Diagnosis and Treatment of Acute Paraproctitis Associated with Non-Clostridial Anaerobic Infection

Диссертация посвящена разработке и совершенствованию подходов к диагностике и хирургическому лечению острого парапроктита, ассоциированного с неклостридиальной анаэробной инфекцией. Исследование включает обзор литературы, анализ клинических материалов, этиологических предпосылок, классификации, клинических проявлений и диагностических критериев заболевания, а также оценку результатов применяемых хирургических и послеоперационных методов лечения. В работе обоснована необходимость индивидуализации объёма и способа радикального оперативного вмешательства в зависимости от тяжести и распространённости патологического процесса, предложены методы профилактики распространения инфекции в забрюшинное пространство и апробированы новые подходы к местному лечению послеоперационных ран с применением гидрофильной бензойной мази. Полученные результаты имеют практическую значимость для колопроктологической практики и позволяют создать лечебно-диагностический алгоритм ведения больных с данной патологией.

Relevance of the problem. In the structure of diseases of the large intestine, acute paraproctitis accounts for a fairly large proportion — 22.5–50% (Aminyev V. M., 1978; Fedorov V. D., Dul'tsev Yu. V., 1984; Frantsuzov V. N. et al., 1998, 2001; Rimov V. L., 2005; Gainutdinov F. M., 2005; Sore R., 1979; Vorob'yev P. I. et al., 1998, 2003). In the structure of the main surgical interventions of proctological departments of Russia in 1997, acute paraproctitis accounted for 9.6% and occupied the 4th place among 24 nosological forms.

The clinicopathological approach to this disease has shown that the number of patients with anaerobic infection of not only soft tissues but also internal organs is increasing and has no tendency to decrease (Sakhorov A. N. et al., 1987; Kakhrov A. N., 1996; Treinin S. O., 1999, 2002). The social significance of the problem is determined by the fact that more than 75% of patients with this pathology are people of working age.

In the last two decades, thanks to the improvement of laboratory methods and techniques of anaerobic bacteriology, a significant role of non-spore-forming anaerobes in the development of purulent surgical infection has been noted (Kolesov A. V. et al., 1989; Kuzin M. I. et al., 1990; Sachkov A. V., 1989; Tsyberna K. A. et al., 1976, 1989; Anderson S., et al., 1976; Anglesey N., et al., 1986; Bartley J., 1983; Dowell V., 1975; Jones J., 1975; Knight R., 1983).

Fatal outcomes in anaerobic paraproctitis associated with non-clostridial anaerobic infection remain high — 40–60% (Kplatadze A. M. et al., 2001, 2003; Caldut D., 1977; Brook J., Walker R., 1984; Fincgold S., 1993; Cteortsev I. X. et al., 2000), and with the spread of infection via the lymphatic pathway into the surrounding cellular spaces — into the retroperitoneal space and the development of sepsis — 100% (A. Kakhrov, 1996).

Wounds of the pararectal zone and the perineum undoubtedly have features characteristic of this localization. Traditional approaches to the treatment of wounds in the specified area cannot provide optimal impact on the course of the wound process taking into account the genesis and anatomical features. Therefore, the development of tissue-sparing treatment methods with simultaneous action on the anaerobic flora becomes relevant.

To date, questions of preoperative and postoperative diagnosis of anaerobic aspirational paraproctitis remain insufficiently developed, and postoperative methods, both microbiological and chromatographic, are labor-intensive, complex, and require significant time. Researchers' opinions differ regarding the volume and stage of surgical interventions — from simple incision of the pathological focus to counter-peritoneal incisions in the iliac regions. At the same time, repeated surgical interventions are often required. However, the specified methods of surgical interventions are not applicable to all forms of anaerobic paraproctitis. Therefore, questions of improving surgical treatment of the disease depending on the severity and extent of the process require further development.

The aim of this study is to improve the diagnosis and methods of surgical treatment of acute paraproctitis associated with non-clostridial anaerobic infection. In accordance with the set goal, the following tasks were formulated:

1. To conduct an in-depth study of clinical symptoms and local intraoperative signs of acute paraproctitis associated with anaerobic aspirational infection.

2. To study the features of the clinical course in connection with the localization of the process and etiological prerequisites of the disease.

3. To improve the methods of surgical interventions in patients with a progressive form of acute aspirational anaerobic paraproctitis.

4. To study the course of the wound process depending on the antiseptic agents used for local treatment of postoperative wounds.

The scientific novelty of the work. Based on clinical symptoms and local intraoperative signs, the forms of acute paraproctitis associated with non-clostridial anaerobic infection have been established, confirmed by bacterioscopy. The existing classification of anaerobic paraproctitis has been improved, taking into account topographic-anatomical features, severity and extent of the pathological process, and the clinical form of the disease course.

It has been established that the severity of the disease course is in direct dependence on the extent of the destructive process in the perirectal and surrounding cellular spaces; the role of these disorders has been assessed and, on their basis, rational pathways for correction have been proposed. Based on the analysis of clinical symptoms and their comparison with local changes, the methods of diagnosis of the disease have been improved.

A method for preventing the spread of infection into the retroperitoneal space by performing incisions ahead of the line of cleavage has been proposed. For the first time, the application of hydrophilic benzoic ointment from the list of A. N. Kakhrov has been proposed for the treatment of acute anaerobic paraproctitis.

Practical significance. Based on the proposed classification, a diagnostic and therapeutic algorithm has been developed that allows individualizing the volume and method of radical surgery and determining the necessary complex of postoperative therapeutic measures.

For the treatment of acute paraproctitis associated with non-clostridial anaerobic infection with ascending lymphangitis, a fundamentally new method of surgical intervention has been developed in the clinic, allowing to prevent the spread of infection into the retroperitoneal space (certificate of recommendation No. 1492 issued by VOIIR TGMU 04.03.94).

In the case of anaerobic non-clostridial paraproctitis, for the purpose of chemical necrectomy, a benzoic ointment on a hydrophilic basis from the list of A. N. Kakhrov has been trialed, which allows maximum preservation of viable tissues and shortening of wound healing terms.

Validation of the work. The main provisions of the dissertation work were reported at the first congress of pediatric surgeons, anesthesiologists, and intensivists of the Republic of Tajikistan (October 10–11, 2001), at the conference of young scientists "Actual Questions of Proctology" (May 31, 2002, Moscow), and at the meeting of the republican expert-problem commission on surgical disciplines of the Ministry of Health of the Republic of Tajikistan (November 29, 2004).