Mechaninës siûlës hemoroidektomija: 29 operacijø patirtis
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1 59 ISSN , ISSN (online) LIETUVOS CHIRURGIJA Lithuanian Surgery 2006, 4(1), p Mechaninës siûlës hemoroidektomija: 29 operacijø patirtis Stapled hemorrhoidectomy: experience after 29 operations Narimantas Evaldas Samalavièius 1, Tomas Poðkus 2 1 Vilniaus universiteto Onkologijos instituto Chirurgijos klinika, Santariðkiø g. 1, LT Vilnius 2 Vilniaus universiteto ligoninës Santariðkiø klinikø Centro filialo III abdominalinës chirurgijos skyriaus Koloproktologijos poskyris, Þygimantø g. 3, LT Vilnius El. paðtas: narimantsam@yahoo.com 1 Vilnius University, Institute of Oncology, Clinic of Surgery, Santariðkiø str. 1, LT Vilnius, Lithuania 2 Vilnius University Hospital Santariðkiø klinikos, Central Branch, 3rd Department of Abdominal Surgery, Division of Coloproctology, Þygimantø str. 3, LT Vilnius, Lithuania narimantsam@yahoo.com Tikslas Ávertinti ankstyvuosius ir vëlyvuosius mechaninës siûlës hemoroidektomijø, atliktø Vilniaus universiteto ligoninës Santariðkiø klinikø Centro filialo III pilvo chirurgijos skyriaus koloproktologijos poskyryje, rezultatus. Ligoniai ir metodai Per ketverius metus, nuo 2001 metø gruodþio iki 2005 metø sausio, mechaninës siûlës hemoroidektomija atlikta 29 ligoniams, sirgusiems III laipsnio (26 ligoniai) ir IV laipsnio (3 ligoniai) hemorojumi. Ið jø buvo 15 moterø ir 14 vyrø, jø amþius metø, vidurkis 54 metai. Operacijai buvo naudojamas PPH. Operacija truko nuo 10 iki 40 minuèiø, vidutiniðkai 30 minuèiø. Rezultatai Vidutinë hospitalizacijos trukmë buvo 5 dienos (nuo 2 iki 8). Chirurginiø komplikacijø po operacijos nebuvo. Sisteminiø analgetikø po operacijos prireikë 21 pacientui vidutiniðkai 2 paras (1 3 paros). Dviem pacientams konstatuotas uþsitæsæs pooperacinis skausmas, kurá reikëjo malðinti vaistais atitinkamai 7 ir 10 dienø po operacijos. Pacientai á darbà ar prie áprastinës gyvenimo veiklos gráþo vidutiniðkai aðtuntà parà po operacijos (nuo 5 iki 14 paros). Po vieneriø metø ið apklaustø 24 pacientø operacijà gerai ir labai gerai vertino 19 (79,2%), patenkinamai 3 (12,5%) ir blogai 2 (8,3%) pacientai: ið pastarøjø vienam liko iðkritimas, o vienam pasikartojo kraujavimas, uþdegimas ir skausmas. Viena pacientë buvo mirusi. Keturiø pacientø apklausti nepavyko. Iðvados Mûsø patirtis parodë, jog mechaninës siûlës hemoroidektomija yra saugi ir patikima. Vëlyvieji operacijos rezultatai yra geri. Reikðminiai þodþiai: iðangë, hemorojus, mechaninë siûlë, chirurginis gydymas, rezultatai
2 60 N.E. Samalavièius, T. Poðkus Objective To evaluate early and late results after stapled hemorrhoidectomy in the colorectal subunit of the third departament of surgery in Vilnius University Hospital Santariðkiø klinikos Central Branch. Patients and methods 29 patients underwent stapled hemorrhoidectomy over a period of four years (from December 2001 to January 2005). 26 patients had third and 3 patients had fourth degree hemorrhoids. There were 15 females and 14 males, age range from 32 to 80 years (mean 54 years). The PPH kit (Procedure for prolapsed hemorrhoids), Ethicon, Johnson and Johnson was used. Operations lasted from 10 to 40 minutes, on average 30 minutes. Results The mean in-hospital stay was 5 days (2 8). No surgical complications occurred. Analgesic medications were needed for 21 patients, on average for 2 days (1 3). Prolonged pain was observed in two patients who required analgesic medications for 7 and 10 days. Patients resumed their routine activities on the 8th postoperative day (5 14 days). After one year, 19 of 24 (79.2%) patients regarded their operation as good or very good, 3 (12.5%) as satisfactory and two (8.3%) as bad: in those patients one had recurrent prolapse, another one had recurrent bleeding, the third one had bleeding and thrombotic episodes. One patient had died of the causes unrelated to the operation, and the other four were out of reach. Conclusions Our experience shows that stapled hemorrhoidectomy is safe and effective. Late follow-up results are good. Key words: anus, haemorrhoids, surgical treatment, stapling, results Ávadas Hemorojus yra seniai þmonijai þinoma liga. Pats ligos pavadinimas yra kilæs ið graikiðkø þodþiø haima, reiðkianèio kraujà, ir rhoos tekëti. Tai nëra gerai atspindintis ligos simptomus pavadinimas, nes dalis hemorojø turinèiø ligoniø niekada nesiskundþia kraujavimu. Ðiandien hemorojaus etiopatogenezei pagrásti áprasta laikytis W.H.F. Thomsono teorijos [1]. Ji teigia, kad iðangës kanale yra kraujagyslinio audinio sankaupø (pagalvëliø), kurias sudaro pogleivis, smulkios kraujagyslës, elastinis ir jungiamasis audinys. Treitzo raiðtis neleidþia ðiam audiniui slinkti þemyn iðangës kanalu, taèiau dël ávairiø veiksniø (nereguliari tuðtinimosi funkcija, stanginimasis tuðtinantis, viduriø uþkietëjimas ir kt.) ðis raiðtis gali nutrûkti, iðangës pagalvëlës iðkristi, uþsikimðti ir kraujuoti. Yra daug hemorojaus gydymo bûdø. Juos galima suskirstyti á tris grupes: konservatyvius, minimaliai invazyvius ir operacinius. Konservatyvus gydymas tai ávairûs tepalai ir þvakutës, á kuriø sudëtá áeina anestetikø ir (ar) steroidiniø preparatø, vidurius laisvinanèios priemonës ir ávairûs vazotoniniai preparatai [2]. Minimaliai invazyvûs bûdai tai skleroterapija, guminiø þiedø ligatûrø metodas, infraraudonøjø spinduliø koaguliacija, elektros srovës terapija, krioterapija ir kitos. Klasikiniai chirurginiai metodai yra ðie (pagal jø apraðymo literatûroje eiliðkumà): þiedinë hemoroidektomija (Whitehead) [3], ekscizijos ir siûlës hemoroidektomija (Mitchell) [4], ekscizijos ir ligatûros operacija (Milligan-Morgan) [5], submukozinë hemoroidektomija (Parks) [6], uþdaroji hemoroidektomija (Ferguson) [7] ir jos modifikacijos. Milligan-Morgan operacija, ko gero, yra daþniausiai atliekama pasaulyje ir ðiandien. Visø ðiø operacijø metu stipriai traumuojama jautri anorektinë zona, todël pooperacinis skausmas yra pagrindinë hemorojaus operacijos problema. Mëginta ávairiomis priemonëmis ðá skausmà
3 61 sumaþinti: vartojant vietiniø ir sisteminiø analgetikø [8, 9], antibiotikø [10], operacijos metu papildomai atliekant ðoninæ sfinkterotomijà [11] ar iðangës raukø plëtimà. Ðios priemonës nedavë patenkinamø rezultatø. Tad jei operacijos negalima iðvengti, t. y. jei maþai invazyvûs metodai negali panaikinti ligos sukeliamø simptomø, patraukli alternatyva yra operacija, po kurios neskaudëtø. Per pastaruosius kiek daugiau nei deðimt metø pasiûlytos net dvi nedideliu pooperaciniu skausmu pasiþyminèios operacijos: mechaninës siûlës hemoroidektomija (Longo) [12] ir hemorojiniø arterijø perriðimas, kontroliuojamas doplerio sonoskopijos bûdu (Morinaga) [13]. Vilniaus universiteto ligoninës Santariðkiø klinikø Centro filialo III abdominalinës chirurgijos skyriaus Koloproktologijos poskyryje ði metodika ádiegta 2001 metais. Pirmoji patirtis mûsø literatûroje jau buvo apraðyta anksèiau [14]. Ðio straipsnio tikslas pateikti dabar sukauptà nemaþa patirtá, vertinant ankstyvuosius ir vëlyvuosius chirurginius rezultatus. Ligoniai ir metodai Per ketverius metus, nuo 2001 m. gruodþio iki 2005 m. sausio, Vilniaus universiteto ligoninës Santariðkiø klinikø Centro filialo III abdominalinës chirurgijos skyriaus Koloproktologijos poskyryje Longo, arba mechaninës siûlës, hemoroidektomija atlikta 29 ligoniams, sirgusiems III laipsnio (26 ligoniai) ir IV laipsnio (3 ligoniai) hemorojumi. Septyniems ligoniams vyravo hemorojaus mazgø iðkritimas, o kitiems 22 ligoniams iðkritimas ir kraujavimas. Operavome 15 moterø ir 14 vyrø, amþius metø, vidurkis 54 metai. Indikacija atlikti mechaninës siûlës operacijà buvo III ar IV laipsnio hemorojaus mazgø þiedinis iðkritimas, t. y. toks, kai standartinë operacija (ðiuo metu atliekame tik uþdaràjà hemoroidektomijà uþpakalinio tarpvietës anestezinio bloko sàlygomis) galëtø lemti nevisiðkà ligos kontrolæ. Kitas svarbus aspektas nedidelis iðorinis hemorojaus komponentas arba su juo susijusiø skundø nebuvimas. Prieð operacijà visiems ligoniams atlikta rektoskopija ir kolonoskopija arba retrogradinë irigoskopija. Dienà prieð operacijà þarnynas buvo ruoðiamas mechaniniu bûdu (Fortrans ar Cololyt). Operacija buvo atliekama litotominëje padëtyje, sukëlus bendrinæ ar epidurinæ nejautrà. Operacijai buvo naudojamas PPH rinkinys ( hemorojiniø mazgø prolapsui, Ethicon, Johnson and Johnson). Já sudaro þiedinis iðangës plëtiklis (37 mm), anoskopas tabokinës siûlei, siûlës traukiklis ir 33 mm skersmens specialus cirkuliarios mechaninës siûlës aparatas. Þiedinis iðangës plëtiklis buvo ástumiamas á iðangæ, prisiuvamas prie odos laikinomis fiksuojanèiomis siûlëmis. Obturatorius iðtraukiamas ir ádedamas tabokinës siûlës anoskopas. Tuomet já sukant 4 cm ir 5 cm nuo dantytosios linijos buvo siuvamos dvi tabokinës polipropileno siûlës. Iðtraukus anoskopà, ástumiamas mechaninës siûlës aparatas, kad jo galvutë bûtø virð tabokinës siûliø. Siûlës traukiklius iðtraukus á iðoræ, siûlës verþiant uþriðamos. Panaudotas aparatas pora minuèiø laikomas neatsuktas, siekiant hemostazës. Paskui anoskopu apþiûrima visa siûlë ir prireikus hemostazë uþtikrinama pavienëmis trijø nuliø vikrilo siûlëmis. Daþniausiai gleivinës jungtis buvo suformuojama 2 cm virð dantytosios linijos. Operacijos truko nuo 10 iki 40 minuèiø, vidutiniðkai 30 minuèiø. Po operacijos rekomenduojama vartoti vidurius laisvinanèiø vaistø vienà savaitæ. Ligoniai iðraðymo dienà ir po dviejø mënesiø buvo apklausiami ir ávertinami digitaliniu tyrimu, o po metø uþpildë klausimynà ar buvo apklausti telefonu. Rezultatai Vidutinë hospitalizacijos trukmë buvo 5 dienos (nuo 2 iki 8), pooperacinë gulëjimo trukmë vidutiniðkai 2 dienos (nuo 1 iki 5). Chirurginiø komplikacijø po operacijos nebuvo. Sisteminiø analgetikø po operacijos prireikë 21 pacientui vidutiniðkai 2 paras (1 3 paros). Dviem pacientams konstatuotas uþsitæsæs pooperacinis skausmas, kurá reikëjo malðinti medikamentais atitinkamai 7 ir 10 dienø po operacijos. Vienas pacientas po operacijos karðèiavo 4 paras, jam diagnozuota ûminë virusinë kvëpavimo takø infekcija. Apþiûrint pirðtu pro iðangæ pacientus iðraðymo dienà, jungties srityje problemø nekonstatuota. Pacientai á darbà ar prie áprastinës gyvenimo veiklos gráþo vidutiniðkai aðtuntà parà po operacijos (nuo 5 iki 14 paros). Praëjus dviem mënesiams po operacijos, visi pacientai nurodë teigiamà efektà ir buvo patenkinti operacija. Po vieneriø metø visiems 29 pacientams iðsiøsti klausimynai, atsakë ar vëliau buvo apklausti telefonu
4 62 N.E. Samalavièius, T. Poðkus 24 (82,8%). Viena ligonë buvo mirusi dël prieþasèiø, nesusijusiø su operacija. Keturiø ligoniø apklausti nepavyko. Po vieneriø metø ið apklaustø 24 pacientø operacijà gerai ir labai gerai vertino 19 pacientø (79,2%), patenkinamai 3 (12,5%) ir blogai 2 (8,3%); ið pastarøjø vienam liko iðkritimas, o vienam pasikartojo kraujavimas, uþdegimas ir skausmas. Diskusija Lyginant mechaninës siûlës hemoroidektomijà su klasikinës operacijos variantais, reikia paþymëti, kad ðiø operacijø tikslai yra skirtingi: mechaninës siûlës hemoroidektomija panaikina iðkritimà, pagerina veniná nuotëká, kartu sumaþëja hemorojinis audinys (iðangës pagalvëlës) ir kraujavimo tikimybë. Klasikinës operacijos metu paðalinamas hemorojinis audinys, kad iðnyktø jo sukeltas iðkritimas ir kraujavimas. Ir nors Longo, arba mechaninës siûlës, hemoroidektomija imta plaèiai taikyti iki pasirodant objektyviems duomenims apie jos pranaðumus, vëlyvieji ðios operacijos rezultatai nëra þinomi. Operacijos oponentai atkreipia dëmesá á tai, jog po mechaninës siûlës hemoroidektomijos bûna komplikacijø, nepasitaikanèiø po áprastiniø operacijø: maþojo dubens sepsis [15], nuolatinis pooperacinis skausmas [16], rektovaginalinë fistulë. Taèiau pirmieji du galëtø bûti kazuistiniai apraðymai, o rektovaginalinë fistulë yra galima, jei nesiimama atsargumo priemoniø. Paprastai, prieð naudojant mechaninës siûlës aparatà, reikia pirðtu ásitikinti, jog makðtis nepatenka á siûlæ. Tai mes atlikome visoms savo pacientëms prieð mechaninës siûlës operacijà. Keletas aspektø yra sunkiai nuginèijami, ir rodo neabejotinus mechaninës siûlës hemoroidektomijos pranaðumus: maþesnis pooperacinis skausmas, trumpesnë hospitalizacijos trukmë ir ankstyvesnis gráþimas á darbà ar prie áprastinës gyvenimo veiklos. Mûsø operuoti pacientai gráþo á darbà ar prie áprastinës gyvenimo veiklos jau antrà savaitæ po operacijos, taèiau duomenø, palyginanèiø jos rezultatus su klasikine hemoroidektomija, pateikti negalime. Daþniausiai mechaninës siûlës hemoroidektomija lyginama su Milligan- Morgan hemoroidektomija. Mechigan ir bendraautoriai nurodo maþesná mechaninës siûlës hemoroidektomijos grupës ligoniø pooperaciná skausmà ir ankstyvesná gráþimà á darbà [16], o hospitalizacijos trukmë nesiskyrë. Rowsell duomenimis, be minëtø skirtumø, buvo trumpesnë ir hospitalizacija [17]. Taèiau ðie abu tyrimai buvo kritikuojami dël maþo pacientø skaièiaus ir neatliko funkcinio bei manometrinio ávertinimo. Ganio ir bendraautoriai 100 pacientø tyrimu, á kurá átraukë serganèius III ir IV laipsnio hemorojumi, vertino klinikinius ir manometrinius duomenis. Jie nustatë, jog mechaninës siûlës hemoroidektomijos grupës ligoniams buvo maþesnis pooperacinis skausmas ir trumpesnë gulëjimo ligoninëje trukmë [18]. Shalaby ir Desoki [19], minëtø dviejø hemoroidektomijø palyginimui iðtyræ 200 pacientø, pastebëjo, jog mechaninës siûlës hemoroidektomijos grupës ligoniams buvo ir maþesnis pooperacinis skausmas ir maþiau komplikacijø. Altomare ir bendraautoriai [20] pabandë mechaninës siûlës hemoroidektomijà ávertinti plaèiau, atlikdami manometrijà, elektrofiziologinius tyrimus ir trimatæ ultrasonografijà prieð operacijà ir praëjus 6 mënesiams po jos. Tyrimas árodë, jog ðio tipo hemoroidektomija nesukelia ilgalaikio iðangës raukø mechanizmo paþeidimo. Ho ir kolegos [21] 58 pacientams dokumentavo prieðoperacinæ ir pooperacinæ iðangës raukø funkcijos bûklæ, atliko manometrijà ir endoanalinæ sonografijà, kad nustatytø, ar operacijai naudojamas iðangës plëtiklis gali sukelti iðangës raukø paþeidimà. Ðis tyrimas árodë, jog nors paþeidimo rizika padidëja, iðangës raukø funkcija nenukenèia. Mûsø duomenys taip pat parodë, jog reikia vertinti ðios operacijos rezultatus vëlyvuoju laikotarpiu, nes visi pacientai praëjus dviem mënesiams po operacijos pasveiko ar jautë pagerëjimà, taèiau penki ið 24 pacientø po vieneriø metø norimo efekto nejautë, o dviem operacija buvo nesëkminga. Lyginti ðias operacijas su klasikinëmis, atliekamomis mûsø poskyryje, taip pat negalime, nes, kaip jau minëta, mechaninës siûlës hemoroidektomija buvo rekomenduojama tiems pacientams, kuriø hemorojiniø mazgø iðkritimas buvo þiedinis. Iðvados Mûsø patirtis parodë, jog mechaninës siûlës hemoroidektomija buvo saugi ir patikima. Vëlyvieji operacijos rezultatai yra geri.
5 63 LITERATÛRA 1. Thomson HF. The nature of haemorrhoids. Br J Surg 1975; 62: Poðkus T, Samalavièius NE, Þeromskas P, Ðiugþda R. Hemorojaus gydymas sudëtiniu preparatu Ginkor Fort. Lietuvos chirurgija 2003; 1: Whitehead W. Surgical treatment of haemorrhoids. Br Med J 1882; 1: Mithchell AB. A simple method of operating on piles. Br Med J 1882; 1: Milligan ETC, Morgan CN, Jones LE, Officer R. Surgical anatomy of the anal canal, and operative treatment of haemorrhoids. Lancet 1937; ii: Parks AG. Surgical treatment of haemorrhoids. Br J Surg 1956; 43: Ferrguson JA, Heaton JR. Closed haemorrhoidectomy. Dis Colon Rectum 1959; 2: Chester JF, Stanford BJ, Gazet JC. Analgesic benefit of locally injected bupivacaine after heamorrhoidectomy. Dis Colon Rectum 1990; 33: Goldstein ET, Williamson PR, Larach SW. Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management. Dis Colon and Rectum 1993; 36: Carapeti EA, Kamm MA, McDonald PJ, Philips RK. Double-blind randomized controled trial of effect of metonidazole on pain after day-case haemorrhoidectomy. Lancet 1998; 351: Mathai V, Ong BC, Ho YO. Randomized controlled trial of lateral sphincteretomy with haemorrhoidectomy. Br J Surg 1996; 83: Longo A. Treatment of haemorrhoids disease by reduction of mucosa and haemorrhoidal prolapse with circular suturing device: a new procedure. In: Proceedings of the Sixth World Congress of Endoscopic Surgery, Rome, Italy, 3 6 June, 1998: Molloy RG, Kingsmore D. Life threatening sepsis after stapled haemorrhoidectomy. Lancet 2000; 355: Samalavièius NE, Poðkus T. Stapled Haemorrhoidectomy: a New Technique in Lithuania. Acta Medica Lituanica 2002; 9(4): Cheetham MJ, Mortensen JJ, Nystrom PO, Kamm MA, Philips RKS. Persistent pain and fecal urgency after stapled haemorrhoidectomy. Lancet 2000; 356: Mechigan BJ, Monson JR, Hartley JE. Stapling procedure for haemorroids versus Milligan-Morgan haemorrhoidectomy: a randomized controlled trial. Lancet 2000; 355: Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: a randomized controlled trial. Lancet 2000; Ganio E, Altomare DF, Gabielli F, Milito G, Canuti S. Prospective randomized multicenter trial comparing stapled with open haemorrhoidectomy. Br J Surg 2001; 88 (5): Shalaby R, Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2001; 88 (8): Altomare DF, Rinaldi M, Sallustio PL, Martino P, De Fazio M, Memeo V. Long-term effects of stapled haemorrhoidectomy of internal anal function ant sensitivity. Br J Surg 2001; 88 (11): Ho YH, Seow-Choen F, Tsang C, Eu KW. Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Br J Surg 2001; 88(11): Gauta: Priimta :
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