INTRODUCTION : Anorectal abscess (ARA) is frequently treated inappropriately with a simple incision and drainage. In 30-50% of the patients this leads to recurrent ARA, chronic rectal fistula and several hospital admissions. PATIENTS AND METHODS : For a ten years period, from 2007 till 2016, 547 patients with ARA were operated. Males were 419 and females 128, with a ratio of 3.3:1. Depending on localization, we divide four types of ARA: perianal - 281 patients (51.4%), ischiorectal - 176 patients (32.2%), intersphincteric - 56 patients (10.2%), supralevator - 34 patients (6.2%). RESULTS : Radical operative treatment of ARA depends of type and location of abscess, its relationship to the sphincter and the extent of the inflammatory process. In 204 patients (37.3%) was performed incision, revision and drainage. In perianal, lower types of intersphincteric ARA incision, revision, excision of the fistula and the crypt is performed. This kind of operation we carried out on 181 patients (33.1%). In all ischiorectal, high intersphincteric and supralevator ARA we made wide incision, digital revision, necrectomy, drainage and seton ligation for gradual and continuous section of the sphincter, performed on 162 patients (29.6%). CONCLUSIONS : Surgical tactics based on individual and differentiated approach of ARA treatment in specialized coloproctologic clinics assures effective and radical management, avoiding secondary abscess or chronic fistulization. Although still on debate, the primary or ligation fistulotomy should become a method of choice for the radical treatment of ARA, eliminating the possibility of recurrent inflammation or fistula-in-ano. Scr Sci Med 2017; 49(3): 45-48
One of the problems of modern surgery is treatment of ventral hernias. It is important to study the process of wound healing in the area of implantation of prosthesis depending on the drugs use that improve the processes of regeneration and repair, in particular ascorbic acid. We carried out the experimental study of 200 white mice with the implanted prosthesis Esfil and ProGrip whose diet included ascorbic acid. The inflammatory response was less pronounced after using ascorbic acid and reached its minimum with endoprosthesis material ProGrip. There was significantly higher content of fibroblasts in the connective tissue capsule after the combined use of the endoprosthesis ProGrip and ascorbic acid.
Pyodermia fistulans sinifica is a relatively rare disease characterized by recurrent abscesses of the apocrine glands in the anogenital areas and less frequently - in these glands in axillary or mammary areas in women. It affects predominantly young men and brings a lot of problems concerning early diagnosis and radical treatment. The course of disease is chronic with frequent recurrences. As a result in the affected areas multiple subcutaneous fistula tracts and chronic suppurative focuses are formed. The main feature of the condition is a wide scar formation in the affected area and chronic puss discharge with an unpleasant odor which gradually leads to disability and a general deterioration in the quality of life. Even today, the exact etiology remains unknown. There is a definite genetic predisposition. The smoking is a trigger factor, while the obesity aggravates the course of the disease. Information about the condition is scarce and disease is often misdiagnosed. This leads to improper treatment tactics, many exacerbations and recurrences. Treatment depends on stage of disease and includes antibiotics, anti-estrogens or androgens and retinoids. In recent years there have been reports on the use of monoclonal antibodies - anti-TNF. Surgical treatment may be limited to incisions with subsequent local excisions. Unfortunately most of the patients usually came into specialized colorectal departments with advanced disease. Then total excision to the underlying fascia followed by secondary wound healing and/or plastic reconstructive operations in the perineal area with flaps or free skin plastics are the only options for radical cure in advanced cases.
Reports from recent studies indicate a causal relationship between all transfusion, infectious complications and recurrent disease in surgical patients. The aim of the presented study is to elucidate the possibilities and indications for autologous haemotransfusion in the elective surgery of the colorectal cancer. Retrospective analysis was per formed over 724 electively operated patients with colorectal cancer. The prospective part includes observation of 20 radically operated patients. In these patients autologous haemotransfusion was per - formed. As indications for autologous haemotransfusion we consider age up to 80 years, hemoglobin levels at least 130 g/l, plasma protein > 65 g/l, body weight > 50 kg, good general condition and absence of decompensated cardiovascular or endocrine dis eases. In two patients with hemoglobin level between 90 – 110 g/l we per formed stimulation by means of Erythropoietin. According to retrospective data ad mission hemoglobin levels varies from 54 g/l to 175 g/l (mean 119 g/l ± 22, 6). From all electively operated patients 33, 9% had hemoglobin values over 130 g/l. The frequency of post-operative infectious complications increases from 9.1% in non-transfused patients to 38,7 % in patients with more than 4 units of allogenic blood trans fused. The prospective part of the study is designed to establish feasibility of the autologous haemotransfusion in clinical practice. The fall of hemoglobin values on the next day after donation varies from 11g/l to 19g/l (mean 15.5 g/l ± 2,19). Erythropoietin stimulation was not found to increase hemoglobin values significantly. There were no complications in the post-operative period in autologous haemotransfusion group with exception of one superficial wound infection. Autologous haemotransfusion is feasible in approximately 1/3 of electively operated patients with colorectal cancer with no ad verse effects or post-operative complications. It de creases the necessity of allogenic bioproducts and hence the risks related. Autologous haemotransfusion is easy to perform and propose ben e fits both from medical and logistic nature. Concerning to stimulation with Erythropoetin in our opinion it is without proven short term efficacy in general surgery so far.
The exact identification of the internal opening in the surgical treatment of anorectal fistulae is of basic importance for their radical treatment. The rule of Goodsall enables identification of the internal opening. 184 patients with anorectal fistulae have been studied (145 male A¨ 39 female). According to the type of the fistulae patients were distributed as follows: 86(46.74%) with transsphincteric, 57(30.98%) with extrasphincteric and 41(22.28%) with intrasphincteric. Most of them 126(68.48%) have had posterior external opening, while 58(31.52%) had anterior external opening. The internal opening has been identified in 169(91.85%) cases. The Goodsall`s rule was observed in 131(77.51%) Exception of this rule was registered in 38 patients - 20 cases with transsphincteric fistulae, 12 with extrasphincteric, 5 with re current fistulae and 1 with intersphincteric. 87.30%(110/126) of the posterior anorectal fistulae fulfilled the rule of Goodsall, while the anterior ones this rule was observed in 33/58(56.90%). From the cases with intersphincteric fistulae in 97.56 % there is match with the rule of Goodsall. The Goodsall`s rule predicts the position of the internal opening, according to the localization of the external opening. Exceptions of this rule were in the anterior fistulae and lying more than 3 cm from the anus /sensitivity of 56.90 %/. The Goodsall`s rule demonstrates highest informativity in posterior fistulae/sensitivity was 87.30 %/.
The anorectal fistula is a disease requiring careful assessment of the local signs and precise localization of the fistula channel. The Seton procedure for treatment of the fistula-in-ano we apply only for the management of trans- or extrasphincteric anorectal fistula. 152 patients with high trans- or extrasphincteric fistula-in-ano were operated. Men were 123/80.92%/, women-29/19.08%/. In 70 /46.05%/ fistula were extrasphincteric, while in 82/53.95%/ they were transsphincteric. Ba sic step is to identify the internal opening of the fistula channel following Goodsal’s rule. The Seton is trespassed through the internal opening and we tight it moderately. Every next tightening is performed at 3 days intervals. Recurrences ware registered in the first 6 months in 8 patients/5.26%/. We conclude that that seton procedure for treatment of trans- and extrasphincteric fistula is an easy to learn and practice radical one stage surgical method with a cure rate of nearly 95%. Elastic Seton ligation technique is a modification of the known from ancient times conventional ligation procedure. The following procedure is an effective method for difficult and high fistula-in-ano.
Perforation of complicated diverticular disease of the colon with generalized peritonitis is common life-threatening emergency requiring surgical intervention. Although the absolute prevalence of perforated diverticulitis complicated by generalized peritonitis is low, its importance lies in the signifcant postoperative mortality, ranging from 4-26%, regardless of selected surgical strategy. The optimal treatment for perforated diverticulitis has been always a matter of debate, changing the ‘‘gold standard`` several times in the last decades. Primary resection has become the standard practice, but fear of anastomotic leakage of ten deterred many surgeons from performing primary anastomosis. Therefore, for many surgeons Hartmann`s procedure has remained the favored option. We share our 10 years de part mental experience in complicated diverticular disease of the colon studying 146 cases with diverticular disease treated in our clinic between 2000-2010. The indications for operation were diverticulitis complications - perforation, obstructiuon and bleeding, demonstrated on clinically by generalized peritonitis - 21, acute obstruction - 4 and rectorrhagia - 2. Operation was performed in 29 patients in urgent setting. Primary resection with anastomosis was done in 12 patients (41.38%). Manual anastomoses were performed in 4 cases, while mechanical anastomoses with staplers were accomplished in 8 cases. In 6/50%/ of the latter we used our standardized technique for linear stapler latero-lateral/functional end-to-end anastomosis, formerly implemented by as for colonic cancer resections and anastomoses. We had have 2 /6.9%/ anastomosis dehiscenses. Hartmann`s procedure was per formed in 17 patients (58.62%).We did not have any complications or death with standardized stapler resections and anastomoses. Hospital operative mortality was 13.79% /4 cases/. We advocate the primary anastomosis as the standard procedure, especially for older patients. Using a standardized technique with linear stapler for primary colon resection and anastomosis in complicated diverticular disease we favor the patient`s outcome with safety, efficiency and effectiveness.
