RU2847019C1 - Method of surgical treatment of anal fissures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to colorectal surgery. Anal fissure is excised, and a sphincter spasm is relieved by graduated laser destruction of the anal sphincter. After the excision, the anal fissure is closed in the longitudinal direction that is followed by the injection of platelet-rich plasma (PRP) in amount of 2.5 ml into the closed wound.

EFFECT: method enables reducing a risk of sutured wound opening, reducing a length of postoperative wound healing, reducing a risk of developing persistent wound.

1 cl, 4 dwg, 2 tbl, 1 ex

Description

The invention relates to medicine, namely to colorectal surgery, and can be used to treat anal fissures (AF) and long-term non-healing wounds of the anal canal with spasm of the anal sphincter.

A known method of surgical treatment of AT is its excision without suturing with lateral closed sphincterotomy, while the healing time of such an unsutured wound is up to 1.5-2 months (1. Danilov MA, Pozdnyakov SV, Nikolaeva AO, Dolgopyatov IA, Atroshchenko AO Advantages of performing lateral dosed sphincterotomy in the surgical treatment of chronic AT // Doctor Ru. 2018. No. 3 (147). P. 42-45. 2. Endoanal ultrasonographic evaluation of an unhealed anal fissure after the lateral internal sphincterotomy. E Yucel et al. Bratisl Lek Listy. 2013; 114 (l): 27-30. 3. Lateral Internal Partial Sphincterotomy Technique for Chronic Anal Fissure. Gurel Nessaret al. Indian J Surg. 2017 Jun. 4. A prospective randomized trial betwen subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks* operation in the treatment of anal fissures. V Filingeri et al. Eur Rev Med Pharmacol Sci. 2005 May-Jun. 5. Partial lateral internal sphincterotomy versus combined botulinum toxin A injection and topical diltiazem in the treatment of chronic anal fissure: a randomized clinical trial. Hossein Gandomkaret al. Dis Colon Rectum. 2015 Feb. 6. Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: a prospective study. Shiraz Ahmad Rather et al. Int J Surg. 2010. 7. Kamaeva Z.Z., Titov A.Yu., Khryukin R.Yu., Anosov I.S., Shelygin Yu.A. Controlled circular dilation and lateral subcutaneous sphincterotomy in the treatment of chronic anal fissures combined with stage 3-4 hemorrhoids. Coloproctology. 2024; v. 23, no. 1, pp. 42-51).

There are known methods of surgical treatment of AT with the so-called plastic closure of the wound. These include VY plastic methods, which include excision of the fissure in combination with the advancement of the anoderm flap (1. Anoplasty and lateral subcutaneous sphincterotomy in the treatment of chronic AT. Arslanbekova K.I., Khryukin R.Yu., Zharkov E.E. 2020. 2. Anoplasty in the treatment of chronic anal fissure 2019. E.A. Zagryadsky. 3. Fissurectomy and anoplasty in posterior normotensive chronic anal fissure. Beatrice D'Orazio et al. Acta Biomed. 2021. 4. Comparative study of conventional lateral internal sphincterotomy, VY anoplasty, and tailored lateral internal sphincterotomy with VY anoplasty in the treatment of chronic anal fissure. Alaa Magdy et al. J Gastrointest Surg. 2012 Oct.).

Flaws : large volume of tissue excision, technical complexity of the methods.

A method of circular excision of the fissure with excision of the external circular nodes is known (our patent for invention No. 2260383, Moscow, 2005). The disadvantages of this method are the large volume of tissue excised and the technical difficulties involved. This method is justified in cases of a combination of anal fissure and hemorrhoids with prominent external circular nodes.

In addition, for any of the above operations, in the case of wound divergence, long healing times are noted and, in some cases, the transition of the said wound into a long-term non-healing wound with healing times of many months.

Purpose of the invention : improve the results of AT treatment, namely: reduce the risk of divergence of the edges of the sutured wound, reduce the healing time of the postoperative wound, reduce the risk of developing a long-term non-healing wound.

The technical result of this work is that After relieving the sphincter spasm, the anal fissure is excised sharply with two oval incisions in the longitudinal direction, followed by wound suturing in the same longitudinal direction. Once the wound is closed, an injection of platelet-rich plasma is administered underneath the wound.

The proposed method, unlike V-Y plastics, which include excision of the fissure in combination with the displacement of the anoderm flap, allows for a significant reduction in the risk of divergence of the edges of the sutured wound and, accordingly, accelerates the overall healing time and reduces the risk of developing a long-term non-healing wound.

The method is convenient and easy to use, and its methodological mastery by proctologists requires a short training course. Therefore, this treatment method can be used on an outpatient basis or in a day hospital setting.

Technique of surgery Under caudal, spinal, or local anesthesia, with the patient positioned as for hemorrhoidectomy, sphincter spasm is relieved (dosed laser destruction of the sphincter, lateral sphincterotomy). Next, under Sims' speculum control, the first "guide" suture is placed 0.5 cm above the proximal edge of the anal fissure with thin catgut. The AT is excised sharply in the longitudinal direction with two oval incisions within healthy tissue, including excision of sentinel tubercles and fibrous polyps, if present. The wound is then sutured in the same longitudinal direction with a continuous suture, overlapping to the distal edge. Intraoperatively, blood is drawn from the patient's vein into special tubes and centrifuged for 8 minutes at 2000 rpm to obtain platelet-rich plasma. 2.5 ml of the platelet-rich plasma is injected under the sutured wound. An aseptic dressing is applied.

List of figures

Fig. 1. Chronic posterior anal fissure with fibrous polyp.

Fig. 2. The crack is excised.

Fig. 3. The wound is completely sutured. Suturing it.

Fig. 4. Completion in a month.

Clinical example Case history from 2023. Patient N., 38, was admitted to hospital complaining of severe anal pain during and after bowel movements, lasting for several hours, and occasional bright red blood stains on paper during bowel movements. According to the patient, he has been experiencing these complaints for the past year. The current exacerbation has been occurring over the past 14 days, following a hard stool.

Local status: a sentinel tubercle is present in the perianal area at 6 o'clock (U/C). When separating the anal edges at 6 o'clock (U/C), a deep mucosal defect with undermined edges and a whitish base is revealed, which is acutely painful upon palpation. Digital examination reveals markedly increased sphincter tone. (Figure 1)

Due to severe pain, further examination was performed under caudal anesthesia with 10 ml of 1% lidocaine. Anoscopy at the 6 o'clock position revealed a deep mucosal defect measuring 1.5 x 0.7 cm.

Diagnosis: Chronic posterior anal fissure with sphincter spasm.

Before surgery, sphincterometry was performed using a WMP Solar Gl (MMS, Netherlands). The average resting pressure was 113 mmHg, with a maximum pressure during voluntary contraction of 240 mmHg. The normal range for men is 43-61 mmHg at rest and 121-227 mmHg during voluntary contraction.

On July 1, 2023, the patient underwent surgical treatment: dosed laser destruction of the anal sphincter. Excision of the anal fissure with longitudinal wound closure. Injection of platelet-rich plasma under the sutured wound.

Under caudal anesthesia, laser destruction of the posterior sphincter was performed using the end-on light guide of the IPQ IRE-Polus laser surgical apparatus with a wavelength of 1.56 μm in a pulse-periodic mode with a power of 10 watts.

Next, under the control of a rectal speculum at the 6 o'clock position along the UC, the anal fissure and sentinel tubercle were excised using two bordering incisions, forming an oval-shaped wound measuring 2.5 x 1.5 cm. The wound was sutured with a continuous suture in the longitudinal direction, capturing the wound bottom with 5-0 catgut. Hemostasis was dry. (Figs. 2, 3).

Ten milliliters of blood were collected from the patient in a test tube containing citrate. The tubes were centrifuged for eight minutes at 2500 rpm. Two and a half milliliters of platelet-rich plasma were collected above the red blood cell count and injected under the sutured wound. The wound was cleaned and hemostasis was maintained. An aseptic dressing was applied. Blood loss was 4 ml.

Histology

Microscopic description: A fragment of mucosa covered with stratified squamous keratinized epithelium. A mucosal defect with hemorrhages is noted in a limited area. The lamina propria contains congested cavernous veins, focal hemorrhages, and focal lymphoplasmacytic infiltration.

Pathological conclusion: The histological picture corresponds to a chronic anal fissure.

The surgery lasted 20 minutes. The postoperative period was uneventful. Pain was virtually absent. The patient was discharged for outpatient follow-up six hours after the surgery. On the first and second days, he took Nimesil, one packet twice daily for pain relief.

Upon examination seven days after surgery, the sutured wound showed no signs of inflammation, and the sutures were intact. Digital examination revealed slightly increased sphincter tone.

The postoperative wound completely healed on the 27th day after surgery. At follow-up examination, the patient has no complaints and has regular bowel movements. Sphincter tone is satisfactory.

Repeat sphincterometry. The average resting pressure was 53 mmHg, and the maximum pressure during voluntary contraction was 181 mmHg. The final result on day 27 is shown in Fig. 4.

Results:

From May 26, 2021, to May 3, 2024, 124 patients underwent surgery at the KDS Clinic. Sixty-eight patients had chronic posterior AT, 45 had chronic anterior AT, and 11 had chronic anterior and posterior AT.

Of these, 72 were men, with an average age of 41 years. The average duration of the disease was 4 months.

Women - 52, average age 39 years. Average duration of illness 7 months.

Before treatment, all patients experienced severe pain during and after defecation, which could persist throughout the day, and spasm of the anal sphincter (confirmed by sphincterometry with a WMP Solar Gl (MMS, Holland) device). The fissure itself was a deep defect in the anoderm mucosa with undermined, scarred edges, the base of which was the sphincter fibers.

Data from anal sphincter tone measurements

Overall, the data obtained indicate increased anal sphincter tone at baseline. Furthermore, after treatment, specifically, after dosed laser destruction of the internal sphincter, sphincter tone returned to normal in all patients.

The second aspect of the surgery is excision of the fissure itself and its suturing. The following results were obtained.

88 patients (71%) of cases - primary healing with an average healing time of 24 days.

In 7 cases (5.5%), the operation was complicated by the formation of a ligature fistula, which was subsequently removed, with an average healing time of 38 days.

In 20 cases (16%) there was partial suture divergence with an average healing time of 42 days.

Nine patients (7.5%) developed a non-healing wound (NW) due to complete suture dehiscence. Seven of these patients successfully healed with active systemic and local treatment, including platelet-rich plasma injections, CO2 laser wound bed scanning, ozone therapy, and wound blockades. The average healing time was 87 days. Of these nine patients, two underwent repeat surgery on the 60th day, with complete wound healing.

No other complications, such as weakness of the anal sphincter, stricture, or postoperative bleeding, were noted.

In total, of the 124 patients operated on, 115 (92.7%) had wounds heal within 24 to 42 days, which is consistent with the healing time for operated anal fissures reported in the literature. The remaining nine patients with DNR remained problematic, with treatment times lasting almost three months; however, despite the complexities of their treatment, these patients ultimately recovered completely.

Thus, the proposed method of wound suturing and treatment with plasma with an increased platelet content allowed for the cure of patients in 100% of cases, with primary healing achieved in less than a month in 71% of cases and in up to 42 days in 21.5%.

Claims (1)

A method for the surgical treatment of anal fissures, including excision of the fissure and relief of sphincter spasm by dosed laser destruction of the anal sphincter, characterized in that, in order to prevent suture divergence and accelerate the final healing of the wound, the latter is sutured in the longitudinal direction after excision, followed by an injection of 2.5 ml of platelet-rich plasma (PRP) into the sutured wound.