RU2753137C1 - Method for surgical treatment of transsphincter and extrasphincter fistulas of rectum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to colorectal surgery. Scraping of the fistula passage is carried out with a ruff-like probe-conductor. Threads from the copolymer of L-lactide with ε-caprolactone “APTOS” with notches are introduced into the fistula course. The threads are fixed with nodular sutures to the fibers of the sphincter and pararectal tissue and additionally along the course of the fistula in a perpendicular direction using an injection needle-cannula to a depth of 1.0 cm under visual control.

EFFECT: method makes it possible to reduce the frequency of postoperative complications, improve functional results, as well as reduce the likelihood of a relapse of the disease, reduce the duration of treatment and disability of patients by preserving the integrity of the sphincter fibers.

1 cl, 4 dwg

Description

The invention relates to medicine, namely to colorectal surgery, and is intended to improve the results of treatment of patients with transsphincteric and extrasphincteric pararectal fistulas.

A pararectal fistula (chronic paraproctitis, anus fistula, rectal fistula) is a chronic inflammatory process in the anal crypt, intersphincter space and pararectal tissue, accompanied by the formation of a fistulous tract. About 95% of patients associate the formation of a fistula with a previous acute paraproctitis. According to statistical studies, the incidence of rectal fistulas is 20 observations per 100 thousand population. Among all patients with coloproctological diseases, the proportion of patients with pararectal fistulas reaches 30%. Most often rectal fistulas are detected at the age of 20 to 50 years. The sex ratio in this nosological group is approximately 2: 1 (men are more likely to suffer from this pathology) [1]. A characteristic feature of rectal fistulas is the presence of the fistulous tract itself, which can be located outward from the sphincter fibers, pass through the sphincter fibers or inwardly relative to the sphincter fibers, as well as the presence of an internal fistulous opening, opening into the intestinal lumen, and an external fistulous opening on the perianal skin. All pararectal fistulas are characterized by the presence of perifocal inflammation in the pararectal tissue, as well as the presence of cicatricial changes in the rectum and surrounding tissues.

In patients with intrasphincteric pararectal fistulas, the interval between acute paraproctitis, subsequent surgical treatment and the formation of a pararectal fistula is relatively short, and the results of surgical treatment of the fistula are quite satisfactory. However, patients with transsphincteric and extrasphincteric pararectal fistulas suffer from their disease for many years, undergo many repeated surgeries, note the appearance of a clinic of anal incontinence of varying severity, and eventually permanently lose their ability to work [2].

Many different methods of treating patients with this pathology have been proposed. However, most of the techniques are accompanied by significant surgical trauma, a long recovery period, and frequent relapse of the disease. The greatest difficulty in the method of surgical treatment of patients with complex pararectal fistulas lies in the direct involvement of the anal sphincter in the pathological process, which causes a high risk of developing anal incontinence (up to 50%) [3]. For this reason, the development of new effective and less traumatic methods of treating patients of this nosological group is an urgent problem of modern colorectal surgery.

A known method of surgical treatment of pararectal fistulas, which consists in eliminating the fistulous course using radio wave coagulation, followed by treatment of the wound canal with enzymes for several days and filling the fistula with biological glue in a delayed period after the end of the exudative process in the wound [4].

The disadvantages of this technique are the high risk of recurrence of the disease due to incomplete removal of the epithelial lining of the fistulous tract and tissue detritus, as well as the high risk of rejection of the adhesive composite from the fistulous tract.

A known method of treating a fistulous course using laser radiation, which consists in coagulating the fistulous course using laser energy delivered through a fiber optic conductor [5].

The disadvantages of this technique are insufficient strength and tightness of the "weld", which leads to frequent relapses. Another equally significant drawback is deep thermal damage to the surrounding tissues (including the sphincter fibers through which the fistulous passage passes) with their subsequent necrosis and rejection, which causes the formation of a wound canal with its subsequent epithelialization and the occurrence of a relapse of the disease.

There is a method of surgical treatment of perrectal fistulas using biological absorbable materials based on human collagen acellular skin matrix (Surgisis AFP), which consists in excision of the fistulous passage and installation of the obturator Surgisis Fistula Plug into the fistulous passage, followed by fixation with interrupted sutures and closure of the wound. (S. Amrani et al., 2008; W. L. Song et al., 2008).

The disadvantage of the proposed method is a breach of tightness arising from a violation of the blood supply of the mucous membrane in the place of its fixation with the wide part of the obturator, which can lead to its necrosis and the re-formation of the fistulous course, as well as the impossibility of using the technique for convoluted and horseshoe-shaped fistulas.

For the prototype we have taken a method of surgical treatment of rectal fistulas using bioplastic material (RF patent No. 2451490, publication date: 05/27/2012).

The method consists in the isolation of the fistulous passage from the external fistulous opening by an acute path, excision of the internal fistulous opening, plastics of the internal fistulous opening using a collagen bioplastic membrane fixed to the separated mucous-muscular layer, followed by filling the bed of the excised fistula with bioplastic material in the form of a tourniquet and injecting a gel Collost ".

The disadvantages of the proposed method is the violation of the tightness of the fistulous tract, arising from the eruption of the fixing catgut sutures and the subsequent migration of the "tourniquet" from the fistulous tract, which contributes to the development of relapse of the disease. Another disadvantage of this technique is the impossibility of adequate curettage of the fistulous tract to remove the epithelial lining, which in turn increases the risk of recurrence of the disease. An equally significant drawback of this technique is the high cost of consumables, which significantly increases the cost of treating patients.

The aim of the present invention is to improve the effectiveness of treatment of patients with transsphincteric and extrasphincteric fistulas.

To eliminate these disadvantages, we have developed a method of surgical treatment of patients using a copolymer of L-lactide with ε-caprolactone as an allograft (absorbable threads "APTOS" metric 5 with notches).

The novelty of the presented technique lies in hermetic filling of the fistulous tract, reliable fixation of the allograft in the cavity of the fistulous tract, and stimulation of reparative processes due to the material used.

The method is carried out as follows:

1. The anal canal is revised using a rectal speculum.

2. The fistulous tract is stained with a solution of methylene blue or a diluted brilliant green solution, followed by probing of the fistulous tract to finally establish the relationship of the fistulous tract to the sphincter fibers.

3. After hydropreparation with a 0.5% solution of novocaine, the muco-submucosomuscular flap of the rectal wall is mobilized by 1/3 of the circumference of the anal canal to the internal fistulous opening and 1.0 cm above it.

4. A radial incision is cut through the perianal skin, excising the external fistulous opening and the distal part of the fistulous tract to the fibers of the anal sphincter, the separated mucous-submucosomuscular flap of the rectal wall is retracted using the Forabef hook.

5. The internal fistulous opening and the surrounding scar tissue are excised by an acute way to the proximal portion of the sphincter fibers;

6. With the help of a ruffled probe-guide (position 1 in Fig. 1) containing in the lumen absorbable threads "APTOS" metric 5.0 with notches (position 2 in Fig. 1), repeated probing of the fistulous tract is performed within the sphincter fibers with simultaneous scraping of the epithelial lining and removal of tissue detritus (Fig. 1).

7. Holding the threads by the ends, the guide probe is pulled out of the fistulous passage so that the threads remain in the lumen of the fistulous passage (position 3 in Fig. 2).

8. The sutures are fixed with an absorbable suture "APTOS" metric 3.5 with notches to the sphincter fibers and pararectal tissue with interrupted sutures on both sides (position 4 in Fig. 3).

9. Additional fixation of the sutures in the fistula is carried out by means of a perpendicular installation of the APTOS sutures metric 3.5 with notches along the fistulous course (position 5 in Fig. 4) using an injection cannula-needle to a depth of 1.0 cm under visual control during avoiding damage to underlying structures.

10. Excess threads are cut off, the wound in the perianal region is sutured tightly with the introduction of a rubber graduate between the sutures.

11. In the postoperative period, patients are prescribed table 0 for 4 days, then a slag-free diet is prescribed. Dressings are performed once a day. The sutures from the perianal skin are removed on the 10th day.

The proposed method of treatment makes it possible to reduce the incidence of postoperative complications, improve functional results, and also reduce the likelihood of recurrence of the disease, shorten the duration of treatment and disability of patients by preserving the integrity of the sphincter fibers and using "APTOS" threads with incisions as an allograft, which are securely fixed in the cavity of the fistulous tract. and stimulating the reparative process in tissues.

Comparison of the proposed method with those known in the field of medicine showed its compliance with the criteria of the invention.

The method is illustrated by 4 figures depicting the main stages of the operation.

Thus, the proposed method provides a decrease in the incidence of postoperative complications, improves the functional results of surgical treatment, and also reduces the likelihood of recurrence of the disease, reduces the duration of treatment and disability of patients, and reduces the costs of a medical organization for the treatment of this category of patients.

SOURCES OF INFORMATION

1. Modern sphincter-preserving methods of treatment of trans- and extrasphincteric pararectal fistulas. CE. Katorkin, A.V. Zhuravlev, A.A. Chernov, V.N. Krasnova. Surgery news. - 2018. Volume 26. No. 2. S. 204-214.

2. Dermal island-flap anoplasty for transsphincteric fistula-in-ano: assessment of treatment failures. Nelson R. L., Cintron J., Abcarian H. Dis. Colon Rectum. - 2000; 43: 681-684.

3. Fundamentals of Coloproctology / under. ed. G.I. Vorobyov. - M .: LLC "Medical Information Agency", 2006. - S. 135-144.

4. Patent RU 2579629, cl. IPC А61В 17/00; publ. 10.04.2016

5. Closure of fistula-in-ano with laser - FiLaC: an effective novel sphincter-savins procedure for complex disease. Giamundo P., Geraci M., Tibaldi L., Valente M. Colorectal disease. - 2014. Vol. 16 (2), - p. 110-115.

Claims (1)

A method of surgical treatment of patients with transsphincteric and extrasphincteric pararectal fistulas, characterized in that the curettage of the fistulous passage is carried out by a ruffled guide probe, followed by the introduction into the fistulous passage of threads made of copolymer of L-lactide with ε-caprolactone "APTOS" with notches that are fixed to the sphincter and pararectal tissue with interrupted sutures, and additionally along the fistulous course in the perpendicular direction using an injection needle-cannula to a depth of 1.0 cm under visual control.

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