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DOI: http://dx.doi.org/10.20534/ESR-17-3.4-70-72
Shamsiev Azamat Mukhitdinovich, Rector of Samarkand State Medical Institute, Professor. E-mail: [email protected] Shamsiev Jamshid Azamatovich, Samarkand State Medical Institute, Professor Head Doctor of the 2 Clinic of Samarkand State Medical Institute
E-mail: [email protected] Saidov Murodillo Sayfulloevich, Samarkand State Medical Institute. Department of Pediatric Surgery, Assistant Professor E-mail: [email protected] Aipov Rasulbek Rakhimberdievich, Professor, Head of the Department of Pediatric Surgery of Children's Hospital of Astana city, Republic of Kazakhstan, E-mail: [email protected] Atakulov Jamshed Ostonakulovich, Samarkand State Medical Institute Department of Pediatric Surgery, Professor.
E-mail: [email protected]
Rehabilitation of children after repeated surgical interventions regarding anorectal malformations
Abstract: aim of our investigation was elaboration of complex step-by-step rehabilitation before and after surgical operations in repeated surgical interventions regarding anorectal malformations. For the period from 1990 to 2015 inclusive 140 children with different recurrent complications after previous surgical correction of anorectal malformations were treated. Boys were 77 (52,4%) and girls were 63 (47,6%). Due to the age children in the age category before 3 years old were predominated. During abdominal-perineum decumuozation good results have observed in 10%, satisfactory results in 25% and unsatisfactory results have been observed in 65% of patients. In the basic group good results have observed in 57,1% of cases, satisfactory results have observed in 35,8% of cases and unsatisfactory results have been observed in 1 (7,1%) patients.
Keywords: Anorectal malformations, rehabilitation, children.
Introduction. Step-by-step complex rehabilitation has a big importance after repeated surgical interventions for the restoration of retentive function of sphincter apparatus and anal sphincter. Treatment of congenital anorectal malformations in children is a complex objective. Anorectal malformations (AM) are included a wide spectrum of congenital abnormalities affecting anus, rectum and urogenital tract. Anorectal malformations is one the most frequent pathologies amongst congenital abnormalities [1]. According to the data of different authors frequency of such pathology is varies from 1:2000 to 1:9000 [2; 3; 4]. In the structure of congenital abnormalities the share of anorectal malformations are approximately 7%, besides they are on the 9 place amongst all abnormalities due to the data of international register [5]. According to the opinion of the number of foreign specialists mortality from anorectal malformations is from 16-19% and high [6]. In spite of the many achievements of the last two decades in the diagnostic and treatment of anorectal malformations, this pathology is left one of the most unsolved problems in pediatric surgery [7; 8; 9; 10]. Rehabilitation of patients after surgical operations remains very debatable problem. The significant rehabilitation component is control of the treatment effectiveness and concrete assessment of the results. We should regret to say that proctologic patients not
always and not in sufficient volume receive restoral treatment, especially after surgical operations. The above mentioned gives us the reason to develop the complex restoral rehabilitation scheme after repeated corrections of AM. This was prerequisite to carry out of the presented work.
The aim of investigation was to elaborate complex step-by-step before and after operational rehabilitation in repeated surgical interventions regarding anorectal malformations.
Materials and methods. For the period from 1990 to 2015 inclusive 62 (44,3%) patients with different recurrent complications after previous surgical correction of anorectal malformations were treated in the Second clinic of Samarkand State Medical Institute and 78 (55,7%) sick children with the same pathology were treated in the surgical department of Scientific Center of Pediatric and Pediatric Surgery ofAlma-Ata city (Republic of Kazakhstan). These 140 children have been included in investigation for the explanation of basic terms of tis work. Boys were 77 (52,4%) and girls were 63 (47,6%). Due to the age children in the age category before 3 years old were predominated.
Diagnosis of anorectal malformation has been classified due to the last consensus of diagnostic standards of anorectal malformations of International Crackenback's classification (2005).
Rehabilitation of children after repeated surgical interventions regarding anorectal malformations
Distribution of patients according to the diagnostic standards with national Crackenback's classification (2005) have been presented in recurrent types of anorectal malformations according to the Inter- table 1 below.
Table 1. - Distribution of patients with recurrent types of anorectal malformations according to the International Crackenback's classification (abs/%)
Types of anorectal malformations Groups of patients
I II In general
Big clinical groups
Perineal fistula 18 (69,2) 6 (30,8) 24 (18,6%)
Recto-urethral fistula in the bulbar part of urethra 9 (64,3) 5 (35,7) 14 (10,0%)
Recto-urethral fistula in the prostate part of urethra 1 (100) - 1 (0,7%)
Recto-vesicular fistula 1 (100) 1 (0,7%)
Vestibular fistula 35 (89,7) 4 (10,3) 39 (28,8%)
Cloaca with general segment less than 3 cm. 1 (50) 1 (50) 2 (1,4%)
Atresia without fistula 23 (82,1) 5 (17,3) 28 (23,6%)
Stenosis of anus 8(100) 8 (5,7%)
Rare/local types
Atresia/stenosis of rectum 1(100) 1 (0,7%)
Recto-vaginal fistula 1 (50) 1 (50) 2 (1,4%)
Recto-urethral H-fistula with perineal syrinx 1 (100) - 1 (0,7%)
Vestibular H-fistula 5 (83,3) 1 (16,7) 6 (4,3%)
Vaginal H-fistula 1 (100) - 1 (0,7%)
Other 1 (100) 1 (0,7%)
In general 107 (82,3%) 23 (17,7%) 130 (100%)
Results and discussion. The level of rectum atresia or anus towards to puborectal muscle has determined the height and type of anorectal malformation. In our series all children were observed lower and intermediate types of anorectal malformations.
1. Lower types of anorectal malformations (perineal, vestibular fistulas, H-fistula, imperforated anus) were observed in 108 (83,1%) of children.
2. Intermediate types of anorectal malformations (recto-ure-thral fistulas in bulbar, cloaca with general segment less than 3 cm) were observed in 22 (16,9%) of children.
Functional disorders of the restrained function of the sphincter apparatus of rectum in all cases have been presented by stool incontinence of the different severity degrees. The degree of stool incontinence was determined according to International Crackenback's classification (2005) [10]. According to which the first degree of
stool incontinence is established during periodic (one or two times per week) episodes of stool smearing in our series of investigations have not been determined. The second degree - every days episodes of stool smearing are not caused any social problems for patients have been observed in 56 (43,1%) children. The third degree - persistent episodes of stool smearing which create social problems for patient have been observed in 74 (56,9%) children.
By the character of the performed reanorectoplastic all children were divided into two groups. The first (basic) group was consisted of 107 children (82,3%) who had different reanorectoplastic from perineal and posterior sagittal approaches with remained mucosal membrane of rectum. The second (control) group were consisted of 23 (17,7%) children who had abdominal-perineal reanorectoplastic with intrarectal demucosation of rectum due to Romualdy-Rebein (table 2).
Table 2. - The results of investigation due to the character of the performed reanorectoplastic (abs/%)
Name of surgical operation Basic group Control group
Amount of patients 107 (82,3) 23 (17,7)
All patients from the basic group before and after operation period were carried out two-step complex rehabilitation. At the same time with generally accepted methods of rehabilitation diagrammatic bougienage, electro-stimulation of rectum and sphincter and also tonic procedures of sphincter apparatus have been included.
All children before radical operation it has been carried out rehabilitation treatment which included aperient diet, cleansing enemas, drug treatment (lactulose, magnesium, wheat brans and others); physiotherapy (electro-stimulation of large intestine, electrophoresis with prozerine on the stomach area).
The II stage of rehabilitation has been started in the post operational period. Besides it has been carried out the individual approach to patients. The course of complex rehabilitation was lasted from 1 to
1,5 years depending on restoration of retentive function sphincter apparatus and anal sphincter.
Simulation has been carried out on "Ultraton - AMP-2INT" apparatus with rectal detector sweeping form of which supplies effective exposure to the walls of rectum during performing proctoplasty operations. The work principle of apparatus (in the ultratono-therapic regime) is based on transformation of system voltage into high sinusoidal voltage (0,5-3 kW) of supersonic (22 kHz) frequency applying to the gas-discharge electrode. Under the impact of high voltage in the balloon of electrode inert gas ionized and gained features of conductor by processing into it glow discharge.
Also we followed the bougienage scheme which has been used in the leading coloproctological clinics. The sizes of bougies were corresponded to the patient's age.
Table 3. - Bougienage schemes in compliance with patient's age
Age Number of Gegar's bougie
1-4 months 12
4-8 months 13
8-12 months 14
1-3 years old 15
3-12 years old 16
Older than 12 years old 17
Bougienage scheme
1. No more than 1 time per day during a month.
2. Once per 3 days during a month.
3. Twice per week during a month.
4. Once per week during a month.
5. Once per month during 3 months.
Special importance we attach to the tonic procedures of sphincter apparatus in the form of exercise with tube by diameter of 2,0 cm
and length of 4-5 cm. in the lumen of rectum it has been put this tube patient is explained procedure which increases the tone of sphincter. Procedure is carried out during the year which begins from 3-5 times. In dynamic these exercises are led to 25-30 times. Also with inserted tube into the rectum in the walking position the child has to hold it during 3-5 minutes. Besides that it has been carried out therapeutic enemas in the concentration of 100-150 ml and child held water in the walking position during 5-7 minutes.
The long-term results have been showed that in abdominoperineal proctoplastics with intrarectal demucosation the good results have observed in 10% of cases, satisfactory results in 25% of cases and unsatisfactory results have registered in 65% of cases. In the basic group the good results have observed in 57,1% of cases, satisfactory results in 35,8% of cases and unsatisfactory results have registered in 1 patient (7,1%).
Conclusions. Thus, intrarectal demucosation cannot in full carry out proprioceptive function of rectum, thereby dictate reason-ability of preservation of the mucous membrane of rectum, and also step-by-step rehabilitation after surgical operation is obligatory in the complex treatment.
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DOI: http://dx.doi.org/10.20534/ESR-17-3.4-72-74
Shodikulova Gulandom Zikriyaevna, Samarkand State Medical Institute, Uzbekistan
E-mail: [email protected]
Special features of clinical and functional disorders in patients with undifferentiated connective tissue dysplasia
Abstract: The objective of the study was to investigate the special features of clinical and functional disorders in patients with undifferentiated connective tissue dysplasia (UCTD) with primary mitral valve prolapse (MVP). The patients were divided into 2 groups depending on the degree of MVP: the 1st group included 97 patients with the 1st degree of MVP and the second group - 111 patients with the 2nd degree of MVP. In the patients, who have UCTD with MVP, the external and internal phenes are clinically observed, a heart rhythm disturbance is noted, and the cardiac hemodynamics indicators undergo statistically significant deterioration in the course of the disease development.
Keywords: undifferentiated connective tissue dysplasia, mitral valve prolapse, external and internal phenes of dysplasia, ECG and EchoCG.
The problem of early diagnostics in modern medicine ofundif- congenital mitral valve prolapse (MVP) determines the necessity for ferentiated connective tissue dysplasia (UCTD) in the patients with advanced study of propagation mechanisms of this disease, which
