RU2847117C1 - Method of treating patients with chronic inflammation of pilonidal cyst - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to surgery and coloproctology. Ultrasound of sacral-coccygeal soft tissues is performed intraoperatively. Pilonidal cyst is inspected. Probe with the silicone guide is taken through the fistulous passage; then probe is removed. Radial waveguide is inserted into the conductor. Guide is removed. Fistulous passage cavity is coagulated with laser at wave length 1940 nm, power 10 W at 1 mm/s. A stromal-vascular fraction of adipose tissue is prepared mechanically. Ultrasound-controlled injection of a stromal-vascular fraction of adipose tissue into a fistulous passage is performed transdermally in dose of 0.1 ml per each prick and intramurally into the bottom and walls of an open wound formed after opening and removing large cavities of the pilonidal cyst in dose of 0.1 ml per prick.

EFFECT: method enables treating the patients with chronic inflammation of the pilonidal cyst, subcutaneous removal of the cavities more than 0.5 cm and all the pilonidal cyst elements, reducing the wound healing time, reducing a recurrence rate and improving the cosmetic effect.

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Description

The proposed invention relates to medicine, in particular to surgery and proctology, and can be used to treat patients with chronic inflammation of the epithelial coccygeal passage (ECC).

Epithelial coccygeal tract (ECT) (pilonoid disease, pilar cyst – cysta pilonidea) is a condition characterized by the presence of a subcutaneous canal that terminates blindly in the coccygeal projection. The canal is lined internally with epithelium containing hair follicles and sebaceous glands, opening through one or more primary openings in the intergluteal fold. It is one of the most common conditions in proctology.

The period of exacerbation typically occurs between the ages of 18 and 35. Therefore, research into this problem has focused on developing a method that could quickly relieve patients of this disease without increasing the risk of relapse.

A method of radical treatment of epithelial coccygeal tract is known, which includes surgical removal of all elements of the pathological focus, leaving an open wound or suturing it tightly (Clinical guidelines. Coloproctology / edited by Yu. A. Shelygin. - M .: GEOTAR-Media, 2015).

In the article by S.B. Kozyrev, I.V. Kostyrev, L.A. Blagodarny and co-authors in the journal "Coloproctology" (volume 22, no. 2), an analysis of literature data was conducted, which demonstrated the high efficiency of most minimally invasive methods, which, along with radical interventions, have entered the spectrum of regular use in the treatment of chronic ECC.

In 1964, a minimally invasive treatment method was first described, namely the use of phenol, but this method did not gain much popularity.

Sinusectomy with skin bridges was deemed the primary method of transition. This method had similar healing times and recurrence rates compared to tight wound closure, but it eliminated the need for spinal anesthesia and a lengthy hospital stay. It was determined that minimally invasive techniques existed in the treatment of ECC, and these methods were refined to improve their results, shorten healing times, and reduce the recurrence rate.

Each of the existing methods of surgical intervention in ECC has its own advantages and disadvantages.

When comparing minimally invasive and radical treatment methods, it's clear that leaning toward minimally invasive techniques increases the recurrence rate in the vast majority of cases, while resorting to more radical methods prolongs healing time and hospital stay. The key to shifting to minimally invasive techniques was the understanding that the primary role in treating fistula openings and secondary lesions must be given to excision.

The lowest recurrence rate occurs with open wound management; in many countries, this method is considered the primary one, despite the long period of hospital stay, disability, and rehabilitation.

A known method is excision of the ECC and all elements up to the sacral fascia with a scalpel, after which the wound is not sutured and open wound management is performed.

The disadvantages of this method are:

- long period of hospitalization - 21 days;

- complete wound healing takes 45 days;

- formation of a rough scar with a cosmetic defect.

Laser obliteration of fistula tracts: DessiLy M. et al. were among the first to use this technology in 2014. This technique utilized a 1470 nm laser with a radial energy output of 10 W. Primary and secondary openings were widened sharply and with a clamp, and the skin around the openings was circularly excised with a biopsy needle (derma-punch).

The recurrence rate with this method reaches 14.3% according to literature and meta-analysis data - with an OR (odds ratio) of 4.02 and 95% CI (confidence interval) at p=0.03. However, the duration of disability is 7.33-6.29 95% CI at p=0.000001.

The disadvantage of this method is:

- high rate of disease recurrence;

- it is impossible to use this technique in the presence of cavities in the subcutaneous tissue larger than 0.5 cm;

- a narrow range of indications for the use of this technique;

- the impossibility of using the method in case of relapse of the disease in the presence of postoperative scars.

A method of sinusectomy by the Swiss surgeon C. Soll, published in 2008, is known, which includes excision of the ECC performed through two separate incisions with the formation of a subcutaneous wound.

Disadvantages of this method:

- development of complications in the form of destruction of the skin bridge, which leads to the formation of an open wound and a long healing period;

- frequent bleeding in the postoperative period from long-term non-healing wounds;

- long recovery period (40.6±8.7 days).

The method of surgical treatment of epithelial coccygeal tract (Patent of the Russian Federation No. 2767887 dated March 22, 2022, authors Serdyukov M.A., Kchibekov E.A.) was chosen as a prototype. It includes excision of the primary fistula opening, revision of the fistula tract, characterized by the fact that under ultrasound control, ligatures in the form of a figure of eight are passed transversely under the formed cavity, stepping back 1 cm from the cavity, the cavity of the fistula tract is coagulated with a laser in continuous mode with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm / s, the threads are tightened until the walls of the fistula tract are connected.

However, the method has the following disadvantages.

When using the prototype, complications may develop, such as destruction of the skin bridge due to early thread penetration, leading to the formation of an open wound and a prolonged healing period, as well as frequent bleeding in the postoperative period from long-term non-healing wounds. The presence of a foreign body (ligature) is associated with the development of an inflammatory process, which prolongs the recovery period.

The objective of the proposed invention is to develop a method for treating patients with chronic inflammation of the epithelial coccygeal passage (ECC), which allows for a reduction in healing time, the frequency of relapses, and an improvement in cosmetic results.

The technical result is complete subcutaneous removal of cavities larger than 0.5 cm and all elements of the epithelial coccygeal passage (ECC), increasing the effectiveness of treatment and reducing wound healing time.

The technical result is achieved by performing an intraoperative ultrasound examination of the soft tissues of the sacrococcygeal region; a probe with a silicone conductor is inserted through the fistula tract; then the probe is removed; a radial light guide is inserted into the conductor; the conductor is removed and the cavity of the fistula tract is coagulated with a laser with a wavelength of 1940 nm and a power of 10 W at a speed of 1 mm / s; stromal-vascular fraction of adipose tissue is obtained mechanically; under ultrasound control, the stromal-vascular fraction of adipose tissue is injected around the fistula tract transdermally at 0.1 ml for each injection, and intramurally into the bottom and walls of the open wound formed after opening and removing large cavities of the epithelial coccygeal tract, at 0.1 ml per injection.

The method is carried out as follows.

Before surgery, all hair in the sacrococcygeal region is removed with a blade. Anesthesia is administered. The patient is positioned prone, face down, on the operating table. The surgical field is then treated three times with povidone iodine. An intraoperative ultrasound of the soft tissues of the sacrococcygeal region is performed before surgery. This ultrasound identifies the presence of subcutaneous tracts and their routes of extension, notes the location of the cyst, and identifies cavities and scar tissue. Next, the skin around the fistula is excised with a scalpel. Fine-tipped scissors are used to remove all fistula elements. The tract is then brushed with a cytology brush. Under ultrasound guidance, if cicatricial adhesions are detected, a counter-opening incision is made with a scalpel in the projection of the fistula tract. A probe and silicone guidewire are then passed through each tract and its branches. The probe is then removed, and a radial light guidewire is inserted into the guidewire. The conductor is then removed from the wound and brought to the surface. The fistula tract is coagulated with a 10 W, 1940 nm laser at a rate of 1 mm/s. The stromal-vascular fraction of adipose tissue is mechanically obtained for injection. A modified Klein's solution (0.2% lidocaine with adrenaline at a ratio of 1:100,000) is injected into the superior outer quadrant of the gluteal region. Fifteen minutes after subcutaneous fat infiltration, a 0.3 cm incision is used to collect up to 100 ml of adipose tissue. Under sterile conditions, the sample is passed through 100 µm mesh filters to obtain a finely dispersed fat suspension. The adipose tissue is centrifuged for 15 minutes in sterile test tubes. The Klein's solution and any oils that form are then removed from the test tubes using a sterile syringe. Under ultrasound guidance, stromal-vascular fraction of adipose tissue is injected transdermally along the fistula at a dose of 0.1 ml per injection and intramurally into the base and walls of the open wound formed after opening and removing large cavities of the endoscopic vascular graft (ECG) at a dose of 0.1 ml per injection. The proposed method is highly effective due to the complete removal of all ECG elements, the sanitizing and coagulating properties of the laser on the fistula tracts, and the injection of stromal-vascular fraction of adipose tissue accelerates the regeneration process and achieves healing by secondary intention in a short period of time.

This method allows to reduce healing time, the frequency of relapses, and improve the cosmetic result.

Clinical example.

Patient B., 21, was admitted to the clinic complaining of fistula tracts in the intergluteal fold, intermittent pain with fever, and purulent discharge. Upon examination, two primary openings, 0.1 cm and 0.2 cm in size, were visualized in the intergluteal fold, 0.4 cm apart. A dense infiltrate was detected 4 cm proximally and 2 cm laterally, extending into the right gluteal region.

Surgical treatment was performed according to the proposed method. Spinal anesthesia (SMA) was administered with 2% lidocaine solution. The surgical field was treated with povidone iodine three times. Next, an intraoperative ultrasound examination of the soft tissues of the sacrococcygeal region was performed: a cyst measuring 2.5 cm × 1.0 cm was detected in the area of the primary fistula openings; a fistula tract in the proximal direction with a diameter of 0.2 cm and a length of 4.5 cm was detected, and an infiltrate with fluid contents 2.5 cm in diameter was detected above. The skin around the fistula tract was excised with a scalpel. A tuft of hair, detritus, and the cyst capsule were removed with sharp scissors (Fig. 1). Next, the tract was brushed with a cytology brush (Fig. 2). Under ultrasound guidance, a counter-opening incision was made with a scalpel in the projection of the infiltrate, with the contents excised. Next, the probe, together with a silicone guidewire, was advanced through the fistula tract and its branch in a straight direction. The probe was then removed, and a radial light guide, through which laser radiation with a wavelength of 1940 nm and a power of 10 W, was inserted into the guidewire. The guidewire was then removed from the wound to the surface, and coagulation of the fistula tract cavity was performed at a speed of 1 mm/s for 45 s (Fig. 3). The stromal-vascular fat fraction was obtained mechanically. Modified Klein's solution (0.2% lidocaine solution with adrenaline in a ratio of 1:100,000) was injected into the upper outer quadrant of the gluteal region. Fifteen minutes after subcutaneous fat infiltration, 40 ml of adipose tissue was collected through a 0.3 cm incision. Under sterile conditions, adipose tissue was passed through 100-μm mesh filters to obtain a finely dispersed fat suspension. The adipose tissue was centrifuged in sterile test tubes for 15 min. Klein's solution and the resulting oils were then removed from the test tubes using a sterile syringe. Under intraoperative ultrasound guidance, the stromal-vascular fraction of adipose tissue was injected transdermally along the fistulas at 0.5 cm intervals with 0.1 ml per injection (Fig. 4) and intramurally into the bottom and walls of the open wound formed after opening and removing large cavities of the endothelial cell carcinoma, uniformly at 0.2 cm intervals with 0.1 ml per injection (Fig. 5).

The patient was discharged in satisfactory condition the following day. He was examined daily and treated with antiseptic solutions. He was out of work for 7 days. Complete wound healing was observed after 19 days.

Three months later, a follow-up soft tissue ultrasound was performed. Echocardiography revealed no signs of recurrence or inflammatory changes in the subcutaneous fat in the sacrococcygeal region (Fig. 6).

The method allowed: performing a radical operation; reducing the hospital stay to 1 day; reducing the healing time to 19 days; returning to work after 7 days.

Claims (1)

A method for treating patients with chronic inflammation of the epithelial coccygeal tract, including revision of the epithelial coccygeal tract, coagulation of the cavity of the epithelial coccygeal tract with a laser, characterized in that an ultrasound examination of the soft tissues of the sacrococcygeal region is performed intraoperatively; a probe with a silicone conductor is passed through the fistula tract; then the probe is removed; a radial light guide is inserted into the conductor; the conductor is removed and the cavity of the fistula tract is coagulated with a laser with a wavelength of 1940 nm, a power of 10 W at a speed of 1 mm/s; stromal-vascular fraction of adipose tissue is obtained mechanically; Under ultrasound control, the fistula tract is injected with stromal-vascular fraction of adipose tissue transdermally at 0.1 ml per injection and intramurally into the bottom and walls of the open wound formed after opening and removing large cavities of the epithelial coccygeal tract at 0.1 ml per injection.