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12
II. ХИРУРГИЯ
doi:io,58o5zs;5k surgical treatment of anal prolapse
mphts and their comparative characteristics
ABOUT THE AUTHORS
Xalilova L.F. -
Scientific Center of Surgery named M.A. Topchibasheva
Keywords
anal prolapse, linear stapler, Longo operation, anal mucosa, hemorrhoidectomy
Khalilova L.F.
Scientific Center of Surgery named after M.A. Topchibasheva, Baku, Azerbaijan Abstract
In the presence of anal prolapse, perform operations on the loose, ulcerated mucous membrane of the anal canal for its sagging is fraught with the danger of bleeding during and after surgery. It is also highly likely that cidiva disease. The purpose of this study is to compare the methods of surgery used for anal prolapse, which most often accompanies stage 4 hemorrhoidal disease. In our study 400 patients in the age group from 20 to 71 years old were operated on from 2006 to 2016. All sick were divided into 3 groups. The main group included 308 (77.0%) patients who underwent hemorrhoidectomy linear stapler. Control group I included 74 patients (18.5%), who produced a typical open.
hemorrhoidectomy. The control group II consisted of patients who underwent surgery according to the method of Longo with use of a circular stapler PPH-18 patients (4.5%). For the duration of the operation using linear the stapler lasted 22.9 ± 0.4 min. The classic Milligan-Morgan operation lasted on average 34.9 ± 0.8 min. Operation Longo took an average of 29.3 ± 1.2 min. Bleeding during surgery was observed in 3 patients (1%) when using a linear stapler, in 6 patients (8.1%) during standard hemorrhoidectomy and in 2 patients comrade (11.1%) during the Longo operation. Long-term complications such as stricture and relapse in the main group one case is 0%; in the control group I, 6patients had a relapse of the disease (8.1%), in 12 cases - a stricture Anal canal (16.2%); in the control group II, there were 2 cases of relapse (11.1%) and 2 cases of stricture (11.1%). Good quality of life was considered by 162 patients (76.4%) who underwent surgery using a linear stapler; 26 patients comrades (50%) who had open hemorrhoidectomy, and 6patients (46.2%) after Longo surgery.
Thus, when evaluating the immediate results of the treatment of anal prolapse, surgery using linear stapler has several advantages. The advantage is expressed in the relative simplicity of the technique, and from the absence of a long-term relapse.
Аналдык пролапстьщ хирургиялык емшщ тYрлерi жэне олардьщ салыстырмалы сипаттамасы
АВТОРЛАР ТУРАЛЫ Халилова Л.Ф. -
М.А. Топчибашев arbiHMaFbi Улттык хирургия орталы^ы
Туйш сездер
анальды пролапс, сызгыш tancbipFbim, Лонго операция-сы, анальды шырышты кабык, геморроидэктомия
Халилова Л.Ф
М.А. Топчибашева атында?ы Рылыми-хирургиялык, орталык,, Баку, Эзiрбайжан Андатпа
Анальды пролапс болтан кезде, анальды каналдыц борпылдак, жаралантан шырышты кдбытына операция кезнде операция кезнде де, одан кейн де кан кету кауп бар. Аурудыц кайталану ыктималдыяы да жотары. Бул зерттеудщ максаты геморроидальды аурудыц 4 сатысымен жи кездесетн анальды пролапс кезнде колданылатын хирургия едстерн салыстыру болып табылады
Бiздiц зерттеуге 2006жылдан бастап 2016 жыш дешн жумыс стеген 20-дан 71 жаска дейнп 400 наукас енпзшд.
Барлык наукастар 3 топка бвлтщ.
Непзп топка 308 (77,0%) наукастар кiрдi, олар геморроидэктомия сызыкты степлермен eni.
I бакылау тобына едеттеп ашык геморроидэктомиясы бар 74 наукас (18,5%) юрд/.
Бакылау тобыныц II тобына пациенттердц PPH-18 двцгелек капсырмаларын (4,5%) крлдана отырып Longo едiсi бойынша операция жасалюн пациенттер юрд1.
Сызыктык капсырманы колдана отырып жумыс узак;тыты 22,9 ± 0,4 минутка созылды. Классикалык Миллиган-Мор-ган операциясы орта есеппен 34,9 ± 0, 8 мин созылды. Longo операциясы орташа алтанда 29,3 ± 1,2 минутты курады. Хирургия кезнде кан кету сызыктык капсырманы колданатын 3 наукаста (1%), стандартты геморроидэктомия кез1нде 6 пациентте (8,1%) жене Лонго операциясы кезнде 2 наукаста (11,1%) байкалды.
Структура жене непзп топтат рецидив сиякты узак мерзiмдi аскынулар, еш бiр жаедайда жаедайда 0%; I бакылау тобында 6 наукаста аурудыц кайталануы байкалды (8,1%), 12 жаедайда - анальды каналдыц структурасы (16,2%); II бакылау тобында рецидивтц 2 жагдайы (11,1%) жене катацдаудыц 2 жатдайы (11,1%) болды.
Сызыктык капсырманыц квмепмен операция жасаткдн 162 пациент (76,4%), 26 наукас (50%) ашык геморроидэкто-миядан вткен, 6 наукас (46,2%) Лонго операциясынан кейн вмiрдiц жаксы сапасын карастырды.
Осылайша, анальды пролапсты емдеудц дереу нетижелерн багалатанда, сызыкты капсыргышты колдантан хирургияныц &рнеше артыщылыгы бар. Артыщылыгы техниканыц салыстырмалы царапайымдылытында жене рецидивтердщ алыс кезец1нде болмауында квртед.
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2-2019
Хирургические методы лечения анального пролапса и их сравнительная характеристика
Халилова Л.Ф. ОБ АВТОРАХ
Научный Центр Хирургии им. М.А. Топчибашева, Баку, Азербайджан Халилова Л.Ф. -
Научный Центр Хирургии им. М.А. Топчибашева
Аннотация
При наличии анального пролапса проводить операции на рыхлой, изъязвленной слизистой анального канала из-за ее провисания чревато опасностью кровотечения как во время, так и после операции. Также высока вероятность рецидива заболевания. Целью данного исследования является сравнить методы операции, используемые при анальном пролапсе, который чаще всего сопровождает геморроидальную болезнь 4 стадии. В проводимое нами исследование включено 400 пациентов в возрастной категории от 20 до 71 года, оперированных с 2006 по 2016 год. Все больные были разделены на 3 группы. В основную группу вошли 308 (77,0%), пациентов, которым выполнена геморроидэктомия линейным степлером. В контрольную группу I включены 74пациента (18,5%), которым произведена типичная открытая геморроидэктомия. Контрольную группу II составили больные, которым выполнена операция по методу Лонго с использованием циркулярного степлера РРН-18 пациентов (4,5%). По длительности операция с применением линейного сшивателя длилась 22,9 ± 0,4 мин. Классическая операция по Миллигану-Моргану длилась в среднем 34,9 ± 0,8 мин. Операция Лонго занимало в среднем 29,3 ± 1,2 мин. Кровотечение во время операции наблюдали у 3 больных (1%) при использовании линейного степлера, у 6 больных (8,1%) во время стандартной геморроидэктомии и у 2 пациен-тов(11,1%) во время операции Лонго. Отдаленные осложнения, такие как стриктура и рецидив в основной группе ни в одном случае 0%; в контрольной группе I у 6 больных наблюдали рецидив заболевания (8,1%), в 12случаев - стриктура анального канала (16,2%); в контрольной группе II 2случая рецидива (11,1%) и 2случая стриктуры (11,1%). Хорошим качество жизни сочли 162 пациента (76,4%), перенесших операцию с применением линейного сшивателя, 26 пациен-тов(50%) перенесших открытую геморроидэктомию, и 6 пациентов (46,2%) после операции Лонго.
Таким образом, при оценке непосредственных результатов лечения анального пролапса операция с применением линейного степлера имеет ряд преимуществ. Выражается преимущество в относительной простоте методики, и отсутствие в отдаленном периоде рецидивов.
Ключевые слова
анальный пролапс, линейный степлер, операция Лонго, слизистая анального канала, геморроидэктомия
Anal prolapse or prolapse of the mucous membrane of the anal canal can be observed as an independent state and may accompany stage 4 hemorrhoidal disease. Muscle and fibroelastic tissues that hold hemorrhoids in the anal canal, under the influence of unfavorable factors are prone to degenerative changes, which leads to «slipping» and displacement of the internal hemorrhoids in the distal direction and later on the mucous membrane of the anal canal. Anal prolapse develops. Maceration of the falling out mucous membrane and anoderm, ulceration of the epithelium, mucus drainage, regular, often heavy bleeding significantly worsen the quality of life of patients.
In all stages, as well as in stage 4 hemorrhoids, the classical Milligan-Morgan operation is used with concomitant anal prolapse [1, 2]. Based on the literature data, a pronounced pain syndrome develops in 23-33% of operated patients. Reflex urinary retention is observed in 14-27% of patients. In 5-7% of operated patients, it becomes bladder atony, requiring prolonged catheterization and medical treatment [3,4]. 4-6% of operated patients develop wound suppuration or early bleeding from the anus [5,6] and 2-4% of patients develop a stricture of the anal canal, insufficiency of the anal press and re-
lapse of the disease [7]. Recent studies comparing the open and closed Milligan-Morgan method were published in 2015 [8]. Despite the slight advantages in the early postoperative period, the authors in the report indicate the absence of a statistically significant difference between open and closed hemorrhoidectomy with 3-4 stages of hemorrhoids. The study lacks data on the presence or absence of rectal or anal prolapse in patients.
Attempts to use a mechanical suture on circular staplers as a lifting operation in the treatment of prolapses were first presented by A. Longo. [9,10]. In contrast to the previously proposed methods, during this operation, the removal of hemorrhoids is not provided.
Although for 20 years considerable experience has been gained in the application of this technique, unambiguous results have not been obtained and data collection continues. The study, conducted by Chinese scientists and published in 2015, involved 1411 patients. This conclusion of the Chinese scientists comes down to the fact that in the presence of anal prolapse, the technique of using the linear PPH stapler has several advantages over standard hem-orrhoidectomy. But in the presence of pronounced prolapse of the mucous membrane and prolapse of
Table 1.
Duration of operations
Average duration Core group n=120 Control group I n=62 Control group II n=18 p
interventions (min) 22,9±0,5 34,9±0,8 29,3±1,2 <0,001
Table 2.
The frequency of bleeding during surgery.
hemorrhoidal nodes of stage 4, the probability of a relapse of the disease is high [11].
There are clinical studies conducted from 2012 to 2014 in several clinics in Italy. The results of these studies were merged and given in a publication in year 2016. The study included patients with anal prolapse in combination with stage 3-4 hemorrhoids. After 12 months, recurrence of hemorrhoids and prolapse was observed in 11 patients out of 621 (1.8%) and in 12 out of 58 patients (1.9%) [12,13]. R. Molloy and D. Kingsmore (2000) described a case of severe pelvic sepsis after the use of a circular mucous-submucosal resection of the rectal section in hemorrhoids [14]. L.P.Wong, J.K.Jiang, S.C.Chang, J.K. Lin (2003) describe a case of rectal perforation with the development of fecal peritonitis after circular stapler hemorrhoidectomy [15].
In 1988 VB Alexandrov and co-authors [16,17,18,19] developed and introduced into practice the method of closed hemorrhoidectomy using a mechanical suture. Yu. K. Bogomazov [20] conducted a comparative assessment of the use of a linear stapler and the operation of Milligan-Morgan [20] in his dissertation work. In the study it was found that postoperative pain is less pronounced in patients of the main group; the decrease in the intensity of pain syndrome is more dynamic in patients of the main group; the need for analgesics, including narcotic ones, is higher in patients of the control group. This paper does not focus on the category of patients - the presence or absence of anal prolapse. Despite the positive opinion on the use of a linear stapler, the technique was not widely used and did not receive recommendations as an option for surgery in the treatment of hemorrhoidal disease. There is also no indication of the possibility of using a linear mechanical suture for the treatment of anal prolapse of both an isolated disease and the accompanying hemorrhoidal disease. In the literature, there are no data on the comparative evaluation of clinical results, in the early and long-term periods, after circular resection of the mucous-submucous layer of the lower ampullae of the rectum, standard hemorrhoidectomy and hemorrhoidectomy using a linear stapler with anal prolapse.
Thus, the relevance of research on the treatment of hemorrhoids with the presence of anal pro-
lapse, a comparative study of clinical results in the early and long-term after circular resection of the mucous-submucosal layer of the lower ampullae of the rectum, standard hemorrhoidectomy and hem-orrhoidectomy using a linear stapler during anal prolapse is obvious.
The purpose of this work is to improve the results of surgical treatment of anal prolapse and hemorrhoidal disease of stage IV.
The main content of the work
In our study, 400 patients were included in the age category from 20 to 71 years old, of which 334 (83.5%) were men and 66 (16.5%) women operated from 2006 to 2016. All patients were divided into 3 groups. The main group included 308 (77.0%) patients who underwent hemorrhoidectomy with a linear stapler UO-40. The control group I included 74 patients (18.5%), who produced a typical open hemorrhoidectomy using an electrocoagulator. The control group II consisted of patients who underwent circular hemorrhoidopexy according to the Longo method using the PPH-01 tool kit specially designed and manufactured by Ethicon (USA) for -18 patients (4.5%).
During the Longo operation, excision of the external hemorrhoidal tissue was not performed at the beginning of the study. But after 2 patients were observed postoperative thrombosis of the external nodes, excision of external hemorrhoids is considered mandatory.
The main criteria for evaluating the immediate results of the intervention in patients of the studied groups were: the duration of the operation; frequency of bleeding during and after surgery; severity and duration of pain; the presence of strictures and recurrence of the disease; quality of life after surgery.
The duration of the operation using a linear stapler lasted 22.9 ± 0.4 minutes. The classic Milligan-Morgan operation lasted an average of 34.9 ± 0.8 min. This is an average of 52.2% longer than the operation using a linear stapler (p <0.001). Operation Longo took an average of 29.3 ± 1.2 min. (Table 1). This is 28% longer than the surgery performed in the main group (p1 <0.001) and 15.9% shorter than standard hemorrhoidectomy (p2 <0.01).
Thus, over time, the average duration of surgery using a linear stapler was significantly less by
Intraoperative Basic Control I Control II Total р
bleeding | 3(01,0%) 6(8,1%) 2(11,1%) 11(2,8%) <0,01
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2-2019
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Complications Basic Control I Control II P
Bleeding 1(0,3%) 3(4,1%) 2 (11,1%)
Edema 0 8(10,8%) 4(22,2%) <0,01
Complication Basic Control I Control II P
Relapse 0 (0%) 6 (8,1%) 2 (11,1%) <0,01
Stricture 0 (0%) 12 (16.2%) 2 (11,1%)
52.2% compared with standard hemorrhoidectomy and 28% less compared with hemorrhoidopexy using the Longo method in the presence of anal prolapse.
Bleeding during surgery was only in 11 (2.8 ± 0.8%) patients out of 400. Of these, in 3 patients (1 ± 0.6%) using a linear stapler, in 6 patients (8.1 ± 3, 2%) during standard hemorrhoidectomy and in 2 patients (11.1 ± 7.4%) during Longo surgery. (table 2). As can be seen from the results of the study, the lowest probability of blood loss during surgery was when using a linear stapler - only 1% (p <0.01).
As pain developed, pain relievers were administered to patients. Their purpose depended on the degree of pain (on a 5-point scale depending on the patient). The intensity of pain after surgery using a linear stapler averaged 4.71 ± 0.03 points; 3.05 ± 0.02 points on the first day after surgery; 2.41 ± 0.03 points on the 7th day after the operation and 0.03 ± 0.03 points 40 days after the operation. The intensity of pain after standard hemorrhoidectomy averaged 4.89 ± 0.04 points; 3.39 ± 0.07 points on the first day after surgery; 2.77 ± 0.06 points on the 7th day after the operation and 0.57 ± 0.09 points 40 days after the operation. The intensity of pain after surgery Longo with the use of a circular stapler 4,17 ± 0,19 points; 3.11 ± 0.2 points on the first day after surgery; 2.39 ± 0.18 points on the 7th day and 0.39 ± 09.14 points 40 days after the operation. The differences were statistically significant (p <0.01).
Early postoperative complications (Table 4) were noted in 1 (0.3 ± 0.3%) patients operated on with the use of a linear stapler (bleeding), in 11 (14.9%) who had undergone classical hemorrhoidectomy. Of these, 8 patients (10.8 ± 3.6%) had external edema of interstitial bridges, 3 had bleeding (4.1 ± 1.2%). 6 cases of complications in the early postoperative period in patients undergoing Lon-go's surgery, of these 4 cases (22.2 ± 9.8%) per edema and 2 cases (11.1 ± 7.4%) of postoperative bleeding (p <0, 01).
Long-term complications (Table 5), such as stricture and relapse in the main group, in no case 0%; in the control group I only in 18 people. Of these, 6 of the disease relapse (8.1 ± 3.2%) and
12 cases of stricture (16.2 ± 4.3%, p <0.01); in the control group II in 4 patients, which is 22.2%. Of these, 2 relapses (11.1 ± 7.4%) and 2 cases of stricture (11.1 ± 7.4%, p <0.01).
Analysis of the quality of patients's life was carried out by the method of questioning. A subjective assessment was considered: the absence of tissue prolapse and at rest and during straining the absence of secretions (mucous, blood), the presence of painless bowel movements. At the same time, a good quality of life was considered in 162 patients (76.4 ± 2.9%) who underwent surgery using a linear stapler, in 26 patients (50 ± 6.6%) who underwent open hemorrhoidectomy, and in 6 patients (46 ± 13, 8%) after surgery Longo (p <0.01).
Thus, when evaluating the immediate results of anal prolapse treatment with surgery using a linear stapler has several advantages over resection of the mucous-submucosal layer with a circular stapler and over classical hemorrhoidectomy, which is also used in the presence of anal prolapse. The advantage is expressed in the relative simplicity of the method (the ability to revise the linear seam and ease of access to it), and the lack of a long-term recurrence period. With the application of UKL, the problems of hemorrhoids and prolapse are solved simultaneously; the connective tissue framework, which forms at the site of the staples, simulates the original ligamentous apparatus, forms a kind of anal framework, which prevents the mucous membrane from sagging again.
When using a circular stapler with a high suture position, it is possible to correct the mucosal prolapse, but hemorrhoropexy cannot be achieved. With a low position of the circular suture, a pronounced pain syndrome is possible, and the problem of prolapse of the anal mucosa is not solved. However, the method is somewhat inferior to the method of Longo in less trauma and, as a result, a more pronounced pain syndrome, provided that the circular mucous-submucous resection is not supplemented by external hemorrhoidectomy. Taking into account all the pros and cons, in the presence of anal prolapse, the use of a stapling apparatus is more appropriate than the use of a circular stapler, and even more so the use of the Milligan-Morgan operation.
Table 4.
The frequency of early postoperative complications
Table 5.
The frequency of complications in the late postoperative period
Findings
1. Surgical treatment of anal prolapse using a linear stapler is a pathogenetically based, radical method, which allows to achieve good results.
2. The elimination of anal prolapse using a linear stapler allows you to minimize pain, to avoid bleeding during surgery and in the early postoperative period. The use of a linear stapler for hemorrhoidectomy makes it possible to avoid such complications as insufficiency of the anal sphincter and anal stricture in the late postoperative period.
4. Linear mucous-submucous resection prevents the building up of the walls of the anal sac cannula, forming a fibrous linear framework that prevents prolapse recurrence.
5. Technically, the technique of using a mechanical stapler is simple to perform and does not
References
1. Milligan E., Morgan G., et al. Surgical anatomy of the anal canal and operative treatment of hemorrhoids. Lancet, 1937, 2:1119-1124
2. Milligan E.T Surgical anatomy of the anal canal and operative treatment of haemorrhoids. / Milligan E.T., Morgan G.N., Jones
3. Fedorov V.D. Proctology / Fedorov VD, Dultsev Yu.V. // M.: Medicine, 1984.-383 p.
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require special skills, which allows to reduce the time of the operation even with pronounced anal prolapse and hyperplastic hemorrhoids.
Practical recommendations
1. Hemorrhoidectomy using a linear stapler is indicated for stage 3-4 hemorrhoidal disease, accompanied by anal prolapse.
2. Perhaps the widespread use of the device in macerated mucous and thick vascular pedicle.
3. After hemorrhoidectomy with the use of a linear stapler, preventive therapy with analgesic drugs is shown, although the pain syndrome with this technique is moderate.
4. Despite the advantages of hemorrhoidectomy with a linear stapler who underwent this operation, it is necessary to comply with all traditional recommendations.
rhoids. Zhonghua Wei Chang Wai Ke Za Zhi. 2015 Dec;18(12):1224-30.
12. Rondelli F1, Mariani L, Tassi A, Stella P, Mariani PG, Bistoni G, Mariani E.//Closed hemorrhoidectomy with linear stapler: a consecutive series of 300 patients.// In Vivo. 2011 Nov-Dec;25(6):1003-7.
13. Sturiale A1, Fabiani B2, Menconi C2, Cafaro D2, Fusco F2, Bellio G3, Schiano di Visconte M3, Naldini G2.// Long-term results after stapled hemorrhoidopexy: a survey study with mean follow-up of 12 years.// Tech Coloproctol. 2018 Sep;22(9):689-696. doi: 10.1007/ s10151-018-1860-8. Epub 2018 Oct 4.
14. Molloy R., Kingsmore D. Life threatening pelvic sepsis after stapled haemorroidectomy. // The Lancet. - 2000. - vol. 355, № 4. - p. 810.
15. Wong L., Jiang J., Chang S., Lin J. Rectal perforation: a life threatening complication of stapled hemorrhoidectomy: report of a case. // Diseases Colon Rectum. -2003, Vol. 46, № 1. - p. 116-117.
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17. Aleksandrov V.B. Closed method of hemorrhoidectomy with the use of a mechanical suture / Aleksandrov VB, Gadzhiev GI, Bogomazov Yu.K., Zorin S.A. // Actual issues of Coloproctology. - Rostov n / a, 2001. -C. 125
18. Dultsev Yu.V. Hemorrhoidectomy using stapling machines. // Dultsev Yu.V., Titov Yu.A., Kalanov R.G. // Surgery.- 1989. №2.-C.115-118
19. Alexandrov V. Original method of hemorroidectomy with stapled suture.//Alexandrov V., Suchov B., Tichonov E., Vinogradov V. // Central European Congress of Coloproctology and Viscerosynthesis 5th.- Brno, 1999/- P. 185.
20. Moskva n/d, 2007. -S. 63-65. Bogomazov Yu.K. Comparative evaluation of the surgical treatment of chronic hemorrhoids using a mechanical suture and a closed standard hemorrhoidectomy -Moskva n / d, 2007. -C. 63-65
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