Хирургические болезни. Практикум = Surgical diseases. Practice book. Учебное пособие

Chapter 15

DISEASES OF THE RECTUM

AND PARAPROCTIUM

Diseases of the rectum and pararectal tissue include more than 200 different nosological forms (according to ICD-10), divided into several subgroups: anomalies and congenital malformations; functional disorders of activity; nonspecific inflammatory processes; nonneoplastic diseases of the anal canal; benign and malignant neoplasms.

15.1. RECTAL PROLAPSE

Rectal prolapse (RP) – a pathological condition characterized by the pelvic diaphragm descent with the outward opening of the lower sections of the rectum through the anus, intrarectal prolapse (or internal rectal prolapse) of the rectum without its outward opening is less frequent.

Classification. RPs occur:

•I type – by the type of intestinal invagination, when some parts of the rectum or sigmoid intestine are introduced into the rectum and form the invaginate in its lumen with its subsequent exit outward;

•II type – by the type of sliding hernia, when due to the increased abdominal pressure and the developed atony of the muscles of the pelvic diaphragm, the peritoneal pelvic (Douglas’) cul-de-sac shifts downwards, getting involved the front wall of the rectum. As the progression occurs, prolapse of the anterior rectum wall through the anal canal. At the site of displacement, the wall of the rectum increases becomes circularly edematous, and in some cases – takes the form of a cone or cylinder.

In case of acute prolapse, emergency reposition of the prolapsed area of the rectum under general anesthesia is indicated. In the presence of necrosis of the prolapsed area of the rectum or signs of peritonitis it is necessary to perform laparotomy, colostomy with removal of the necrotic area (more often – in the volume of abdominal-anal resection).

Treatment. In the first type of prolapse, the following interventions are indicated:

•resection of prolapsus of the part of the rectum. It is performed only in elderly patients with severe concomitant pathology. The intervention includes excision of the mucous prolapsed part of the R, followed by putting in corrugating sutures in the intestinal wall and the formation of a circular roll around the anus (surgery proposed by Delorme in 1901);

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•fixing operations aimed at retention of the rectum in the abdominal cavity. They include operations of:

Zerenin-Kummel – colopexy by pulling up the rectum and fixing it above the promontory to the anterior longitudinal ligament of the spine;

Ripstein – posterior colopexy by fixing rectum to the sacrum using a synthetic net;

•operations aimed at plastic surgery of the anal canal and pelvic floor. They are carried out by sewing the edges of the levators according to Braitsev or with the help of prosthetics (solid) synthetic meshy, more rarely – “strip-like” implants, or fascia (the method of Payra);

•intra-abdominal distal resections of the sigmoid and rectum segments. They are performed by applying a minimally invasive transanal resection of excess mucosa using a circular stapler (operation of Longo, 1994).

In the treatment of RP, a combination of all provided interventions is used, which provides a favorable follow-up result in 75–80% of cases.

15.2. EPITHELIAL COCCYGEAL PASSAGE

(PILONIDAL CYST)

Epithelial coccygeal passage (EPC) (synonym: pilonidal cyst (PC)) represents up to 3–4 cm in length, narrow, lined with an epithelium and located in the subcutaneous tissue of the sacrococcygeal region, opening on the intergluteal fold with one, more rarely – several external fistulous perforations.

The etiopathogenesis of the PC is based on the defect in the formation of the caudal part of the embryo, which causes the appearance of an uninterrupted subcutaneous passage in the intergluteal fold (between the end of the coccyx and the edge of the anus) lined with epithelium on the inside.

It occurs in 4–5% of the examined children and adolescents. It is more often found in young men (up to 20 years) with a strongly developed hair coat due to the epidermis ingrowth, hairy bulbs and their subsequent immersion in the deep intergluteal fold (in incomplete hygiene). Later, a hair (pilonidal) cyst is formed, acquiring connection with the environment in the manner of a sinus tract, containing epithelium, hair bulbs, sweat and sebaceous glands surrounded by connective tissue capsule.

Clinical picture. Four courses are distinguished in the course of PC:

1.Uncomplicated (without clinical manifestations).

2.Acute inflammation:

•a type of acute abscess;

•by the type of infiltrate with a further outcome in abscessing. 3. Chronic inflammation, proceeding as:

•infiltration;

•recurrent abscess formation with appearance of external purulent fistula. 4. With prolonged remission.

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Treatment. 1. In an uncomplicated PC course, a planned intervention is indicated, consisting in preliminary staining of the epithelial passages (through the primary holes) with a solution of methylene blue or brilliant green and subsequent excision of the entire skin-subcutaneous flap with epithelial passages located in it, their branches up to the fascia covering the coccyx. The operation is completed by suturing the wound with mattress vertical U-shaped sutures after Donati-Ryzhyh or in Depage modification (at the bottom with the removal of the ligatures through the skinsubcutaneous flaps in a staggered-order).

2.In case of acute inflammation and formation of infiltrate, PC treatment includes measures aimed at reducing local inflammation by antibacterial therapy, physiotherapy (UFO, magnetotherapy), local applications with 25% dimexide gel; 0.05% chlorhexidine solution or water-soluble ointments. After relieving the inflammation, a radical intervention aimed at eliminating PC is performed.

In case of abscess formation the operation is divided into two stages. At the first stage the abscess is opened and its subsequent sanation by daily dressings is performed. At the second stage in two or three months a radical operation with the application of primary sutures is performed. In a number of specialized hospitals, the second phase of intervention is performed in 4–5 days after the first stage without discharging the patient from the hospital.

3.In chronic inflammation of the PC, planned surgical intervention is indicated in the form of a radical operation.

15.3. ACUTE PARAPROCTITIS

Acute paraproctitis (APp) is an acute secondary inflammation of the paraproctium caused by the infection from the primary infected anal crypts and anal glands. It occurs in 1% of the adult population, and it is about 15–20% of patients with diverse coloproctological pathology.

Acute paraproctitis is more often caused by a mixed nonspecific aero- bic-anaerobic microflora: Staphylococci, Streptococci, Proteus, E. coli are dominated among the aerobes: Bacteroides, Fusobacteria and Peptostreptococci are dominated among asporous anaerobes.

Classification. By localization, the following types of APp are distinguished:

•subcutaneous (perianal);

•submucosal;

•pelviorectal (pelvic rectal);

•ischiorectal (ischial-rectal);

•retrorectal.

Treatment. The treatment of APp should take into account the location, the spread of damage of paraproctium and localization of purulent leakage towards the fibers of the external sphincter.

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In perianal submucous APp a semilunar incision is performed on the projection of the abscess, stepping back 3–4 cm from the edge of the anal orifice. Then, from the side of the wound and through the sinus tract a bul- bous-end probe is introduced, the outlet of the probe is controlled with a finger in the lumen of the intestine (through the affected crypt). Then, after preliminary staining of the sinus tract, crypts and purulent cavity (1% solution of methylene blue or brilliant green), all the devitalized tissues are excised: the area of the skin, suppurative cavity, sinus tract with mucous membrane and the site of the affected crypt. This intervention is called the operation of Gabriel-Ryzhyh-Bobrova.

In case of ischiorectal, rectro-rectal or pelviorectal localization of APp, after external opening and evacuation of the pus a single cavity should be formed and then the grooved probe is introduced through the internal opening of the sinus tract. This introduction enables you to evaluate both the localization of the fistula (transor extrasphincter) towards the fibers of the external sphincter and the degree of its complexity. In surface localization (intratransphincter) fistula, the latter is excised into the lumen of the intestine on the probe with the subsequent cuneate removal of its internal opening together with the adjacent affected crypts.

In extrasphincter sinus tract, when a large portion of the external sphincter muscles is located between sinus tract and the lumen of the rectum, the ligature method (Hippocrates operation) is applied by means of conduction of thick ligature through the internal fistula and the excised affected crypt outside with the subsequent gradual dosated tightening it over the fibers of the outer and inner muscles of the sphincter for 2–3 weeks. Such intervention does not lead to the damage of the closing function of the rectum.

15.4. CHRONIC PERIPROCTITIS (RECTAL FISTULA)

Chronic periproctitis (ChrP) – a chronic inflammatory disease of paraproctium involving the anal crypt which represents inner fistulous opening and the presence of transphincteric sinus tract that forms purulent cavity (inflammatory infiltration in the surrounding tissues), followed by formation of the external fistula on the skin of the perineum.

Constant inflammation in the paraproctium is maintained by the entering of rectum infected contents into the sinus tract and causes the inability of its spontaneous healing.

Treatment. Treatment of chronic periproctitis is surgical, has an individual character, depending on:

•relationship to the tissues of the sphincter (for extrasphincteric fistulas it depends on the degree of its complexity);

•the presence of common purulent leakage and the degree of their intensity (infiltration or purulent cavity);

•the degree of intensity of incontinence;

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• the stage of the process (planned intervention is performed only in the absence of exacerbations).

In case of intransphincteric fistulae of the rectum, after their preliminary staining, their wedge-shaped excision into the lumen of the intestine – Gabriel’s operation is performed.

In case of transphincteric fistulae of the rectum, after their excision, additional suturing of the muscles of the sphincter with drainage of the purulent cavity is performed.

In case of the most complicated types of extrasphincteric fistulae, the previously introduced ligature method or the plastic covering of the excised inner hole by the displaced musculomucosal graft is applied.

15.5. HEMORRHOIDS

Hemorrhoids is a disease of hemorrhoidal tumor, caused by hyperplasia of cavernous corpuscles of the rectum.

It occurs in 70% of adults over 30 years of age, which is 150–160 new cases per 1000 adults or about 35% of the entire coloproctological pathology. It occurs two times more often in men aged 35–50 years.

Etiology. The initial trigger factor and, often a reversible factor in the pathogenesis of hemorrhoids only at the early stages, is hemodynamic, that contributes to the dysfunction of the venous (cochlear) veins of the cavernous plexuses of the rectum with their overfilling.

In the future, as the dystrophic disorders progress, changes in the fibromuscular framework of the cavernous plexuses and the holding tissues (the so-called Ligament of Parks) occur. They are accompanied by an irreversible displacement of the hemorrhoids (from the anal canal outside).

In turn, persistent and prolonged prolapse of hemorrhoids is accompanied by their secondary changes in the form of atrophy of the submucosal layer. This is manifested by acute (thrombosis and incarceration of nodes) or by chronic variants of the course according to the type of recurrent anal bleeding or repeated prolapse of nodes.

Treatment. In II–III stages of chronic hemorrhoids, minimally invasive surgical technologies are used:

•infrared (1979; A. Neiger) or laser photocoagulation of hemorrhoids (cryotherapy was used previously);

•sclerotherapy by introducing hemorrhoidal nodes into the lumen: aethoxysklerol (lauromacrogol 400), fibro-vein (tetradecyl sulfate), etc.;

•ligation of the crura of internal hemorrhoids with latex rings (Barron’s method), followed by tissue necrosis and node rejection within 10–15 days. The effectiveness of the technique reaches 80–85%;

•sutural ligation of the terminal branches (not less than 8–10) of the superior rectal artery under the control of an anoscope with the ultrasound

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transrectal Doppler sensor – a technique called “disarterization” of hemorrhoids (K. Morinaga, K. Hasuda, 1995). Its efficiency reaches 85–90%.

•traditional hemorrhoidectomy is performed with excision of three basic groups of cavernous bodies (at 3, 7, 11 o’clock on the clock dial in the position of the patient on the back) and subsequent ligation of their vascular crura (Milligan-Morgan operation, 1934).

Recently in performing this intervention, the following is actively used:

•ultrasonic laser scalpel;

•radiofrequency wave device “Surgitron” (Ellman International, USA);

•high-frequency apparatus “Liga Sure”, which allows operating at the out-patient department with significant reduction of postoperative rehabilitation periods.

In chronic hemorrhoids of stage IV Longo’s operation consisting in circular transanal resection of the excess portion of the mucous-submucosal

layer of rectum, which is achieved with the help of a special stapling apparatus, has been applied since 1993 along with traditional hemorrhoidectomy.

15.6. ANAL FISSURE

Anal fissure (AF) is a disease of the anal canal, characterized by the spontaneously arising longitudinal linear rupture of its mucosa.

It occurs in 2% of the adult population; these are 20–22 new cases per 1000 adult population or 10–15% of all coloproctological diseases of the colon. It is more common in women aged 25–50 years.

Classification. AFs are distinguished by:

•the nature of morphostructural changes:

acute (up to 4 weeks);

chronic (more than 8 weeks due to the appearance of sclerosis of the edges and “sentinel piles” – connective-tissue thickenings, the most severe in the distal part of the fissure (from the side of the hypertrophied anal papilla);

•localization:

posterior wall (~ 85%);

anterior wall (~ 8–10%);

side walls (in combination with hemorrhoids, ~ 3%);

•the condition of the anal sphincter:

without spasm of sphincter;

severe sphincterospasm.

Etiology. Various predisposing factors lead to a linear rupture of the anal mucosa, which with a persistent pain syndrome is accompanied by a prolonged spasm of anal sphincter. The latter leads to additional activation of pathogenetic factors and the progression of fibroplastic changes in the sphincter, which contributes to the chronic process.

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Treatment. Treatment of acute AF includes the administration of:

•combined rectal suppositories or ointments (after the act of defecation) – relief, ultraproct, aurobin;

•drugs that contribute to relaxation of the internal sphincter of the rectum:

potassium channel blockers (nifedipin, dialtiazem);

donators of nitric oxide, applied transanally in the form of 0.4–0.5% nitroglycerin ointment 2 times a day for two months. The effectiveness of the method is 75%.

Indications for surgical treatment of AF are: the failure of conservative therapy for 4–5 weeks; the outcome in a chronic form.

The main type of surgical intervention in case of AF is a planar excision of it (with edges and with the floor) by means of two fringing longitudinal incisions, supplemented later with lateral sphincterotomy at 3 o’clock on the clock dial in the position of the patient on the back, resulting in a dosed transection of the distal portion of fibers of spasmed internal sphincter.

The wound defect after the excision of the fissure is sutured by rare stitches (The Ligament of Parks) or is conducted by an open method (Eisenhammer method).

15.7. COLON POLYPOSIS (POLYPS)

Polyposis is a benign growth of the glandular epithelium, which rises above the level of the mucous membrane in the form of a fungiform mass.

It is revealed in 2–35% of the adult population; it is about 10% of the entire coloproctological pathology. In men, polyposis is 2–3 times more common than in women. After 60 years of age polyposis is detected in more than 20% of the total adult population.

Classification. The international histological classification distinguishes the following types of polyps, presented by:

•adenoma (~ 80%) in the form of:

tubular or adenomatous polyps;

villous adenoma, represented by 2 forms:

−nodal (in the form of an exophytic node on a wide and short base);

−“spreading” in the form of flat, circularly spreading on the surface of the mucosa, formations); characterized by a high risk of malignancy, reaching up to 15–30%;

tubular-villous adenoma;

•adenomatosis (adenomatous polyp of the intestine);

•tumor-like lesions, including:

hamartoma, due to atypical differentiation of cellular material (mucosa);

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CONTROL TESTS

Control test on Chapter 1 “Vascular diseases. Local manifestations of circulatory disorders”

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