RU2841962C1 - Method for perioperative management of patients with virtual colostomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery and proctology, and can be used for perioperative management of the patients with virtual colostomy. Operation is preceded by bowel cleansing. Circular resection of the rectal wall is performed with a stapling apparatus with a two-row stapling suture, a graduated divulsion of the anal sphincter is performed, disposable anoscope is used to leave a soluble haemostatic cone-shaped sponge in an anal canal. After the operation, at the first stage, instead of food, a liquid is used in the form of tea, coffee, juices without pulp and compote without berries, and the preparation of postoperative enteral nutrition Nutridrink without fibres at 20 ml/kg three times a day, haemostasis is controlled by observing a bandage on an anal area. In 7 postoperative days, the diet is expanded by a combination of the preparation Nutridrink with dietary fibres at 10 ml/kg and a sparing diet excluding vegetables and fruit for 7 days. In 14 days after operation pass on general diet. At the second stage of the postoperative period on 60^th day after operation, control endoscopic examination of rectum is performed using a disposable proctoscope.

EFFECT: method provides a good functional result of the operation, is a low-impact, effective method for managing the perioperative period, enables avoiding parenteral nutrition, reducing a rate of potential complications and pain syndrome, providing early rehabilitation of the patients due to a combination of the techniques of the declared invention.

1 cl, 2 ex

Description

The invention relates to medicine, namely to surgery, proctology, and is intended for the management of patients with pararectal fistulas, acute and chronic hemorrhoids, rectocele, rectal polyps, paraproctitis after surgical treatment, including complications: acute thrombosis of hemorrhoidal nodes, bleeding, prolapse of nodes and concomitant pathology (anal fissures, anal itching, etc.).

The aim of the invention is to improve the management of patients after surgical treatment of patients with rectal diseases, improve treatment results, reduce the duration of hospitalization, and reduce the frequency of postoperative complications.

A surgical approach is known for treating patients with hemorrhoids and their complications. All patients who have undergone surgical treatment, for example, for hemorrhoidal disease, are recommended to undergo multi-stage rehabilitation measures, the purpose of which is the complete social and physical recovery of the patient [Shelygin Yu.A., Blagodarny L.A. Proctologist's Handbook. Moscow: Littera, 2012. Pp. 64-89].

The need for rehabilitation of patients with rectal diseases in the postoperative period is due to surgical trauma to the perianal region, anal canal and lower ampullar part of the rectum with the presence of postoperative sutures. The presence of postoperative wounds (violation of integrity in the specified anatomical areas), their healing by secondary intention, sutures in the places of suturing of hemorrhoidal arteries determine the risk of purulent-septic complications, postoperative bleeding in case of failure of the applied sutures. Pain syndrome of varying severity and possible disorders of the defecation function and continence function in the postoperative period can lead to significant social maladjustment and reduce the quality of life of this category of patients [Corman ML. Hemorrhoids. In: Corman ML, eds. Colon and rectal surgery. 6th ed. Philadelphia, USA: Lippincott; 2013:272-366].

The general principles of rehabilitation after surgical treatment of rectal pathology are as follows: assessment of the patient's initial condition taking into account his/her concomitant diseases (diabetes mellitus, obesity, exhaustion, connective tissue dysplasia), drawing up a plan of diagnostic and therapeutic measures necessary for rehabilitation, a comprehensive approach to organizing rehabilitation care, monitoring the effectiveness of the therapy during the rehabilitation process.

The most important tasks facing the surgeon after the operation are pain relief, elimination of tissue edema and inflammation, proper management of postoperative wounds in various phases of the wound healing process. Severe pain syndrome, which is observed in almost all patients with proctological diseases in the postoperative period, is caused by local action of inflammation mediators. This determines the high efficiency of non-steroidal anti-inflammatory drugs (NSAIDs) in the postoperative period in order to reduce the severity of pain. Analgesics (analgin, baralgin, spazgan, etc.), as well as detralex, anavenol, escusan, non-steroidal anti-inflammatory drugs are prescribed after the operation. Ointments are used locally: heparin, heparoid, hepatrombin, troxevasin, proctosedyl; suppositories - nigepan, proctosedyl, etc.). It is considered advisable to use Ultraproct suppositories or ointment for no more than 5 days during the first 4-5 days after surgery. [Semyonkin E.I. Coloproctology (Study Guide) - M: ID MEDPRAKTIKA - M, 2004, 234 p., pp. 47-49].

However, the use of NSAIDs in therapeutic doses may be ineffective due to weak accumulation in tissues. A number of systemic side effects (ulcerogenic and others) are also noted.

The stages of rehabilitation of patients after surgical treatment are also known:

Stage 1 - early rehabilitation, from 4-6 to 7-10 days after surgery. During this period, the patient undergoes inpatient rehabilitation treatment for 3-5 days, after which further rehabilitation takes place for 7-14 days in a short-stay hospital or on an outpatient basis. The task of stage 1 of rehabilitation is to normalize the functioning of the gastrointestinal tract with the formation of normal consistency and frequency of stool. In addition, at this stage, hemostasis, wound healing and relief of postoperative pain are monitored. Stage 2 (15 to 45 days after surgery) is aimed at accelerating reparative processes and geometrically correct, programmed healing of postoperative wounds with control of the gastrointestinal tract. When deciding on the tactics of surgical management of patients with acute and chronic hemorrhoids in the postoperative period, the most important are during the first 1-3 months after surgery: hygienic measures (washing with cool water, baths with the addition of chamomile decoction), regulation of the frequency and consistency of stool. It is necessary to achieve regular daily stool of soft consistency that does not injure the wound surfaces in the anal canal and perianal area [Hemorrhoids, hemorrhoidal disease. Clinical guidelines of the Russian Federation 2018-2020 (Russia). All-Russian public organization "Association of Proctologists of Russia". P. 18-21].

There is a known method of treating hemorrhoids: Longo's operation (hemorrhoidectomy using a hemorrhoidal stapler). Longo's operation is performed in the operating room with the patient in a supine position with legs drawn up to the abdomen and placed on special supports, under general anesthesia. A disposable set of instruments is used for the operation, including a circular suturing apparatus. Internal hemorrhoids are reduced and a purse-string suture is applied. This suture captures only the mucous membrane of the rectum and is applied 4-5 cm above the dentate line. It is applied by carefully rotating the retractor around the circumference. The mucous membrane is resected and stitched with 2 rows of tantalum staples. Then the apparatus is removed from the rectum together with its resected mucous membrane. The operation is completed by introducing a hemostatic sponge into the anal canal [Vorobyov G.I., Shelygin Yu.A., Blagodarny L.A. Hemorrhoids. Moscow: Litterra, 2010, 116-127 p].

The method of postoperative patient management described in the clinical guidelines [Hemorrhoids, hemorrhoidal disease. Clinical guidelines of the Russian Federation 2018-2020 (Russia). All-Russian public organization "Association of Coloproctologists of Russia". Pp. 18-21], according to which therapeutic nutrition is one of the important components of postoperative rehabilitation at an early stage, was chosen as a prototype. For this purpose, patients are recommended to consume an adequate amount of fluid and dietary fiber. Wheat bran, seaweed and flaxseed in their natural form or in the form of pharmacological preparations are used as a source of dietary fiber (the most commonly used are products based on the shell of psyllium seeds, lactulose, macrogol, which have a high water-holding capacity, which allows to soften the consistency of stool, promotes regular and complete bowel movements, eliminating the need for straining to empty the rectum). Hemostasis control: after surgical treatment of hemorrhoids, accompanied by removal of external and internal components of cavernous tissue, wounds are located in a well-supplied area. In this regard, bleeding of postoperative wounds is often noted during the first 2-3 weeks. Rehabilitation measures for increased bleeding of wounds consist of their regular inspection, the use of ointment compositions with a complex effect, including capillary strengthening, normalization of stool consistency with limitation of excessive straining. Various local hemostatic agents (hemostatic sponges, cauterizing agents), electrocoagulation of bleeding surfaces can be used. Pain relief: the severity of pain depends on the extent of surgical trauma to the perianal area, anal canal and lower ampullar part of the rectum, individual pain threshold, the presence of sutures on the wounds of the anal canal and at the sites of ligation of the branches of the superior rectal artery. Systemic or local agents for pain relief are selected individually by the attending physician depending on the degree of its intensity, as well as the severity of psychoemotional disorders. As a rule, analgesics from the group of non-steroidal anti-inflammatory drugs, antispasmodics, local combined analgesic and anti-inflammatory drugs in the form of gels, creams, ointments and suppositories, which include local anesthetic components and glucocorticoids, are used. Programmed wound process: correct management of the wound process, starting from the 2nd day after the operation until complete epithelialization of the wounds implies: daily sanitation of wounds with antiseptic solutions, dressing with ointment applications (the composition of the ointment is determined by the stage of the wound process); dynamic monitoring by a proctologist (digital examination of the rectum is performed every two days); microbiological control (if purulent-septic complications and wound infection are suspected). In order to accelerate reparative processes, reduce the inflammatory response and more correctly progress the wound process, it is necessary to carry out physiotherapy in the volumes prescribed by a physiotherapist [Hemorrhoids, hemorrhoidal disease. Clinical guidelines of the Russian Federation 2018-2020 (Russia). All-Russian public organization "Association of Proctologists of Russia". P. 18-21].

The goal of the 2nd stage of rehabilitation of patients who have undergone surgical treatment of hemorrhoids is the final epithelialization of postoperative wounds and prevention of the development of postoperative complications: stricture and cicatricial deformation of the anal canal (6-9%); postoperative insufficiency (1.8-4%) of the anal sphincter. Also, during the 2nd stage of rehabilitation, it is important to monitor the consistency and frequency of stool, pain syndrome, and control the course of the wound process. In order to prevent cicatricial deformation and stricture of the anus, it is necessary to be monitored by a proctologist with a digital examination every 3-5 days. In order to early detect postoperative insufficiency, in the presence of subjective complaints of impaired function of maintaining the anal sphincter, all patients after surgery need to undergo a pathophysiological study (sphincterometry) on the 40th day after surgery, followed by consultation with a physiotherapist.

The prototype has the following disadvantages. The absence of preoperative bowel cleansing guarantees the presence of an early act of defecation after surgery and the beginning of food intake, which is an important factor in suture infection both in "open" surgery and in endoscopic imposition of anastomosis in the rectum. Severe pain forms "fear of the chair" and spasm of the anal sphincter, which leads to an aggravation of pain sensations according to the "vicious circle" type, conditions for suture divergence in the anal canal area arise. The use of the "open" modification of hemorrhoidectomy often leads to the occurrence of serious complications in the immediate postoperative period. As a result, hematomas and suture divergence may form; a keloid scar may form, leading to stenosis of the anus in the late postoperative period. The hospitalization period is extended to 6-7 days of the inpatient period and stay on sick leave, treatment costs increase, the quality of life of active patients of working age decreases. In case of suture divergence and complications in the form of bleeding, there is a need for repeated emergency hospitalization, suturing of bleeding areas. In case of surgery for pararectal fistulas, a relapse of the disease may occur. Surgical interventions for rectal diseases performed by "open" access, using incisions and sutures in the anus and anal canal, lead to damage to the anoderm. Trophic disorders in the area of direct regeneration of the anoderm lead to severe postoperative pain syndrome, requiring relief with narcotic analgesics. The need for frequent digital rectal examination, application of ointments and other therapeutic agents into the anal canal is a painful procedure leading to a deterioration in the quality of life of patients in the postoperative period. Early appearance of independent stool after surgery brings physical suffering to the patient, causes prolonged burning in the anus, persistent spasm of the sphincter, and also affects the postoperative sutures, causing their inflammation and divergence, the formation of chronic anal fissure. As a result, there is a pronounced duration of the stages of rehabilitation of patients in the postoperative period.

These shortcomings prompted us to develop a new approach to pre- and postoperative management of patients with rectal diseases.

The objective of the invention is to develop a universal, easily reproducible tactic of pre- and postoperative management of patients with rectal diseases - with acute and chronic hemorrhoids and their complications, pararectal fistulas, rectocele, polyps of the anus and rectum, which eliminates the shortcomings of known methods of operations and postoperative management, primarily the risk of inflammatory complications, hematoma formation, creates a good aesthetic effect of the operation, reduces the treatment time, does not require infusion parenteral nutrition, and reduces the stages of patient rehabilitation.

The technical result of the invention is the simplicity and ease of implementation of the method, the use of careful preoperative preparation, hardware mechanical suture for the operation, the use of special enteral nutrition in the postoperative period to stop the fecal flow, without the use of infusion parenteral nutrition; acceleration of the healing time and rehabilitation in the postoperative period; at the same time, a single-stage surgical intervention is possible in case of combined proctological pathology (for example, a combination of chronic hemorrhoids and rectocele, chronic hemorrhoids and pararectal fistula), as well as the elimination of the risk of suture divergence in the anoderm area, the absence of cicatricial deformations of the anus.

The stated objective is achieved by the fact that in the claimed method, the surgical approach to the treatment of rectal diseases begins immediately after the diagnosis and the patient's consent to surgery, is performed regardless of the severity of the pathology, provides a radical cure for the patient in a short period of treatment, with a short stay in the hospital and a reduction in pain.

The claimed method is carried out as follows. The patient is prescribed bowel cleansing the day before the operation, similar to preparation for a colonoscopy, including adherence to a low-slag diet for 3 days, and then taking laxatives, for example, Fortrans, Eziclen, for 24 hours; surgical treatment of pararectal complete fistulas, rectocele, hemorrhoidal disease, removal of rectal polyps is carried out by an endoscopic approach, by circular resection of the rectal wall with a suturing apparatus with the imposition of a double-row staple suture; prevention of gas accumulation after surgery - by dosed divulsion of the anal sphincter using a disposable anoscope and leaving a soluble hemostatic sponge in the form of a cone in the anal canal; after the operation, at the first stage, instead of food, the so-called "light liquid" is prescribed, including the use of tea, coffee, juices without pulp, compote without berries, and as a source of nutrition we prescribe the intake of a drug for postoperative enteral nutrition, for example, "Nutridrink", without dietary fiber, at the rate of 20 ml / kg of the patient's weight, three times a day, depending on the patient's weight, to prevent stool; in this case, a digital rectal examination and the introduction of rectal suppositories into the rectum are not performed for seven days, hemostasis is monitored by observing the bandage on the anus. At the 2nd stage of the postoperative period, after 7 days of the postoperative period, we begin to expand the diet in the form of a combination of the drug "Nutridrink" with dietary fiber at the rate of 10 ml / kg in combination with a gentle diet, not including in it products containing fiber (vegetables and fruits), for a period of seven days; 14 days after the operation, we prescribe a transition to a normal diet (common table), allowing alcohol and "spicy" food; from the 15th to the 45th day after the operation, only periodic digital rectal examination is performed once a week for 3 weeks, a control examination 3 months after the operation using a disposable proctoscope, to monitor the formation of the scar and possible removal of individual remaining staples.

The proposed method of perioperative period management in the treatment of rectal pathology ensures its smooth course, reduces the duration and cost of a long two-stage postoperative period, excludes painful surgical manipulations in the early postoperative period, the need for dressings and frequent digital rectal examination in the early postoperative period, the operation is performed according to the principles of "endoscopic" surgery, including aesthetically advantageous results of postoperative wound closure. Stage 1 - early rehabilitation, occurs from the 2nd to the 7th day after surgery, since the patient is discharged the next day after the operation. During this period, the patient is on outpatient rehabilitation treatment for 5 days, after which further rehabilitation continues for 7-14 days on an outpatient basis. The objective of stage 1 of rehabilitation is to achieve the absence of independent stool in the patient, without "false" urges to defecate and straining. In addition, at this stage, hemostasis, wound healing, and postoperative pain syndrome are controlled. Stage 2 (from 8 to 14 days after surgery) is designed to gradually restore regular fecal flow in the form of daily semi-formed stool.

The method ensures a good functional result of the operation, is a low-traumatic, effective method of managing the perioperative period, allows to refuse parenteral nutrition, reduce the frequency of possible complications and reduce pain syndrome, ensure early rehabilitation of patients.

Clinical example of the implementation of the method.

Example No. 1. Patient B., 29 years old, height 188 cm, weight 94 kg. He underwent emergency surgery for grade III chronic hemorrhoids complicated by prolapse of nodes, recurrent bleeding, and anal polyps. The patient was advised to exclude fiber-containing foods (vegetables, fruits) from his diet three days before the surgery. Before the surgery, he was prescribed bowel cleansing with the drug "Fortrans", 4 packets per day. Three hours before the surgery, an enema was performed with the drug "Microlax"; surgical treatment of hemorrhoidal disease, removal of rectal polyps was performed using an endoscopic approach, by circular resection of the rectal wall with a suturing device and the application of a two-row staple suture. A disposable set of instruments and the PYGC - 34 apparatus manufactured by PRECISION (CHANGZHOU) MEDICAL INSTRUMENTS were used for the operation; the purse-string suture was applied proximally to the border of the hemorrhoidal nodes. Two circular sutures were applied, which captured the rectal mucosa and submucosal layer, 4-5 cm above the dentate line. After inserting the head of the hemorrhoidal stapler, the right purse-string suture was tied first, then the left one, so that the sutures tightly covered the working rod of the apparatus under the head. Pulling the threads as holders and rotating the wing nut on the end of the apparatus, the head and the base of the apparatus were brought together until a green line appeared in the viewing window. The mucous membrane was resected and simultaneously stitched with tantalum staples by quickly squeezing the handles of the device once, while feeling the crunch of the stitched tissues. Then the device was removed from the rectum together with the resected mucous membrane. The operation was completed by introducing a hemostatic sponge folded into a cone, also moistened with a betadine solution, into the anal canal. An aseptic patch was applied to the anus. After the operation, the so-called "light liquid" was prescribed, including the use of tea, coffee, juices without pulp, compote without berries, and as a source of nutrition, the patient took the postoperative enteral nutrition drug "Nutridrink" without dietary fiber, at a rate of 20.0 ml / kg, three times a day, to prevent stool passage; in addition, it was allowed to dissolve lollipops and caramel candies, based on taste and body needs. The patient was transferred to the postoperative ward, pain relief on demand and antibiotic therapy were prescribed. After the end of the spinal block, the patient was given a single injection of analgesics, no further pain relief was required. From the first day of the postoperative period, instead of food and meals, regular intake of the enteral surgical mixture "Nutrikomp Drink Plus" was started, in order to prevent stool in the postoperative period. The patient was discharged from the hospital the next day, for 7 days, as the only source of nutrition, he took 4-5 bottles of the mixture "Nutrikomp Drink Plus" daily, there was no formed stool. The patient was sent home, where he took care of the perineum, wiping the skin around the bandage with a chlorhexidine solution. Rectal examination and the introduction of rectal suppositories into the rectum were not performed for seven days, hemostasis was monitored by observation and changing the bandage in the anus. During this period, a single leakage of scant liquid stool was noted on the 4th day of the postoperative period, which required a change of the dressing. From the 8th day of the postoperative period, the patient began to expand the diet, taking the drug "Nutridrink" with dietary fiber 15.0 ml / kg and receiving a gentle diet that does not include fiber-containing products (vegetables and fruits) for a period of seven days - boiled egg, white bread, sausages, cottage cheese, juices with pulp, kefir, soups, porridge. From the 9th day of the postoperative period, semi-formed stool appeared, 14 days after the operation, a transition to a normal diet (common table) was prescribed, not allowing alcohol and "spicy" food; At the 2nd stage of the postoperative period, on the 14th day after the operation, a digital rectal examination was performed - the anastomosis line was consistent, slightly edematous, the examination was painless, single staples were palpated; weekly rectal examinations were performed for 3 weeks, during the last one, complete removal of the staples was noted. Three months after the operation, a control endoscopic examination of the rectum was performed using a disposable proctoscope, the anastomosis line was in the form of a thin circular scar, there was no data on the recurrence of hemorrhoidal disease, staples were absent in the anastomosis area.

Example No. 2. Patient T., 47 years old, height 166 cm, weight 64 kg. She underwent a planned operation for grade II rectocele and grade II chronic internal hemorrhoids complicated by recurrent spotting and chronic constipation. Constipation lasted for 2-3 days, periodically requiring manual assistance during bowel movements. Three days before the operation, the patient excluded fiber-containing foods from her diet. Before the operation, she underwent bowel preparation by taking Fortrans, 3 packets per day. Three hours before the operation, an enema was performed using Microlax; surgical treatment of rectocele and hemorrhoidal disease was performed by circular resection of the rectal wall with a suturing apparatus with the application of a double-row staple suture, under spinal anesthesia. A disposable set of instruments and the P-34 apparatus manufactured by PRECISION (CHANGZHOU) MEDICAL INSTRUMENTS were used for the operation. The mucous membrane was resected with simultaneous suturing with tantalum staples; the apparatus was removed from the rectum together with the resected mucous membrane. The operation was completed by introducing an absorbable hemostatic sponge folded into a cone and moistened with a betadine solution into the anal canal. An aseptic sticker was applied to the anus area. After the operation, the patient took the so-called "light liquid", including tea, coffee, juices without pulp, compote without berries, and as a source of nutrition, the patient took the postoperative enteral nutrition preparation "Nutridrink" without dietary fiber, at a rate of 20.0 ml/kg, three times a day, to prevent stool passage; lollipops and caramel candies. From the 8th day of the postoperative period, the patient took the drug "Nutridrink" with dietary fiber 10.0 ml / kg and received a gentle diet without fiber (vegetables and fruits), for a period of seven days - boiled egg, white bread, sausages, cottage cheese, juices with pulp, kefir, soups, porridges. The patient did not have a plentiful and formed stool until the 10th day. 14 days after the operation, she began to eat a common diet, the stool was daily, semi-formed; at the 2nd stage of the postoperative period, on the 14th day after the operation, a digital rectal examination was performed - the anastomosis line is consistent, slightly edematous, the examination is painless, single staples are palpated; weekly rectal examination was performed for 3 weeks, the last one showed complete discharge of the staples. After 3 months. After the operation, she was examined by a gynecologist, a control endoscopic examination of the rectum was performed using a disposable proctoscope, the anastomosis line was in the form of a thin circular scar, there was no evidence of recurrence of rectocele or hemorrhoidal disease, there were no staples in the anastomosis area.

A comparative analysis of the claimed method with the prototype shows that the claimed method does not involve anoderm incisions, the surgical stage is performed by an endoscopic approach through an anoscope, in a zone covered with mucous and devoid of sensitive innervation, which facilitates the healing process. The claimed invention allows for effective radical surgery of complicated forms of rectal diseases: pararectal fistulas after exacerbation, rectocele complicated by coprostasis and internal intussusception, acute thrombosed and bleeding hemorrhoids, without delaying the treatment period. The use of surgical intervention outside the anal canal zone allows avoiding leaving the gas outlet tube in the intestinal lumen, tamponing the intestinal lumen with ointment napkins, additional fixation with adhesive tape and sutures, ensures natural gas discharge in the postoperative period, does not require a painful procedure for removing the gas outlet tube, eliminates the need for dressings and local treatment by endorectal procedures. An important advantage of the proposed approach is its applicability to all variants of rectal diseases in case of an endoscopic approach to the treatment of pathology, at any stage of the process. The difference from the standard treatment technology in the form of "preventive colostomy" when applying anastomosis after rectal resection is the absence of the need for a repeated operation to close the colostomy and, at the same time, the method ensures the interruption of the fecal flow necessary for the time of healing of the anastomosis, eliminates the risk of infection and divergence of the anastomosis. The speed of applying a mechanical suture, the absence of bleeding during mucosal incisions do not worsen the general condition of the patient with an inflammatory process as a result of thrombosis and bleeding. An important difference and a necessary stage of treatment in the postoperative period is the refusal to take regular food, rectal administration of suppositories, digital examination and infusion therapy in the form of parenteral nutrition. The use of enteral postoperative mixtures to ensure a long absence of formed stool, intake of "light" liquid, ensures a favorable course of the postoperative period, the absence of divergence of the mechanical suture, and a decrease in the level of pain syndrome. In addition, the claimed surgical method allows accelerating the process of treatment and recovery of patients with a complicated course of the postoperative period.

Since 2018, the authors have performed surgical treatment in 35 patients with complications of hemorrhoidal disease, pararectal fistulas, rectocele, rectal polyps, paraproctitis after surgical treatment, including complications: acute thrombosis of hemorrhoids, bleeding, prolapse of nodes and concomitant pathology, studied the immediate and long-term results of surgical treatment in those who underwent emergency hemorrhoidectomy according to the proposed technique, healing was assessed according to the VAS pain scale, visual assessment of the forming scar, general clinical and laboratory parameters. The postoperative period was uneventful, without a significant increase in temperature. Parenteral analgesics were administered in the first 24 hours, then patients took painkillers and antibiotics in tablet form on demand, at night. Patients were discharged on day 1-2 of the postoperative period, the average hospital stay was 28 hours. Sick leave - up to 8-9 days, including hospitalization. In all cases, formation of a thin smooth linear scar was observed, there was no divergence of sutures. No relapses were noted. There was no stenosis of the anus.

The conducted analysis of patent and scientific-medical literature showed that the proposed method contains features that distinguish it not only from the prototype, but also from other options for patient management after surgical treatment of patients with rectal diseases. These differences allow us to conclude that the claimed technical solution complies with the invention criterion "novelty".

A comparative analysis of the claimed method and the prototype shows that the claimed method differs from the known prototype in that in the preoperative period, bowel cleansing is prescribed, similar to preparation for a colonoscopy; in the postoperative period, regular intake of enteral surgical mixtures for postoperative nutrition for 7 days is prescribed, instead of food, as the only source of nutrition, as well as the so-called "light liquid", which eliminates the appearance of formed stool and causes an interruption of the fecal flow, as in the operation of imposing an unnatural anus - colostomy, which allowed this method to be called "virtual colostomy".

The claimed method ensures radical elimination of rectal pathology and smooth healing of the endorectally formed anastomosis, and allows to reduce the rehabilitation period after surgery. The patient can take care of the forming scar in the rectum at home, following a diet and observing hygienic measures, periodically showing up for examination. Dressings, rectal examinations in the acute period, within a week after surgery as such are not required.

Thus, the proposed method allows us to conclude that it meets the invention criterion of “inventive step”.

The method constituting the claimed invention is intended for use in healthcare. This method can be used in proctology, general surgery. It is possible to use the claimed method in outpatient conditions, as well as as an operation in a one-day hospital. The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the invention criterion "industrial applicability".

LIST OF REFERENCES:

1. Vorobyov G.I., Shelygin Yu.A., Blagodarny L.A. Haemorrhoids. M.: Litterra, 2010, 116-127 p.

2. Hemorrhoids, hemorrhoidal disease. Clinical guidelines of the Russian Federation 2018-2020 (Russia). All-Russian public organization "Association of Proctologists of Russia". Approved by the Scientific and Practical Council of the Ministry of Health of the Russian Federation. P. 18-21.

3. Semionkin E.I. Coloproctology (Study manual) - M: ID MEDPRAKTIKA - M, 2004, 234 p., pp. 47-49.

4. Shelygin Yu.A., Blagodarny L.A. Proctologist's Handbook. Moscow: Littera, 2012. P. 64-89.

5. Corman ML. Hemorrhoids. In: Corman ML, eds. Colon and rectal surgery. 6th ed. Philadelphia, USA: Lippincott; 2013:272-366.

Claims (1)

A method of perioperative management of patients with a virtual colostomy, including adherence to a diet, characterized in that the patient undergoes bowel cleansing before the operation, performs circular resection of the rectal wall with a suturing apparatus with the application of a double-row staple suture, performs a dosed divulsion of the anal sphincter using a disposable anoscope, leaves a soluble hemostatic sponge in the form of a cone in the anal canal, after the operation at the first stage, instead of food, liquid is used in the form of tea, coffee, juices without pulp and compote without berries and the drug of postoperative enteral nutrition "Nutridrink" without fibers at the rate of 20 ml / kg three times a day, hemostasis is monitored by observing the bandage on the anus, 7 days after the operation, the diet is expanded in the form of a combination of the drug "Nutridrink" with dietary fiber at the rate of 10 ml / kg and the use of a gentle diet excluding vegetables and fruits for seven days, 14 days after the operation, they switch to general table, at the second stage of the postoperative period on the 60th day after the operation, a control endoscopic examination of the rectum is performed using a disposable proctoscope.