RU2841167C1 - Method of treating complex forms of epithelial pilonidal fistula - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to colorectal surgery, and can be used for treating pilonidal cyst. Under local anaesthesia, after excising primary and secondary fistulous openings with a bulbous probe, fistulous passages are inspected. A Volkmann spoon is used to remove the granulated contents of fistulous passages; the cavity is washed with povidone-iodine 10%. A rubber suture is inserted along the primary fistula. In 5 days, the fistulous passages are ultrasound-controlled, and if the main fistulous passage narrows to 1 cm and the additional fistulous passages are obliterated, the remaining fistulous passage is coagulated with a continuous-mode laser at wave length 1470 nm, power 9 W, at rate of 1 mm/s.

EFFECT: method is high-effective, reduces length of treatment, prevents recurrences and postoperative complications, improves cosmetic effect ensured by a combination of drainage of the main fistulous passage with a rubber thread and laser ablation of fistulous passages.

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Description

Field of technology to which the invention relates

The invention relates to medicine, namely to colorectal surgery, and can be used to treat epithelial coccygeal tract.

State of the art

Epithelial coccygeal passage is a congenital disease caused by a developmental defect of the caudal end of the embryo, in which a passage lined with epithelium remains under the skin. This anomaly is quite common. The adult population, children and adolescents suffer from the presence of epithelial coccygeal passage and its complications in more than 5% of cases (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M., 1998). The incidence of epithelial coccygeal passage is 7.1 per 1000 population. Among rectal diseases, this disease accounts for 14-20%. (Vrublevsky V.A., Militarev Yu.M. Problems of proctology. - M., 1983, Issue 4, pp. 6-9). Conservative treatment methods do not provide a lasting cure, since they do not eliminate the causes of the disease and the conditions of its development. Such methods include the use of sclerosing agents, treatment with silver nitrate or hydrochloric acid (Berger H. US Navy med. Bull-1945. Korb J. Milit. Surg.-1951.-Vol. 108. - P. 29-34) Burns F. Arch. Surg. - 1946. - Vol. 52. - P. 33-41).

V.I. Pomazkin developed a classification of chronic fistulous forms of the epithelial coccygeal tract with gradation according to three degrees of complexity: IA Single fistulous tract with minimal inflammatory infiltrate or its absence, with external fistulous openings located in the projection of the middle of the intergluteal fold or no more than 3 cm from it.

IB - a single fistula tract with minimal inflammatory infiltrate or its absence with external fistula openings located in the projection of the middle of the intergluteal fold or no more than 3 cm from it with unfavorable anatomical features of the sacrococcygeal region.

PA - fistula tracts with secondary external fistula openings located at a distance of more than 3 cm from the middle of the intergluteal fold, but not extending beyond the inner slope of the buttocks.

IIB - fistula tracts with secondary external fistula openings located at a distance of more than 3 cm from the middle of the intergluteal fold, but not extending beyond the inner slope of the buttocks in the presence of unfavorable anatomical features.

III - multiple fistula tracts with external openings extending beyond the inner surface of the buttocks, in the presence of pronounced scars and infiltrates around the fistulas.

In this classification, in addition to assessing the immediate prevalence of the pathological process, the presence of unfavorable anatomical features of the sacrococcygeal region was also taken into account (Pomazkin V.I. Analysis of the results of treatment of epithelial coccygeal passage with differentiated choice of surgery / V.I. Pomazkin // Ural Medical Journal. - 2010. - No. 4. - P. 36-39).

The main and effective method of treatment is surgical, which consists of excision of the epithelial coccygeal passage, which is divided into: blind suturing with various types of sutures, the use of skin plastics; partial wound suturing (Nalivkin A.I., Ektov V.N., Khryachkov A.A., Mukhopadov G.V., Surgical treatment of the epithelial coccygeal passage in the acute inflammation stage. Surgery, 1983, No. 6, pp. 46-48), suturing the edges of the wound to its bottom in various modifications (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M.: Medicine, 1988, p. 129), open wound management (Allabergenov A., Koplatadze A.M., Nazemets V.M., Martynenko A.P., Problems of proctology - M., 1980. Issue 1. - P. 55-58). A method of radical surgical treatment of the epithelial-coccygeal passage, consisting of excision of the epithelial-coccygeal passage without suturing the wound with its subsequent open management (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M.: Medicine, 1988, pp. 92-94; Lavreshin P.M., Nikulin D.Yu., Korablina S.S. Diagnostics and treatment of the epithelial coccygeal passage. Medical Bulletin of the North Caucasus, No. 4, 2011, p. 100).

The disadvantage of these known types of surgical treatment is the long period of wound healing and, as a consequence, a long period of disability.

In complex forms of epithelial coccygeal tract, it is necessary to use treatment methods aimed at creating conditions for optimal wound healing and preventing relapses with correction of the anatomy of the sacrococcygeal region, which is achieved using plastic surgery to close the wound defect (Pomazkin V.I. Selection of surgery for the treatment of patients with epithelial coccygeal tract / V.I. Pomazkin, Yu.V. Mansurov // Bulletin of surgery named after I.I. Grekov. - 2008. - Vol. 167. - No. 1. - P. 85-87). One-stage and two-stage operations performed on patients with pyoderma foci of the perineum, having an isolated nature of the lesion or combined with other proctologic diseases, should be performed during the period of minimal activity of the purulent process. For this purpose, during the preparation for surgery, after determining the composition of the microflora, the discharge from the fistulas and the sensitivity of the microbes to antibiotics and antiseptics, drainage of abscesses and targeted installations of purulent cavities and passages are performed until the maximum possible process of subsiding of the inflammatory process. These measures allow sufficiently good preparation of the skin for its use during interventions for the purpose of plastic covering of extensive wound surfaces after removal of the affected tissues (Nahas S.C. Results of the surgical-treatment of non-complicated pilonidal disease / S.C.Nahas, C.W.Sobrado, S.E.Araujo // Rev. Hos. Clin. Fac. Med. Sao. Paulo. - 1997. - Vol. 52. - №6. - P. 287-290). (Mosguera D.A. Bascomis operation for pilonidal sinus / D.A. Mosguera, J.B. Quayle // J.R. Soc. Med. -1995. - V. 88, No. 1. - P. 45-46).

The disadvantages of these surgical treatment analogues are: a long period of inpatient treatment of the patient, a high risk of developing purulent complications and rejection of the skin flap.

According to some authors, when excising a pathologically altered area, some surgeons usually make an ellipsoid incision. It is simple, but has a number of disadvantages. With a very large axis of the ellipsoid incision, it is sometimes necessary to remove more healthy tissue than necessary. After the wound heals, an excessively long scar is determined. When the short axis is lengthened, such a defect may occur that it will be impossible to directly apply sutures to the edges of the wound.

The above methods have negative results. For example, in case of purulent complications or bleeding, they resort to opening the wound for the purpose of its revision and sanitation. As a result, the healing process takes longer and often ends with the formation of coarse scars and frequent relapses of up to 14.7-20.4% (lesalnieks I., Fiirst A., Rentsch M. Rezidivrisiko nach primarem medianem Wundverschluss bei Patienten mit Pilonidalsinus Surgery. - 2003. - Vol. 74. - S. 461-468).

There is also a known method for treating the epithelial-coccygeal tract proposed by Duxbury and colleagues (Duxbury M.S, Finlay I.G, Butcher M, Lambert A.W. Use of a vacuum assisted closure device in pilonidal disease. J Wound Care. 2003 Oct; 12(9):355. doi: 10.12968: jowc 2003.12.9. 26538.), which includes excision of the epithelial-coccygeal tract. 48 hours after excision of the epithelial-coccygeal tract, a replaceable drainage dressing is applied and round-the-clock vacuum therapy is performed in a constant mode with a negative pressure of 125 mm Hg. The drainage dressing is subsequently changed every 3 days. The course of vacuum therapy is 6 weeks, and the period of complete wound healing is 8 weeks. A known method of treating the epithelial-coccygeal tract uses vacuum therapy (Farrell D., Murphy S. Negative pressure wound therapy for recurrent pilonidal disease: a review of the literature // J. Wound. Ostomy Continence Nurs. - 2011. - Vol. 38(4). - P. 373-378. - doi: 10.1097/WON.0b013e31821e5117), which involves excision of the epithelial-coccygeal tract, application of a removable drainage dressing, and round-the-clock vacuum therapy in a constant mode with a negative pressure of 125 mm Hg. Drainage dressings are changed every 2 days. The course of vacuum therapy is from 4 to 9 weeks. Vacuum therapy is stopped after the wound is completely filled with granulations; while the period of complete wound healing is from 9 to 22 weeks.

It is known to use the method of plastic closure of rhomboid defects on the body surface in the primary closure of large wounds. Rhomboid excision of epithelial coccygeal cysts and closure of the resulting defect with a flap taken from the neighborhood is considered to be very effective. According to the principles of local plastic surgery, rhomboid excision of the pathologically changed area and additional incisions ensures plastic closure of the defect. A necessary condition: the rhombus must consist of two equilateral triangles. After careful hemostasis with electrocoagulation, rhomboid plastic surgery begins. Its main and defining components are as follows: 1) simple convergence and suturing of the wound edges; 2) plastic surgery with the displacement of two opposing triangular flaps. Double-row U-shaped sutures with catgut are applied along the perimeter of the surgical wound: the first - near the bottom of the wound, and the second - subdermally. (Vorobey A.V. Rhomboid skin grafting in the treatment of abscessing epithelial coccygeal passage / A.V. Vorobey, V.L. Denisenko, M.I. Rimzha // Current issues of proctology. - Rostov n / D. - 2001. - P. 19-21).

The disadvantage of the above treatment methods is the long period of wound healing, which ranges from 8 to 22 weeks, as well as the possibility of developing postoperative complications in the form of wound divergence and infection.

Recently, there has been a search for and development of new technologies using various physical factors that affect inflammatory processes in the sacrococcygeal region. Particular attention in recent years has been paid to laser therapy (Kuzin V.V., Morozov Yu.I. All-Union Conference on Proctology, 2nd: Abstracts of Reports, Moscow, 1981, pp. 106-107; Yaremchuk A.Ya. Vesti khirurgii, 1982, v. 122, no. 4, pp. 64-66).

There are known methods of treating wounds after excision of the epithelial coccygeal passage using ultrasound and _CO2 laser (Yaremchuk A.Ya. Vestnik khirurgii 1982. - T - 122. - №4. - P. 64-66; Skobelkin O.L., Efindiev A.I. Radical treatment of suppurating epithelial cysts of the coccyx. Research Institute of Laser Surgery of the Ministry of Health. USSR, 1987; Nurlyev K.G., Babayev H.B., Tachmuradov B.N., Kakabaeva O.S. TSMU, Patent for invention. Method of surgical treatment of epithelial coccygeal passage. 1989; Ulyashev N.V., Penkov A.L. Treatment of patients with epithelial coccygeal passages with a CO2 laser, Stavropol, 1990). The disadvantage of these methods is the preliminary opening of the inflammatory focus, which significantly prolongs the healing and recovery time and contributes to the formation of coarse scars. The healing time of the wound defect can reach several months. (Bascom J. Pilonidal sinus: experience with the Karydakis flap. Br. J. Surg.-1998. Vol. 85.-R 874-877; Berger A., Frileux P. Sinus pilonidal. Pilonidal sinus. Ann. Chir. - 1995. - Vol. 49. - P. 889-892).

The prototype of the claimed method is a method of minimally invasive treatment of pilonidal cysts (Abushkin I.A., Krochek I.V., Privalov V.A. Patent of the Russian Federation No. 2283632 C1. dated September 20, 2006). A method of surgical treatment of the epithelial coccygeal tract, including laser treatment with cleansing of the tract and evaporation of altered tissues, the cavity of pockets and fistula tracts, according to the invention, the treatment is performed by 2-3-fold intra-tissue laser thermotherapy with a diode laser in a continuous mode with a wavelength of 970 nm, a power of 2.5 W with the introduction of a monofiber laser light guide with a diameter of 0.4 mm without widening the coccygeal tract through primary openings or transcutaneously, wherein the treatment is performed under ultrasound control for a duration of 30-180 s.

For laser destruction, an infrared diode laser LS-0.97- "IRE-Polus" with a wavelength of 970 nm in continuous mode was used. The treatment was performed under local anesthesia with visual and ultrasound control. Puncture and evacuation of the contents from the cyst cavity were performed through the primary openings of the epithelial coccygeal passage or transcutaneously. After that, a thin quartz light guide was inserted through the existing primary openings or from additional punctures and laser treatment of the coccygeal passage, cavities, pockets was performed in a gentle laser thermotherapy mode. If necessary, the procedure is repeated up to three times with an interval of 10 days.

The disadvantage of the prototype is the repeated use of the laser, leading to multiple trauma and infection of the wound and prolongation of the healing time of the postoperative wound. This significantly prolongs the recovery time to 30 days.

The objective of the claimed invention is to develop a highly effective method for treating complex forms of epithelial coccygeal tract, reducing treatment time, preventing relapses of the disease and postoperative complications, and improving cosmetic results.

Disclosure of the essence of the invention

The problem is solved by the fact that the technical result of surgical treatment of complex forms of epithelial coccygeal tract is achieved by combining drainage of the main tract with a rubber thread and laser ablation of fistula tracts.

The claimed method consists in the following: under local anesthesia, after excision of the primary and secondary fistula openings with a button probe, revision of the fistula tracts is carried out, the contents of the fistula tracts with granulations are removed with a Volkman spoon, the cavity is washed with a 10% povidone-iodine solution, a rubber thread is installed along the main fistula, after 5 days an ultrasound control of the fistula tracts is carried out and, when the main fistula tract narrows to 1 cm and additional fistula tracts are obliterated, coagulation of the remaining fistula tract is performed with a laser in a continuous mode with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm / s.

The use of a rubber thread in the treatment of a complex epithelial coccygeal tract allows for adequate drainage of the cavity, which ensures the outflow of exudate from additional fistula tracts along the main one containing the rubber thread, while additional fistula tracts are obliterated, and the formed fistula tract around the ligature allows for a single and radical procedure of laser ablation of the cavity without repeated interventions.

For the treatment of epithelial coccygeal tract, a 1470 nm long-wave laser is used, portable and compact. Laser radiation of a 1470 nm long wave, due to its physical properties, has a pronounced sanitizing and coagulating effect on epithelial coccygeal tracts. This method achieves a good cosmetic effect. The high efficiency of the proposed method for treating epithelial-coccygeal tract due to the reduction in the time of complete wound healing and the exclusion of the possibility of postoperative bleeding allows for treatment in outpatient settings.

Implementation of the invention

The method we proposed was implemented in the work of the surgical department of the private healthcare institution "RZhD-Medicine" in Astrakhan and was used in examining 16 patients. The results of the testing are given below.

Example 1.

Patient A., 30 years old. Hospitalized with a diagnosis of complex epithelial coccygeal tract grade II B. The patient complains of moderate pain in the coccyx area, itching and periodic serous-purulent discharge from the primary and secondary openings. On examination, there are two primary fistula openings up to 0.3 cm in the intergluteal fold, and 4 cm from the primary openings, there are secondary openings up to 0.4 cm in diameter on the right and left buttocks. The patient had been ill for 2 years. The patient underwent surgery. Under local anesthesia, after excision of the primary and secondary fistula openings, a button probe was used to revise the fistula tracts, the contents of the fistula tracts with granulations were removed with a Volkmann spoon, the cavity was washed with a 10% povidone-iodine solution, and a rubber thread was installed along the main fistula. After 5 days, an ultrasound check was performed, the fistula tract was narrowed to 1 cm, additional fistula tracts were obliterated. Coagulation of the remaining fistula tract was performed under local anesthesia with a laser in continuous mode with a long wave of 1470 nm, a power of 9 W, at a speed of 1 mm/s.

The postoperative period was pain-free. The patient was discharged from the department on the 7th day in a satisfactory condition with a good cosmetic effect. Further observation took place on an outpatient basis. The period of incapacity for work was 7 days. There were no relapses during the control examination after six months.

Claims (1)

A method for surgical treatment of complex forms of epithelial coccygeal tract, including drainage and laser ablation of the epithelial coccygeal tract, characterized in that under local anesthesia, after excision of the primary and secondary fistula openings with a button probe, revision of the fistula tracts is performed, the contents of the fistula tracts with granulations are removed with a Volkman spoon, the cavity is washed with a 10% povidone-iodine solution, a rubber thread is installed along the main fistula, after 5 days an ultrasound control of the fistula tracts is performed and, when the main fistula tract narrows to 1 cm and additional fistula tracts are obliterated, coagulation of the remaining fistula tract is performed with a laser in a continuous mode of a long wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm / s.