ULTRASOUND DIAGNOSTICS OF CHRONIC CONSTIPATION IN CHILDREN: RESULTS OF A CLINICAL STUDY

Chronic constipation (CC) is an important medical and social problem, as it can lead to the development of complications, fecal intoxication, social disadaptation and self-isolation of a child, as well as significantly reduce the quality of life. The article presents the results of a clinical study of CC in children using a new diagnostic method - transabdominal and transperianal ultrasound examination (US) of the colon and anorectal zone. The objective of the study was to analyze the course of CC in children depending on the mechanism of its formation according to US of the colon and anorectal zone. Materials and methods of research: the prospective cohort study included 470 children with an established diagnosis of CC at the age of 1 month to 17 years old. The patients were divided into 3 age groups: 1 month. – 3 years (n=166), 4–10 years (n=102), 11–17 years (n=202). The median follow-up was 48 months. The age distribution of children with CC was carried out on the basis of the frequency of visits, against the background of the beginning of attending kindergarten and/or elementary school groups, and the emergence of psychological problems due to the difficulty of going to a public toilet. An evaluation of analysis of the dynamics of US changes in the colon and anorectal zone was carried out by the method of ultrasound diagnosis of Hirschsprung's disease in children (patent № 2547614, authors M.I. Pykov, M.M. Kolisnichenko, I.V. Poddubny). Results: in children aged 1 month to 3 years, 66.9% of cases are statistically significantly dominated by proctogenic constipation type of constipation with US signs of anus spasm and anal sphincter insufficiency. In children aged 4 to 10 years, the mixed mechanism of CC formation prevails (41.1%), and in patients aged 11 to 17 years – cologenic (77.7%), for which the most typical ultrasound signs are dolichocolon (22.8%), anus spasm (8.7%), anal sphincter insufficiency (4.7%). It has been established that despite adequate therapy, the number of patients with the above-described mechanisms of formation of CC increases, which indicates the recurrence and progression of pathological process in children of different age groups. Conclusion: the proposed diagnostic method – transabdominal and transperianal US of the colon and anorectal zone is a highly informative, pathogenetically substantiated method for examining the state of the colon and anorectal zone in children with CC, built on precise objective criteria that are available at any age.

Diagnostic and the surgical treatment tactics in the rectal mucosa prolapse with the anal sphincter insufficiency

Objective. To improve the results of diagnosis and surgical treatment of rectal mucosa prolapse, complicated by the anal sphincter insufficiency. Materials and methods. Analysis of the diagnosis and surgical treatment results in the rectal mucosa prolapse with the anal sphincter insufficiency was done in 23 patients, ageing 31 - 65 yrs old and the age median (41.5 ± 1.8) yrs old, of them 17 women-patients. Results. There was revealed, that most frequently and in mostly progressive forms the rectal mucosa prolapse with the anal sphincter insufficiency occurs in women, aged more than 36 yrs old. Conclusion. Miniinvasive transanal operations, submucosal injection procedures and sphincteroplasty “end-to-end” were used predominantly, owing less morbidity potency (26.1%), favorable remote functional results - the recurrence rate lowering (4.3%), the fecal incontinence degree lowering (78.6%), and the patients’ quality of life improvement.

PREOPERATIVE DIAGNOSIS OF THE FUNCTIONAL STATE OF THE SPHINCTER COMPLEX IN THE TREATMENT OF RECTAL FISTULAS

Introduction. Preoperative determination of the functional state of the sphincter apparatus of the rectum is an important part of the treatment of patients. Assessment and analysis of the functional viability of the anal sphincter are necessary for the choice of tactics for surgical correction of rectal fistulas. This approach makes it possible to assess the effectiveness of a specific surgical method and determine the degree of sphincter insufficiency in the postoperative period. The aim of the study: to assess the normative values of neurophysiologicsl parameters of the sphincter apparatus of the rectum and pelvic floor muscles by using the method of electrosphincteromyography. Materials and methods. The study included 93 patients who were treated in the surgical department of the Kharkiv Regional Hospital for rectal fistulas. Indicators of the contractile function of the sphincter apparatus were determined by the method of interference electrosphincteromyography in the preoperative period. The comparison group consisted of 28 volunteers who did not have rectal diseases associated with impaired intestinal retention function (0 points on the Wexner incontinence scale). Results. The standard values of the bioelectrical activity of the sphincter apparatus were obtained by examining a group of volunteers by the method of interference electrosphincteromyography. The analysis of the results obtained demonstrates a slight decrease in the initial indicators of the bioelectric activity of the sphincter complex in the postoperative period. Conclusions. Minimally invasive methods of surgical treatment of rectal fistulas are preferred, because during the study, patients showed a decrease in the initial parameters of the contractile viability of the anal sphincter.

NEUROLOGICAL EXAMINATION AND TREATMENT OF CHILDREN OPERATED ON FOR SPINAL HERNIA

Among the most severe consequences of spinal hernia surgery (SHG) are spinal neurogenic bladder (SNGB) and impaired bowel movement. SNGB, in addition to its main manifestations in the form of violations of the accumulative function of the bladder and the function of emptying, is dangerous for the development of complications – vesicoureteral reflux, ascending infection of the urinary system and chronic kidney disease. Clinical manifestations of SNGB do not always accurately indicate a variant of bladder dysfunction. The authors presented variants of the results of urodynamic studies in children operated on for SHG SHG. The state of the detrusor – hyperactivity or atony and the sphincter – insufficiency or hyperactivity and the selection of a pathogenetically justified treatment option are described.

Insufficiency of the anal sphinter in women

Aim. To analyze and assess the clinical course and changes under instrumental-functional examination (MRI) in the muscles of the obturator apparatus of the rectum in women with anal sphincter insufficiency (ASI).Material and methods. Clinical and instrumental research methods, as well as modern scales for assessing ASI (Wexner score scale), were used in the current study.Results and discussion. The study showed that 110 out of 228 patients with anal sphincter deficiency showed only an organic form of ASI, and 118 (51.8%) had a mixed form (organic and functional). This study shows that the degree of postpartum perineal rupture depends on the factors producing the damage to the pelvic floor muscles.Conclusion. Analysis of the clinical course of ASI in women showed that gender-related factors in 51.8% of cases contributed to the development of a mixed form of the disease. Functional research methods showed that along with the external and internal sphincters of the rectum, the pubo-rectal muscle is damaged in patients with ASI, which should be taken into account when choosing a treatment strategy for the mixed form of ASI.

The first experience of using «evagination» method in patients with rectovaginal fistulas

Despite the variety of methods of rectovaginal fistulas surgery, the recurrence of the disease reaches 80 % of cases. The «evagination» method was proposed in the NMRC of coloproctology for the combined treatment of RVF and anal sphincter insufficiency. The study included 10 women with rectovaginal fistula and anal sphincter insufficiency. The age of patients was from 25 to 52 (33,6 ± 7,73) years. Etiology of rectovaginal fistula: postpartum — 7 (70.0 %); iatrogenic — 2 (20.0 %); malformation — 1 (10.0 %). The follow-up period ranged from 4 to 14 months (8,4 ± 2,9). The «evagination» method was used in all patients. The disease recurrence occurred in 1 patient (10.0 %) on the 8th day after surgery. Conclusion: the «evagination» method can be considered as a surgery of choice in the treatment of extended defects of the rectovaginal septum with anal sphincter insufficiency due to its defect.

Possibility of osteopathic correction inclusion in the complex treatment of anal incontinence in teenagers

Introduction. Anal incontinence (insufficiency of the anal sphincter) is a disease in which there is an uncontrolled discharge of intestinal contents through the anal canal when it is impossible to keep the episode of defecation to an acceptable place, which is a socially significant problem. Patients suffering from anal incontinence experience a feeling of psychoemotional inferiority and are often socially maladjusted. Insufficiency of the anal sphincter is a widespread pathology. The course of therapy is, as a rule, complex, and usually includes the use of medications, cleansing enemas, as well as non-drug methods of treatment (exercise therapy, massage, physiotherapy). At the same time, information on the possibility of including such a method of non-drug treatment as osteopathic correction in the complex therapy of anal incontinence in the available literature has not been found.The aim of the research was to study the possibility of including osteopathic correction in the complex treatment of anal sphincter insufficiency in teenagers.Materials and methods. The study involved 32 teenagers with functional anal sphincter incontinence, aged 14–17 years, undergoing treatment in the department of surgery. The patients were divided into 2 groups by the method of simple randomization — the main group (16 people, they received osteopathic correction in addition to the standard treatment) and the control group (16 people, they received only the standard treatment). At the beginning and at the end of the study there were assessed the osteopathic status and the disease severity using the Wexner scale and the Browning–Parks scale. The obtained results were analyzed by methods of nonparametric statistics. Results. It was found that the inclusion of osteopathic correction in the complex treatment of teenagers with anal sphincter insufficiency is accompanied by a statistically significant (p<0,05) decrease in the severity of the disease. It was revealed that children suffering from anal sphincter insufficiency are characterized by a high frequency of detection of regional (pelvic region, lumbar region) and local (some skull sutures, rectum, ascending and descending colon) somatic dysfunctions. After osteopathic correction, the frequency of detecting regional and local dysfunctions in teenagers is statistically significantly lower (p<0,05) compared with children who did not receive osteopathic correction.Conclusion. The obtained results demonstrated the ability to include the osteopathic correction in the complex treatment of teenagers with anal sphincter insufficiency.

ANOPLASTY AND LATERAL INTERNAL SPHINCTEROTOMY FOR CHRONIC ANAL FISSURE (systematic review and meta-analysis)

INTRODUCTION: Lateral internal sphincterotomy (LIS) is considered the ‘gold standard’ therapy for chronic anal fissure (CAF). Advantages of LIS over other surgical techniques include higher rate of healing and lower risk of fissure recurrence. However, this procedure is associated with a high risk of anal sphincter insufficiency (ASI) in the postoperative period. Anal advancement flap (AAF) is an alternative surgical procedure for CAF, which requires the use of local flaps. Anal advancement flap is associated with a significantly lower risk of anal incontinence.AIM: to compare short-term and long-term outcomes of аnal advancement flap and lateral internal sphincterotomy in patients with chronic anal fissure.METHODS: a systematic review and meta-analysis of studies comparing outcomes of Anal advancement flap and lateral internal sphincterotomy was conducted. We evaluated the following parameters: the rate of epithelialization, the rate of anal sphincter insufficiency, and the rate of postoperative complications. We carried out statistical analysis using the Review Manager software (Review Manager 5.3.)RESULTS: the systematic review included four studies that presented the results of 278 patients. Compared with LIS, the odds for healing after AAF were 63% lower (OR=0.37; CI=0.19;0.74; P<0.005). We found no significant differences in the rate of postoperative complications (OR=1.43; CI=0.54;3.78; P=0,47). Compared with AAF, the odds for anal incontinence after LIS were 94% greater (OR=0.06; CI=0.01;0.37; P=0,002).CONCLUSION: both lateral internal sphincterotomy and аnal advancement flap are effective in curing CAF. However, considering the ambiguity and poor quality of data from the studies comparing these procedures, a high risk of bias for comparison groups and heterogeneity of the studies, one should interpret the results with caution; the aforementioned limitations dictate the need for further research.

ADVANTAGES OF USING MODIFIED LIFT TECHNIQUE FOR SURGICAL CORRECTION OF THE RIVER FURS

Summary. The aim of the study was to compare and analyze the results of surgical treatment of patients with rectal fistulas by performing standard techniques and modified fistula ligation techniques. Materials and methods: a retrospective study 55 patients who underwent surgical treatment for transfusion of the rectum between January 2017 and April 2019. The patients were divided into two groups: 29 patients (52.7%) were operated by standard procedures, 26 patients (47.3%) underwent surgery using a modified fistula ligation technique. Results. The use of standard techniques for surgical treatment of rectal fistula provided 86.2% satisfactory results. However, in addition to disease recurrence, 6.8% of the development of anal sphincter insufficiency was recorded. Using modified LIFT technology, 84.6% of successful operations were achieved. There were no cases of sphincter apparatus failure. Conclusions. Performing minimally invasive techniques for surgical correction of rectal fistula significantly reduces the risk of anal sphincter insufficiency in the postoperative period.

COMPARISON OF MODIFIED METHOD OF LIGATION OF INTERSPHINCTERIC FISTULA TRACT (LIFT) AND STANDARD OPERATIONS IN PATIENTS WITH TRANSSPHINCTERIC RECTAL FISTULAS

COMPARISON OF MODIFIED METHOD OF LIGATION OF INTERSPHINCTERIC FISTULA TRACT (LIFT) AND STANDARD OPERATIONS IN PATIENTS WITH TRANSSPHINCTERIC RECTAL FISTULAS Kryvoruchko I.A. , Firsyk T.M.,. Bozhko O. P. Background. The search for and development of new minimally invasive methods for the surgical treatment of anal fistulas is a relevant area of surgery. Such methods combine less traumatization and preservation of the sphincter’s complex. Employment of such methods for surgical treatment of anal fistulas reduced the time of stay of patients in the hospital and improved their quality of life. Subjects and methods. A retro- and prospective study involved 58 patients with uncomplicated transsphincteric anal fistulas. All patients were treated in the hospital from January 2014 to April 2019. The patients were divided into two groups: the first group included 32 patients who were operated on according to the standard procedure using fistulotomy and Seton procedure; the second group consisted of 26 patients who were operated on using the modified LIFT method. Results. Most of these patients (72.4%) were men at the age of 42.536.79. The median of BMI was 25.7 kg/m2. There wasn’t mortality after operations. The median follow-up was 21 (6-48) weeks. In the first group there were 3 cases (9.3%) of anal sphincter insufficiency and 7 cases of recurrent fistulas (21.9%) at different times after surgery. In the second group there were no anal sphincter failure following administration of the modified method LIFT, but there were 15.4% of recurrent anal fistulas. Conclusion. The proposed modified method of ligation of intersphincteric fistula tract is an effective method for the treatment of anal fistulas. The results obtained suggest that the developed method can be used to treat other types of anal fistulas. Keywords: transsphincteric anal fistula, surgical treatment, LIFT technique, postoperative complications. Резюме. ПОРІВНЯННЯ МОДИФІКОВАНОГО МЕТОДУ ЛІГАЦІЇ ІНТЕРСФІНКТЕРНОГО ФІСТУЛЬНОГО ТРАКТУ (LIFT) ТА СТАНДАРТНИХ ОПЕРАЦІЙ У ХВОРИХ З ТРАНСФІНКТЕРНИМИ РЕКТАЛЬНИМИ СВИЩАМИ Криворучко I.A., Фірсик Т.М., Божко О. П. Вступ. Пошук та розробка нових малоінвазивних методів хірургічного лікування анальних свищів є актуальною областю хірургії. Такі методи поєднують меншу травматизацію і збереження сфінктерного комплексу прямої кишки. Застосовання таких методів хірургічного лікування анальних свищів скоротило час перебування хворих у стаціонарі і поліпшило їх якість життя. Об'єкт і методи. Ретро- і проспективне дослідження було проведено у 58 пацієнтів з неускладненими транссфінктерними анальними свищами. Всі пацієнти проходили лікування в лікарні з січня 2014 року по квітень 2019 року. Пацієнти були розділені на дві групи: перша група включала 32 пацієнтів, яких оперували за стандартною процедурою з використанням фістулотомії та процедури Сетона; другу групу склали 26 хворих, яких оперували за допомогою модифікованого нами способу лігування інтрасфінктерного фістульного тракту (LIFT). Результати. Більшість цих пацієнтів (72,4%) були чоловіками у віці 42,536,79 років. Медіана ІМТ склала 25,7 кг/м2. Після операцій летальних випадків не було. Медіана спостереження після операції склала 21 (6-48) тиждень. У першій групі ми отримали 3 випадки (9,3%) недостатності анального сфінктеру і у 7 випадках рецидив свищів (21,9%) в різний час після операції. У другій групі після застосування модифікованого методу LIFT ми не отримали жодної недостатності анального сфінктеру, але у цих пацієнтів спостерігалося 15,4% рецидивів анальних свищів. Висновок. Запропонований модифікований спосіб лігування інтрасфінктерного фістульного тракту є ефективним методом лікування анальних свищів. Отримані результати свідчать про те, що розроблений метод може бути використаний для лікування інших видів анальних свищів. Ключові слова: транссфінктерні анальні свищі, хірургічне лікування, техніка LIFT, післяопераційні ускладнення. Резюме. СРАВНЕНИЕ МОДИФИЦИРОВАННОГО МЕТОДА ЛИГАЦИИ ИНТЕРСФИНКТЕРНОГО ФИСТУЛЬНОГО ТРАКТА (LIFT) И СТАНДАРТНЫХ ОПЕРАЦИЙ У БОЛЬНЫХ С ТРАНСФИНКТЕРНИМЫ РЕКТАЛЬНЫМИ СВИЩАМИ Криворучко I.A., Фирсик Т.М., Божко А. П. Введение. Поиск и разработка новых малоинвазивных методов хирургического лечения анальных свищей является актуальной проблемой хирургии. Такие методы сочетают в себе меньшую травматизацию и сохранение сфинктерного комплекса прямой кишки. Применение таких методов хирургического лечения анальных свищей сократило время пребывания больных в стационаре и улучшило их качество жизни. Объект и методы. Ретро- и проспективное исследование было проведено у 58 пациентов с неосложненными транссфинктерными анальными свищами. Все пациенты проходили лечение в больнице с января 2014 по апрель 2019 года. Пациенты были разделены на две группы: первая группа включала 32 пациентов, оперированных по стандартной процедуре с использованием фистулотомии и процедуры Сетона; вторую группу составили 26 больных, оперированных с помощью модифицированного нами способа лигирования интрасфинктерного фистульного тракта (LIFT). Результаты. Большинство этих пациентов (72,4%) были мужчинами в возрасте 42,536,79 лет. Медиана ИМТ составила 25,7 кг/м2. После операций летальных исходов не было. Медиана наблюдения после операции составила 21 (6-48) неделю. В первой группе мы получили 3 случая (9,3%) недостаточности анального сфинктера и в 7 случаях рецидив свищей (21,9%) в разное время после операции. Во второй группе после применения модифицированного метода LIFT мы не получили ни недостаточности анального сфинктера, но у этих пациентов наблюдалось 15,4% рецидивов анальных свищей. Вывод. Предложенный модифицированный способ лигирования интрасфинктерного фистульного тракта является эффективным методом лечения анальных свищей. Полученные результаты свидетельствуют о том, что разработанный метод может быть использован для лечения других видов анальных свищей. Ключевые слова: транссфинктерные анальные свищи, хирургическое лечение, техника LIFT, послеоперационные осложнения