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19МЕДИЦИНСКИЕ НАУКИ
ПРИЧИНЫ ОСЛОЖНЕНИЙ И РЕЦИДИВОВ АНОРЕКТАЛЬНЫХ МАЛЬФОРМАЦИЙ У ДЕТЕЙ Атакулов Д.О.1, Шамсиева Л.А.2
1Атакулов Джамшид Останокулович — доктор медицинских
наук, профессор;
Шамсиева Лайло Алишеровна — студент, кафедра детской хирургии, педиатрический факультет, Самаркандский государственный медицинский институт, г. Самарканд, Республика Узбекистан
Аннотация: хирургическое лечение врожденных аноректалъных пороков у детей представляет сложную задачу. Значимость проблемы обусловлена, во-первых, существенной заболеваемостью этой патологией среди остальных аномалий желудочно-кишечного тракта, а во-вторых, неудовлетворительными результатами как в ближайшем, так и в отдаленном послеоперационном периодах. Целью нашего исследования явилось изучение причин рецидивов и осложнений аноректальных мальформаций, после перенесенных проктопластик. По результатам нашего исследования мы определили основные причины осложнений и рецидивов аноректальных мальформаций.
Ключевые слова: аноректальная мальформация, рубцовый стеноз, рецидивы, проктопластика.
Relevance. According to various authors, the frequency of unsatisfactory results in this pathology in the long term is from 30 to 60% [1,5]. On the one hand, this is due to an anomaly of anatomical and physiological relationships of the anorectal zone, underdevelopment of the nervous system and muscle structures of the pelvic diaphragm. On the other hand, the reasons for unsatisfactory results of surgical treatment of anorectal malformations are the inadequacy of the chosen operation, errors in the implementation of the intervention, incorrect assessment of surgical access [2,3,4]. The above indicates the high relevance of
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the problem, which was a prerequisite for the implementation of this work.
The purpose of the research. Our research was to study the causes of relapses and complications of anorectal malformation (ARM) after undergoing proctoplasty.
Materials and methods research. We studied 130 children with late postoperative complications and relapses of ARM that developed after various types of proctoplasty and required repeated surgical correction. Before coming to us, patients underwent from 1 to 3 unsuccessful surgical interventions in the form of various perineal and abdominal-perineal anoplastics. As a rule, children were admitted after performing the most popular and most frequently used type of surgery -various types of perineal proctoplasty-there were 117 such patients (90.0%). Quite rarely, we observed a relapse of ARM after transperitoneal extirpation (6 cases) and invaginal extirpation of the Lenushkin N-fistula (3 cases), as well as abdominal-perineal proctoplasty (4 cases).
Almost half of the patients with recurrent ARM were children with difficult to correct forms of the defect - 62 (47.7%), whose radical elimination required the use of technically complex reconstructive and reconstructive interventions and who were characterized by a high frequency of postoperative complications.
The results of the research and their discussion. The main clinical manifestation of the relapse of ARM of all 130 patients had fecal incontinence, including 35 (26,9%) encopresis was associated with constipation, when postoperative scar stenosis of the anus leads to a strong stretching of the end of the rectum stagnant fecal masses, causing nerve endings and muscles of this area lose sensitivity and the ability to react, in order to keep the stool.
Analysis of the causes that led to postoperative failure of the sphincter apparatus of the rectum showed that 68 (52,3%) children had diagnostic, tactical errors (22%), technical errors (15,7%) in the performance of primary operations. And only in 13 (10%) patients, the cause of ARM recurrence was postoperative purulent-inflammatory complications.
It should be noted that 115 (88.5%) children were operated in general surgical departments of district hospitals by surgeons who did not have specialized training in the surgical treatment of newborns with ARM. Surgeons in the field often do not differentiate between high and low forms of the defect, as a rule, do not diagnose rectal fistulas with the child's genitourinary system, and without taking into account these features of the disease, they are fond of performing perineal access proctoplasty, which does not always provide adequate and radical elimination of malformation. As we mentioned above, 90% of patients are admitted after perineal proctoplasty. The most common technical errors of the operation, allowed by general surgeons, include inadequate mobilization of the rectum by perineal access in supralevator forms of ARM, when the reduced intestinal mucosa is fixed to the neoanus with tension, which is the main and well-known cause of postoperative necrosis and retraction of the mucosa. Not all surgeons who performed primary operations have the necessary skills to rehabilitate this category of children. In particular, they do not comply with the generally accepted scheme of postoperative neoanus bugging, do not send children to courses of electrostimulation of the sphincter apparatus, do not engage in procedures aimed at increasing the tone of the newly formed sphincter apparatus.
In addition, during the initial operation, more than half of 69 patients (53.1%) had the neoanus formed outside of the puborectal muscle, which did not ensure the full functioning of the neoanus and made it extremely difficult to perform repeated reconstructive and reconstructive surgery, significantly increasing its trauma.
Conclusions. Thus, the causes of complications and recurrences of ARM are: diagnostic, tactical and surgical errors. Surgical treatment of ARM should be performed in specialized children's surgical departments. Postoperative rehabilitation of patients plays an important role in obtaining good results.
Список литературы
1. Shamsiev J.A., Saidov M.S., Aipov R.R. Ultrasound sonography in the diagnosis of anorectal malformations in children // Coloproctology, 2017. № 3S. P. 49a-50.
2. Rentea R. M. et al. Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations //Journal of Pediatric Surgery, 2019. T. 54. № 10. P. 1988-1992.
3. Lenushkin A. I. Children's Coloproctology // Medicine, 2004. T., 2004. P. 57-66.
4. Vinokurova N.V., Sap N.A. Comprehensive approach to the treatment of anorectal malformations in children // Bulletin of the Ural state medical University, 2018. № 1.
5. Ren X. et al. Single-incision laparoscopic-assisted anorectoplasty for treating children with intermediate-type anorectal malformations and rectobulbar fistula: a comparative study //Pediatric surgery international, 2019. T. 35. № 11. P. 1255-1263.
