provides for the intronodal (submucosal) installation of a laser fiber into the tissue of the internal hemorrhoid, with its subsequent destruction without thermal damage to the mucosa and sphincter apparatus of the rectum. In this technically simple procedure, the success of treatment and the absence of complications depends on the modes of laser exposure and the technical characteristics of the laser fibers used.

An in-depth analysis of the literature data did not reveal any contraindications for performing minimally invasive laser methods for treating hemorrhoids (M.Yu. Gain. Laser technologies in the treatment of hemorrhoids // Surgery News. - Volume 21. - No. 1. - 2013. P. 103), which makes these techniques most in demand in the treatment of chronic hemorrhoids.

A method for the treatment of chronic hemorrhoids is described (Geynits A.V., Elisova T.G. // Low-intensity laser radiation in the complex treatment of hemorrhoids. - Laser medicine. - 2008. - T. 12 - Issue 2. - P. 22-25)

For laser therapy sessions, the Mustang laser therapeutic apparatus was used, which generates infrared laser radiation with a wavelength of 0.97 microns, a pulse power of up to 10 W, and a frequency from 80 to 3000 Hz. Laser exposure of the anorectal zone was carried out by the contact method: the radiating head was pressed directly to the hemorrhoid. During the laser exposure session, a special proctological nozzle was used, which is included with the apparatus. With the help of this nozzle, the anal canal was irradiated in the projection of the localization of hemorrhoidal nodes in the scanning mode. The time of exposure to laser radiation at one point was 2 minutes, the total exposure time to the patient averaged 12 minutes. The identical parameters of the laser radiation power of 8-10 W per pulse were maintained, and the frequencies were 1500 Hz. The dose of energy received by the patient was on average 10 mJ.

There is a method of sclerosing treatment of hemorrhoids (RF patent No. 2463090, 10.10.2012), characterized in that they conduct a vibroacoustic session on sclerizable hemorrhoids in the frequency range of 0.26 kHz and 0.55 kHz alternately for 30 s for 3 minutes immediately after introducing a detergent into the hemorrhoid.

A known method of minimally invasive treatment of internal hemorrhoids (RF patent No. 2532013, 10.27.2014), based on the reduction of blood supply and fixation of internal hemorrhoids with eight-shaped sutures, followed by the introduction of a sclerosing drug from the group of detergents into the submucosal layer of the hemorrhoidal nodes, characterized in that the terminal branches of the upper of the rectal artery, the blood supplying internal hemorrhoidal nodes, are stitched and bandaged 2.5-3.0 cm above the dentate line, resorbing with eight-shaped sutures ysya thread based glycolide which simultaneously fixed internal hemorrhoids, with subsequent introduction it into cavernous tissue of internal hemorrhoids below sutures sclerosing agent from the group of detergents.

A known method of treating chronic hemorrhoids (RF patent No. 2565654, 10.20.2015) by latex ligation of the mucosa of the lower ampullar rectum 5 cm above the dentate line in the projection of the main vascular arteries at 3, 7 and 11 hours on the dial, with the effect of local mucopexy and mucosal lifting in the manipulation zone, characterized in that at the same time as the mucosal site, ligation of the submucosa with a diameter of about 3 cm is carried out.

The disadvantages of these methods

Performing such additional manipulations as flashing and dressing of the arterial hemorrhoid nodes, as well as ligation of the mucosa of the lower ampullar rectum in the projection of the main vascular arteries, significantly increases the invasiveness of the intervention, increases the need for anesthesia up to general anesthesia. In addition, with these types of intervention, there is a risk of necrosis of the vast surfaces of the rectal mucosa, leading to the formation of long-term non-healing infected wounds and late bleeding, lengthening the rehabilitation of patients. The use of sclerosing drugs does not exclude the development of local or systemic allergic reactions.

The method of subdermal-submucous destruction is described: first, with a radiation of 970 nm and a power of 12 W, a transdermal puncture of the skin is performed with a light guide and its passage into pararectal tissue. Next, the fiber is carried out under the control of pilot laser radiation with a red or green indication in the submucosal layer inside the hemorrhoid, and radiation of 1560 nm is already carried out its destruction. When using the end fiber, submucous wiring is carried out along 3-4 sectoral lines, while using the distance-radial one along one center line. In both cases, a power of 8 W is used, the length of one pulse is 1-2 s and the interpulse interval is 0.5-1 s, the absorbed energy per node is 90-110 J when using the end fiber, when using the radial fiber, 70-90 J. When the destruction is performed, the fiber is removed along the exposure sector in the active mode. In the form of a tumescent solution, the developed combination of drugs is used, consisting of a 0.25% solution of lidocaine buffered with sodium bicarbonate in combination with a 0.5% solution of bupivocaine and adrenaline injected into the solution immediately before the procedure. The technique is supplemented by suturing the tissues over the performed destruction zone with a continuous mucous-submucosal obstructive suture with subsequent binding of the proximal and distal ends of the thread (M.Yu. Gain // Laser technologies in the complex treatment of hemorrhoids. - Surgery News. - 2013. - Volume 21. - No. 1.- S. 94-104).

The disadvantages of this method are the use of end fibers for intronodular laser coagulation, and therefore, coagulation of the entire volume of a node requires multiple conduction of the fiber across sectors or the use of a specially manufactured optical tool with a special form of sharpening and grinding its end, which increases the width of the radiation beam. The lack of individual selection of laser energy for the hemorrhoidal tissue and, as a result, increased risks of developing necrosis of the mucosa of the anal canal and rectum, damage to its sphincter apparatus, increased risk of inflammatory complications and postoperative bleeding. Additional stitching of tissues over the performed destruction zone complicates the technique, increasing its invasiveness.

A known method of treating hemorrhoids (RF patent No. 2436537, 12/20/2011), including the destruction of hemorrhoidal nodes, characterized in that the revision of the anal canal is carried out using an anoscope, and the destruction of the hemorrhoid is carried out under the control of the anoscope with a hollow pointed needle with a movable fiber placed in the lumen, moreover, the needle is connected by a flexible fiber-optic cable with a laser radiation source and, together with the fiber, is inserted into the hemorrhoid by 0.5-1.5 cm, then the hollow pointed needle is retracted 2-6 mm from the distal end The fiber or fiber is introduced into the tissue of the hemorrhoidal node 2-6 mm distal to the pointed end of the needle, and then the exposure is selected depending on the volume of the coagulated tissue and thermal destruction is performed by laser irradiation of the hemorrhoidal tissue in a pulsed mode 500/500 ms with a power of 3- 4 watts

The disadvantages of this method

The use of a special, individually made instrument in the form of a hollow needle with a holder for conducting a laser fiber limits the introduction of this method into practice. In addition, the use of an end laser fiber and the absence of clear criteria for choosing the amount of transmitted laser energy does not allow one to control the completeness of coagulation of the site and the absence of undesirable thermal effects from the underlying tissues.

This method of treating hemorrhoids is closest to the claimed, therefore, is selected as a prototype.

These shortcomings are eliminated in the claimed technical solution.

The objective of the invention is the development of a method of intronodal laser coagulation (INLK) of internal hemorrhoidal nodes on an outpatient basis without suture material, with minimal damaging effect on the mucous membrane of the internal hemorrhoidal nodes and internal sphincter.

The problem is solved in that the claimed method provides for intronodal laser coagulation of the hemorrhoidal node with a radial fiber, equipped in the working part of the fiber with a microlens, which ensures uniform emission of laser radiation. Pre-determine the volume of the hemorrhoid by the formula

, где

where

V is the volume of the ellipsoid in cm ³

ширины а основания узла в см,R1 is

width and base of the knot in cm,

R2 is a measure of the height b of the node in cm,

длины с узла в апикально-каудальном направлении в см,R3 -

the length from the node in the apical caudal direction in cm,

π = 3.14,

while the hemorrhoidal node located at 3 o’clock of the conditional dial is measured in the position on the right side, the hemorrhoidal node located at 11 o’clock is measured in the position for stone section, the hemorrhoidal node located at 7 o’clock is measured in the knee-elbow position, then calculate the necessary energy of laser exposure to tissue according to the formula

W = K * V _node ,

where K = 50 J / cm ³ is a constant coefficient,

V _node - pre-calculated volume of hemorrhoid in cm ³ ,

and carry out a transmucous installation of a laser fiber, followed by laser exposure to a laser with a wavelength of 980 nm, a power of 8 W and an energy W calculated for each particular node.

T.O. individual, differentiated selection of the amount of laser energy emitted during the destruction of the hemorrhoidal node is carried out, which is necessary for its complete destruction while minimizing undesirable consequences.

The method allows to reduce the time of surgery and the volume of damaged tissue, does not require long-term observation in the early postoperative period, provides prophylaxis of infection of the rectal wall, and its asepticity (high temperature in the exposure zone) reduces the likelihood of purulent complications due to the absence of postoperative wounds and open areas of coagulation necrosis.

The emergence of radial laser optical fibers and Radial Elves Painless technology (Biolitek AG, Germany) has become quite promising in the development of laser intronodal techniques in the treatment of internal hemorrhoids. This is a new generation of optical fibers equipped with a microlens at the tip of the optical fiber, which ensures uniform, spherical emission of laser radiation (around the working part of the optical fiber).

This provides a harmonious distribution of laser energy and allows you to use the technique for large internal hemorrhoidal nodes. The radial part of the fiber for proctology, in addition to an optical system with a microlens, which provides uniform emission of laser radiation, has a special conical shape for easy installation of it transmucosally into the tissue of the hemorrhoid.

In laser surgery, laser radiation is used for the destructive effect on biological tissue with the help of thermal energy, therefore its efficiency is determined by the efficiency of converting laser radiation energy into thermal energy in the absorbed volume of biological tissue. At the same time, the efficiency of this transformation is determined both by the physical parameters of radiation (power, radiation wavelength, exposure duration, laser spot size) and the physical and morphological parameters of biological tissue (absorption coefficient of ma radiation in soft tissues on natural endochromophores, coefficient of morphological features of their structures )

Laser radiation entering a biological tissue can be scattered and absorbed by it, reflected from the tissue or passed through it. Reflection accounts for 30 to 70% of the energy, so the most effective way to deliver radiation to tissues is not remote, but invasive (interstitial) exposure (by immersing the radiation source in the target). In the claimed method, a laser light guide is transmucously installed in the node tissue, which facilitates its pointed, conical shape.

Such access avoids damage to the well-innervated anoderm located below the dentate line, which significantly reduces the intensity of the pain syndrome in the postoperative period, and also prevents some other undesirable consequences of excision of internal hemorrhoidal nodes.

эллипсоида. Как известно, эллипсоид - это тело, полученное в результате деформации шара в трех взаимно перпендикулярных плоскостях. В нашем случае эллипсоид располагается вертикально и геморроидальный узел выглядит как его нижняя половина (фиг. 1). Тогда R1 - это

ширины а его основания (1/2*а), R2 - показатель высоты b узла и R3 -

длины с узла в апикально-каудальном направлении (1/2*с). Это позволяет вычислить объем конкретно каждого геморроидального узла по формуле для определения объема эллипсоида (http://fislub.ru/prim24/22.htm). Она стандартная и имеет вид:Hemorrhoidal nodes at 3, 7, 11 o’clock positions on the conditional dial in the patient’s position for stone cutting are considered standard in proctology. The shape of the internal hemorrhoidal node, which is displayed for measurements in the upper position (i.e., the hemorrhoidal node at 3 o’clock of the conditional dial is measured in the position on the right side, 11 o’clock in the position for stone cutting, 7 o’clock in the knee-elbow position) looks like

ellipsoid. As you know, an ellipsoid is a body obtained as a result of deformation of a ball in three mutually perpendicular planes. In our case, the ellipsoid is located vertically and the hemorrhoidal node looks like its lower half (Fig. 1). Then R1 is

width a of its base (1/2 * a), R2 is an indicator of the height b of the node and R3 is

the length from the node in the apical-caudal direction (1/2 s). This allows you to calculate the volume of each particular hemorrhoid according to the formula for determining the volume of an ellipsoid (http://fislub.ru/prim24/22.htm). It is standard and has the form:

,

,

where V is the volume of the ellipsoid in cm ³ ,

ширины а основания узла (R1=1/2*a) в см,R1 is

the width of the base of the node (R1 = 1/2 * a) in cm,

R2 is a measure of the height b of the node (R2 = b) in cm,

длины с узла - в апикально-каудальном направлении (R3=1/2*c) в см,R3 -

lengths from the knot - in the apical-caudal direction (R3 = 1/2 * c) in cm,

π = 3.14.

этого объема, т.е.We are interested in

of this volume, i.e.

.

.

ширины его основания (измеряемая нами величина а), также и R3 - эта величина, получаемая математически в виде

длины узла в апикально-каудальном направлении (измеряемая нами величина с).In figures 1 and 2 it can be seen that in the formula we have the semi-axes of the ellipsoid (these are the values of R). We completely measure the axis, except for b - the indicator of the height of the node in cm - it is really equal to R2. The axis of R1 we get mathematically as

the width of its base (the quantity a measured by us), and also R3 — this value obtained mathematically in the form

the length of the node in the apical-caudal direction (measured by us value c).

ширины его основания в см, R1=1/2*а,R1 - get mathematically as

the width of its base in cm, R1 = 1/2 * a,

R2 - an indicator of the height b of the node in cm (obtained by direct measurement), R2 = b,

длины с узла в апикально-каудальном направлении в см, R3=1/2*с,R3 -

the length from the node in the apical-caudal direction in cm, R3 = 1/2 * s,

Wherein:

a is the measured base width of the hemorrhoidal node,

b is a measure of the height of the node in cm,

c is the measured length of the node in the apical-caudal direction.

To calculate the laser energy W, we use the formula W = K * V of the _node , where K = 50 J / cm ³ is a constant coefficient of direct dependence between the volume V of the hemorrhoid in cm ³ and the necessary energy W of the laser radiation for each specific node, expressed in joules.

In the course of our research of the claimed methodology for treating internal hemorrhoidal nodes, their volume was previously measured and recorded in medical documentation. Then, laser coagulation was performed using a Polyus laser device in the mode: wavelength 980 nm, power 6 W, in a pulsed mode with a pulse duration of 1 s and an interpulse interval of 0.1 s. The appearance of clinical signs of carbonization was considered a criterion of sufficiency of exposure: an increase in smoke in the fiber standing position, an increase in the sound of tissue evaporation, the appearance of the first unpleasant thermal sensations in a patient. As a result, according to the data of the laser indicator, depending on the volume and consistency of the hemorrhoidal node, energy from 80 to 170 J. was spent on each node. For 8 months we treated 32 people, 30 of them were re-examined after 3 months. In 5 people, when using energies of more than 140 J, complications arose associated with damage to surrounding tissues in the form of necrosis (4 people), in 1 - transient sphincter weakness. In 3 people, due to the low energy of the laser exposure, after 3 months the nodes were almost the same dimensions as before the exposure. T.O. in 8 people, the energy of the transmitted laser radiation was recognized as inadequate (low or excessive). The remaining 22 patients achieved positive treatment results, therefore, their indicators were taken to calculate the average amount of laser energy transferred to 1 cm ³ of hemorrhoid tissue for its adequate (complete) and safe coagulation. So, the number of nodes in 22 patients was 52 (in the majority 2-3 nodes were coagulated at the same time), by statistical processing of the data and analysis of the correspondence of the volume of the node and the expended laser radiation energy, we obtained an empirical coefficient K equal to 50 J per 1 cm ³ of node tissue .

Thus, our studies have shown that the use of excess laser energy when exposed to tissue can lead to the formation of a vast zone of necrosis. The use of low laser energy does not lead to a stable positive result of treatment, which causes a relapse of the disease.

In this regard, the pathogenetically substantiated personalized approach to the selection of the amount of necessary laser energy for laser coagulation of internal hemorrhoidal nodes, proposed by the claimed method of treatment is particularly relevant.

The invention is illustrated by figures 1 and 2. In FIG. 1 shows the location of the measured parameters of the hemorrhoid, conventionally represented as an ellipsoid. In FIG. 2 shows a view of the internal hemorrhoidal nodes and the location of the measured parameters, where

a is the measured base width of the hemorrhoid in cm,

b is a measure of the height of the node in cm,

C is the measured length of the node in the apical-caudal direction in cm.

A detailed description of the method and examples of its clinical application

Using the described method, the treatment of uncomplicated chronic hemorrhoids of stage 3 was carried out according to the classification of SSCC. Intervention was performed on an outpatient basis without general anesthesia. Before surgery, all patients undergo standard clinical laboratory and instrumental examinations. Preoperative preparation of the gastrointestinal tract is carried out the day before according to the standard scheme.

эллипсоида.The method is as follows. The preoperative determination of the volume of each of the standard hemorrhoidal nodes during anoscopy is performed in its upper position (to facilitate measuring its height), that is, the hemorrhoidal node at 3 o’clock on the conditional dial is measured in the position on the right side, 11 o’clock in the position for stone cutting, 7 o’clock - in the knee-elbow position. Using a measuring compass, the height of the node and the width of its hemorrhoidal base are measured in centimeters (with an accuracy of 0.1), then the approximate volume of the hemorrhoidal node is calculated, assuming conditionally that the shape of the internal hemorrhoidal node is

ellipsoid.

The volume of the ellipsoid is calculated by the formula

,

,

where V is the volume of the ellipsoid in cm ³ ,

ширины а основания узла (1/2*а) в см,R1 is

the width of the base of the node (1/2 * a) in cm,

R2 is a measure of the height of the node b in cm,

длины узла с в апикально-каудальном направлении (1/2*с) в см,R3 -

the length of the node s in the apical-caudal direction (1/2 * s) in cm,

π = 3.14.

T.O. we transform the formula

and calculate the V _node - the volume of the hemorrhoid in cm ³ .

Next, we calculate the necessary laser irradiation energy in J for each particular node using the formula W = K * V of the _node , where K = 50 J / cm ³ is the constant empirically derived coefficient of direct dependence between the volume of the hemorrhoid in cm ³ and the necessary laser irradiation energy expressed in joules.

The patient is placed in a proctological chair, in the position for stone cutting, an anoscope Self light Sapimed with a diameter of the working part of 23 mm is installed in the anal canal, the internal hemorrhoidal node is brought out into the anoscope. Before the INLK of hemorrhoidal nodes immediately above the dentate line, an anesthetic solution was injected under the node (1% solution of lidocaine 2.5 ml per 1 node or Artikain 4% Inibs with epinephrine 1: 100.000 - 1.8 ml per 1 node was used), after which is transmucose, a laser fiber Radial Elves Painless (Biolitek AG, Germany) was inserted above the dentate line into the internal hemorrhoid in such a way as to install the entire radial working part of the fiber into the lumen of the hemorrhoid, which facilitates the pointed, conical shape of the fiber. Then, laser coagulation is carried out with a domestic Pole laser with a wavelength of 980 nm, a power of 6 W in a pulsed mode with a pulse duration of 1 s and an inter-pulse interval of 0.1 s. The energy spent on coagulation of each node was previously calculated according to the above formula, depending on the volume of the node and taken into account according to the laser indicator, averaging from 80 to 140 J. After the transfer of the calculated amount of energy, the effect ceased.

After exposure is complete, the laser light guide and anoscope are removed. In the postoperative period, patients receive non-narcotic analgesics for 1-3 days, detralex 2 tablets 3 times a day for 7 days was included in the treatment regimen, then 2 tablets. 2 times a day for 10 days, locally - candles Relif_Advance, Ultra-proct or natalside - 2 times a day for 7 days. Systemic antibiotic therapy is not carried out.

We give a clinical example, confirming the efficiency of the proposed method.

Example 1

Patient K-ko, 48 years old, complained of significantly enlarged nodes in the anus, periodically (during defecation) falling out, self-adjusting, slight dull pain in their area, periodic discharge of fresh blood after defecation on the feces.

From the anamnesis it is known that he considers himself to be a patient with hemorrhoids for many years when the complaints described above appeared, the disease proceeds with periods of exacerbations and remissions, recently the complaints described above have been stubborn, treated conservatively with a small positive dynamics, and have been admitted for minimally invasive treatment.

Status localis. When examined with an anoscope and a digital rectal examination, significantly increased internal hemorrhoids are detected at 3, 7, 11 hours, the sphincter tone is preserved, the study is painless, and mucus on the glove. The chair is the norm.

Clinical diagnosis - chronic hemorrhoids 3 tbsp.

According to the claimed method, each of the standard hemorrhoidal nodes was measured in turn, the measurement results are listed in table 1.

The calculation of the amount of laser energy needed to coagulate each of the hemorrhoidal nodes with the sequential entry of the results in table 2.

In the position of the patient for stone cutting in the proctologic chair, the INCL of hemorrhoids was sequentially performed at 3, 7 and 11 hours.

For this, an anesthetic solution was injected immediately above the dentate line (in this case, 1% solution of lidocaine 2.5 ml per node was used), after which a laser fiber was introduced transmucosally over the dentate line into the internal hemorrhoid in the laser exposure mode in this way to install the entire radial working part of the fiber into the lumen of the hemorrhoid. Then laser coagulation was carried out: a node at 3 hours with an energy of 120 J according to a laser indicator, a node at 7 hours with an energy of 150 J according to a laser indicator, a node at 11 hours with an energy of 90 J according to a laser indicator (according to calculated indicators). After the transfer of the calculated amount of energy, the effect ceased.

After exposure, the laser fiber was removed.

In the postoperative period, the patient took ketorol 1 tablet twice a day for 1 day. (10 mg), there was no need for systemic painkillers in the future, detralex was included in the treatment regimen - 2 tablets 2 times a day - for 20 days, topically - locally - natalside suppositories 2 times a day - 5 days. Systemic antibiotic therapy has not been conducted. Disability was restored after 4 days, there were no complications.

Examined 3 months after surgery. A complete regression of hemorrhoid symptoms was noted: the absence of bleeding, prolapse of nodes, and anal discomfort. According to anoscopy, a significant decrease in the size of internal hemorrhoidal nodes. The treatment results are considered good.

T.O. under the influence of laser radiation, a rapid regression of the local symptoms of the disease was noted: a decrease in local tissue edema, a decrease in tension and loss of hemorrhoids, their bleeding. Accordingly, an improvement in the quality of life of patients was noted: the regularity and effectiveness of the act of defecation was quickly restored, the physical activity and performance of the patients increased.

Under observation were 54 patients treated by this method for chronic hemorrhoids 3 tbsp. in the classification of SSCC. Clinical analysis exposed the data of a general examination of patients (physical, laboratory), the results of anoscopy in the pre- and postoperative periods. When evaluating the results of treatment, attention was drawn to the presence of operational and postoperative complications, the severity of pain on an analog 5-point scale, the need for non-narcotic analgesics after surgery. Long-term treatment results were evaluated according to anoscopy, clinically - based on the disappearance of hemorrhoid symptoms and by a comparative assessment of the quality of life on the SF-36 scale before and after surgery. The treatment results were evaluated daily for the first 5 days, then 1 time in 7-10 days - 1 month. The terms of postoperative observation ranged from 6 months to a year.

Statistical data processing was carried out using the program "Statistica 6.0". The calculation of indicators of the mean value, standard deviation, minimum and maximum values (Me ± SD, min-max). Treatment by the claimed method showed its high efficiency.

The practical result of the method is to reduce the number of relapses of the disease in the long term, as well as reduce the number of complications. This result is achieved due to the complete coagulation of the hemorrhoidal node by using intronodal laser coagulation of hemorrhoidal nodes using a radial fiber equipped with a microlens in the working part of the fiber, which ensures uniform emission of laser radiation. And also due to the preliminary calculation of the necessary laser energy for each hemorrhoidal node individually for each patient.

The positive sides and advantages of this method include the possibility of performing it under local infiltration anesthesia on an outpatient basis, the absence of a clinically significant rehabilitation period, quick recovery and return of the patient to his usual way of life and work.

All of the above leads to an increase in the quality of life of patients, which provides significant social and economic effects and suggests the promise of using new techniques in outpatient and minimally invasive proctology and surgery.

The method of internal hemorrhoids developed by us can be a minimally invasive alternative to hemorrhoidectomy and is recommended for use in an outpatient operating room or in a hospital ward with short-term patient stays.

Claims (11)

A method of treating internal hemorrhoidal nodes, comprising intronodal laser coagulation of internal hemorrhoidal nodes, characterized in that the volume of the hemorrhoidal node is previously determined by the formula

where V is the volume of the ellipsoid in cm ³ , R1 is

the width of the base of the node in cm, R2 is a measure of the height of the node in cm, R3 -

the length of the node in the apical caudal direction in cm, π = 3.14, while the hemorrhoidal node located at 3 o’clock of the conditional dial is measured in the position on the right side, the hemorrhoidal node located at 11 o’clock is measured in the position for stone section, the hemorrhoidal node located at 7 o’clock is measured in the knee-elbow position, then calculate the necessary energy of laser exposure to tissue according to the formula

where K = 50 J / cm ³ is a constant coefficient, V _node is the pre-calculated volume of the hemorrhoidal node in cm ³ , and a transmucous installation of a laser fiber is carried out, followed by laser exposure to a laser with a wavelength of 980 nm, a power of 8 W and energy W calculated for each particular node.

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