-Injection haemorrhoidal sclerotherapy using 5% phenol in almond oil, a revision of sixteen years practice at a single clinic
Izzat B.N.Muttosh, M.B.CH.B., D.G.S., C.A.B.S. Assistant Professor.
Department of Surgery, College of Medicine, Hawler Medical University, Erbil, Iraq.
E mail: izzatbnm1@gmail.com
Another accounts: izzatbnm@ yahoo.com
Mobile No. 009647504346673
https://scholar.google.com/citations?user=AT5cWK0AAAAJ&hl=en
ABSTRACT
Background and objectives: Haemorrhoid is one of the common health problems met during medical practice, many methods were tried seeking for an ideal one which is yet unavailable, and one of these methods is the sclerotherapy treatment.Injection sclerotherapy is well known for treatment of internal hemorrhoids since more than a century, different agents were used to induce fibrosis around the internal haemorrhoidal veins, causing their collapse.
Patients and methods: This is a retrospective study to evaluate the outcome of injecting 5% phenol in almond oil for patients with internal hemorrhoids mainly first and second degree piles during sixteen years of practice in one office. The total number of patients treated was (422) patients.
Results: the success rate was (86.73%) provided the injections are repeated when indicated, with no significant complications.
Conclusion: Injection hemorrhoidal sclerotherapy is a good option for bleeding 1st and 2nd degree pile as far it is a quick, needs no anaesthesia, outpatient procedure, and carries the least complications, but still the recurrence rate (13.27%) is considered higher than that after surgery (2%).
Key wards: Haemorrhoid management, sclerotherapy.
INTRODUCTION
Haemorrhoids [Greek: haima = blood, rhoos = flowing; synonym: piles (Latin: pila = a ball)] are dilated veins occurring in relation to the anus. Such haemorrhoids may be external or internal, i.e. external or internal to the anal orifice. The external variety is covered by skin, while the internal variety lies beneath the mucous membrane. When the two varieties are associated, they are known as interoexternal haemorrhoids. Bleeding as the name haemorrhoid implies is the principle and earliest symptom. [1] Most colorectal surgeons use the grading system published in 1985 by Banov et al. [2] Internal haemorrhoids that bleed but do not prolapse are designated as first-degree haemorrhoids. Those that prolapse and reduce spontaneously (with or without bleeding) are second-degree hemorrhoids. Prolapsed hemorrhoids that require reductions are third-degree hemorrhoids. Prolapsed internal hemorrhoids that cannot be reduced are fourth-degree hemorrhoids. Symptoms of internal hemorrhoids include bleeding and protrusion. Prolapsed haemorrhoids are a cause of soiling and mucus discharge, and both lead to secondary pruritus ani. Advanced prolapsed hemorrhoids may become incarcerated and strangulated. [2] Internal haemorrhoids are the commonest cause of rectal bleeding in adults. The treatment of haemorrhoidal disease needs to be tailored according to the degree of haemorrhoids, patient preference, and availability and expertise of the procedure. Broadly, first and second degrees haemorrhoids are treated with non-operative treatment in the form of dietary modification, injection sclerotherapy, rubber band ligation, endoscopic band ligation, electrocoagulation (bipolar diathermy and direct-current electrotherapy) or infrared coagulation. [3], [4], [5]. For third degree haemorrhoids modalities like banding, Doppler guided haemorrhoidal artery ligation, or stapler surgery [1], [6] are available. However, surgery is the treatment of choice for fourth degree haemorrhoids and complicated haemorrhoids. [3], [4], [5] Primary goal of all forms of therapy is to treat hemorrhoids with the least pain and complications. Sclerotherapy is one of the oldest forms of nonoperative treatment; it was first described in 1869 by Morgan in Dublin. [7]. The proposed mechanisms of sclerotherapy are thrombosis of vessels, sclerosis of the connective tissue, sub mucosal fibrosis, shrinkage and fixation of the overlying mucosa. [5] Conventionally, it is performed using a rigid proctoscope, long injector needle such as lumbar puncture needle and a sclerosant (5% phenol in almond oil, 5% quinine and urea or 23.4% hypertonic saline) injected at the base of hemorrhoidal complex. [8] Also polidocanol injection through flexible endoscope [9] and 50% Dextrose- water [10] are being described recently. Sclerotherapy requires no anesthesia and takes only minutes to perform through an anoscope. [7]. Subsequent injections if indicated are performed at 6 weeks intervals. Khoury et al. performed a prospective trial of patients with first- or second-degree haemorrhoids [7] in that trial; sclerotherapy improved or cured 89.9% of the patients, with no difference between single and multiple injections. Even though sclerotherapy is minimally invasive, it can cause complications.Pain is variably reported in 12%–70% of patients.[7], 11, [12] Impotence,[13] urinary retention, and abscess [14] have also been reported. The recurrence rate is variable, and seems to increase with longer follow up, it is around 11% during the first year. [7] In one study, haemorrhoidal symptoms recurred in about 38% of patients 4 years after initially successful sclerotherapy. [7]
PATIENTS AND METHODS
This is a retrospective study to review the results of injecting first and second degree haemorrhoids with 5% phenol in almond oil during 16 years time, extended between the years 1996 - 2011. The number of patients (pts) received injection haemorrhoidal sclerotherapy (IHS) was (652) pts.
Exclusion criteria:
- Those pts who lost follow up (No.230) are excluded.
- All third, fourth degree piles and complicated piles.
- Haemorrhoids associated with fissure in ano and or perianal fistulae.
Four hundred twenty two pts were followed successfully for one year or more, and hence included in the study, among them, (43) patients were females and (379) patients were males.
Distribution regarding the degree of pile: (Table 1) , First degree pile patients: 310 pts. (73.46%), Second degree pile: 112 pts. (26.54%)
Presentations: (Table 1)
• All first degree pile patients (310) had presented with bleeding.
• Fifty two patients with second degree piles had presented with bleeding in addition to prolapse, the rest (60) pts were presented with prolapse only. The procedure was performed at one doctor's office. After taking full history and proper physical examination, a proctoscopic evaluation is done, when haemorrhoids were evident but showing no features of bleeding, a sigmoidoscopic examinations were done to exclude other source for the bleeding. All injections were performed while patients in left lateral position, along spinal needle with an anoscope are used, at the base of each pile, 3-4 ml of 5% phenol in almond oil is injected, usually at 3,7,11 o'clock, (The well known positions for piles), the injection site is above the dentate line to insure painless puncture, after each injection the area will get swollen with some color fainting. Occasionally 1-2 drops of blood from the injections site may be seen. Afterwards patients were informed to avoid unnecessary standing for 3-4 days, and given a suitable oral analgesic in case needed. All the patients were advised to be seen again after a week, six weeks, and six months intervals, or whenever bleeding recurs. For data management and statistical analysis, SPSS-10 software was used. A p value of less than 0.05 was considered significant.
RESULTS
All those patients who received injection haemorrhoidal sclerotherapy with 5% phenol in almond oil stopped bleeding within two to four days after the procedure, in addition to unexplained feeling of satisfaction. Recurrence of bleeding and or prolapse was treated by repeated injections. Ninety six patients needed more than one injection (22.74%). More than three injections proved to add no benefits regarding recurrence of bleeding, and or prolapse. The overall one year recurrence rate was (13.27%), (56 pts).
Regarding complications:
Only (46/422) of patients (10.9%) experienced mild dull aching pain lasting not more than few hours after the injection that necessitated oral paracetamol. None of the complications mentioned in literature, Impotence, [12], urinary retention, or abscesses [11] have been reported.
DISCUSSION
There is more than one nonoperative method to deal with first and second degree piles, namely: sclerotherapy, rubber band ligation, bipolar diathermy, direct-current electrotherapy, and infrared photocoagulation, and each one treatment has its proponents. A meta-analysis by Johanson and Rimm examined 5 trials involving 862 patients with first- or second-degree hemorrhoids who underwent infrared photocoagulation, sclerotherapy or rubber band ligation. [16] Rubber band ligation was more effective than sclerotherapy, and patients treated with rubber band ligation required fewer additional treatments than those treated with sclerotherapy or infrared photocoagulation. However, rubber band ligation was associated with a significantly higher incidence of pain than the other 2 treatments. Thus, Johanson and Rimm favored infrared photocoagulation as the nonoperative treatment of choice. [16] MacRae et al. performed a similar meta-analysis covering 23 studies that compared rubber band ligation, infrared photocoagulation, sclerotherapy, haemorrhoidectomy, and manual dilation of the anus for patients with first-, second-, or third-degree hemorrhoids.[17] Like Johanson and Rimm, they found that rubber band ligation was more effective than sclerotherapy, less likely to require additional therapy than either sclerotherapy or infrared photocoagulation, and more likely to cause pain. Despite these identical findings, MacRae et al. concluded that rubber band ligation was the initial procedure of choice for first-, second-, and third-degree hemorrhoids because of its higher rate of efficacy. In a study comparing conventional injection sclerotherapy and surgery in patients with second and third -degree internal hemorrhoids at 28 days after treatment, the disappearance rate of prolapse was similar between injection sclerotherapy and surgery, 94% (75/80 patients) and 99% (84/85 patients), respectively. The 1-year recurrence rate was 16% (12/73 patients) in the sclerotherapy group and this value was satisfactory because of its less invasive nature while it was more or less higher compared with 2% (2/81 patients) in the surgery group. The incidence of pain and bleeding were lower in the injection sclerotherapy group. [18] Sclerotherapy requires no anesthesia and takes only minutes to perform through an anoscope. [7] In our clinic we adopted IHS using 5% phenol in almond oil for first and second degree haemorrhoids, for 16 years time, decisions to apply the procedure were made after thorough discussion with the patients about the advantages and disadvantages of all the available options including surgery. Our results seemed to carry no much deference from other studies of the same procedure. • The rate of post procedural pain (which is usually mild dull ache) was (10.9%) this is comparable with the variably reported rates for the same symptom in 12%–70% of patients.[7],[11], [12]
• The complications were absent in our study, in comparison to other studies with varying results (0-2%). [11]
• In our study, the recurrence rate (13.27%) within the first year of therapy was comparable with other studies (11.1%) [7] and (16%) [18] recurrence rates no matter which sclerosant was used. [7].
CONCLUSIONS
• To evaluate our procedure, we did revision of all patients who had underwent injection haemorrhoidal sclerotherapy during the period 1996-2011, we excluded patients who lost proper follow up.
• Comparison with other studies of IHS was made, No significant differences in regards recurrence or complications rate were detected.
• In comparison with other modalities of haemorrhoid treatments; Sclerotherapy proved no superiority over rubber band ligation, or over infrared photocoagulation therapy in regard of success, although it carried less pain suffering and complications.
• In comparison to surgery: the one year recurrence rate (16%) is significantly higher than that of surgery (2%), but the incidence of pain and bleeding were lower in injection sclerotherapy. [18]
• And lastly meta-analytic studies confirmed the opinion that there is no ideal method for treatment of haemorrhoids the one that is painless and gives high success rate with no complications.
• IHS is an excellent method being painless, needs no anaesthesia and carrying low complication rate, but it also has a high recurrence rate which may reach 38% after 4 or 5 years time. [7], [19], [20], [21]
• Repeated injections can make difference to arrest bleeding, but not so for controlling prolapse. And this does not fit with the prospective study made by Khoury et al [7], where no difference between single or repeated injections were recorded in arresting bleeding.
REFERENCES
1- R.C.G.Russell, Norman S.Williams & Christopher J.K. Bulstrode.chapter The anus and anal canal, Bailey& love's Short practice of surgery 24th Edition2004 (page 1242-1271)
2- Banov L, Knoepp LF, Erdman LH, Alia RT. Management of hemorrhoidal disease. J S C Med Assoc. 1985; 81:398–401 View in ArticleMEDLINE
3- Madoff RD, Fleshman JW. American Gastroenterological Association Technical Review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126:1463-73.
4- Steele SR, Madoff RD. Systematic review: the treatment of anal fissure. Alimentary Pharmacology & Therapeutics 2006; 24: 247-57.
5- Chong PS, Bartolo DCC. Hemorrhoids and Fissure in Ano. Gastroenterol Clin N Am 2008; 37:627-44.
6- Gravié JF, Lehur PA, Huten N, Papillon M, Fantoli M, Descottes B, Pessaux P, Arnaud JP. hemorrhoidopexy versus milligan-morgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year postoperative follow up. PMID: 15973098 PMCID: PMC1357701
7- Khoury GA, Lake SP, Lewis MC, Lewis AA. A randomized trial to compare single with multiple phenol injection treatment for haemorrhoids. Br J Surg. 1985; 72:741–742
8- Sim AJ, Murie JA, Mackenzie I. Three year follow-up study on the treatment of first and second-degree hemorrhoids by sclerosant injection or rubber band ligation. Surg Gynecol Obstet 1983;157:534-6.
9- Nijhawan S, Udawat H, Gupta G, Sharma A, Mathur A, Sapra B, Nepalia S. Flexible video-endsocopic injection sclerotherapy for second and third degree internal hemorrhoids. J Dig Endosc 2011; 2:1-5
10- Alatise OI, Arigbabu OA, Lawal OO, Adesunkanmi AK, Agbakwuru AE, Ndububa DA, Akinola DO.Endoscopic hemorrhoidal sclerotherapy using 50% dextrose water: a preliminary report. PMID: 19529900
11- Sim AJ, Murie JA, Mackenzie I. Comparison of rubber band ligation and sclerosant injection for first and second degree haemorrhoids—a prospective clinical trial. Acta Chir Scand. 1981;147:717–720
12- Bullock N. Impotence after sclerotherapy of haemorrhoids (case reports). Br Med J. 1997; 314:419
13- O’Callaghan JD, Matheson TS, Hall R. Inpatient treatment of prolapsing piles (cryosurgery versus Milligan-Morgan haemorrhoidectomy). Br J Surg. 1982;69:157–159
14- Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG. Symptomatic hemorrhoids (current incidence and complications of operative therapy). Dis Colon Rectum. 1992;35:477–481
15- Lee HH, Spencer RJ, Beart RW. Multiple hemorrhoidal bandings in a single session. Dis Colon Rectum. 1994;37:37–41
16- Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids (a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy). Am J Gastroenterol. 1992;87:1600–1606
17- MacRae HM, Temple LK, McLeod RS. A meta-analysis of hemorrhoidal treatments. Semin C R Surg. 2002;13:77-83
18- Takano M, Iwadare J, Ohba H, Takamura H, Masuda Y, Matsuo K, Kami T et al. Sclerosing therapy of internal hemorrhoids with a novel sclerosing agent. Comparison with ligation and excision. Int J Colorectal Dis 2006;21:44-51.
19- Hardwick RH, Durdey P. Should rubber band ligation of haemorrhoids be performed at the initial outpatient visit? Ann R Coll Surg Engl. 1994;76:185–187
20- Savioz D, Roche B, Glauser T, Dobrinov A, Ludwig C, Marti MC. Rubber band ligation of hemorrhoids (relapse as a function of time). Int J Colorectal Dis. 1998; 13:154–156
21- Cosman BC, Eastman DA, Perkash I, Stone JM. Hemorrhoidal bleeding in chronic spinal cord injury (results of multiple banding). Int J Colorectal Dis. 1994; 9:174–176
Table 1: The distribution of patients in regard of haemorrhoids degrees and presentations.
Degree of haemorrhoid / No. of patients / % / Bleeding / % / Prolapse only / %
First degree. 310. 73.46% 310. 73.46% None. 0%
Second degree. 112. 26.54% 52. 12.32%. 60 14.22%
Total 422. 100% 362 85.78%. 60 14.22%
AUTHORSHIP AND CONSENT FORM
This manuscript (Injection haemorrhoidal sclerotherapy using 5% phenol in
almond oil, a revision of sixteen years practice at a single clinic) is an unpublished work which is not under consideration elsewhere and the results contained in this paper have not been published previously in whole or part, except in abstract form.
In consideration of the Conference accepting my submission for publication, the author undersigned.
It is expressly certified that I have done/actively participated in this study and agree to the accuracy presentation
Izzat B.N.Muttosh
29/7/2012
Email: scientific.conference@hmu.edu.iq
Injection haemorrhoidal sclerotherapy using 5% phenol in almond oil , a revision of sixteen years practice at a single clinic
Authors : Izzat B.N. Muttosh
Publication date: 2012
Conference : 3rd International Conference for Medical Sciences
Volume 1; Issue; Proceeding book, Pages: 104-109
Publisher: Hawler Medical University
Management of fistula in ano with a steel wire cutting Seton
Izzat B.N.Muttosh
Senior lecturer, M.B.CH.B., D.G.S., C.A.B.S., College of Medicine, Hawler Medical University, Erbil, Iraq.
https://scholar.google.com/citations?user=AT5cWK0AAAAJ&hl=en
(1)
Abstract
This is a retrospective study aimed to review the results of a modified surgical procedure adopted to treat high type fistula in ano, carried between Feb. 1995 and Dec. 2005. Many surgical procedures have been described in literature to treat high type fistula in ano and this reflects the lake of an ideal one, the one that is expected to carry the minimum rate of recurrence, sphincter incontinence in addition to patient's compliance and satisfaction. .One of these surgical methods is the use of a (Seton), The Seton is a ligature of silk, nylon, silastic, or linen.It is applied in two ways: The ( non cutting Seton ), that is lied in place loosely after excision of the part of fistula tract out side the sphincter complex under G. A., Later after four weeks interval , fistulotomy is performed. The (Cutting Seton) method is done in the same above mentioned way but the Seton is tightened at weekly intervals.
This study reviewed our experience in performing the (Cutting Seton) method, with some modifications. These modifications are:
-The initial operation of excising part of the tract is omitted.
-The Seton used is a segment of steel wire which is easily twisted, re-twisted and easily untwisted on need.
-A short (usually 2-7cm) segment of soft rubber tube is used to surround the wire when it comes in contact with the perianal skin.
The no. of patients included in the study was (18). The duration of treatment ranged between 4 and 8 weeks, they were followed for various periods ranged between 6-24 months. The results were encouraging. One patient only got recurrence. Three patients developed minor degree of incontinence which was a temporary incontinence. No major incontinence was evident. These results were significant in comparison to other studies. The procedure is performed under local anesthesia at the office
INTRODUCTION
Fistula -in- ano is one of the commonly encountered surgical problems. Most of these fistulae develop after drainage of an anorectal abscess. Drainage of an anorectal abscess results in cure for about 50% of patients1. The remaining 50% develop a persistent fistula in ano1. Other rare causes include trauma, crohn's disease, malignancy, radiation, TB, actinomycosis and Chlamydia(1,2), are not to be overlooked. Different classifications have been put, which categorize these fistulae into low or high, simple or complex, or according to their anatomy: intersphincteric, transsphincteric, suprasphincteric and extrasphincteric1. High fistula in ano is far less common than low type3. Low fistulae in ano (low intersphinctric and low transphincteric) are the commonest anal fistulae and can easily be treated by laying- open technique (fistulotomy) (4,5).
The high fistulae in ano are difficult to treat since the conventional laying-open technique will lead to division of most of the anal sphincter muscle resulting in incontinence1.
The goal of treatment of fistula in ano is eradication of sepsis without sacrifying continence1. To reach this goal in high anal fistulae, different surgical techniques have been described in literature from time to time, these include: fistulotomy, insertion of a seton(7,8)(cutting or non cutting)1, primary fistulotomy and occlusion of the internal ostium9, fistulotomy with primary repair of the sphincter10, endorectal advancement flaps (11,12 ), anocutaneous advancement flaps(13,14), repair of fistula using fibrin adhesiveglue15, Re-routing the fistula16. The non-cutting seton is a thick silk thread or a soft drain1-2that is applied loosely after excision of the lower part of the fistula (that portion below the sphincter complex) and left in the residual portion of the fistula to maintain drainage and induce fibrosis, after about 4 weeks interval, another operation is designed to lay-0pen the residual portion of the tract (fistulotomy) with no subsequent incontinence as long as fibrosis is developed7. The cutting Seton consists of a suture or rubber band that is placed through the fistula and intermittently tightened in the office (1, 18).
This study helps evaluating this last method using steel wire Seton.
MATERIALS AND METHODS
This is a prospective study which was conducted during the years 1995-2005.
Patients with low type anal fistulae were excluded from the study; these are simply treated by laying-open the tract. The number of patients with high type fistula was 18 of them 2 were females and 16 male, their age ranged from 20 years to 59 years (the average age 36y). History regarding mode of onset, duration of illness and any data referring to previous disease including crohn's disease, ulcerative colitis, tuberculosis, and malignancy, are obtained. Three patients were suffering from recurrent fistulae after some surgery. Two patients were hypertensive, and three patients were diabetic.
A thorough discussion about the procedure is made with each patient, and his, her agreement along with his, her address and phone no. are obtained.
Proctoscopy is performed routinely to exclude any abnormality, and to identify the internal fistula opening. Under local A. with or without pudendal n. block, the external opening of the fistula is probed gently and the internal opening is negotiated during digital rectal examination or by injection of hydrogen peroxide through the fistula. a segment of silver wire is attached to the probe which is then withdrawn through the internal opening, The two limps of wire thus obtained are threaded to a segment of soft rubber tube it's length equals to the distance of the external opening from the anal verge (usually 2-7cm), and a hole is created at it's centre, the rubber tube serves to protect the skin from pressure of the wire while the hole facilitate twisting the wire ends together. The pt. is informed to return back at weekly intervals for extra twists of the wire. Finally the wire will come out after a time. To decrease the no. of twists, after few subsequent examinations when the internal opining seemed to be dislocated to a new lower position, at the anal sphincter, ( so that less than 30% of the sphincter is remained )1a fistulotomy is performed under local
Figure -I- Steel wire Seton for fistula in ano
RESULTS
Eighteen patients were included in this study, of them sixteen were male with two females, and the male to female ratio was 8:1. The incidence was low in both sexes below 20 years and above 50 years of age. Peak occurrence was noted between 20 to 40 years.Incidence according to age is shown in Table I.
Table 1 age distribution of patients with fistula in ano.
Age group No. of patients % age
10-20 years. 1 5.55
21-30 years 5 27.77
31-40 years 7 38.89
41-50 years 3 16.66
51-60 years 2 11.11
The no. of weekly twists ranged from 4 -7.
Thirteen patient developed increase discharge from the fistula during the first week (72.2 %), this is explained to be due to better drainage.
Only three patients (16.7%) developed minor incontinence (incontinence to flatus) which was transient, the worst disappeared after 8 weeks, No permanent incontinence is detected.
One patient developed recurrence (5.55%) four months after the last (fifth) session of treatment.
DISCUSSION
A vast majority of perianal fistulae belong to the low variety which can easily be treated by simple laying-open technique with out division of anal sphincter muscle and thus with out causing permanent incontinence(4,5,1,17). High fistulae are rare3. Both the
diagnosis and treatment of high anal fistulae are difficult, so various surgical procedures have been described to treat these fistulae (9,10,19,20,21).
Laying - open technique in high fistula in ano may involve sacrifice of part or whole of the sphincter muscle impairing continence, it is quite obvious that the more the extent of anal muscle division ,the greater the degree of anal incontinence1. Seton fistulotomy either performed in two stages (two-stage fistulotomy) or using (cutting Seton) which has high success rates (16,22) . Our procedure belongs to the (cutting Seton) method using steel wire as a Seton. The advantages of this method are:
It is easily handled and easily re twisted at weekly intervals.
It does need neither general anesthesia nor admission to hospital, it is an outpatient procedure.
It carried low recurrence rate (5.55%) which is comparable to those obtained when other materials (rubber or silk) are used (8.34%)23,and when two staged fistulotomy with seton is followed (8%)7,(8.5)23.
Three patients developed transient minor incontinence (16.7), in comparison to (two- stage) Seton fistulotomy (50%)23.
REFERENCES
1. Kelli M. Bullard and David. A. Rothenberger , Colon, Rectum, and anus, Schwartz's principles of surgery, eighth edition, 2005, (P. 1055-1119).
2. Parks AG, Gardon PH, Hardcastle JD. A Classification of fistula-in-ano. Br J Surg 1976; 63: 1-12.
3. Marks CG, Ritchie JK. Anal fistula at St. Marks’s Hospital. Br J Surg 1977:64:84-91.
4. EU KW. Fistulotomy and marsupialization for simple fistula-in-ano. Singapore Med J 1992; 33(5):532.
5. Yang CY. Fistulotomy and marsupialization for fistula-in-ano. Singapore Med J 1992; 33(3): 268-70.
6. Khubchandain. Comparison results of treatment of fistula-in-ano. J R Soc Med 1984; 77(5): 369-71.
7. Williams JG, Mac Leod A, Rothenberger A, Goldberg M. Seton treatment of high anal fistulae. Br J Surg 1991; 78: 1159-61.
8. Norman S. Williams, chapter The anus, and anal canal, Bailey& love's Short practice of surgery 24thEdition2004 (page 1242-1271)
9. Athanasiadis S, Lux N, Fischbach N, Meyer B. One stage surgery of high trans and supra-sphincteric anal fistulae using primary fistulectomy and occlusion of the internal ostium. A prospective study of 169 patients. Chirurg 1991; 68(8): 608-13.
10. Parkash S, Lakshmiratan V, Gajendran V. Fistula-in-ano; Treatment by fistulectomy, primary closure and re-construction. Aust NZ J Surg 1985; 55(1): 23-7.
11. Van-de-Stadt-J. Fistula-in-ano: the place of rectal advancement flap technique. Acta Chir Belg. 2000; 100(3): 123-7.
(8)
12. Miller GV, Finan PJ. Flap advancement and core fistulectomy for complex rectal fistula. Br J Surg1998; 85(1): 108-10.
13. Jun-SH, Choi GS. Anocutaneous advancement flap closure of high anal fistula. Br J Surg 1999; 86(4): 490-2.
14. Nelson RL, Cintron J, Abcarian H. Dermal island-flap anoplasty for transphincteric fistula-in-ano: assessment of treatment failure. Dis Colon Rectum 2000; 43(5): 681-4.
15. Cintron JR, Park JJ, Orsy CP, Pearl RK, Nelson RL, Sone JH, et al. Repair of fistula-in-ano using fibrin adhesive glue; long term follow-up. Dis Colon Rectum 2000; 43(7): 944-50.
16. Thomson JPS, Ross AHMcL. Can the internal sphincter be preserved in the treatment of trans-sphincteric fistula-in-ano? Int J Colorectal Dis 1989; 4:247-50.
17. Vainlevsky CA, Gordon PH. Results of treatment of fistula-in-ano. Dis Colon Rectum 1985; 28: 225-31.
18- Ramanujam PS, Parsad ML, Abecarin H. The role of Seton in fistulotomy of the anus. Surg Gynaecol Obstet 1983; 157: 419-22.
19- Mann CV, Clifton MA. Re-routing of the track of high anal and anorectal fistulae. Br J Surg1985; 72: 134-7.
20- Jones IT, Fazio VW, Jagelman DG. The use of transanal advancement flaps in the management of fistulas involving anorectum. Dis Colon Rectum 1987; 30: 919-23.
21- Wedell J, Meir ZW, Fissen P, Danzhaf G, Klein L. Sliding flap advancement for the treatment of high level fistulae. Br J Surg 1987; 74: 390-1.
22- Culp CE. Use of Penrose drain to treat certain anal fistulae. A Primary operative seton. Mayo Clin Proc 1984; 579: 613-7.
(9)
23-J.Garcia-Aguilar,C. Belmonte,W. wong, D.W. Goldberg, R.D. Madoff, cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fisula,BJS ,vol.85 issue 2 ,(1 Feb.1998).
الخلاصة
هدف هذه الدراسة هو القاء نظرة بطريقة رجعية لاسلوب جراحي معدل في علاج ناسور الشرج من النوع المرتفعتم اتباعه بين سنة 1995 وسنة 2005 في موقع جراحي واحد. ان وجود عدة اساليب جراحيه لمعالجة هذا المرض هو دليل على عدم وجود طريقه مثالية ناجحه باقل نسبه نكوس محتمله وباقل مايمكن من المضاعفات وخاصة السلس المقعدي (عدم السيطره على الاخراج) الذي يمثل مشكله امام جميع اشكال الاساليب المستعملة.
ومن هذه الطرق استعمال ا لسيتون ((seton.
والسيتون هو رباط من حرير او نايلون سيلاستيك او كتان.
ويستعمل بطريقتين:
أ- السيتون اللاقاطع : بعد ازالة جزء من الناسور الواقع خارج محيط العضله العاصره للشرج تحت التخدير العام يتم ادخال السيتون داخل الجزء المتبقي ويترك بشكل مرتخ لمدة اربعة اسابيع بعدها يتم اجراء عملية ثانية يفتح فيها الناسور ويترك مفتوحا ( fistulotomy).
ب- السيتون القاطع : وتجرى بنفس الطريقه اعلاه ولكن هنا يتم ربط السيتون بشده اكثر ويتم زيادة هذه الشده تدريجيا كل فتره تقارب الاسبوع.
أ- تدريجيا كل فتره تقارب الاسبوع.
خلال فترة الدراسه تم اتباع الاسلوب الثاني ( السيتون القاطع ) ولكن مع بعض التعديلات وهي :
v لقد تم الغاء المرحله الاولى للعمليه وهي عملية قطع وازالة الجزء الاسفل من الناسور.
v استعمال مادة ( steel wire) بدل المواد المعروفه للسيتون. وهي ماده تتميز بسهولة اللي والبرم وتكرار البرم او العكس .
v استخدام جزء من انبوب مطاط لين بطول (2-7سم) لتغليف السلك الملامس لجلد منطقة حول الشرج .
شملت هذه الدراسه 18 مريض وتراوحت مدة علاجهم بين 4-8 اسابيع وتم متابعتهم لفترات متفاوتة تراوحت بين 4 و 24 شهرا .
(10)
اما عن النتائج فكانت مشجعة بوضوح وهي كالاتي :
· حالة نكوس واحدة (رجوع الناسور) .
· سلس المقعد (عدم السيطره على الاخراج) البسيط و المؤقت عند ثلاثة مرضى فقط .
· لم يثبت حصول سلس مقعدي شديد او دائم عند جميع من شملتهم الدراسه .
· وهذه النتائج مقارنة بالدراسات الاخرى التي اجريت لنفس المرضى تعتبر مشجعة جدا .
بقي ان نعرف ان هذا الاجراء الجراحي في جميع الحالات قد تم في العياده الجراحيه الخارجيه .
Management of Fistula in Ano with a Steel Wire Cutting Seton
Authors: Izzat B. N. Muttosh
Publication date: 2008
Journal: ZANCO JOURNAL OF MEDICAL SCINCES
Volume: 12
Issue: Special issue
Pages: 81-84
Publisher: Hawler Medical University