RU2785255C1 - Method for treatment of hemorrhoidal disease stage 2-3 - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to coloproctology, can be used to treat hemorrhoidal disease stage 2-3. A method for surgical treatment of stage 2-3 hemorrhoidal disease is proposed. It includes the destruction of the cavernous tissue of each internal hemorrhoidal node using pulsed laser exposure. Laser exposure to each internal hemorrhoid is carried out as follows. In the perianal region, at a distance of 0.5-1 cm from the mucocutaneous fold of the anal canal, the skin is punctured with a diameter of 1-2 mm. A light guide is passed through the puncture, using a conductor with an outer diameter of 1.47 mm, to the proximal border of the internal hemorrhoid. Pulsed laser exposure through the light guide is performed, capturing the entire cavernous tissue of the internal hemorrhoid, with a wavelength of 1940 nm, a power of 3 W, a pulse duration of 500 ms and a pause between them of 750 ms when the light guide is passed in the opposite direction to the distal border of the internal hemorrhoid. At the same time, pendulum-like movements of the light guide are performed, so that the movements of its end face are limited by the walls of the internal hemorrhoid.

EFFECT: method allows to simultaneously reduce the invasiveness of the intervention and prevent the recurrence of hemorrhoidal disease.

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Description

The invention relates to medicine, namely to coloproctology, can be used to treat hemorrhoidal disease stage 2-3.

One of the most common diseases in coloproctology is hemorrhoids. The prevalence of the disease in the world's population varies from country to country (Gazet JC, Redding W, Rickett JW. The prevalence of haemorrhoids. A preliminary survey. Proc R Soc Med. 1970;63:78-80.). So, in Russia it is 130-145 people per 1000 of the adult population, and the proportion of hemorrhoids in the structure of diseases of the colon ranges from 34 to 41% (Vorobiev G.I., Shelygin Yu.A., Grateful L.A. Hemorrhoids. 2nd edition, Moscow: Litera, 2010, 188). In Europe and the USA, its prevalence ranges from 39% to 64% (Chen JS, You JF. Current status of surgical treatment for hemorrhoids - systematic review and meta-analysis. Chang Gung Med J. 2010;33:488-500).

The possibilities of using laser technologies in the treatment of hemorrhoidal disease are known.

In 2009, Salfi R. first described and applied the HeLP (Hemorrhoid laser prosedure) technique, based on intraoperative determination of the terminal branches of the superior rectal artery using a Doppler probe and the use of a 980 nm diode laser to block arterial inflow. The technique is carried out as follows: a specially designed disposable proctoscope is inserted into the rectum, in the distal part of which there is a small window with a Doppler sensor. Using a Doppler probe (20 MHz probe, 3 mm in diameter) 3 cm proximal to the dentate line, the location of the terminal branches of the superior rectal artery is determined. The Doppler transducer is replaced by a laser light guide. The use of a diode laser with a wavelength of 980 nm (pulsed mode, 15-30 J per node, a total of about 60-120 J at a power of 10-25 W). The duration of the operation was 15 minutes. The effectiveness of this method was estimated within 12 months and amounted to 91% (Salfi R. A new technique for ambulatory hemorrhoidal treatment. Coloproctology. 2009; 31:99-103.).

However, the most frequent complications in the application of this technique are: intraoperative bleeding, bleeding in the early postoperative period, feeling of incomplete emptying, prolapse of internal hemorrhoids after defecation.

A known method for the treatment of chronic hemorrhoids using laser coagulation (RU 2702599, C1). This method is based on the transdermal effect of laser radiation on the cavernous tissue of the internal hemorrhoidal node using a laser in continuous mode with a wavelength of 1560 nm and a power of 8 W and the effect on the terminal branches of the superior rectal artery at a distance of 3 cm from the dentate line. This method combines two methods of laser exposure: on the cavernous tissue of the internal hemorrhoidal node itself and on the terminal branches of the superior rectal artery, which creates additional traumatization of the rectal mucosa, which can cause complications.

A known method for the treatment of hemorrhoids, which is based on transnodal exposure to laser radiation with a wavelength of 980 nm using a pulsed mode of 500/500 ms with a power of 3-4 W (RU 2436537, C2).

The disadvantages of this method are the effect of hemoglobin-absorbing laser radiation directly through the puncture of the internal hemorrhoid, which additionally injures the mucosa covering the internal hemorrhoid and can lead to bleeding and the development of acute inflammatory diseases of the pararectal tissue, both due to the use of the technique itself and the use of laser radiation. with a wavelength of 980 nm.

As a prototype, we chose the method of laser hemorrhoidoplasty (LHP - Laser Hemorrhoidoplasty Procedure) using a diode laser with a wavelength of 980 nm, described by Karahaliloglu in 2007, who applied this technique in patients with stage 2-3 hemorrhoids (Karahaliloglu AF. First Results after Laser Obliteration of First- and Second-Degree Hemorrhoids Coloproctology 2007; 29:327-36). This minimally invasive technique for the treatment of hemorrhoids is based on dosed interstitial heating of the hemorrhoidal node by means of supplied laser radiation. The nature of the impact of laser radiation depends on its characteristics (power, wavelength, duration of exposure) and the operation technique, as a result of which various effects can be obtained, such as coagulation or vaporization of the cavernous tissue that was in contact with the working part of the light guide. Under local anesthesia in the position of the patient for lithotomy, 1 ml of anesthetic is injected into each hemorrhoid, then a tunnel is formed through a puncture on the skin of the perianal area using a Billroth clamp to the internal hemorrhoid, after which a laser fiber is introduced into the tunnel and laser energy is supplied in a pulsed mode : 2 impulses to the center of the hemorrhoid, 2 impulses to the right and 2 impulses to the left of the hemorrhoid. With this technique, despite the thermal effect on the cavernous tissue of the hemorrhoid, the mucous membrane and the structure of the sphincter are not damaged. In addition, the replacement of cavernous tissue with connective tissue with its fixation to the mucous membrane prevents the occurrence of prolapse.

Frequent complications for the author were: intraoperative bleeding, submucosal hematoma, which is associated with traumatic access to the internal hemorrhoid, the need for a second stage of laser destruction due to the return of symptoms of hemorrhoidal disease due to partial preservation of the cavernous tissue of the internal hemorrhoid.

The objective of the present invention is to create a method for minimally invasive surgical treatment of stage 2-3 hemorrhoids, which simplifies the operation, reduces the operation time, reduces the duration of temporary disability, the intensity of pain in the postoperative period, and the possibility of performing the procedure on an outpatient basis.

The technical result achieved in the implementation of the invention is the simultaneous

- reducing the trauma of the intervention, complications in the intraoperative and postoperative periods (bleeding, pain syndrome) due to the use of low-traumatic access to internal hemorrhoids and the exclusion of damage to the tissues surrounding them by choosing a gentle mode of laser exposure;

- prevention of recurrence of hemorrhoidal disease due to reliable exposure and treatment of cavernous tissue of hemorrhoids with laser energy by providing the possibility of sequential movement of the light guide throughout its volume due to the proposed mode of laser exposure.

The essence of the invention is as follows.

A method for surgical treatment of hemorrhoidal disease stage 2-3 is proposed. It includes the destruction of the cavernous tissue of each internal hemorrhoidal node using pulsed laser exposure. Laser exposure to each internal hemorrhoid is carried out as follows. In the perianal region, at a distance of 0.5-1 cm from the mucocutaneous fold of the anal canal, the skin is punctured with a diameter of 1-2 mm. A light guide is passed through the puncture, using a conductor with an outer diameter of 1.47 mm, to the proximal border of the internal hemorrhoid. Pulsed laser exposure through the light guide is performed, capturing the entire cavernous tissue of the internal hemorrhoid, with a wavelength of 1940 nm, a power of 3 W, a pulse duration of 500 ms and a pause between them of 750 ms when the light guide is passed in the opposite direction to the distal border of the internal hemorrhoid. At the same time, pendulum-like movements of the light guide are performed, so that the movements of its end face are limited by the walls of the internal hemorrhoid.

The method is carried out as follows.

Under local or spinal anesthesia in the position of the patient for lithotomy, a fenestrated anoscope is inserted into the lumen of the anal canal, which is positioned so that the internal hemorrhoid prolapses into the lumen of the anoscope. To implement the proposed technique, we use a diode-pumped fiber laser doped with thulium ions with a wavelength of 1940 nm manufactured by NTO IRE-Polyus LLC, Russia. Then, at a distance of 0.5-1 cm from the mucocutaneous fold of the anal canal, a puncture of the perianal skin is performed, 1-2 mm long. The puncture can be performed both with the help of an electrocoagulator and with the help of a laser instrument.

Then, through the puncture, the end light guide is inserted into the internal hemorrhoidal node to its proximal border. The location of the laser fiber in the internal hemorrhoid is assessed by the pilot beam, which is located at the end of the light guide, and only after its location at the proximal edge of the internal hemorrhoid, the laser energy is supplied, which ensures the impact of laser energy on both the cavernous tissue and the terminal branches of the upper rectum. arteries. A pulsed mode with a power of 3 W is used, the pulse duration is 500 ms, the pause time is 700 ms.

When advancing the laser tool in the distal direction, pendulum movements are performed to treat a larger area of cavernous tissue. Similarly, laser exposure is carried out on other internal hemorrhoids.

Clinical example 1.

Patient 3., 40 years old, was admitted to the clinic with complaints of prolapse of internal hemorrhoids during defecation, reduced with a manual aid, itching, burning sensation and discomfort in the anal canal, periodic bleeding during defecation. From the anamnesis it is known that the above complaints have been noted for about 6 years. Long-term conservative therapy without a positive effect. Hospitalized for surgical treatment. Locally: when examining the perianal region, there are no scratches and macerations. Anus closed. When diluting the edges of the anus, anoderm defects are not determined. At 3,7,11 hours enlarged external hemorrhoids without signs of thrombosis and inflammation. The reflex from the perianal skin is preserved. At digital examination: sphincter tone is preserved, volitional efforts are satisfactory, enlarged internal hemorrhoids are determined at 3,7,11 hours without signs of thrombosis and inflammation.

The patient was diagnosed with Combined hemorrhoids of the 3rd stage.

Under local anesthesia in the position of the patient for lithotomy using a laser device with a wavelength of 1940 nm in a planned manner, the patient underwent laser destruction of internal hemorrhoids in accordance with the proposed method. At the same time, the skin puncture in the perianal region was performed at a distance of 0.5 cm from the mucocutaneous fold of the anal canal with a diameter of 1.47 mm. The postoperative period was uneventful, the patient was discharged for outpatient aftercare after 4 days. The control examination was carried out on the 7th day after the operation. A digital examination of the rectum is painless, in the anal canal there are zones of compaction in the projection of the internal hemorrhoids that have arisen due to the thermal effect of laser radiation on the cavernous tissue of the internal hemorrhoids. The patient began to perform his usual work activities on the 8th day after the operation. The follow-up examination was carried out after 1,3,6 months: the patient did not complain, there were no recurrences of the disease during these periods.

Clinical example 2.

Patient S., 30 years old, was admitted to the clinic with complaints of blood in the stool, prolapse of internal hemorrhoids during the act of defecation, repositioning on their own. From the anamnesis it is known that the above complaints have been noted for about 2.5 years. Conservative therapy with a temporary effect. Hospitalized for surgical treatment. Locally: when examining the perianal region, there are no scratches and macerations. The anus is closed. When diluting the edges of the anus, anoderm defects are not determined. The reflex from the perianal skin is preserved. On digital examination: the sphincter tone is preserved, volitional efforts are satisfactory, enlarged internal hemorrhoids are determined at 3,7,11 hours without signs of thrombosis and inflammation.

The patient was diagnosed with internal hemorrhoids stage 2.

Under local anesthesia in the position of the patient for lithotomy using a laser device with a wavelength of 1940 nm, laser destruction of internal hemorrhoids was performed in a planned manner in accordance with the proposed method. In this case, the skin puncture in the perianal region was performed at a distance of 1 cm from the mucocutaneous fold of the anal canal 2 mm. The postoperative period was uneventful, the patient was discharged for outpatient aftercare after 4 days. The control examination was carried out on the 7th day after the operation. A digital examination of the rectum is painless, in the anal canal there are zones of compaction in the projection of internal hemorrhoids, which have arisen as a result of the thermal effect of laser radiation on the cavernous tissue of the internal hemorrhoids. The patient began to perform his usual work activities on the 8th day after the operation. The follow-up examination was carried out after 1,3,6 months: the patient did not complain, there were no recurrences of the disease during these periods.

Thus, the proposed invention provides:

- simplification of the implementation of surgical intervention;

- reduction of operation time;

- the possibility of performing the operation under local anesthesia;

- reduction of blood loss during surgery;

- absence of wounds in the anal canal;

- low level of pain syndrome that occurs in the postoperative period;

- no need to prescribe narcotic analgesics;

- reduction of terms of hospital treatment and postoperative rehabilitation.

The proposed technique is minimally invasive and can be used in short-stay hospitals and outpatient settings.

The use of a fiber laser with a wavelength of 1940 nm is safe, since there is no laser effect on the underlying tissues.

Claims (1)

A method for laser destruction of internal hemorrhoids using a laser device with a wavelength of 1940 nm, which is based on the destruction of the cavernous tissue of the internal hemorrhoid and occlusion of the terminal branches of the superior rectal artery in the surgical treatment of stage 2-3 hemorrhoidal disease, characterized in that on the perianal area on a point puncture is carried out at a distance of 0.5-1 cm from the mucocutaneous fold of the anal canal, through which a light guide is passed to the proximal border of the internal hemorrhoid, pulsed laser exposure is carried out through the light guide, capturing the entire cavernous tissue of the internal hemorrhoid, with a wavelength of 1940 nm, with a power of 3 W, a pulse duration of 500 ms and a pause between them of 750 ms, when the light guide is held in the opposite direction to the distal border of the internal hemorrhoid, the light guide is pendulum-shaped.