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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_953_Библиотеки_им_академика_М_И_Перельмана.pdf
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►Содержание►
POSTOPERATIVEMANAGEMENT
Patientsbeginsitzbathsontheeveningofthesurgery;ahigh-fiberdiet and/orfibersupplementsarerecommendedtomaintainasoftandbulky stool.Analgesicsareprovidedandpatientsareinformedthat postoperativepaintypicallyresolveswithin1week.Patientsresume activitiesastoleratedandareexpectedtoreturntonormalfunctions within2weeks;fissurehealinggenerallyoccurswithin4weeks.

COMPLICATIONS

Abscess Fistula-in-ano Fecalincontinence Recurrentandunhealedfissure
Alteredbowelfunctionandcontinencearenotunusualfollowingthe surgeryandareaccentuatedwiththeuseofahigh-fiberdiet.Alterations tocontrolaremorelikelytooccurwithflatusthanfeces(Table21-1). Garcia-Aguilaretal.reported30%and12%lossofcontroltoflatusand feces,respectively.Otherstudies(Table21-1)reportafarlower percentageoflossofcontrol(0–9%).Impairmentofcontrolofflatus (31%)andfeces(23%)andincreasedsoilinghavebeenreported.The impairedcontrolistemporary.Thereisnoquestion,however,thatLISis effective.Theoverallpercentageoffissurerecurrenceislow(0–5.6%) exceptforonestudybyGarcia-Aguilarwhoreportedarecurrencerateof
10.9%.However,ofthosepatientswithrecurrenceonly3.4%requiredre­operation(Table17-1).
TABLE21-1 PatientOutcomesFollowingOpenLateralInternal
Sphincterotomy
Author Year
No.of
patients
Impaired
control
Fecal
soiling
(%)
Flatus
(%)
Feces
(%)
Abcarian 1980 Retrospective 150 0 0 0
Maryaetal. 1980 Retrospective 100 0 0 0
Ravikumaretal. 1982 Retrospective 60 0 0 5
Jensenetal. 1984 RCT 30 0 0 0
Frezzaetal. 1992 Retrospective 134 0 0 0
Leongetal. 1994 Retrospective 114 7.9 0 NR
PernikoffandSalvati 1994 Retrospective 500 2.8 0.4 4.4
RomanoGetal. 1994 Prospective 44 9 4.5 4.5
Neufeldetal. 1995 Retrospective 112 12.5
*
0.9 8.9
Ohetal. 1995 Retrospective 1313 1.5
*
1.5 0
Usatoffetal. 1995 Retrospective 98 7 1 11
Garcia-Aguilaretal. 1996 Retrospective 324 30 12 27
HananelandGordon 1997 Retrospective 265 0.4 0.4 0.4
NyamandPemberton 1999 Retrospective
†
487 31
*
23
*
39
*
Argovetal. 2000 Retrospective 2,108 1.5
*
0 1
Richardetal. 2000 RCT 38 0 0 0
CasillasandHull 2005 Retrospective
†
298 30 2.8 0
Arroyoetal. 2005 RCT 40 2.5 5 NR
Elsebaeetal. 2007 RCT 46+ 0 2.17 0
46++ 0 0 0
Mousavietal. 2009 RCT 29 0 0 0
Silerietal. 2010 Prospective 72 0 0 0
*
Impairedcontrolreportedastemporary.
†
Surveyofpreviouslyoperatedpatients.Responseratesvary.
+,traditionalLIS;++,“tailored”LIS;NR,notreported;RCT,randomizedcontroltrial.
Arandomizedcontrolledtrialcomparing“tailored”LISwithtraditional LISshowsadecreasedriskofalterationincontrol.Thereisadecreased rateoffecalincontinencewith“tailored”LIS.However,treatmentfailure isslightlyhigher.
Persistentandrecurrentfissuresareinfrequent,anddependingon clinicalfindings,mayrequireanadditionallimitedsphincterotomyon thecontralateralsideoranadvancementflap.Inarecentstudy,therisk ofredosphincterotomywasminorincontinenceinonly4%ofpatients withanoverallhealingrateof98%.
AbscessformationisuncommonwithanopenLISbecauseany collectionoffluidlikelydecompressesthroughthesurgicalincision. Fistulaformationisalsouncommonandmaybeduetoincisionor compromiseoftheanoderm.

CONCLUSIONS

OpenLISisasafesurgicaloptionforthetreatmentofanalfissures.Most LISproceduresareperformedduetochronicsymptomsdespite nonoperativemanagement,but,occasionally,anLISisnecessaryinthe acutesettingofseverepain.
RECOMMENDEDREFERENCESAND READINGS
AbcarianH.Surgicalcorrectionofchronicanalfissure:resultsoflateralinternalsphincterotomy
vs.fissurectomy–midlinesphincterotomy.DisColonRectum1980;23:31–6. ArgovS,LevandovskyO.Openlateralsphincterotomyisstillthebesttreatmentforchronicanal
fissure.AmJSurg2000;179:201–2. ArroyoA,PérezF,SerranoP,CandelaF,LacuevaJ,CalpenaR.Surgicalversuschemical
(botulinumtoxin)sphincterotomyforchronicanalfissure:long-termresultsofaprospective
randomizedclinicalandmanometricstudy.AmJSurg2005;189(4):429–34. CasillasS,HullTL,ZutshiM,TrzcinskiR,BastJF,XuM.Incontinenceafteralateralinternal
sphincterotomy:areweunderestimatingit?DisColonRectum2005;48:1193–9. EisenhammerS.Thesurgicalcorrectionofchronicinternalanal(sphincteric)contracture.SAfr
MedJ1951;25:486–9. ElsebeeMM.Astudyoffecalincontinenceinpatientswithchronicanalfissure:prospective,
randomized,controlledtrialoftheextentofinternalanalsphincterdivisionduringlateral
sphincterotomy.WorldJSurg2007;31:2052–7. FrezzaEE,SandeiF,LeoniG,BiralM.Conservativeandsurgicaltreatmentinacuteandchronic
analfissure.Astudyon308patients.IntJColorectalDis1992;7:188–91. Garcia-AguilarJ,BelmonteC,WongWD,LowryAC,MadoffRD.Openvs.closedsphincterotomy
forchronicanalfissure:long-termresults.DisColonRectum1996;39:440–3.
p.163
p.164
GoligherJC,DuthieHL,NixonHH.SurgeryoftheAnus,RectumandColon.5thed.London:
BailliereTindall,1984. GorfineSR.Treatmentofbenignanaldiseasewithtopicalnitroglycerin.DisColonRectum
1995;38:453–6;discussion6–7. HananelN,GordonPH.Lateralinternalsphincterotomyforfissure-in-ano–revisited.DisColon
Rectum1997;40:597–602. JensenSL,LundF,NielsenOV,TangeG.Lateralsubcutaneoussphincterotomyversusanal
dilatationinthetreatmentoffissureinanoinoutpatients:aprospectiverandomisedstudy.Br
MedJ(ClinResEd)1984;289:528–30. JonasM,NealKR,AbercrombieJF,ScholefieldJH.Arandomizedtrialoforalvs.topical
diltiazemforchronicanalfissures.DisColonRectum2001;44:1074–8. JostWH,SchimrigkK.Useofbotulinumtoxininanalfissure.DisColonRectum1993;36:974. LeongAF,HusainMJ,Seow-ChoenF,GohHS.Performinginternalsphincterotomywithother
anorectalprocedures.DisColonRectum1994;37:1130–2. LiangJ,ChurchJM.Lateralinternalsphincterotomyforsurgicallyrecurrentchronicanalfissure.
AmJSurg2015;210:715–9.
LittlejohnDR,NewsteadGL.Tailoredlateralsphincterotomyforanalfissure.DisColonRectum
1997;40:1439–42. LockMR,ThomsonJP.Fissure-in-ano:theinitialmanagementandprognosis.BrJSurg
1977;64:355–8. MaryaSK,MittalSS,SinglaS.Lateralsubcutaneousinternalsphincterotomyforacutefissurein
ano.BrJSurg1980;67:299. MousaviSR,SharifiM,MehdikhahZ.Acomparisonbetweentheresultsoffissurectomyand
lateralinternalsphincterotomyinthesurgicalmanagementofchronicanalfissure.J
GastrointestSurg2009;13(7):1279–82. NeufeldDM,ParanH,BendahanJ,FreundU.Outpatientsurgicaltreatmentofanalfissure.EurJ
Surg1995;161:435–8. NyamDC,PembertonJH,IlstrupDM,RathDM.Long-termresultsofsurgeryforchronic
constipation.DisColonRectum1997;40:273–9. OhC,DivinoCM,SteinhagenRM.Analfissure.20-yearexperience.DisColonRectum
1995;38:378–82. PernikoffBJ,EisenstatTE,RubinRJ,OliverGC,SalvatiEP.Reappraisalofpartiallateralinternal
sphincterotomy.DisColonRectum1994;37:1291–5. RavikumarTS,SridharS,RaoRN.Subcutaneouslateralinternalsphincterotomyforchronic
fissure-in-ano.DisColonRectum1982;25:798–801. RichardCS,GregoireR,PlewesEA,etal.Internalsphincterotomyissuperiortotopical
nitroglycerininthetreatmentofchronicanalfissure:resultsofarandomized,controlledtrial
bytheCanadianColorectalSurgicalTrialsGroup.DisColonRectum2000;43:1048–57;
discussion57–8. RomanoG,RotondanoG,SantangeloM,EsercizioL.Acriticalappraisalofpathogenesisand
morbidityofsurgicaltreatmentofchronicanalfissure.JAmCollSurg1994;178:600–4. SileriP,StolfiVM,FranceschilliL,etal.Conservativeandsurgicaltreatmentofchronicanal
fissure:prospectivelongertermresults.JGastrointestSurg2010;14(5):773–80. SultanAH,KammMA,NicholisRJ,BartramCI.Aprospectivestudyoftheextentofinternalanal
sphincterdivisionduringlateralsphincterotomy.DisColonRectum1994;37:1031–3. UsatoffV,PolglaseAL.Thelongertermresultsofinternalanalsphincterotomyforanalfissure.
AustNZJSurg1995;65:576–8.
Chapter22
ClosedLateralInternal Sphincterotomy
SeanJ.LangenfeldandJoshuaI.S.Bleier

INTRODUCTION

Lateralinternalsphincterotomy(LIS)isasafeandeffectivetechniquefor thetreatmentofchronicanalfissures.AtraditionalopenLISinvolvesa radialincisionovertheinternalanalsphincter(IAS)todividethemuscle underdirectvisualization.TheclosedLIStechnique,alsoknownasa subcutaneoussphincterotomy,hasbeenadvocatedasaless-invasive approachwithequivalentratesoffissurehealing.

INDICATIONS/CONTRAINDICATIONS

Indications
ClosedLISforanalfissurehasthesameindicationsastheopen technique.LISistypicallyperformedforchronicanalfissuresrefractory tomaximummedicaltherapy,includingstoolsofteners,sitzbaths, topicalvasodilatoryagents,andbotulinumtoxininjection.LISisalso appropriateasaprimaryapproachforacuteanalfissureswhenthereis severe,unrelentingpain.OnceLISischosen,thesurgeonshouldstill addressthepatient’sunderlyingboweldysfunction,includingdiarrhea and/orconstipation,toensureasuccessfulsurgery.
Contraindications
RelativecontraindicationstoclosedLISincludelow-pressurefissures, preexistingfecalincontinence,uncontrolledbleedingdisorders,and activeanorectalCrohn’sdisease.PatientswithpreviousLISshouldalso beselectedcarefullytopreventunwantedchangesinlong-termfecal continence.Patientswithimmunosuppressionand/oratypicalfissure locationsshouldalsobeselectedcarefullytoensurethesurgeonhasthe correctdiagnosis.
PREOPERATIVEPLANNING
Appropriatesurgicalcareofthepatientwithananalfissurebeginsinthe officesetting,wherethesurgeonshouldperformathoroughhistoryand physicalexamination.Thisincludesanin-depthreviewofthepatient’s medications,medicalandsurgicalhistory,andlifestyleissuesthatmaybe contributingtothecurrentpathology.Afissurecanusuallybeidentified duringtheexternalexaminationandfissure-relatedpainmaylimitthe patient’stoleranceofadetailedanorectalexamination.However,adigital rectalexamination,anoscopy,andrigidproctoscopyshouldbeperformed ifpossible,becauseitallowsforanassessmentofhypertonicity,andthe exclusionofotheranorectalpathologyincludinginfectionand inflammation.“Typical”analfissuresarefoundineithertheposterior (mostcommon)oranterior(lesscommon)midline.Identificationof “atypical”fissuresthatlieinlateralpositions,orhaveanatypical appearanceshouldpromptworkupforalternativeetiologiessuchas HumanImmunodeficiencyVirusandsexuallytransmitteddiseases,and theunderlyingdiseaseprocessshouldbeidentifiedandtreated.
OncethedecisionhasbeenmadetoperformLISinthesettingofa typicalfissure,thepatientshouldbeappropriatelyeducatedonwhatto expectbeforeandafterthesurgery,andwhatstepsshouldbetakentoaid inthehealingprocess.Formostanorectalsurgeries,apreoperative enemacanbeself-administeredtoremovestoolsfromtheoperativefield andimprovevisualization.However,patientswithananalfissureare oftenintolerantofthis,anditcanbeomittedsafelywhennecessary.

SURGERY

Positioning
ClosedLIScanbeperformedsafelyinthepronejackknifeposition,dorsal lithotomy,orleftlateraldecubituspositionwithequalefficacy,andthis decisioncanbemadebasedonsurgeonpreference.Itistheauthor’s preferencetousethelithotomypositionwithcandycanestirrupsbecause itisoftenquickerandsubjectivelypreferredbytheanesthesiateam. However,itshouldbenotedthatthepronejackknifepositionoffers enhancedvisibilityandtheeasieruseofanassistant.
Technique
Locoregionalblock Inspectionforotherconcomitantpathologies Identificationoftheintersphinctericgroove Insertionofalow-profilescalpelwithcarefuldivisionoftheIAS
Generalanesthesiaisoftenused,butitisalsosafetoinsteaduse monitoredanesthesiacare(MAC).Theanusispreppedwithpovidone­iodineanddrapedinasterilefashion(Fig.22-1),andalocalanestheticis usedtoperformalocoregionalblock,typicallywith30–40mlof0.25% bupivacainewithepinephrine.WhenMACisused,initialinfiltrationwith 1%lidocainewithorwithoutepinephrineoffersaquickerandlesspainful onsetoflocalanesthesia.
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