Хірургічне лікування рецидивуючого хронічного парапроктиту з використанням колагенового імплантату

Abstract

Проведене дослідження показало, що хірургічне лікування рецидивуючого хронічного парапроктиту з висіченням внутрішнього отвору нориці та закриттям цієї ділянки дефекту алогенною колагеновою плівкою забезпечує ефективну регенерацію сполучної тканини і попереджує рецидив нориці. Встановлено, що повторний рецидив захворювання у пацієнтів пролікованих з використанням традиційної методики виник в 23,8% випадків, а при застосуванні колагенової плівки в 4,7% випадків. Доведено, що алогенна колагенова плівка є стійкою до бактеріальних колагеназ, що дозволяє використовувати її в присутності персистуючої інфекції.

Проведенное исследование показало, что хирургическое лечение рецидивирующего хронического парапроктита с иссечением внутреннего отверстия свища и закрытием этой области дефекта аллогенной коллагеновой пленкой обеспечивает эффективную регенерацию соединительной ткани и предупреждает рецидив свища. Установлено, что повторный рецидив заболевания у пациентов пролеченных с использованием традиционной методики возникал в 23,8% случаев, а при использовании коллагеновой пленки в 4,7% случаев. Доказано, что аллогенная коллагеновая пленка является стойкой к бактериальным коллагеназам, что позволяет ее использование в присутствии персистирующей инфекции.

Patients with chronic paraproctitis amount to 0.5-4% among general surgical ones and 15-40% in proctological disease distribution. Relapses of perianal fistulae occur in 5.2-40.2% of patients. Thus, the lack of aunifi ed tactics relative et othe volume of surgical treatment in one or another form of chronic paraproctitis, high rate of diseaser elapses, highr ate of general and local complications even after radical surgical interferences, as well as long period of treatment make it necessary to develop new ways of their prevention and treatment, applying modern methods of diagnostics and surgical treatment. Purpose of the work is to improve the results of surgical treatment of chronic paraproctitis. Object and methods. With in the period from 2012 to 2016, 48 patients with chronic paraproctitis under went surgery at the clinic of the Department of Surgery and Proctology. The patients’ age was 25-60 years. The average age was 52.3±2.1 years. There were 28 men (58.3%), and 20 women (41.6%). Depending on the method of surgical treatment the patients were divided into 2 groups. The first group included 24 patients who underwent the surgical treatment with the use of lyophilized allogeneic dermal collagen; the method was developed by us. The essence of the surgery was that after intraoperative diagnostics of a pararectalfistulous passage with a probe and intake of methylene blue, the skin and the hypoderm are dissected with two arcuate incisions up to 0.5 cm around the external fistula opening, the external opening of the fistula and scar tissuesand fistula expansion are dissected out in paraproctium, at extra-sphincter and intra-sphincter location of the fistula the internal opening was dissected out, and at trans-sphincter location it was dissected in such a way as not to damage the sphincter fibers. An allogeneic dermal collagen implant 2.0x1.5 cm in size was applied on the area of the dissected out and dissected internal opening and was fixed with Vicryl suture 2.0 along the perimeter. The surgery was finished with stitching the dermal wound and its drainage with polyvinylchloride tube. The second group included 24 patients who underwent the classical methods of dissecting out perianal fistulae. Results and their discussion. The immediateres ult sof the surgical treatment in the first group of patients who underwent the surgical treatment accordingt othe developed method sin gallogeneic collagen implants showed that the post surgical period went by with out any complications, wound abscesso ccurredin 1 (4.0%) patient, serous inflammation of surgical wound appeared in 3 (12.5%) patients, and it was eliminated with drainage and prescribing anti-inflammatory therapy (diclofenac 3.0 1 time i.m.), the wound healed up on the 10 ± 3.12 day. The period of full postoperative rehabilitation amounted to 28 ± 2.1 days. In the second group of the patients who underwent the classical methods of surgical treatment, at early postoperative period some local complications in the form of wound abscess occurred in 5 (23.8%) patients, partial flatal incontinence occurred in 4 (16.6%) patients, the wound healed up on the 24±4.3 day. The long-term results that were studied within 1-48 months by examination and questioning of 20 patients from the first group and 21 patients from the second group: the partial flatal incontinence occurred in 4 (19.0%) patients of the second group, no flatal incontinence occurred in the patients of the first group, the disease relapse occurred in 3 (14.2%) patients of the second group; at the same time no disease relapses occurred in the first group. The results obtained show the substantial advantages of surgical treatment of chronic paraproctitis using collagen film in contrast with the traditional treatment methods. Conclusion. The surgical treatment of chronic paraproctitis with dissecting out the internal opening at fistulae, with dissecting the internal opening at a trans-sphincter fistula, and closure of these defect areas with collagen film ensures effective regeneration of connective tissue and prevents the relapse of a fistula. Allogeneic collagen film is resistant to bacterial collagenases, so it can be used at persistent infection.