Plastic surgery in the surgical treatment of fistulas adrectal
Science Articles / / April 26, 2016
Zhukov BN, Isaev VR, AI Savinkov, Chernov AA, Kudryashov SK, Polikashin NN
Department of Hospital Surgery SSMU, Samara
Chronic abscess is one of the most common diseases of the anal canal and adrectal the area in which you need surgical treatment.According to various authors, patients with this pathology make up more than 25% of all Proctologic patients requiring surgical treatment.Surgical treatment of rectal fistula has an ancient history.The first operation incision fistula from the outer to the inner hole with a knife go ligatures are described in the writings of Hippocrates.Total offered more than 100 transactions and their modifications for the treatment of patients with anorectal fistula.
The biggest problem is the surgical treatment of complex and ekstrasfinkternyh chressfinkternyh adrectal fistula.Any surgical intervention aimed at eliminating radical pararectal fistula to a greater or lesser extent injures obturator device bears direct that leads to the development or worsening of anal
All operations currently used to treat adrectal fistula can be divided into four main groups :
- excision of a fistula in the rectum lumen (Gabriel surgery, excision of a fistula with dissection and suturing of the anal sphincter);
- ligature method and its numerous modifications;
- excision of a fistula with a plastic displacement of the anal canal mucosa (Jada Roble, Moslyaka, Blinnicheva);
- excision of the fistula using the auto - or allo-transplant.
In coloproctological hospital surgery clinic SSMU office for the period 1997-2003.were treated 702 patients with various forms adrectal fistula.Achieved operations 675 (96%).27 patients in the surgical treatment is denied because of severe comorbidities.They were a course of conservative treatment with a temporary improvement in the flow of the inflammatory process in the tissue adrectal.
operations are usually performed under spinal anesthesia with 2% solution of novocaine or lidocaine 2% solution at a dose of 2.0-2.5 ml.In cases where the planned duration of the operation more than 1 hour, epidural anesthesia was applied with the involvement of an anesthesiologist.When subcutaneous submucosal adrectal fistulas allows the use of local infiltration anesthesia.
Patients with intrasfinkternymi and chressfinkternymi adrectal fistulas with a surface location of the fistulous combined into one group - 307 persons (45.5%).All of these patients underwent surgery for excision of a fistula Gabriel and excision of a fistula in the rectum lumen suturing the wound bed with good early and late results.Complete recovery was observed in 98% of patients.In 57 patients diagnosed with an inner part pararectal fistula, which often (45%) combined with chronic anal fissure.In these cases, surgery was performed excision of the fistula and anal fissure by Gabriel method.In the presence of purulent cavity in the submucosal layer of the cavity produced scraping spoon Volkmann with excision of overhanging edges of the mucosa for adequate drainage in her colon lumen.In 4 cases, the processing of purulent cavity, detected foreign bodies - chicken or fish bone.
patients with complete ekstrasfinkternymi chressfinkternymi and complex fistulas adrectal a group of 273 patients (40.4%).In this group of patients, the most frequently used operations of excision of the fistulous with plastic lateral movement of the anal canal mucosa.Achieved 166 such operations.
the presence of purulent cavities, fistulous buhtoobraznyh extensions, recurrent course pararectal fistula surgery performed excision of a fistula with a plastic displacement rectal mucosa and sustainable drainage of purulent cavities duration of 15-20 days.When the location of purulent cavity behind the rectum produced cut-anal coccygeal ligament.Adequate sustainable drainage of purulent cavities and wounds after excision of a food moves creates favorable conditions for the healing of the internal opening of the fistula.By this method 68 performed operations.
operations related to mobilization and bringing down the mucosa for the purpose of hiding the internal opening of the fistula but the method of Jada Roble not used because of the risk of retraction downmix graft and fistula recurrence pararectal.Not widely used in our clinic operations pararectal fistula excision with total or partial dissection of the anal sphincter because of the high chance of developing anal incontinence.
39 patients with the most complicated variants ekstrasfinkternyh fistula, as well as with persistent recurrent course of chronic abscess surgery performed excision of fistula ligature method in clinical modifications.
A special group isolated patients with true incomplete external fistula adrectal - 39 people.Choosing surgery in these patients depended on the reasons for the formation of a fistula in adrectal area.
not enough satisfactory results of treatment of complex fistulas ekstrasfinkternyh adrectal (relapses reach 8,5-12%) contribute to the development of new methods of treatment and improvement of common surgical procedures.The clinic is designed modification operation excision pararectal fistula ligature method of using the device for the dosed tension ligature original design and high-energy laser radiation.
High-energy laser irradiation applied to the allocation of the fistulous stage, treatment of purulent cavities defocused laser beam, as well as to cross the bridge of tissue at the ligature method of excision pararectal fistula.Use domestic surgical lasers "Scalpel-1" and "Daisy-2."Achieved 26 surgical interventions with a good result.The use of high-energy laser exposure in the surgical treatment of fistulas ekstrasfinkternyh adrectal 3-4 degrees of complexity to avoid bacterial contamination of wounds, reduce the severity of perifocal inflammation, reduce the duration of the operation.
In the last 2 years in the surgical treatment of complex fistulas adrectal began to use modern alloplastic materials.Their use allows you to securely seal the internal bore of the fistulous with the formation of a strong and elastic scar in the submucosa of the anal canal, avoiding recurrence of fistula and anal sphincter insufficiency.Achieved 5 operations with plastic inner hole pararectal fistula polypropylene mesh.Monitoring of patients within one year showed no recurrence pararectal fistula and anal sphincter insufficiency.
Application of plastic surgery, developed in the clinic, and modern laser technologies in the surgical treatment of a false adrectal fistula leads to better treatment results and reduce the number of relapses from 8.5 to 4.5%, while maintaining the function of the anal sphincter.