RU2715681C1 - Method of treating transsphincteric fistulas of rectum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery and coloproctology. Transsphincteric fistula is transferred into intrafincteric fistula. Transverse incision 1.5 cm long in a medial edge of the fistulous passage at distance of 1.5 cm from the edge of the anal ring. Skin is dissected with subcutaneous fat, fistulous passage is separated within 1.0 cm without exposing its lumen. Two ligatures are used to tie a fistulous passage; a fistulous passage is dissected between the ligatures; a fistiform altered tissue in the form of a triangular flap is excised in the area of the internal opening of the fistulous passage in the involved crypt of the anal canal. Then, transverse incision 0.2 cm above an internal fistulous passage is used to cut out a mucous membrane on pedicle 1.5 cm long and 0.8 cm wide, which is laid without tension on the inner opening of the fistulous passage and fixed with 3 sutures to the flap edges, and the mucous defect remaining after movement is closed with 2 interrupted sutures. Wound is closed with medical glue "Sulphacrylate", the wound area is additionally covered with haemostatic sponge. Outer opening of the fistulous passage is sanitized daily with antiseptics for 3 days; 3 % alcohol solution of iodine or 70 % ethyl alcohol is introduced into the lumen.

EFFECT: method enables reducing length of treatment and rehabilitation of patients by 50 %, minimizing purulent complications and anal sphincter failure.

1 cl, 1 ex, 1 dwg

Description

The invention relates to surgery, namely to coloproctology and can be used for the treatment of transsphincteric fistulas of the rectum.

Treatment of transsphincteric fistulas still remains an urgent problem, since the proposed methods have a high percentage of relapses and postoperative complications. Various treatment methods are described in the literature and conflicting data are often found regarding the appropriateness and effectiveness of the use of a particular technique.

Analogs:

Fistula excision with ligature

The known method is based on the fact that a ligature is drawn from the perineal wound through the internal fistulous opening, which covers portions of the anal sphincter in the form of a ring and the ligature is tightened to the intersection of a certain portion of the muscles. As the perineal wound heals, the ligature is gradually tightened, which gradually crosses the captured sphincter fibers and fistulous course (Vorobyev, G.I., Kamaeva D.K., Koplatadze AM, Kim S.D. Results of treatment of patients with acute paraproctitis by the ligature method. Annals chir. 2001. - No. 1. - S. 54-58).

The disadvantages of the method are:

- a gradual, phased intersection of the fibers of the anal sphincter with a ligature with complete intersection of the muscle ring and the formation of a deforming scar, which in some patients leads to the development of insufficiency of the anal sphincter, which manifests itself up to stool incontinence;

each tightening of the thread is accompanied by severe pain, so there is a need for repeated local or conduction anesthesia;

- The average duration of treatment reaches 2 months.

There is also a known method for excising a fistula with suturing the ends of crossed portions of the anal sphincter - a method that allows you to completely excise the fistulous passage into the lumen of the rectum, followed by suturing the edges of the crossed portions of the muscle of the anal sphincter ((Rybkin B.J. I., Bronstein A.S., Fayn S .N. Guide to Coloproctology. - M .: Medicine, 2001.- P. 64-81). The disadvantages of the method are:

- with this method, there is a complete intersection of the sphincter fibers captured by the fistula, there is a risk of developing anal sphincter insufficiency. Purulent-septic complications and relapse of the disease are also frequent.

- with this method, bed rest and stool retention for a period of 4-6 days are required, which negatively affects the psychological state of the patient.

Excision of the fistula with suturing of the internal fistulous opening - a method consisting in excising the fistulous passage to the intestinal wall with excision of the internal fistulous opening from the side of the rectal lumen and subsequent suturing of the internal fistulous opening. With this method there is no damaging effect on the anal sphincter, which significantly reduces the risk of developing anal incontinence in the postoperative period (Kapitonov, A.S., Narcisov T.V., Brezhnev V.P. treatment of fistula of the rectum. Overview. // Klin, Khir . - 1991. - No. 2.- S. 35-38).

The disadvantages of the method are:

- there is a high risk of relapse of the fistula due to the eruption of sutures in the area of the sutured internal fistulous opening and its opening due to the fact that with increasing pressure in the rectum, the load on the suture line significantly increases the risk of their divergence;

- tightly sutured the internal opening of the fistulous passage is difficult due to the cicatricial process.

Prototype

As a prototype, we have taken a method for the treatment of transsphincteric and extrasphincteric fistulas of the rectum, in which the authors: Kostarev I.V., Mudrov A.A., Titov A.Yu. (Patent No. RU 2564086) offer a methodology for the treatment of transfinkter and extrasphincter fistulas of the rectum. The method consists in isolating a fistula from the external fistulous opening on the perineal skin to the wall of the rectum, without damaging the elements of the anal sphincter. At the wall of the rectum, the fistulous passage is cut off, preserving its proximal part in the thickness of the anal sphincter or extrasphincterously. An elastic latex ligature is passed through the internal fistulous opening into the wound, covering the mucous-submucous layer and part of the internal sphincter in the form of a ring. The crossed part of the external sphincter is sutured, closing the ligature with the sphincter muscle tissue. The ligature extends from the internal fistulous opening, leaving a completely intact line of sutures on the sphincter. The proposed method allows you to eliminate the fistula of the rectum, with minimizing the risk of divergence of sutures on the sphincter, the development of insufficiency of the anal sphincter and relapse of the disease due to the formation of the intrasphincter fistulous course in the treatment of transfinkter and extrasphincter fistulas of the rectum. The outcome of the operation is the conversion of a trans- or extrasphincteric fistula into an intrasphincteric fistula. Subsequently, after healing of the perineal wound, the second stage of surgical treatment is performed - dissection of the mucous membrane, submucosal and smooth muscle layers above the ligature into the intestinal lumen.

The prototype method has several disadvantages:

1. The duration of treatment is about a month at the first stage and about 2 weeks at the 2nd stage.

2. Partial intersection of the fibers of the internal sphincter and complete intersection of the external sphincter can lead to weakness of the anal sphincter and incontinence in a certain percentage of patients

3. The risk of postoperative suppuration of the perineal wound is quite high.

Given the high postoperative percentage of incontinence, a large number of purulent-septic complications and relapses, a minimally invasive sphincter-preserving method for the surgical treatment of trans-sphincter fistula is proposed.

The purpose of the invention

The aim of the invention is to improve the results of surgical treatment of patients, the reduction of postoperative complications with transsphincteric fistulas of the rectum. This goal is achieved by using the minimally invasive sphincter-preserving method.

The essence of the method

The proposed method is illustrated in FIG. 1, where pos. 1 - the inner hole of the fistulous course, pos. 2 - cross section on the skin, pos. 3 - the outer opening of the fistulous course, pos. 4 - a triangular flap of the rectal mucosa. Pos. 5 - Two ligatures pos. 6 - The selected triangular flap of the mucosa on the leg

The essence of the proposed method lies in the fact that after visualization and introduction into the lumen of the external fistulous passage (item 3) of the button probe, it is reorganized.

A transverse incision (pos. 2) 1.5 cm long at the medial edge of the fistulous passage, at a distance of 1-1.5 cm from the edge of the rectum, cut the skin with subcutaneous tissue, secrete a fistulous passage for up to 1.0 cm, without opening its lumen, and they are tied with two ligatures at a distance of up to 0.5 cm from each other (pos. 5) and between them the fistulous passage is dissected. In the area of the internal opening of the fistulous passage, in the affected crypt (item 1), scar-changed tissues are excised in the form of a triangular flap (item 4). To close the internal opening of the fistulous passage, from the side of the rectal lumen, with the diameter of the internal opening of the fistulous passage up to 0.4 cm, the method of segmental movement of the rectal mucosa (pos. 6) is used, and when the diameter of the fistulous passage is more than 0.5 cm, it is moved mucus-muscular flap of the rectum on the leg, (pos. 6) After hydraulic preparation, a transverse incision 0.2 cm above the internal fistulous passage, a triangular flap of the mucous on the leg is cut, which should freely close the internal opening without tension The term fistula. It is fixed with 3 sutures with Vicryl No. 3 to the edges of the fistulous passage and rectal mucosa, and the wound from ingestion and suppuration is covered with Sulfacrylate medical glue, which has an antibacterial, hemostatic effect. The glue is applied in a thin layer. To strengthen the seam, after applying glue, the edges of the displaced mucosa are kept in a connected state for 2-3 minutes. During the specified time, a strong adhesive suture is formed on the connected wound surfaces. The resulting adhesive film is elastic, does not break within 10-15 days. This period is enough for primary healing of the wound, tissue inflammation does not occur. A hemostatic sponge is placed on the wound. The external opening of the fistulous passage is sanitized daily with antiseptics, for 3 days, a 3% alcohol solution of iodine or 70% ethyl alcohol is introduced into the lumen. This leads to sclerosis and elimination of the external opening of the fistula within 3-5 days.

An example of using this method:

Patient K., 45 years old, was admitted with complaints of a fistulous opening in the perianal region with purulent discharge. On visual inspection, the anus is closed, the anal reflex is alive. At a distance of 5 cm from the edge of the anus there is an external fistulous opening 0.3 cm in diameter with purulent discharge. With a digital examination of the rectum, the sphincter tone is preserved, the internal fistulous opening with a diameter of 0.3 cm with cicatricial edges is determined on the posterior wall. When a button probe is inserted through the external fistulous opening, the probe goes to a depth of 6 cm and penetrates the intestinal lumen. The course of the fistula is transphincterous.

Ultrasound examination showed the presence of an internal fistulous opening, 6 cm long, 0.3-0.4 cm in diameter. No leakage cavities were found along the fistulous course.

Fistulography: contrasted fistulous passage 6 cm long, going transfinternally. The patient was diagnosed with a posterior transsphincter fistula of the rectum of 3 degrees of complexity.

09/06/2018, the surgery was performed according to the method proposed as an invention. The postoperative period was uneventful. Pain is negligible. Regular stool from 3 days after surgery. For 3 days, daily sanitation of the external fistulous opening according to the method described above. When viewed per rectum, the displaced flap is wealthy, there are no signs of inflammation. On the 5th day, the external opening of the fistula was closed. Discharged on the 6th day. On the 12th day it was examined on an outpatient basis - the fistula of the rectum is closed, the moved flap has taken root completely.

The follow-up period for the patient after surgery was 2.5 months. There are no complaints, no relapse of the fistula.

The positive effect of the application of the invention

- The terms of treatment and rehabilitation of patients are reduced by 50%;

- Purulent complications and insufficiency of the anal sphincter are minimized;

- The postoperative period runs smoothly;

- the method allows you to radically eliminate the fistulous course with transphincter fistula 1-3 degree of complexity.

- reduced material costs;

The use of this method of operation for 15 patients with transsphincteric fistula allowed to reduce the treatment time for these patients by more than 2 times. The postoperative rehabilitation period was 10-15 days. Most patients started work on the 10-15th day. Monitoring patients for more than 3 months has shown the effectiveness of this method. No cases of recurrence of the disease, or postoperative complications were observed.

Claims (1)

A method of treating transsphincteric fistulas of the rectum, which consists in converting trans to an intrasphincteric fistula, characterized in that a skin with subcutaneous tissue is cut through a transverse section 1.5 cm long at the medial edge of the fistulous passage 1.5 cm from the edge of the anal ring fistulous passage is isolated for up to 1.0 cm without opening its lumen, a fistulous passage is tied with two ligatures, a fistulous passage is cut between ligatures, a ru is excised in the area of the fistula passage internal opening at the affected crypt of the anal canal Tissue-modified tissues in the form of a triangular flap, then a transverse incision 0.2 cm above the internal fistulous passage is cut out a mucous flap on a leg 1.5 cm long and 0.8 cm wide, which is laid without tension on the internal opening of the fistulous passage and fixed 3 - with sutures to the edges of the flap, and the mucosal defect remaining after displacement is sutured with 2 nodal sutures, the wound is closed with Sulfacrylate medical glue, the wound area is additionally covered with a hemostatic sponge, the external fistulous opening is sanitized daily with antiseptic ticks for 3 days, introduced into the lumen of a 3% alcohol solution of iodine or 70% ethyl alcohol

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