RU2625277C1 - Method for chronic haemorrhoid low-invasive treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: desarterisation of internal hemorrhoids and their subsequent sclerosing is performed. To carry out internal hemorrhoids desarterisation, each terminal branch of the upper rectal artery feeding the corresponding hemorrhoidal node is stitched at its base with a resorbable suture material with a Z-shaped suture. Sclerotherapy is performed with Ethoxysclerol, which, at a dose of 10-20 mg, is first introduced into the "vascular pedicle", then into the cavernous tissue of each internal hemorrhoidal node using an ultrasound "specialized needle" for "Prokson" ultrasonic treatment of biological tissues. The ultrasonic exposure is provided in the output power mode of the "Prokson" generator of 09 units and "specialized needle" ultrasonic action time equal to 20 s for each hemorrhoidal node.

EFFECT: elimination of postoperative pain syndrome and a significant decrease in the number of disease relapses.

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Description

The invention relates to medicine, namely to coloproctology, and can be used in the treatment of chronic hemorrhoids of the II-IV stages, including complicated by bleeding, mild and moderate anemia, as well as with large sizes of hemorrhoids.

Proctological diseases are one of the most common human diseases. Among proctologic diseases, the share of chronic hemorrhoids accounts for from 34 to 41% of the total number of coloproctological patients, while the incidence of hemorrhoids is about 140-160 cases per 1000 adult people (Shelygin Yu.A., Blagodarny L.A. Hemorrhoids. Material for doctors Atlas. - M.: SSC Coloproctology. 2012.P. 2).

Currently, in world practice, minimally invasive methods of treating chronic hemorrhoids are becoming more widespread, such as: sclerotherapy of hemorrhoids, ligation of internal hemorrhoids with latex rings, infrared coagulation and electrocoagulation, ultrasonic cavitation with sclerotherapy, deserterization of internal hemorrhoids under control of dopplerometry with , mucopexy of the mucosa and in combination with sclerotherapy (Zagryadsky E.A. Minimally invasive hemo-surgery S. Slavyanov.Spheroidal disease -. M .: "IPK" House of Books "2014 S. 7-8)..

The weakness of these methods, in our opinion, is their lack of effectiveness, due to the manifestation of relapse of the disease in complicated forms of chronic hemorrhoids: bleeding, anemia, concomitant diseases of the anal canal, large sizes of nodes.

Thus, the development of new highly effective minimally invasive methods of treating chronic hemorrhoids is an urgent task of coloproctology.

Conducted research on the medical-scientific and patent literature found various minimally invasive methods of treating chronic hemorrhoids.

So, in the work of Titov A.Yu. et al. “Deserterization of internal hemorrhoidal nodes with sclerotherapy in the treatment of patients with chronic hemorrhoids” (Medical Council. 2012. No. 9. P. 94-96) describes a minimally invasive method for the treatment of chronic hemorrhoids. A special anoscope with a built-in ultrasonic Doppler sensor is introduced into the anal canal and diagnostic Dopplerometry is performed. The anoscope is rotated along the axis, arterial pulsation of the terminal branches of the upper hemorrhoidal artery is revealed. By the intensity of the pulse wave, as a rule, 4-6 branches of the artery, located at 1, 3, 5, 7, 9 and 11 hours, are determined by the conditional dial. After the appearance of a sound signal through a special window of the anoscope, eight-shaped sutures are sutured and the artery branches are ligated with an acrylic thread on an atraumatic needle 4-5 cm proximal to the dentate line, then the mucous membrane of the distal rectum with the capture of the underlying muscle layer is stitched. In the submucous layer of the lower ampullar part of the rectum, below the sutures, in the area of internal hemorrhoidal nodes, a sclerosing drug from the group of detergents is introduced in a volume of 0.3 to 1 ml, depending on their size.

The disadvantages of this method are its lack of effectiveness, due to the possibility of developing postoperative pain syndrome; the probability of deformation of the anal canal, since the mucosal flashing with the capture of the underlying muscle layer leads to its excessive tension; the risk of recurrence of the disease in case of using the method with heavy bleeding, as well as with large sizes of nodes.

RF patent No. 2553937 (published on 06/20/2015) protected "A method for minimally invasive treatment of patients with hemorrhoids of stages 3 and 4". Carry out transanal Doppler-controlled desarterization of internal hemorrhoidal nodes. The branches of hemorrhoidal vessels at the base of the nodes are stitched through an anoscope. An eight-shaped suture is applied on the atraumatic needle with absorbable material. Hemming of the rectal mucosa and hemorrhoidal node is performed using the same thread. A submucosal suture is applied distally to the apex of the hemorrhoid. Turn in the perpendicular direction with the capture of the submucosal layer. The thread is returned up towards the ligature unit and the second free end of the thread. After the puncture, the ends of the thread are tied together. The hemorrhoidal node is tightened with a ligature and fixed to the site of vascular stitching above the anorectal line.

The disadvantages of this method are:

- the possibility of developing postoperative pain and deformation of the anal canal, since the hemming of the rectal mucosa and hemorrhoid can lead to its excessive tension;

- the inability to achieve stable hemostasis in the presence of bleeding due to the lack of exposure to the cavernous tissue of the hemorrhoid.

In the patent of the Russian Federation No. 2202290 (published on April 20, 2003), a “Method for the treatment of hemorrhoids” is described. The location of the terminal branches of the superior hemorrhoidal artery is determined by rectal ultrasound dopplerometry. A sclerosing solution is injected into the region of the terminal branches of the superior hemorrhoidal artery into the submucous layer of the lower ampullar part of the rectum. In this case, the introduction is carried out above the internal hemorrhoidal nodes.

A significant drawback of this method is the likelihood of a relapse of the disease, since this method does not have a complex effect on the cavernous tissue of the hemorrhoids and on the pathogenetic factor of the disease - dystrophic changes in the ligamentous apparatus of hemorrhoids.

RF patent No. 2560023 (published on 08/20/2015) protected the "Method of minimally invasive treatment of chronic hemorrhoids." Anus divulsion is performed, retractors are placed in the rectum cavity. Fix them on the ring, simulating the operating space. Provide direct visual control over the area of the anatomical location of hemorrhoidal vessels. Perform a circular excision of the strip of the wall of the rectum with a width of 5-15 millimeters. The rectal wall defect is restored with a manual suture, after which the retractors are removed.

The disadvantages of this method are the risk of cicatricial narrowing of the anal canal in the postoperative period as a consequence of circular excision of the rectal mucosa, as well as the possibility of relapse of the disease, since this method does not have a complex effect on the cavernous tissue of the hemorrhoid and the pathogenetic factor of the disease - dystrophic changes in the ligamentous apparatus hemorrhoidal nodes.

The closest technical solution taken as a prototype is the "Method of minimally invasive treatment of internal hemorrhoids" described in the patent of the Russian Federation No. 2532013 (published on 10.27.2014).

The method provides for the deserterization of internal hemorrhoidal nodes and their subsequent sclerotherapy with a drug from the group of detergents. The terminal branches of the superior rectal artery are stitched and bandaged 2.5-3.0 cm above the dentate line. At the same time, internal hemorrhoidal nodes are fixed with the same eight-shaped sutures. A sclerosing preparation is injected into the submucosal layer of hemorrhoids below the stitches.

The disadvantage of the prototype is its lack of effectiveness, due to the possibility of developing a pain syndrome, relapse of the disease during bleeding and with large sizes of nodes due to the possible revascularization of the internal hemorrhoid. When internal hemorrhoidal nodes are fixed with additional ligatures, mucosal tension occurs, which negatively affects the condition of the rectal mucosa and the physiology of the anus and can lead to the development of pain and deformation of the anal canal. It is also possible to cut through the mucous membrane of hemorrhoidal nodes during their fixation due to loose and eroded mucosa and, as a result, bleeding.

The objective of the claimed invention is to develop a highly effective method for minimally invasive treatment of chronic hemorrhoids.

The technical result manifested in the implementation of this method is the exclusion of postoperative pain, reducing the number of relapses of the disease.

The technical result is achieved by deserterization of the internal hemorrhoidal nodes and their subsequent sclerosis. To carry out the deserterization of internal hemorrhoidal nodes, each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node is flashed at its base with an absorbable suture material with a Z-shaped suture. Sclerosis is performed with Ethoxysclerol, which is administered at a dose of 10-20 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid using the “specialized needle” ultrasound instrument “Proxon” for ultrasonic treatment of biological tissues. Ultrasonic exposure is performed in the output power mode of the generator of the Proxon apparatus 09 units. and the ultrasonic time of the specialized needle tool, equal to 20 s, for each hemorrhoid.

Detailed description of the method.

The patient the night before and two hours before the operation perform microclysters “Microlax” or cleansing enemas. In the position of the patient on the back with the lower limbs bent at the knee and hip joints, the perianal skin and anal canal are treated with antiseptic solutions. An anoscope is inserted into the rectum, after which deserterization of the internal hemorrhoidal nodes and their subsequent sclerosis are performed. To carry out the deserterization of internal hemorrhoidal nodes, each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node is flashed at its base with absorbable suture material, for example, Vicryl 2-0, Z-shaped suture. Sclerosis is carried out with the Ethoxysclerol drug, which is introduced at a dose of 10-20 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid using the “specialized needle” ultrasonic instrument Proxon, manufactured by SIMBITEK NPO ", Volgograd, Russia. Ultrasonic exposure is performed in the output power mode of the generator of the Proxon apparatus 09 units. and the ultrasonic time of the specialized needle tool, equal to 20 s, for each hemorrhoid. After surgery, a hemostatic sponge is inserted into the anal canal.

The drug is ethoxysclerol (international nonproprietary name - lauromacrogol-400). Registration number: Π N011397 / 01 of 01/14/2009. Dosage form - solution for intravenous administration. Composition: 1 ampoule (2 ml) of the solution contains: active substance: lauromacrogol-400 - 10 mg, 20 mg or 60 mg. The pharmacotherapeutic group is a venosclerosing agent.

The practical feasibility of this method is illustrated by examples from clinical practice.

Example 1: patient G., 43 years old, turned to the State Autonomous Institution of the Rostov Region “Regional Consultative and Diagnostic Center” (GAU RO “OKDC”) with complaints of scarlet blood, hemorrhoid prolapse during defecation.

When examining the perianal region: the skin is not changed, fistulous openings are not determined. External hemorrhoid nodes collapsed in the form of small fringes. Anus is closed. With a digital examination of the rectum, the sphincter tone is normal. The ampoule is empty, there is no overhanging walls, the mucous membrane is elastic, mobile. Internal hemorrhoidal nodes are typically located at 3, 7, 11 hours of the conditional dial, enlarged to 1.0 × 1.5 cm, when strained, drop out of the anal canal, and are adjusted independently. The mucous membrane over hemorrhoids with erosion, bleeds contact.

Patient G. was examined according to established standards. In the general analysis of blood: HB - 86 g / l, red blood cells - 3.74 × 10 ¹² / l, Ht - 34.70%. Colonoscopy revealed no organic pathology.

Patient G. was diagnosed with chronic hemorrhoids of the II stage. Complication: mild posthemorrhagic anemia. On an outpatient basis, the patient underwent minimally invasive treatment of chronic hemorrhoids according to the claimed method.

Patient G. the night before and two hours before the operation performed microclysters “Microlax”. In the position of the patient on the back with lower limbs bent at the knee and hip joints, the perianal skin and anal canal were treated with antiseptic solutions. An anoscope was inserted into the rectum, after which desarterization of the internal hemorrhoidal nodes and their subsequent sclerosis were performed. To carry out the deserterization of the internal hemorrhoidal nodes, each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node was stitched at its base with a resorbable suture material Vikril 2-0 Z-shaped suture. Sclerotherapy was carried out with the Ethoxysclerol drug, which was introduced at a dose of 10 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid with an ultrasound instrument “specialized needle” for Proxon ultrasound treatment of biological tissues manufactured by NPO SIMBITEK, Volgograd, Russia. Ultrasonic exposure was performed in the power output mode of the generator of the Proxon apparatus 09 units. and the time of ultrasonic exposure of the specialized needle tool, equal to 20 s for each hemorrhoid. After surgery, a hemostatic sponge was introduced into the anal canal of patient G.

In the postoperative period, pain was not observed. In the distant postoperative period, no relapse was detected.

Example 2: patient K., 34 years old, turned to GAU RO OKDC with complaints of scarlet blood, hemorrhoid prolapse during defecation, and constant discomfort in the anus.

When examining the perianal region: the skin is not changed, fistulous openings are not determined. External hemorrhoidal nodes are not enlarged. Anus is closed. With a digital examination of the rectum, the sphincter tone is normal. The ampoule is empty, there is no overhanging walls, the mucous membrane is elastic, mobile. Internal hemorrhoidal nodes are typically located at 3, 7, 11 hours of the conditional dial, enlarged to 1.5 × 2.0 cm, when strained, drop out of the anal canal at 3 and 7 hours, are repaired with manual assistance. The mucosa above the hemorrhoidal nodes with erosion does not bleed contact.

Patient K. was examined according to established standards. In the general analysis of blood: HB - 145 g / l, red blood cells - 4.49 × 10 ¹² / l, Ht - 41.60%. Colonoscopy revealed no organic pathology.

Patient K. was diagnosed with stage III chronic hemorrhoids and on an outpatient basis, minimally invasive treatment of chronic hemorrhoids was performed according to the claimed method.

Patient K. the night before and two hours before the operation was performed microclysters "Microlax". In the position of the patient on the back with lower limbs bent at the knee and hip joints, the perianal skin and anal canal were treated with antiseptic solutions. An anoscope was inserted into the rectum, after which desarterization of the internal hemorrhoidal nodes and their subsequent sclerosis were performed. To carry out the deserterization of the internal hemorrhoidal nodes, each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node was stitched at its base with a resorbable suture material Vikril 2-0 Z-shaped suture. Sclerotherapy was carried out with the Ethoxysclerol drug, which was introduced at a dose of 10 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid with an ultrasound instrument “specialized needle” for Proxon ultrasound treatment of biological tissues manufactured by NPO SIMBITEK, Volgograd, Russia. Ultrasonic exposure was performed in the power output mode of the generator of the Proxon apparatus 09 units. and the time of ultrasonic exposure of the specialized needle tool, equal to 20 s for each hemorrhoid. After the operation, a hemostatic sponge was introduced into the anal canal of patient K.

In the postoperative period, pain was not observed. In the distant postoperative period, no relapse was detected.

Example 3: patient D., 42 years old, turned to GAU RO OKDC with complaints of excessive discharge of red blood, loss of hemorrhoids during defecation, weakness, and malaise.

When examining the perianal region: the skin is not changed, fistulous openings are not determined. External hemorrhoid nodes collapsed in the form of fringes. Anus is closed. With a digital examination of the rectum, the sphincter tone is normal. The ampoule is empty, there is no overhanging walls, the mucous membrane is elastic, mobile. Internal hemorrhoidal nodes are typically located at 3, 7, 11 hours of the conditional dial, enlarged to 2.0 × 2.5 cm, when strained, drop out of the anal canal at 7, 11 hours, are repaired with manual allowance. The mucous membrane over hemorrhoidal nodes with confluent erosion, bleeds sharply in contact.

Patient D. was hospitalized, examined. In a general blood test: HB - 57 g / l, red blood cells - 2.98 × 10 ¹² / l, Ht - 19.30%. Colonoscopy revealed no organic pathology.

Patient D. was diagnosed with stage III chronic hemorrhoids, recurrent hemorrhoidal bleeding. Complication: moderate posthemorrhagic anemia. Patient D. performed minimally invasive treatment of chronic hemorrhoids according to the claimed method.

Patient D. the night before and two hours before the operation performed microclysters “Microlax”. In the position of the patient on the back with lower limbs bent at the knee and hip joints, the perianal skin and anal canal were treated with antiseptic solutions. An anoscope was inserted into the rectum, after which desarterization of the internal hemorrhoidal nodes and their subsequent sclerosis were performed. To carry out the deserterization of the internal hemorrhoidal nodes, each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node was stitched at its base with a resorbable suture material Vikril 2-0 Z-shaped suture. Sclerotherapy was carried out with the Ethoxysclerol drug, which was introduced at a dose of 15 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid with an ultrasound instrument “specialized needle” for Proxon ultrasound treatment of biological tissues manufactured by NPO SIMBITEK, Volgograd, Russia. Ultrasonic exposure was performed in the power output mode of the generator of the Proxon apparatus 09 units. and the ultrasonic time of the specialized needle tool, equal to 20 s, for each hemorrhoid. After the operation, hemostatic sponge was introduced into the anal canal of patient D. and antianemic therapy was prescribed.

In the postoperative period, pain was not observed. In the distant postoperative period, no relapse was detected.

Example 4: Patient J., 56 years old, turned to GAU RO OKDC with complaints of scarlet blood, hemorrhoid prolapse during defecation, and weakness.

On examination of the perianal region: the skin is not changed. Fistulous openings are not detected. External hemorrhoid nodes collapsed in the form of fringes. Anus is closed. With a digital examination of the rectum, the sphincter tone is normal. The ampoule is empty, there is no overhanging walls, the mucous membrane is elastic, mobile. Internal hemorrhoidal nodes are typically located at 3, 7, 11 hours of the conditional dial, enlarged to 2.5 × 3.0 cm, when strained, drop out of the anal canal at 3, 7 hours, partially corrected with manual allowance. The mucosa above the hemorrhoidal nodes with erosion, the contact bleeds slightly.

Patient J. was hospitalized, examined. In the general analysis of blood: HB - 79 g / l, red blood cells - 3.74 × 10 ¹² / l, Ht - 27.40%. Colonoscopy shows signs of chronic colitis.

Patient J. was diagnosed with stage IV chronic hemorrhoids. Complication: mild posthemorrhagic anemia. Patient J. was performed minimally invasive treatment of chronic hemorrhoids according to the claimed method.

Patient J. the night before and two hours before the operation performed microclysters “Microlax”. In the position of the patient on the back with lower limbs bent at the knee and hip joints, the perianal skin and anal canal were treated with antiseptic solutions. An anoscope was inserted into the rectum, after which desarterization of the internal hemorrhoidal nodes and their subsequent sclerosis were performed. To carry out the deserterization of the internal hemorrhoidal nodes, each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node was stitched at its base with a resorbable suture material Vikril 2-0 Z-shaped suture. Sclerotherapy was carried out with the Ethoxysclerol drug, which was introduced at a dose of 20 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid with an ultrasound instrument “specialized needle” for Proxon biological tissue ultrasonic processing apparatus manufactured by NPO SIMBITEK, Volgograd, Russia. Ultrasonic exposure was performed in the power output mode of the generator of the Proxon apparatus 09 units. and the ultrasonic time of the specialized needle tool, equal to 20 s, for each hemorrhoid. After the operation, a hemostatic sponge was introduced into the anal canal of patient J.

In the postoperative period, pain was not observed. In the distant postoperative period, no relapse was detected.

According to the claimed method, in the conditions of GAU RO "OKDC", we treated 38 patients (21 women, 17 men aged 24 to 78 years) with chronic hemorrhoids of the II-IV stage, as with complications (bleeding, mild and moderate anemia) so without them. 10 patients had chronic hemorrhoids of the II stage, 16 patients with chronic hemorrhoids of the III stage, 12 patients with chronic hemorrhoids of the IV stage.

In the postoperative period, none of the 38 patients experienced pain. In the group of patients with chronic hemorrhoids of the II stage, there were no relapses of the disease. In 1 patient (6.2%) with chronic hemorrhoids of the III stage, a relapse of the disease was noted in the postoperative period. In 2 patients (16.7%) with chronic hemorrhoids of stage IV in the remote postoperative period, a relapse of the disease was noted.

We carried out a retrospective analysis of 52 case histories of patients (29 women, 23 men aged 22 to 77 years) with chronic hemorrhoids of the II-IV stage, who underwent minimally invasive surgery in the GAU RO “OKDC” and in the surgical department of the clinic of Rostov State Medical University treatment of chronic hemorrhoids according to the prototype. 13 patients with chronic hemorrhoids of stage II, 22 patients with chronic hemorrhoids of stage III, 17 patients with chronic hemorrhoids of stage IV. The analysis showed that in 2 patients (15.4%) with chronic stage II hemorrhoids, in 4 patients (18.2%) with stage III chronic hemorrhoids and in 6 patients (35.3%) with stage IV chronic hemorrhoids postoperative pain syndrome. In 1 patient (7.7%) with chronic hemorrhoids of stage II, in 5 patients (22.7%) with chronic hemorrhoids of stage III, and in 4 patients (23.5%) with chronic hemorrhoids of stage IV - relapse of the disease.

Thus, the proposed method of minimally invasive treatment of chronic hemorrhoids is highly effective, eliminates postoperative pain and significantly reduce the number of relapses of the disease.

Claims (1)

A method for minimally invasive treatment of chronic hemorrhoids, including desterterization of internal hemorrhoidal nodes and their subsequent sclerotherapy, characterized in that each terminal branch of the superior rectal artery supplying the corresponding hemorrhoidal node is sutured at the base with an absorbable suture material of a Z-shaped suture to deserterize internal hemorrhoidal nodes; sclerotherapy is carried out with the Ethoxisclerol preparation, which is introduced at a dose of 10-20 mg first into the “vascular pedicle”, then into the cavernous tissue of each internal hemorrhoid using the “specialized needle” ultrasonic instrument “Proxon” for ultrasonic treatment of biological tissues in the generator power output mode of apparatus 09 units and the ultrasonic exposure time of the instrument for 20 s per hemorrhoid.