RU2800333C1 - Method of the treatment of transsphincter pararectal fistulas - Google Patents

Abstract

FIELD: medicine, surgery and coloproctology.

SUBSTANCE: invention can be used in the surgical treatment of patients with chronic paraproctitis. An audit of the fistulous tract is carried out 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. Through an incision in the projection of the intersphincteric space, the fistulous tract is tied up not reaching the internal opening of 0.5 cm, followed by ablation of the distal fistulous tract 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. Then, in the lumen of the rectum, the internal opening of the fistulous tract is sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter.

EFFECT: method provides reduction of treatment time, prevention of recurrence of the disease and postoperative complications due to laser treatment of the fistulous tract, which has a pronounced sanitizing and coagulating effect without damaging the sphincter, and due to applying a Z-shaped suture to the internal opening of the fistula with capture of the internal sphincter muscle, which prevents the formation of a rough scar and residual cavity.

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Description

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

Fistula of the rectum (chronic paraproctitis) is a chronic inflammatory process in the crypt, intersphincter space and pararectal tissue with the presence of a formed fistulous tract. The affected crypt is the internal opening of the fistula. According to various authors, rectal fistulas occur in 20-40% of patients with diseases of the rectum and perineum (V.D. Fedorov, 1984, G.I. Vorobyov, 2001). Determination of tactics and choice of treatment method in this disease directly depends on the ratio of the fistulous tract to the fibers of the anal sphincter.

Currently, a classification is widely used, according to which the fistulas of the rectum are divided into: intrasphincteric, transsphincteric and extrasphincteric (Dultsev Yu.V., Salamov K.N., 1981). 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 passage 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 s].

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. Despite the large number of developments and proposals for the treatment of chronic paraproctitis, recurrence after surgery is still more than 15% (V.D. Fedorov, Yu.V. Dultsev, 1984). 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 treatment of fistulas of the rectum Tatyanchenko V.K. (RF patent No. 2326604 dated June 20, 2008) involving the excision of a colored fistula with surrounding scar tissue and plastic restoration of the rectal wall in the area of the internal fistula opening, characterized in that the U-shaped fascio-muscular graft is cut out on the basis of the medial portion of the gluteus maximus muscle with the gluteal fascia located above it, and then the muscular part of the graft is immersed into residual cavity with fixation of the fascial part of the graft to the fascial sheath of the rectum at an angle of 90° to the horizontal axis of the pelvis in the symphysopetal type of pelvic topography and at an angle of 120° to the horizontal axis of the pelvis in the sacropetal type of pelvic topography.

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, achieving 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 absorbent thread 1.0. The wound in the postoperative period healed by secondary intention.

Known methods have a number of disadvantages.

- when using the methods, residual cavities can be 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;

As a prototype adopted a method of surgical treatment of fistulas of the anal canal (Fedotov DV patent No. 2558454 dated 08/14/2014) The patient under anesthesia with a rectal mirror inserted into the rectum, perform sphincter divulsion. 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 970 nm 25 W diode laser. 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. The internal fistulous opening is sutured with a double-row catgut suture.

The prototype has several disadvantages.

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

- performance of 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 present invention is the development and implementation of a new method of minimally invasive treatment of trance-fincter pararectal fistulas.

This goal is achieved by the fact that under local anesthesia with potentiation with a bellied probe, the fistulous passage is revised through the external opening, the fistulous passage is washed with a 0.05% aqueous solution of chlorhexidine, followed by treatment of the passage with a Volkmann spoon, the fistulous passage is bandaged through an incision in the projection of the interphincteric space without reaching the internal opening of 0.5 cm, followed by ablation of the distal fistulous passage surgical laser "Lakhta-Milon" 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 the internal opening of the fistulous tract is sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter.

The proposed method was operated on 7 patients in the surgical department of CHUZ CB "RZD-Medicine", Astrakhan. Examples of clinical implementation of the method:

Example. Patient A., 31 years old. Hospitalized with a diagnosis of chronic paraproctitis. Complete trance-fincter 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 1.5 × 1.5 mm is visualized, the skin around is compacted. When pressed, a serous discharge is released from the fistulous passage. When auditing with a probe, the fistula passes through the sphincter fibers, goes towards the rectum at a depth of 6 cm. The probe is brought out through the internal opening at 12 o'clock. Sphincter tone is normal. Under anesthesia, the fistulous tract was washed with a 0.05% aqueous solution of chlorhexidine, treated with a Volkmann spoon, the fistulous tract was tied up through an incision in the projection of the intersphincteric space, not reaching the internal opening of 0.5 cm, followed by ablation of the distal fistulous tract with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a wavelength of 1470 nm , with a power of 9 W, at a speed of 1 mm/s, then in the lumen of the rectum, the internal opening of the fistulous tract was sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter.

The postoperative period was pain-free. On the 7th 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:

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

- the imposition of a Z-shaped seam on the internal opening of the fistula with the capture of the muscle of the internal sphincter prevents the formation of a rough scar and residual cavity.

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

Claims (1)

a method for treating transsphincteric pararectal fistulas by treating the fistulous tract with subsequent use of a surgical laser, characterized in that, under anesthesia with a bellied probe, the fistulous tract is inspected 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, through the incision in the projection of the intersphincter space, the fistulous tract is bandaged without reaching internal opening of 0.5 cm, followed by ablation of the distal part of the fistulous tract with a surgical laser "Lakhta-Milon" 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 the internal opening of the fistulous tract is sutured in the lumen of the rectum by applying a Z-shaped suture with the capture of the muscles of the internal sphincter.