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2MODERN APPROACH TO THE TREATMENT OF PATIENTS WITH NECROTIZING ISCIORECTAL PARAPROCTITIS
Karabayev J.A.
Samarkand State Medical University https://doi.org/10.5281/zenodo.12577421
Abstract: The article discusses the results of treatment in 254 patients operated on in the proctology department of the multidisciplinary clinic of the Samara State Medical University in the period 2016-2022, among which patients with necrotic forms of the disease accounted for 31 (12.2%) patients. Among them, 236 (92.9%) had an aerobic etiology of damage to the perirectal tissue. The mean age of the patients was 62.1±3.9 years.
Keywords: acute paraproctitis, necrotizing paraproctitis, abscess, abscess drainage, sepsis, multiple organ failure.
СОВРЕМЕННЫЙ ПОДХОД К ЛЕЧЕНИЮ БОЛЬНЫХ С НЕКРОТИЧЕСКИМ ИШИОРЕКТАЛЬНЫМ ПАРАПРОКТИТОМ
Аннотация: В статье рассмотрены результаты лечения у 254 больных, оперированных в проктологическом отделении многопрофильной клиники СамГМУ в период 2016-2022 г., среди которых пациенты с некротическими формами заболевания составили 31 (12,2%) больных. В их числе у 236 (92.9%) отмечена аэробная этиология поражения околопрямокишечной клетчатки. Средний возраст больных составил 62,1±3,9 года.
Ключевые слова: острый парапроктит, некротический парапроктит, абсцесс, дренирование гнойника, сепсис, полиорганная недостаточность.
INTRODUCTION
An analysis of the literature of recent years shows that today there is no tendency to reduce the frequency of purulent-inflammatory diseases. Patients with purulent-necrotic processes of various localization make up about 30% of surgical patients. Various forms of acute paraproctitis account for 0.5% - 4% of the total number of surgical patients and 21% -50% of all proctological patients.
Acute paraproctitis is the most common pathology in the practice of emergency surgical proctology, while necrotic forms of the disease occur in only 3-6% of cases; in the analysis of the literature, most authors do not include necrotizing paraproctitis in the research, emphasizing the extreme complexity of its diagnosis and treatment.
The development of the treatment of necrotic paraproctitis is determined by the fact that this disease is among the life-threatening ones, the mortality rate is from 15 to 40%, and when the process is generalized, up to 80%. The foregoing is due to the fact that the etiological factor of necrotic paraproctitis is combinations of opportunistic autoflora, in which anaerobes with high invasiveness and toxicity become the leader-associate, which determines the rapid generalization of the process and causes difficulties in diagnosis and the complexity of complex postoperative treatment of septic conditions.
Currently, streptococci, staphylococci, fusobacteria, spirochetes and other associations of anaerobic and aerobic bacteria are considered as pathogens. Septicemia observed in necrotizing paraproctitis is usually caused by streptococci. According to the data of modern literature, the anaerobic orientation of the process is due to the high dose and virulence of the infecting agent
against the background of a decrease in the immunological resistance of the body. Indeed, necrotizing paraproctitis often occurs with insufficient hygiene in combination with diabetes. The literature also indicates other factors that affect systemic immunity and predispose to the development of anaerobic inflammation of pararectal tissue: autoimmune diseases and the use of steroid hormones, antitumor chemotherapy, neurosensory diseases, periarteritis nodosa, etc.
Despite the improvement of surgical technique, the development of progressive methods of detoxification and antibiotic therapy, the treatment of acute necrotizing paraproctitis still remains a complex and largely unresolved problem of modern surgery and coloproctology, which determines the need for further developments in this area.
Purpose of the study. To develop and improve treatment tactics for acute gangrenous-necrotic paraproctitis.
MATERIAL AND METHODS OF RESEARCH
During the period of2016-2022, 254 patients with various types of acute paraproctitis were operated on in the proctology department of the multidisciplinary clinic of Samara State Medical University, among which patients with necrotic forms of the disease accounted for 31 (12.2%) patients. Among them, 236 (92.9%) had an aerobic etiology of damage to the perirectal tissue. The mean age of the patients was 62.1±3.9 years. There were no statistically significant differences in the age of men and women.
All patients underwent a clinical examination, a digital examination of the rectum, transabdominal and transrectal ultrasound, bacteriological examination of the wound discharge.
RESULTS AND ITS DISCUSSION
Surgical interventions in all cases were performed according to urgent indications. The operation was delayed by 1 -4 hours only in cases where preoperative preparation of extremely severe patients was necessary. Necrotic abscess of the perineum was opened only under general anesthesia. The intervention was carried out through a wide incision over the entire identified area of inflammatory changes, according to the type of surgical access. This allowed for a thorough intraoperative revision with an assessment of the volume of soft tissue damage, demarcation of the boundaries between visible altered and healthy tissues, and detection of possible pockets and leaks. Since the main task at this moment was to save the life of the patient. The criteria for the viability of the formed wound surface were distinct capillary bleeding of tissues. The operation was completed by jet irrigation of the wound with antiseptic solutions and bandaging with decasan solution. In two cases, due to necrotic changes in the wall of the rectum, a sigmostoma was applied. In all other observations, the fecal stream was not turned off. In no case with necrotic paraproctitis did we eliminate the purulent tract simultaneously with the main radical operation.
Antibiotic therapy was started 30-40 minutes before surgery. Intensive detoxification, infusion, symptomatic therapy was also carried out, tube nutrition was carried out with enteral balanced mixtures. After the operation, the wound surfaces and dressings were examined several times a day, 2-3 times on average. In 82% of patients, in the first few days of the postoperative period, newly emerging foci of necrosis were found, which were removed in an acute way during dressings.
It is very important in the surgical treatment of acute gangrenous-necrotic paraproctitis to determine the boundaries of the prevalence of irreversible pathological changes. This is necessary to perform necrectomy of the optimal volume, which significantly affects the result of treatment. In our study, we relied on the method of laser Doppler flowmetry, considering the characteristics
of tissue microcirculation as an important indicator of the extent of the inflammatory process. Lethal outcome occurred in 2 (0.5%) patients with acute necrotizing paraproctitis.
Long-term results were traced in 19 (5.1%) patients by examination and questionnaire method. Most of them did not file any complaints requiring any involvement. However, in 4 (1.1%) patients, extrasphincteric fistulas of the rectum were formed, which, 6 months after the main interventions, were successfully eliminated by various surgical methods.
CONCLUSION
Acute necrotic paraproctitis is one of the severe, life-threatening diseases and is accompanied by high mortality. The success of treatment largely depends on the early diagnosis of the inflammatory process, the earliest possible emergency operations with sufficient necrectomy and adequate intensive care.
Most often, unsatisfactory results of treatment are due to late treatment of patients for specialized medical care (71.7% of cases), as well as late diagnosis of the disease in non-specialized institutions. This leads to widespread damage to the cellular spaces of the pelvis and muscle fibers of the sphincter, which makes it difficult to carry out a radical intervention.
The results of the studies indicated that a timely and radically performed operation, supplemented with antibacterial and detoxification therapy, led to recovery.
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