RU2795092C1 - Method for minimally invasive treatment of trans- and extrasphincter pararectal fistulas - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: surgical exploration of the fistulous passage through the external opening is carried out. The fistulous passage is washed with a 0.05% aqueous solution of chlorhexidine, followed by treatment of the passage with a Volkman spoon and ablation with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a wavelength of 1,470 nm, a power of 9 W, at a speed of 1 mm/s. In the longitudinal direction, two incisions bordering the internal fistulous opening are excised as a single block of the mucosa together with the submucosal layer and the opening to the muscular layer of the internal sphincter. The resulting defect after treatment with a 0.05% aqueous solution of chlorhexidine is sutured by applying a Z-shaped suture to the internal fistulous opening with the capture of the muscle of the internal sphincter. The same thread is continuously sutured with screwing sutures of the rectal mucosa in the longitudinal direction.

EFFECT: method allows to atraumatically remove the epithelial lining of the fistula and hypergranulation without the damage to the sphincter does not lead to tissue deficiency, reduces treatment time, prevents disease recurrence and postoperative complications, and improves cosmetic results.

1 cl, 1 ex

Description

The invention relates to medicine, namely to coloproctology, and can be used in the surgical treatment of patients with chronic paraproctitis.

Fistulas of the rectum is one of the most common coloproctological diseases, their frequency ranges from 15% to 30% [Zhukov B.N., Shabaev V.N., Isaev V.R., Lysov I.A. Coloproctology. - Samara, Samara State Medical University, 1999, - 132 p.; Rivkin V.L. et al. "Hemorrhoids and other diseases of the anal canal", M., 1994, - 238 p.]. At the same time, fistulous forms of paraproctitis occur in 28% of cases among all proctological diseases [Zhukov B.N., Shabaev V.I., Isaev V.R., Lysov N.A. Coloproctology. - Samara, Samara State Medical University, 1999, - 132 p.; Rivkin V.L. et al. "Hemorrhoids and other diseases of the anal canal", M., 1994, - 238 p.].

Depending on the location of the fistulous passage in relation to the external sphincter of the anus, intra-, trans- and extrasphincteric fistulas of the rectum are isolated [Vorobiev G.I. Fundamentals of coloproctology. - Rostov-on-Don: Phoenix, 2001, - 414 p.]. Extrasphincteric fistulas are high-level fistulas in which the course goes around the outside of the sphincter of the anus. The treatment of complex (extrasphincteric) fistulas remains an urgent task, since the fistulous tract is located high, it can occupy several cellular spaces with the formation of streaks, and there is a risk of sphincter injury during the operation [Semionkin E.I. Coloproctology. - M.: ID Medpraktika. - M., 2004, - 224 p.].

A characteristic feature of fistulas of the rectum is the presence of the fistulous tract itself, which can be located outward from the sphincter fibers, pass through the sphincter fibers or medially 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.

Treatment of pararectal fistulas is still a difficult problem. In this category of patients, fistula recurrences often occur, and the postoperative period is often complicated by the development of anal sphincter insufficiency. The emergence of minimally invasive methods for the treatment of anal fistulas has led to the rapid introduction of these techniques among proctologists in Western Europe, as evidenced by numerous publications. The emergence of radial laser fibers with uniform emission of laser radiation due to microlenses at the end of the working part opens up new prospects for the minimally invasive treatment of rectal fistulas, as it allows reliable ablation of a large diameter fistulous tract. Many different methods of treatment of patients with this pathology have been proposed. However, most of the techniques are accompanied by significant surgical trauma, a long recovery period and frequent recurrence 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 leads to a high risk of anal incontinence (up to 50%) [Fundamentals of coloproctology / under. ed. G.I. Vorobyov. - M.: LLC "Medical Information Agency", 2006. - S. 135-144]. 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 minimally invasive treatment of complex pararectal fistulas proposed by Solovyov O.L. (RF patent No. 2440164 dated September 23, 2010) including treatment with ultrasonic vibrations with simultaneous supply of the liquid phase and subsequent evacuation of the liquid phase, while first conducting a study of the fistulous tract, determining its direction and the presence of external and internal holes, then sequentially process each fistulous tract through the external opening, with obturation of the external opening of the untreated fistulous tract, at least twice, with an interval of two days, the treatment is carried out for 40-80 seconds with ultrasonic vibrations with a frequency of 20-60 kHz, and an alcohol solution in the amount of 10 -20 ml, depending on the size of the fistula, which is served at a rate of 0.25 ml per second.

Also known is a method for the treatment of complex forms of rectal fistulas using a modified Filac technology (Khitaryan A.G., Kovalev S.A., Kislov V.A., Romodan N.A., Alibekov A.Z., Orekhoa A.A. .). The method was performed as follows. Taking into account the data of ultrasound and MRI, the main fistulous tract was found in the surgical wound and crossed at a distance of 1 cm from the entrance to the anal sphincter array, where the fistulous tract is no longer tortuous. The fistulous tract was catheterized with an Elves Radial Biolitec spherical laser light guide and then laser ablation of the fistulous tract was performed with a laser with a wavelength of 1470 nm, a power of 6 W, in a pulsed mode "0.9 sec pulse, 0.1 sec interval", with a total energy of 200 J, reaching ablation and decontamination of the latter, without damaging the anal sphincter and the fibrous membrane of the fistula. Then the postoperative wound was sutured by suturing the edges of the skin wound to the underlying tissues of the perineum along its entire length with an absorbent thread 1.0. The wound in the postoperative period healed by secondary intention.

As a prototype, we have adopted a method of surgical treatment of anal fistulas (Fedotov DV patent No. 2558454 dated 08/14/2014). A patient under anesthesia with a rectal mirror inserted into the rectum is performed with a divulsion of the sphincters. A dye is injected into the external fistulous opening and the localization of the internal fistulous opening is determined. A bellied probe is passed through the external fistula opening, to destroy adhesions inside the fistula canal and expand the lumen, the canal is washed with a 3% hydrogen peroxide solution using a sterile syringe. Then the fistulous canal is treated with laser radiation from a Lakhta-Milon diode laser 970 nm 25 W. The choice of a surgical laser is determined by the fact that the wavelength of the working radiation of 970 nm falls on the local absorption maximum of the biological tissue. In addition, the risk of damage to underlying organs by laser radiation is reduced. Radiation provides a good coagulating effect. To do this, a laser electrode with a circular spectrum is passed through the fistulous canal to the inner hole to the inner hole. Start laser processing with a laser power of 14 W, a pulse duration of 900 ms and an interval between pulses of 10 ms. Initially, 6 pulses are applied, then the light guide is pulled back by 3-5 mm and the cycle is repeated. During the entire procedure, the radiation is not turned off. The electrode head is brought to the external fistulous opening, not reaching 5-10 mm, so as not to burn the skin of the perineum. It is important to observe the specified operating parameters, since if the specified parameters are reduced, the desired result will not be obtained, i.e. there is no coagulation of the tissues of the fistulous canal. On the contrary, with an increase in the power and time of laser exposure, a burn of the surrounding pararectal tissue occurs at the point of impact, or a perforation of the fistulous canal occurs. In order to prevent the laser fiber from sticking to the wall of the fistula canal during the procedure and to minimize the risk of injury, the pulse is not stopped until the fiber is removed. The internal fistulous opening is sutured with a double-row catgut suture.

Known methods have a number of disadvantages:

- when using the method with complex fistulas, a residual cavity is formed, which increases the risk of developing purulent complications (infiltrates, abscesses and recurrence of fistulas);

- there is a risk of eruption of sutures with the development of cicatricial deformity of the intestine and, at the same time, insolvency;

- necrosis of the muco-muscular flap, eruption of sutures when performing this method inevitably leads to a recurrence of the fistula;

- the operation and adequate closure of the internal opening of the fistula in this way is not feasible with cicatricial changes covering more than the semicircle of the rectum.

The aim of the invention is to reduce the duration of treatment, prevent recurrence of the disease and postoperative complications and improve cosmetic results.

The objective of the invention is the development and implementation of a new method for minimally invasive treatment of trans- and extrasphincter pararectal fistulas.

This goal is achieved by the fact that under local anesthesia with potentiation with a bellied probe, the fistulous tract is revised through the external opening, the fistulous tract is washed with a 0.05% aqueous solution of chlorhexidine, followed by treatment of the tract with a Volkmann spoon and ablation with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm / s, then in the longitudinal direction with two incisions bordering the internal fistulous opening, the mucous membrane is excised in a single block together with the submucosal layer and the opening to the muscle layer of the internal sphincter, the resulting defect after treatment with a 0.05% aqueous solution of chlorhexidine, it is sutured by applying a Z-shaped suture to the internal fistulous opening with the capture of the muscle of the internal sphincter, and the rectal mucosa is continuously sutured with the same thread with screw sutures in the longitudinal direction.

The proposed method was operated on 10 patients in the surgical department of CHUZ KB "RZD-Medicine" in Astrakhan. An example of the clinical implementation of the method:

Patient B., 42 years old. Hospitalized with a diagnosis of chronic paroproctitis. Complete transsphincteric pararectal fistula. Complaints of periodic pain in the anus, purulent discharge from the anus. When viewed in the anus in the knee-elbow position at 12 o'clock, an external fistulous opening 2 × 2 mm is visualized, the skin around is compacted. When pressed, a serous discharge is released from the fistulous passage. During revision with a probe, the fistula passes through the sphincter fibers, goes towards the rectum at a depth of 7 cm. The probe is brought out through the internal opening at 12 o'clock. Sphincter tone is normal. Under local anesthesia, the fistulous tract was washed with a 0.05% aqueous solution of chlorhexidine, treated with a cytobrush of the company, and ablation was performed with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm/s . The internal fistulous opening was excised in a single block to the muscle layer, the resulting defect after treatment with a 0.05% aqueous solution of chlorhexidine was sutured with a Z-shaped suture and the rectal mucosa was sutured in the longitudinal direction with the same thread continuously screwing sutures. The postoperative period was pain-free. On the 5th day he was discharged from the department in a satisfactory condition. Further observation took place on an outpatient basis. At the control examination after six months, there were no relapses.

The advantages of the invention are:

- treatment of the fistulous passage with a Volkmann spoon allows atraumatic removal of the epithelial lining of the fistula and hypergranulation;

- laser treatment of the fistulous tract has a pronounced sanitizing and coagulating effect without damaging the sphincter;

- excision of the mucosa with the submucosal layer and the internal opening of the fistula in the longitudinal direction does not lead to tissue deficiency;

- the imposition of a Z-shaped suture on the internal opening of the fistula with the capture of the muscle of the internal sphincter and suturing with the same thread with a continuous screwing suture of the rectal mucosa in the longitudinal direction prevents the formation of a rough scar and a residual cavity.

The proposed method can be recommended for use in clinical practice in the treatment of pararectal fistulas.

Claims (1)

A method for minimally invasive treatment of trans- and extrasphincteric pararectal fistulas by processing the fistulous tract followed by the use of a surgical laser, characterized in that under local anesthesia with potentiation with a button probe, the fistulous tract is revised through the external opening, the fistulous tract is washed with a 0.05% aqueous solution of chlorhexidine, with subsequent processing of the passage with a Volkmann spoon and ablation with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm / s, then in the longitudinal direction, two incisions bordering the internal fistula opening are excised with a single the mucous membrane together with the submucosal layer and the opening to the muscle layer of the internal sphincter, the resulting defect after treatment with a 0.05% aqueous solution of chlorhexidine is sutured by applying a Z-shaped suture to the internal fistulous opening with the capture of the muscle of the internal sphincter and the same thread is continuously sutured with screwing sutures of the straight mucosa intestines in the longitudinal direction.