Functional state of the obturator apparatus of the rectum after surgical treatment of grade 4 ­hemorrhoids with an ultrasonic scalpel

Abstract

Background. Despite the improvement of surgical techniques for the treatment of chronic hemorrhoids, the problem of incontinence of the components of the intestinal contents in the postoperative period remains relevant.

Aim. Evaluation of the functional state of the rectal obturator in patients with grade 4 hemorrhoids before and after surgical treatment with an ultrasonic scalpel.

Material and methods. At the National Medical Research Centre for Coloproctology named after A.N. Ryzhikh of the Ministry of Health of Russia, 500 patients with grade 4 hemorrhoids operated on with an ultrasonic scalpel for the period 2015–2017 were examined using anorectal manometry (profilometry). The mean age of the patients was 49.2±12.4 years (from 22 to 65 years). At the same time, initially, 11/500 (2.2%) patients even before the operation had periodic complaints of gas incontinence (grade I anal sphincter insufficiency; 2.5±1.3 points on the Wexner scale). For statistical processing, the Student's t-test or the nonparametric single-sample Wilcoxon criterion were used.

Results. On average, manometric indicators for the group before surgery were within the physiological norms. In 11 patients with complaints of incontinence, the pressure in the anal canal was initially reduced both at rest and during volitional contraction. At the same time, among the rest of the patients without any complaints of incontinence, 55/489 (11.2%) cases of subclinical (without manifestations) form of anal incontinence were identified only by a decrease in the manometric indicators of the sphincter rest tone, which made it possible to refer these patients to the group risk for the development of postoperative anal incontinence. After surgery, clinical complaints of gas incontinence appeared in 14/55 (25.5%) patients with subclinical anal sphincter insufficiency. In total, by the 45th day, anal incontinence according to complaints and the results of an objective study was registered in 25/500 (5.0%) patients.

Conclusion. Clinical and instrumental signs of anal sphincter insufficiency after surgical treatment of stage 4 hemorrhoids with an ultrasonic scalpel were registered in 5.0% of cases, while in 2.2% they were at baseline (in patients with a decrease in intraanal pressure and complaints), and in 2,8% appeared after surgery (in patients with subclinical anal incontinence).

Keywords

grade 4 hemorrhoids / ultrasonic scalpel / anorectal manometry / profilometry / anal incontinence / gas incontinence

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