*Małgorzata Kołodziejczak1, Przemysław Ciesielski1, 2
Advances in proctology
Postępy w proktologii
1 Warsaw Proctology Centre, Saint Elizabeth’s Hospital in Warsaw
2Department of General Surgery, Poviat Hospital in Wołomin
Streszczenie
W ostatnich latach nastąpił postęp w diagnostyce proktologicznej, zaś operacje proktologiczne wzbogaciły się o kolejne techniki małoinwazyjne. Autorzy przedstawiają najnowsze opcje diagnostyczne w proktologii, w tym dotyczące m.in. dynamicznej defekografii w technice 3DE, tzw. echodefekografii, a także volume render mode (technika polegająca na obróbce komputerowej uzyskanych obrazów ultrasonograficznych). Przedstawiono też aktualny stan wiedzy na temat leczenia podstawowych jednostek chorobowych w proktologii: choroby hemoroidalnej, przetoki odbytu, szczeliny, nietrzymania stolca, wypadania odbytnicy i cysty włosowej. Według dostępnych analiz pacjentom najbardziej zależy na zachowaniu pełnej kontynencji gazów i stolca po zabiegu proktologicznym, zaś skuteczność operacji stawiają na drugim miejscu. Naprzeciw tym oczekiwaniom wychodzi współczesna chirurgia, rozwijając diagnostykę przedoperacyjną i techniki małoinwazyjne, nieuszkadzające zwieraczy. Omówiono wskazania do zastosowania tych metod, ich ograniczenia, a także możliwe komplikacje pooperacyjne. Nadal w proktologii ma swoje miejsce klasyczne leczenie chirurgiczne, które wzbogaciło się o metody wspomagające terapię trudno gojących się ran i stanów zapalnych okolicy anorektalnej: opatrunki podciśnieniowe i komorę hiperbaryczną.
Summary
In recent years there has been progress in proctological diagnostics and minimally invasive procedures. We present the latest diagnostic options in proctology, including dynamic 3D anorectal ultrasonography technique, the so-called echodefecography, as well as volume render mode, a technique based on computer processing of ultrasound images. The current state of knowledge on the treatment of the most common proctological diseases: haemorrhoidal disease, anal fistula, anal fissure, stool incontinence, rectal prolapse and pilonidal sinus, was also presented. According to the available analyses, patients are most interested in maintaining full postoperative gas and stool continence, while the effectiveness of the surgery comes second. Modern surgery meets these expectations by developing preoperative diagnosis and minimally invasive techniques which do not cause sphincter damage. Indications for the use of these methods, their limitations, and possible postoperative complications were discussed. There is still some room for classical surgical techniques, which have been enriched with methods supporting the healing of difficult healing wounds and inflammation of the anorectal region: negative pressure wound therapy systems and hyperbaric chambers.
Introduction
As in many other areas of surgery, significant advances can also be seen in proctological surgery. Not only progress has been made in the diagnosis, but new minimally invasive proctological techniques have been introduced.
What do proctological patients expect from a surgeon?
According to the available literature as well as our observations in clinical practice, full postoperative gas and stool continence is the most important aspect for patients, whereas surgical success comes second (1).
Modern surgery meets these expectations by developing preoperative diagnosis and minimally invasive techniques.
Advances in proctological diagnosis
Although medical history and rectal examination are still most important in proctological diagnosis, additional investigations are also of key importance due to the proven relationship between certain anatomical defects and many proctological conditions. Two- and three-dimensional ultrasonography and magnetic resonance are first-line diagnostic modalities in gas and stool incontinence. MRI defecography is invaluable in patients with defecation disorders and the assessment of the lowering of pelvic floor muscles, often associated with rectal prolapse.
Ultrasonography has a well established position as a diagnostic tool for proctological conditions due to its low costs, limited invasiveness and almost complete absence of adverse effects. However, the researchers increasingly emphasise the importance of operator’s experience (2). Defecography, which may be considered historical, is experiencing a renaissance in the preoperative diagnosis of rectal prolapse, the assessment of rectocele, diagnosis of proctalgia, constipation and incontinence. The tool was upgraded by combining it with magnetic resonance imaging.
In recent years, there have been reports on dynamic 3D defecography (3-7). Echodefecography is highly compatible with conventional defecography and, at the same time, significantly less invasive for the patient (no exposure to X-rays), and cheaper. The authors of the cited papers used this diagnostic option in a group of patients with constipation. The tool allows for detecting pelvic floor dysfunction and helps choose the most beneficial surgical technique in patients with rectal prolapse. Another modern diagnostic modality, known as the volume render mode, which involves computer processing of the obtained ultrasound images (digital amplification of the obtained voxels), is a technique allowing for, among other things, consulting ultrasound images in another centre, as well as it may be used for educational purposes (7, 8).
Functional assessment still uses anorectal manometry and sphincterometry, of which the latter option is currently more often used due to higher availability and lower costs. Sphincterometry is a very simple technique, sufficient to assess internal and external sphincter tone. The examination takes only a few minutes and poses no significant burden for the patient.
Fistuloscope (VAAFT) is used in only few reference coloproctology centres. It is a diagnostic and therapeutic method known since 2012, involving the use of a specially constructed fistuloscope, which allows for intraoperative assessment of fistulous tract(s) under visual control, which makes it possible to identify the internal opening.
Fistuloscope is useful in the diagnosis of fistulas, identification of the internal opening and additional tracts, and it also features a therapeutic option (cleaning and electrocoagulation of fistulous tract).
Treatment outcomes using this method are as follows: 73% cure rates for simple fistulas, 39% cure rates for branching (complex) fistulas, and 87% efficacy, as reported by the author of the method (9, 10).
Advances in the treatment of haemorrhoidal disease
Current treatment of haemorrhoidal disease is based on conservative management at the initial stages of the disease. Minimally invasive instrumental techniques are used in grade 3 and, partially, grade 2 haemorrhoids. Surgical management is recommended for patients with grade 4 haemorrhoids, as well as cases complicated by thrombosis or heavy bleeding with secondary anaemia. Minimally invasive treatment is also indicated in immunocompromised patients (e.g. HIV-positive individuals, patients after transplantation or chemotherapy). Of the historical instrumental methods, Barron’s rubber band ligation is the most common technique used in Poland (11). Novel techniques include endoscopic rubber band ligation (ERBL), i.e. haemorrhoid ligation using a gastroscope and a kit of elastic rubber bands for oesophageal varices (12). The cited study included 116 patients. The number of rubber bands used during the ERBL procedure ranged between one and six, including at least three bands per procedure in 84 (72.4%) patients. The authors considered the method to be safe and effective in the treatment of symptomatic grade 2-3 haemorrhoids.
Obliteration of haemorrhoids is another historical technique, which is still used in the treatment of less advanced haemorrhoidal disease. Novelties published in recent years mainly relate to preparations or the form of administration (foam) used for obliteration, while the method itself remained unchanged (13).
Recent years have witnessed advances in laser techniques used in proctology.
Laser hemorrhoidoplasty (LHP)
Laser treatment of haemorrhoidal disease ? indications for haemorrhoid obliteration include grade 2 and 3 haemorrhoids, as well as symptomatic grade 1 and 2 haemorrhoids (heavy bleeding, recurrent thrombosis or frequent inflammation).
However, the method has its limitations: it fails to remove hypertrophied marginal folds and proves ineffective in cases of large grade 4 haemorrhoids. Patients undergoing laser treatment often expect painless postoperative and short convalescence period. Patients awaiting the procedure should be informed about the possibility of persisting oedema, which may resolve after 4 weeks, as well as pain in some cases. The method may be performed under local anaesthesia as an outpatient procedure.
Laser treatment should be preceded by medical history on potentially photosensitising agents used by the patient (some antihypertensives, antidepressants, antibiotics, sulphonamides). As any other treatment modality, laser technique is not devoid of complications. We have performed several procedures in patients with septic complications after laser hemorroidoplasty (anal abscess and fistula).
Doppler-guided haemorrhoidal artery ligation (Morinaga’s technique)
The method involves selective Doppler-guided ligation of vessels. Despite its undoubted advantages (painless and virtually free of complications), it did not withstand the test of time due to high equipment costs and high recurrence rates. Modification of this method, which involves placement of a suture to pull up the prolapsed mucosa (Recto Anal Repair ? RAR), is currently more commonly used. This modification increases the efficacy of the procedure.
Bipolar coagulation of haemorrhoid pedicle vessels
Bipolar coagulation (HET Bipolar System, Medtronic) is indicated in less advanced haemorrhoidal disease (grade 1 and 2).
In their study published in 2019, Filgate et al. (14) described good treatment outcomes using this method in patients with grade 1 and 2 haemorrhoids, comparing their results with a group of patients treated with rubber band ligation. They demonstrated higher efficacy of bipolar coagulation and lower postoperative pain.
Radiofrequency coagulation
The method involves closing the lumen of blood vessels using a radio wave generated from a base unit by applying a special electrode to the haemorrhoid. All three haemorrhoids are managed during a single procedure. Radiofrequency coagulation is indicated in grade 1 and 2 haemorrhoids, especially those accompanied by heavy bleeding. Radiofrequency may be used as an outpatient procedure. Results published by researchers in India confirmed a comparable efficacy of rubber band method (e.g. Barron’s technique) (15). At the same time, patients reported lower pain and higher satisfaction with final treatment outcomes.
Stapled hemorrhoidopexy
The once popular Longo’s stapled hemorrhoidopexy, which has been less often performed in recent years due to a large number of serious complications (sensory stool incontinence, anal stricture), is currently making a comeback. However, indications for its use have been significantly limited. The technique may be used in circumferential prolapsed grade 4 haemorrhoids and in patients with partial-thickness rectal prolapse, replacing Delorme’s procedure in these cases.
Zindel et al. (16) summarised current trends in the treatment of haemorrhoidal disease.
Initial stages of haemorrhoidal disease should be managed conservatively by means of anticonstipation diet and pharmacotherapy.
If conservative treatment fails, instrumental methods are used in less advanced haemorrhoidal disease.
Sclerotherapy is considered to be an effective and safe method, which is mainly used in bleeding haemorrhoids.
RBL ? the most popular alternative treatment method for haemorrhoidal disease, usually recommended for prolapsing grade 2 and 3 haemorrhoids without hypertrophied marginal folds.
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