Method for treating encopresis caused by sphincter-levator insufficiency after surgical treatment of anorectal malformations

Abstract

FIELD: pediatric surgery; proctology.SUBSTANCE: used in the treatment of encopresis caused by sphincter-levator insufficiency after surgical correction of anorectal malformations. An incision is made along the posterior semicircle of the rectum. The mobilized levator muscles are transposed forward to the wall of the rectum and upward to the level of the last vertebra and the levator muscles are fixed with sutures to its periosteum and the rectum. Individual interrupted sutures are applied to the levator muscles along their portion facing the wound, starting from the upper edge to the lower edge in the caudal direction, followed by suturing of the postoperative wound.EFFECT: method allows for the restoration of the pelvic floor's closure and retention functions, the elimination of fecal incontinence, and the normalization of defecation function by creating a rigid fixation of the levator muscles to the periosteum of the last vertebra and the formation of a strong muscular cape in the caudal direction, which provides reliable anatomical support for the rectum, restores the anorectal angle, eliminates tissue tension, and minimizes the risk of recurrence of sphincter-levator insufficiency.1 cl, 1 ex

Description

[0001] This invention relates to medicine, specifically to surgical methods for eliminating encopresis due to sphincter-levator insufficiency following surgery for anorectal malformations. The need to restore the sphincters and anorectal angle of the rectum is dictated by the need to eliminate encopresis due to insufficiency of the rectal retaining apparatus following surgery for anorectal malformations.

[0002] Surgical methods for restoring the retaining apparatus of the rectum are known [Koynov Yu.Yu., Gramzin A.V., Krivosheenko N.V., Tsyganok V.N., Pavlushin P.M., Chikinev Yu.V. Repeated operations in children with anorectal malformations. Siberian Scientific Medical Journal. 2020; 40 (1): 67–72. doi 10.15372 / SSMJ20200109]. All patients, due to insufficient functional capacity of the anorectal region, secondary changes in the perineum and external genitalia, undergo surgical correction - anterior sagittal anoproctoplasty;

[0003] The above method has serious disadvantages:

[0004] - impossibility of reconstruction of the anorectal angle;

[0005] - impossibility of circular reconstruction of the sphincter complex of the rectum;

[0006] - impossibility of restoring the physiological parameters of the rectal retaining apparatus;

[0007] The following surgical method for restoring the retaining apparatus of the rectum is also known [Aliev M. M., Terebaev B. A., Ollabergenov O. T., Narzullaeva M. Kh. Selection of the method for correcting postoperative anal incontinence in children. Young scientist. 2020; 22: 433-437]. The technique for creating an internal anal sphincter from the reduced intestine was performed as follows: a circular incision was made around the anus, stepping back from its edge by 1.5–2.0 cm, a circular isolation of the muscular layer of the intestinal wall and anal canal was performed from the bottom up. The lower edge of the isolated muscular layer was folded upward and fixed with separate sutures, creating a double muscular coupling. The edges of the skin wound were sutured to the lower edge of the muscular coupling, and the intestinal mucosa was sutured from above. This surgery is aimed at correcting anal canal insufficiency by creating a smooth muscle internal sphincter. However, this method has several disadvantages:

[0008] - impossibility of reconstruction of the anorectal angle;

[0009] - impossibility of restoring the physiological parameters of the rectal retaining apparatus;

[0010] An operative method for puborectalis muscle reconstruction is also known [Marchenko V.K. Method for puborectalis muscle reconstruction. Russian Federation Patent No. 2135092 dated July 12, 1996]. A U-shaped graft is cut from the xenopericardium. A tunnel is formed by incisions above the pubic bones and behind the rectum above the upper edge of the external sphincter. The ends of the puborectalis muscle are isolated. The graft is placed into the formed tunnel. The corresponding ends of the graft are fixed to the ends of the puborectalis muscle.

[0011] This method has a number of disadvantages:

[0012] - formation of the anal canal of insufficient length;

[0013] - low level of anorectal angle formation;

[0014] - use of non-functional allograft;

[0015] A surgical method for plastic surgery of the external anal sphincter in children is also known [Shchapov N.F. et al. Method of partial plastic surgery of the external anal sphincter in children. Patent of the Russian Federation No. 2820000 dated October 4, 2023]. Electrical myostimulation is performed to determine the zone of no contractions. Stay sutures are applied to the mucocutaneous junction in the area of ​​the sphincter defect. The anterior wall of the rectum is mobilized from the soft tissues of the perineum to the depth of the border of the mid-ampullary and lower ampullary parts of the rectum. A triangular segmental resection of the rectal wall is performed. A continuous single-layer hemostatic suture is applied through all layers of the intestine. Resection of the cicatricial skin in the defect area is performed. Layer-by-layer suturing of the soft tissues of the perineum is performed with the application of individual interrupted sutures to portions of the anal sphincter under the control of electrical myostimulation.Finally, an additional U-shaped cutaneous-mucocutaneous suture is applied to the projection of the restored external anal sphincter.

[0016] This method has a number of disadvantages:

[0017] - impossibility of reconstruction of the anorectal angle;

[0018] - impossibility of restoring the physiological parameters of the rectal retaining apparatus;

[0019] The closest in technical essence to the claimed method is the method of reconstruction of the anorectal angle [Komissarov I.A., Kolesnikova N.G., Glushkova V.A. Repeated surgical interventions for anal incontinence in children (lecture). Russian Bulletin of Pediatric Surgery, Anesthesiology and Resuscitation. 2013; 3(4): 92-97]. Identification of muscle structures is facilitated by the use of electrical stimulation. They enter the intersphincteric space separating the smooth muscles of the rectal wall from the skeletal muscles of the pelvic floor. They pass through it to the levators and suture their left and right portions in layers from the depth in the distal direction (iliococcygeus, pubococcygeus and the most superficial puborectalis muscle) to the level of the external sphincter of the anus.In this case, the anal canal lengthens, narrows and thickens with a corresponding increase in the average residual and arbitrary pressure, and the anorectal angle also decreases by displacing the anorectal junction upward and forward.

[0020] This method has a number of disadvantages:

[0021] - lack of fixation of the puborectalis muscle;

[0022] - uncertainty of localization of the puborectalis muscle at the level of the rectum;

[0023] - guaranteed realizable risk of downward migration of the anorectal angle;

[0024] - guaranteed realizable risk of reduction in the length of the anal canal with recurrence of encopresis;

[0025] The objective of the invention is to improve the results of the method for eliminating encopresis due to sphincter-levator insufficiency after operations for anorectal malformations.

[0026] The technical result of the stated problem is achieved by the fact that in the method for treating encopresis caused by sphincter-levator insufficiency after surgical treatment of anorectal malformations, including an incision along the posterior semicircle of the rectum, mobilization of the levator muscles, characterized in that the mobilized levator muscles are transposed forward to the wall of the rectum and upward to the level of the last vertebra and the levator muscles are fixed with sutures to its periosteum and the rectum, individual interrupted sutures are applied to the levator muscles along their portion presenting to the wound, starting from the upper edge to the lower edge in the caudal direction, with subsequent suturing of the postoperative wound.

[0027] The above techniques recreate the anorectal angle at a physiological height, namely, at the level of the last vertebra. Furthermore, fixation of the levator muscles to the periosteum of the last vertebra prevents them from slipping downward, which over time shortens the anal canal and leads to recurrence of encopresis. High physiological fixation of the levator muscles allows for the formation of the required anal canal length, which facilitates intestinal retention.

[0028] The method is performed as follows. Under anesthesia, in the lithotomy position, a semicircular incision is made along the posterior semicircle of the rectum. The presenting portion of the levator muscles is mobilized layer by layer, using blunt and sharp dissection, to the level of the last vertebra. The mobilized levator muscles are then moved anteriorly and superiorly to the level of the last vertebra. At this level, they are secured with separate interrupted sutures to the rectal wall and the periosteum of the last vertebra. Subsequently, separate interrupted sutures are placed on the mobilized levator muscles along their presenting portion, starting from their superior edge to their inferior edge in a caudal direction, followed by suturing of the postoperative wound.

[0029] Example. Patient Sh., 7 years old, was admitted to the surgical department of a clinical hospital on January 25, 2024. Diagnosis: Grade 3 encopresis due to sphincter-levator insufficiency after surgery for rectal atresia with a rectovestibular fistula. The surgery was performed using the stated method. The patient was discharged in satisfactory condition. A follow-up examination after 6 months revealed complete fecal and gas retention and occasional incontinence of liquid feces.

[0030] This technique was successfully used in 50 patients with grade 3 encopresis due to sphincter-levator insufficiency following surgery for anorectal malformations. No complications were observed with this surgical technique. The effectiveness rate was 60%. The remaining patients had satisfactory results as assessed by the FISI scale of the American Society of Surgeons. There were no unsatisfactory results.

[0031] Significant advantages of the claimed method:

[0032] - restoration of anorectal angle;

[0033] - high efficiency;

[0034] - restoration of physiological parameters of the rectal retaining apparatus;

[0035] - guaranteed prevention of downward migration of the anorectal angle;

[0036] - guaranteed prevention of reduction in the length of the anal canal with recurrence of encopresis;

[0037] - minimally invasive and easy to perform.

Claims

A method for treating encopresis caused by sphincter-levator insufficiency after surgical treatment of anorectal malformations, including an incision along the posterior semicircle of the rectum, mobilization of the levator muscles, characterized in that the mobilized levator muscles are transposed forward to the wall of the rectum and upward to the level of the last vertebra and the levator muscles are fixed with sutures to its periosteum and the rectum, individual interrupted sutures are applied to the levator muscles along their portion presenting to the wound, starting from the upper edge to the lower edge in the caudal direction, followed by suturing of the postoperative wound.