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POSSIBILITIES FOR IMPROVING THE RESULTS OF SURGICAL
TREATMENT OF PATIENTS WITH TRANSSPHINCTERIC FISTULAS
OF THE RECTUM
Sherkulov Kodir Usmonkulovich
Atoyeva Mokhigul Otabekovna
Usmonov Amirbek Usmonovich
Usmonkulov Ma`rufjon Kodirovich
Samarkand State Medical University, Republic of Uzbekistan, Samarkand
Bukhara State Medical Institute, Republic of Uzbekistan, Bukhara
https://doi.org/10.5281/zenodo.12720139
Relevance.
A variety of studies and meta-analyses indicate that there is no
single standard that fully guarantees the successful treatment of complex rectal
fistulas, especially in transsphincteric forms [2, 3, 5, 7]. Traditional surgeries,
although usually leading to recovery in most patients, are often accompanied by
traumatic effects on the anal sphincter, which stimulates the search for new
methods of intervention [1, 4, 6].
Purpose of the study
is to improve the results of treatment of patients
with transsphincteric fistulas of the rectum by improving the technical aspects
of excision of the fistulous passage.
Materials and methods of research.
The study is based on the data of
examination and treatment of patients with rectal fistula operated in the
proctology department of the multidisciplinary clinic of Samarkand State
Medical University in the period from 2018 to 2023. 105 cases were selected for
the prospective dynamic active study. Among them were patients with
transsphincteric fistulas of the rectum. All patients were operated on routinely
and, depending on the chosen treatment tactics, divided into two groups. The
first group, the Control group, included 56 (53.3%) patients who had their
fistulas excised using traditional methods. The second group, the main group,
included 49 (46.7%) patients in whom fistula dissection was performed using
modified instruments. Patients in the main group with transsphincteric fistulae
underwent LIFT (Ligation of Intersphincteric Fistula Tract, i.e., ligation of the
fistula tract in the intersphincteric space) with the elimination of the internal
opening of the fistula at its base after turning it inside out into the rectal lumen.
For this purpose, a modified button probe with an olive or a flexible cylindrical
guide with an olive was used in case of a tortuous fistulous passage. In the
presence of purulent accumulations in the pararectal tissue, in addition to
excision of the fistula, we performed dissection, scraping of the walls of the
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purulent cavity, washing with antiseptics and drainage of the residual cavity.
The average age of the patients in this group was 45.3 ± 7.1 years.
Technical aspects.
The operation was performed under spinal, epidural or
combined anesthesia. The patient was placed on the operating table on his back
with his legs bent at the knee and hip joints on special supports. The lumen of the
rectum and the surgical field were treated with an alcoholic iodine solution. After
standard diagnostic procedures, such as staining the fistula passage with a
methylene blue solution and examining the fistula passage with a button probe,
the exact location of the internal fistula opening was determined. An important
stage of the operation was to carry a button probe through the entire fistula
passage, since the probe served as a guide for the correct location of the fistula
and to prevent damage to the wall of the fistula passage during its mobilization in
the intersphincter space. A flexible cylindrical conductor developed by us was
used for patients with branched and sinuous fistula passages. The intersphincter
sulcus was palpated in the projection of the internal fistula. A semilunar incision
1.5-2.0 cm long was made along the furrow.
A part of the fistula was carefully isolated in the intersphincter space,
avoiding damage to the muscle fibers of the anal pulp. Then, with the help of a
dissector, the ligature was brought under the fistula. The inserted conductor was
pulled through the external fistula opening to the intersphincter space, and after
ligation of the distal part at the level of the recess of the rod, the fistula passage
was tied with a ligature. When the probe was pulled back, the olive fixed the
mucous membrane of the fistula and pulled it into the lumen of the rectum, thus
the proximal part of the fistula turned into the lumen of the rectum. The fistula
was cut off at the very base after stitching and bandaging. It should be noted that
the operation was performed without traumatization of the anal sphincter. After
ligation and crossing of the fistula, a sample was performed with the
introduction of a methylene blue solution through the external fistula opening.
When the stroke was sealed, the dye did not penetrate into the wound, but
completely flowed back through the external fistula opening. If the tightness was
insufficient, the dye began to flow into the wound. However, this was not a
criterion for the unreliability of the operation, since it is more important to
ensure the tightness of the fistula stump in the area of the internal sphincter. In
case the dye got into the wound, the stumps of the fistula were additionally
immersed in separate sutures with vicryl 2-0 with the capture of the external
sphincter. The walls of the peripheral part of the fistula, in the absence of
congestion in the pararectal tissues, were scraped through the external fistula
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opening using a Volkmann spoon. With a deep location of the fistula passage and
an extended wound, a latex drainage was installed in the intersphincter space
between the sutures. If there was no inflammatory process and abundant
discharge, the drainage was removed after 3-5 days. In transsphincter fistulas
with purulent cavities in the pararectal cellular spaces, the fistula passage was
also crossed in the intersphincter space (LIFT).
The results of the study.
In patients who underwent LIFT surgery using
modified conductors and without disruption of the muscle fibers of the anal
pulp, there was a significant decrease in the level of pain in the postoperative
period and after acts of defecation. This reduction in pain reduces the need for
narcotic analgesics and significantly improves the quality of life of patients.
During the first two days after surgery, patients in the main group had daily
aseptic bandages changed in the perianal area, after which daily dressings were
no longer required. This made it possible to reduce the burden on medical
personnel and reduce the consumption of dressing material. In the Control
group, daily bandages were performed with periodic tightening of the ligature
every 4-5 days before its removal. The low invasiveness of surgery using
modified conductors without damaging the muscle fibers of the anal sphincter
had a significant impact on the length of stay of patients in the hospital. On
average, patients of the main group spent 10.1±2.2 days in the hospital (the
preoperative period was 3.2± 3.2 days, the postoperative period was 7± 1.9
days). The duration of inpatient treatment was determined by the need for a
comprehensive examination, including fistulography, ultrasound examination of
the rectum and pararectal tissue, as well as magnetic resonance imaging. After
the introduction of a new algorithm for examination and treatment, 15 patients
operated on in 2021 managed to reduce the length of hospital stay to 7.9±1.1
bed days. In the Control group, the average length of hospital stay was 17.4±3.1
days (preoperative period - 5.3±3.1 days, postoperative - 11.4±2.2 days).
Conclusions:
The developed innovations in the technical aspects of surgical
treatment of patients with transsphincter rectal fistulas led to an improvement
in the standards of medical care, reducing the frequency of immediate
postoperative complications from 8.9% to 2.0%. The use of a modified button
probe and a flexible cylindrical conductor with an olive tree in the surgical
treatment of transsphincter rectal fistulas not only simplifies the process of
technical implementation, but also prevents damage to the muscle fibers of the
anal pulp.
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