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Terebaev Bilim Aldamuratovich, Ph. D., in medicine, associate professor, the Department of Faculty Pediatric Surgery Tashkent Pediatric Medical Institute Atamuratov Akmal Kattaevich, Pediartic Surgeon Clinic of Tashkent Pediatric Medical Institute Mardonov Muzaffar Murodulla ogli, master, of 2 course the Department of Faculty Pediatric Surgery Tashkent Pediatric Medical Institute E-mail: [email protected]
ANALYSIS OF CAUSES OF POSTOPERATIVE ANAL INCONTINENCE IN CHILDREN
Abstract: A preliminary analysis of the treated 151 children in the TashPMI clinic from 2015 to 2018 with a diagnosis of anal incontinence showed that all patients had a history of surgical interventions for anorectal malformation in 82 and Hirschsprung's disease in 69 patients. The main contingent of children was between the ages of 6 months to 17 years, with a 67.5% prevalence of boys.
The frequency of complications in the long term after perineal and abdominal perineal proctoplasty depends on the following factors: from the correctly established diagnosis, the patient's good preparation for the operation, from the method of surgical correction and the ongoing rehabilitation treatment. The choice remains of the method of primary surgical correction of the defect and restoration of the anatomical and physiological topography of the lowered intestine. The technique of transanal endorectal lowering of the large intestine and the Soave-Bolei STD in Hirschsprung's disease is effective and gives good results up to 90% of cases in young children.
Keywords: anal incontinence, diagnosis of anal incontinence, surgical treatment, children.
Relevance. After surgical correction in the anorectal area was identified after abdominal perineal proctoplasty, which
and large intestine, a derangement of the defecation control is could result from a significant ligating of the main vessels af-
considered a big trouble for children and parents of the child, ter repeated surgical interventions during mobilization and
even in cases of the presence of an external sphincter and the repositioning of the distal sections, as well as the result of ten-
absence of neurological disorders. Many factors lead to anal sion, torsion of the mesentery, retroperitoneal dislocation of
incontinence. The importance of the levators and the external the displaced colon. The tension of the pulled-through intes-
sphincter is well known [1, 4, 8, 14]. Another factor leading tine is clinically manifested by chronic constipation and has
to incontinence is a disturbance of sensitivity and proprio- a characteristic radiological picture - the absence of gaustra-
ceptivity from the side of the pulled-through intestine. At the tion and the involuntary position of the intestine in the form
request to keep a stool, children strain the muscles of the but- of a strained string; Stenosis of rectal anastomosis was more
tocks and the abdominal wall, and not the external sphincter, often observed after operation Soave; An important cause of
which leads to the opposite result [2, 6, 9, 12]. development of scar tissue is the inflammatory process, which
A study of the literature showed that the most frequent often occurs in the anastomosis zone recorded in half of the
cause of unsatisfactory results of surgical interventions in the observations [3, 5, 7, 10, 11, 13, 15].
developmental and colon malignancies is the retraction of the Thus, analysis of the literature shows that a significant
pulled-through intestine. This complication of proctoplasty is proportion of operated patients with anorectal malformation,
associated with insufficient mobilization of the pulled-through as well as Hirschsprung disease, suffer from derangements of
intestine and its tension. Necrosis of the pulled-through intes- stool control in the late period and have an unsatisfactory
tine, which is also an early postoperative complication, which quality of life.
is caused by pronounced impairment of blood supply in the In this paper, we present a comparative evaluation of
distal section of the pulled-through intestine. Chronic isch- the results of surgical treatment of anorectal malformations,
emia of the pulled-through colon, so-called ischemic colitis, Hirschsprung disease, and the causes of anal incontinence (AI).
Goal. Investigation of the frequency and causes of anal incontinence after corrective surgery for anorectal malformation and Hirschsprung disease in children.
Material and methods. A preliminary analysis of the treated 151 children in the TashPMI clinic from 2015 to 2018 with
Table 1. - The distribution of patients as
MODERN VIEW OF THE PROBLEM OF OBESITY IN WOMENOF A REPRODUCTIVE AGE
a diagnosis of anal incontinence showed that all patients had a history of surgical interventions for anorectal malformation in 82 and Hirschsprung disease in 69 patients. The main contingent of children was between the ages of 6 months and 17 years, with the prevalence of boys 67.5% (Table 1).
a function of age and pathology (n = 141)
Age Type of pathology Sex Total
Anorectal malformation Hirschsprung disease boys Girls
Up to 1 year 12 6th 13 5 18
1-3 years 24 23 29 18 47
4-7 years 16 22 28 10 38
Older than 7 years 30 18 32 16 48
Total 82 69 102 49 151
To assess the long-term outcome of the treatment, functional studies of the rectum apparatus were performed. The main attention was paid to the following clinical factors: the appearance of the anus and perineum, the localization of the anus, the prolapse of the mucosa, the stenosis of the anus. The methodology for evaluating long-term postoperative results is based on anatomical and functional effects, which were evaluated by clinical data and by radiographic data.
Results and discussion. In the postoperative period, all children were in the intensive care unit. The average time spent in intensive care was 2.6 days (an average of 2 to 5 days). Complete enteral nutrition after the operation was scheduled for 4 days. Independent stool was noted 12-48 hours after surgery.
In the early postoperative period complications in the form of intestinal paresis, bleeding from the anastomosis zone, stenosis of the anastomosis zone were noted in children operated according to the procedure of Soave-Lenyushkin, Duhamel. Then, after operations using the Soave-Boley procedure technique and the De La Torre transanal procedure, noted pains during the act of defecation and calming, which, when treated, completely stopped at the end of 3 months. A
rectal examination was performed in all children on the 12th day after the operation.
A follow-up analysis of 69 children operated on for Hirschsprung disease was performed. 29 patients underwent Soave Lenyushkin procedure, 19 had a Soave Boley procedure, 11 had a De La Torre transanal procedure, 7 Svenson Hiat procedure, and 3 patients with Duhamel-Martin procedure.
In the study ofthe results of surgical treatment, according to the methods of operation, it was found out that in 37 (53.6%) patients, anal incontinence of the 1st degree was diagnosed (Soave Lenyushkin procedure- 17, Soave Boley procedure - 12, De La Torre procedure - 7, Swenson Hiat - 1), manifested in the weakening of the tone of the sphincter and malleable stenosis of the anastomosis zone, which with the help of rehabilitation measures were eliminated. The remaining in 32 patients was the cause of anal incontinence, stenosis of the anastomosis zone in 18 (26.1%) patients, derangement of innervation of the small pelvis muscles - in 6 (8.7%), anal canal deformity in 5 children (7.2%). and a derangement of the integrity of the anal sphincter in 3 (4.3%) patients. The causes of anal incontinence according to the methods of surgical interventions are given in (Table 2).
Table 2.- Causes of anal incontinence in children, depending on the method of operation in anorectal malformations
Number of patients Reasons for AI
№ Type of operation Stenosis of the anastomosis zone Cicatricial deformity of the anal canal Partial or complete destruction of the sphincter Derangement of the innervation of the muscles of the small pelvis
1 2 3 4 5 6 7
1. Soave Lenyushkin procedure 18 15 3 - -
2. Soave Boley procedure 3 2 1 - -
3. Transanal procedure by De La Torre 2 1 1 - -
1 2 3 4 5 6 7
4. Swenson procedure 6 - - - 6
5. Duhamel-Martin procedure 3 - - 3 -
Total 32 18 5 3 6
In young children, submucosal dissection was easier and more difficult in older children, which was due to a pronounced thickening of the intestinal wall, repeated episodes of enterocolitis, a more pronounced enlargement and hypertrophy of the large intestine. The development of a rough cicatricial process, which is poorly susceptible to conservative therapy, was promoted by diastase between the mucosa of the pulled-through intestine and the stumps of the rectum.
In 82 patients with anal incontinence, the following corrective operations were primary: the Solomon procedure in 21 children, the pull-through procedure in the clinic modification - in 10, Stone Benson procedure - in 20 and Romualdi procedure in 31 children.
In 37 (45.1%) children, anal incontinence of the 1st degree was noted (pull-through procedure by Solomon -9, pull-through procedure by Romualdi - 13 for sexually transmitted infections, 13 in the Clinic version of pull-through procedure, pull-through procedure by Stones Benson-7), lasting up to one year after surgery, There was a pliable stenosis, which was easily stopped during the bougienage process. Forty-two (54.8%) patients had AE2-3 degrees after the primary operation, lasting from 4 to 14 years, the causes were: stenosis and scar deformity of the anus, mucosal clearance of the brought down intestine, neoanus ectopia and partial or complete destruction of the sphincter table - 3).
Table 3.- Causes of anal incontinence in children, depending on the method of operation in anorectal malformations
№ Type of operation Number of patients Reasons for AI
Stenosis and scar deformity of the anus Extension of the mucosa Partial or complete destruction of the sphincter Ectopia of neoanus Outside sphincter reductions
1. Solomon procedure 10 2 3 - 5 -
2. Romualdi procedure 19 8 4 7 - -
3. Clinic version of pull-through procedure 3 2 1 - - -
4. Stone-Benson procedure 13 6 2 2 - 3
Total 45 18 10 9 5 3
Stenosis and scar deformity of the anus were noted in 18 (40.0%) children, mainly after the operation of Stone-Benson and Romualdi procedure. Partial or complete destruction of the sphincter apparatus was observed in 7(14.8%) patients after the Romualdi procedure and in 2(4.4%) observations after the Stone Benson procedure. No less frequent pull-through of rectum via sphincter, after operation of Stone-Benson in 3(6.7%) patients and anterior ectopy of the anus after Solomon's operation in 5(11.1%) patients.
The function of keeping and the quality of life of children after surgery of perineal and abdominal perineum proctoplasty were evaluated on the Wexner scale (Cleve-
land Clinic, 1993) [16] which patients were filled in 1, 2 and 3 years after proctoplasty. Depending on the frequency of manifestation of incontinence, a certain number of points (from 0 to 4) was exhibited at 5 positions. When interpreting the results, the total number of points corresponded to: 20 incomplete incontinence points - testified to the absence of the holding function, 11 to 15 unsatisfactory results, 6 to 10 points to satisfactory results and a good score from 0 to 5 points and an excellent score of 0 points. In the postoperative period, all children underwent rehabilitation measures, depending on the function of holding the anal sphincter (Table 4).
ANALYSIS OF CAUSES OF POSTOPERATIVE ANAL INCONTINENCE IN CHILDREN
Table 4.- The incontinence assessment scale by Wexner (1993)
Factors Frequency
Type of incontinence Never Rarely (less than 1 time per month) Sometimes (less than 1 time per week, but more than 1 time per month) Usually (less than 1 time per day, but more than once a week) Always (more than 1 time per day)
Hard stool 0 1 2 3 4
Liquid stool 0 1 2 3 4
Gases 0 1 2 3 4
Wearing pads 0 1 2 3 4
Change in lifestyle 0 1 2 3 4
The conclusion. Thus, the frequency of complications in the long term after the perineal and abdominal perineal proctoplasty depends on the following factors: from the correctly established diagnosis, the patient's good preparation for the operation, from the surgical correction method and the rehabilitation treatment. The choice remains of the meth-
od of primary surgical correction of the defect and restoration of the anatomical and physiological topography of the pulled-through bowel. The technique of transanal endorectal pul-through of the colon and Soave-Boley procedure in Hirschsprung disease is effective and gives good results up to 90% of cases in young children.
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