ART OF MEDICINE 2017
FEATURES OF SURGERY TREATMENT OF POSTOPERATIVE STRICTURES OF ANAL CANAL
I.Y. Sadovyj, I.M. Shevchuk
Abstract. The results of treatment of 50 patients with postoperative stricture of anal canal (PSAC) have been analyzed. All patients were treated in proctology department of the Ivano-Frankivsk Regional Hospital during 2006-2016 years. We have diagnosed compensated PSAC in 11 (22%) patients, subcompensated – in 31 (62%) and decompensated in 8 (16%). Surgical treatment of PSAC was used in 41 (82%), conservative treatment was effective in 9 (18%) patients.
In 2006-2007, 11 (22%) patients with PSAC where surgically treated by methods of those time (comparison group), of which in 5 (45,4%) were diagnosed compensated SAC. From 2008 to 2016, 39 (78%) patients were hospitalized (study group), due to them new approaches to diagnostics have been worked out. Surgical treatment has been used in 30 (76,9%) patients.
After Milligan-Morgan surgery with chronic hemorrhoids of III-IV degree, stricture of the anal canal was diagnosed in 46 (92%), elimination of chronic anal fissure - in 3 (6%), perianal genital warts - in one (2%) patient. Compensated stricture was diagnosed in 11 (22%), subcompensated - in 31 (62%), decompensated - in 8 (16%) patients. Low stricture in 33 (66%), medium - in 12 (24%), high - in 3 (6%), total - in 2 (4%) patients.
Clinical manifestations of the disease occurred on average after 3.79 ± 1.58 months. In 16-38% of patients, a finger examination of the rectum, sigmoidoscopy, irrigography could not be performed because of a significant degree of constriction and deformation of the anal canal.
Deformation of the anal canal caused by hypertrophic scars protruding above the skin level was diagnosed in 35 (70%) patients with low and total PSAC. At PSAC in the stage of decompensation in 8 (16%) patients, the finger study of the rectum was impossible even with a little finger, the diameter of the anal canal in them did not exceed 0.5 cm. In 19 (38%) patients, anoscopy and RRS failed to perform because of the difficulties of transrectal administration of the device. In 8 (16%) patients, conducting irrigography was impossible due to the difficulties of transrectal introduction of the rubber tube of the apparatus Bobrova.
Consequently, 16-38% of the subjects examined the digital examination of the PC, anoscopy, RRS and irrigography turned out to be impossible.
We have proposed and implemented an X-ray method of research of anal canal, the use of which has made it possible to objectively identify and objectively evaluate its changes (Ukrainian patent number 73986). For this purpose, special X-ray contrast rectal suppositories containing barium sulfate 1 g and cocoa butter were used (Ukrainian patent number 73987)
A method for X-ray examination of the anal canal with the help of rectal suppositories with barium sulphate 1 g in its composition was developed. The method can be used as an objective diagnostic criterion and addition to the classification of the disease proposed by Pomazkin VI, Mansurov Yu.V. (2011). The method of isolated X-ray proctography can objectively establish the shape, diameter and degree of narrowing anal canal. It can be used as a screening method of inspection and additional objective criterion is necessary to select surgical tactics of treatment.
A method for surgical treatment of stricture with excision of its tissues in the form of a triangle, a vertex directed in the cranial direction, mobilization of the mucosal submucosal flap to the sides and in the cranial direction is 0.5-0.8 cm larger than the wound size, the reduction of the obtained mobile flap.
The main indications for surgical treatment were as follows: compensated stricture of the anal canal in case of complications; subcompensated stricture after 3-4 months of diagnosis, after 2-3 courses of conservative treatment in the absence of a persistent positive result and short remissions; all cases of decompensated stricture of the anal canal.
The use of the proposed surgical tactics with the use of an isolated radiological examination of the anal canal and the developed method of surgical treatment made it possible to reduce the incidence of the restriction up to 6.7% (in the comparison group, 45.4%).
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