530Bo0czna sfifkts Boczna sfinkterotomia wewnętrzna ... ?· bytu, odbytnicy i jelita grubego. Poradnik…

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<p>530</p> <p>Krzysztof Bielecki</p> <p>Boczna sfinkterotomia wewntrzna</p> <p>z niewielkiego pionowego cicia w rowku midzyzwie-raczowym wypreparowuje si misie zwieracz wewntrz-ny odbytu, ktry przecina si na dugoci odpowiadajcej dugoci szczeliny odbytu. zwykle zabieg ten wykonuje si na godzinie 3. w uoeniu pacjenta w pozycji litotomijnej.</p> <p>cakowite wycicie mezorektum</p> <p>tme (ang. Total Mesorectal Excision) polega na pozaodbytniczym wyciciu mikkich tkanek a do po-ziomu dna miednicy i mini dwigaczy odbytu. Pre-parowanie odbywa si w tzw. holy space przestrze beznaczyniowa w okolicy przedkrzyowej.</p> <p>o waciwym wyciciu mezorektum wiadczy niena-ruszona powi waciwa odbytnicy i nieuszkodzone sploty ylne przedkrzyowe.</p> <p>Podwizanie ttnicy krezkowej dolnej</p> <p>Niskie podwizanie ttnicy krezkowej dolnej</p> <p>Polega na podwizaniu ttnicy poniej (obwodowo) od odejcia od niej ttnicy okrniczej lewej.</p> <p>Wysokie podwizanie ttnicy krezkowej dolnej</p> <p>Polega na podwizaniu ttnicy w odlegoci 1 cm od jej odejcia od aorty.</p> <p>wymienione powyej definicje i okrelenia to tyl-ko cz rekomendowanego nazewnictwa prokto-logicznego, ktre zawiera wspomniana na wstpie broszura pt. nazewnictwo proktologii, ktr de-dykujemy naszemu nauczycielowi Panu docentowi mieczysawowi tylickiemu, twrcy polskiej prokto-logii.</p> <p>niniejszy artyku pragn zakoczy piknym cyta-tem konfucjusza:</p> <p>Jeli definicje s niewaciwe, wtedy twierdzenia nie zgadzaj si z faktami, kiedy za twierdzenia i fakty nie s zgodne, wtedy poprawne wykonanie zadania nie jest moliwe. (Konfucjusz I)</p> <p>If terms be incorrect, then statements do not accord with facts and when statements and facts do not accord, then business is not properly executed. (Confucius I)</p> <p>P i m i e n n i c t w o</p> <p>1. Bielecki k, koodziejczak m: nazewnictwo w proktologii. Pod-stawowe pojcia i definicje. wydawnictwo standardy medycz-ne w Praktyce, warszawa 2012, isBn-978-83-60020-01-2.</p> <p>2. corman ml: colon, and rectal surgery. lippincott-raven, wyd. 4, Philadelphia, new york 1998.</p> <p>3. zama n, fazio Vw, jagelman dG et al.: efficacy of pelvic pack-ing in maintaining hemostasis after rectal excision for cancer. dis colon rectum 1988; 31: 923-928.</p> <p>4. Quinyao w, weiijn s, youren z et al.: new concepts in severe presacral hemorrhage during proctectomy. arch surg 1985; 120: 1013-1020.</p> <p>5. crapp ar, cuthbertson am: william waldeyer and the rectosa-cral fascia. surg Gynecol obstetr 1974; 138: 252-256.</p> <p>6. Grochowicz P, koodziejczak m, ziembikiewicz a: choroby od-bytu, odbytnicy i jelita grubego. Poradnik dla lekarzy i pacjentw. wydawnictwo medyczne Borgis, warszawa 2010.</p> <p>7. Gryglewski a: Podstawy proktologii praktycznej. wydawnictwo Via medica, Gdask 2001.</p> <p>8. lowry ac, simmong cl, Boulos P et al.: consensus statements of definitions for anorectal physiology and rectal cancer. dis co-lon rectum 2001; 44(7): 915-919.</p> <p>9. townsend cm, Beauchamp rd, evers Bm, mattox kl: sabiston tectbook of surgery. elsevier saunders, wyd. 17, Philadelphia 2004.</p> <p>10. Herman rm, nowakowski m: choroby jelita grubego i odbytu. [w:] szmidt j, kuzda j (red.): Podstawy chirurgii. medycyna Praktyczna, krakw 2010.</p> <p>11. Goligher j: surgery of anus,rectum and colon. Bailliere tindall, london 1975.</p> <p>12. Bielecki k, dziki a: Proktologia. Pzwl, warszawa 2000.13. Grochowicz m: Podstawowe pojcia i definicje. [w:] koo-</p> <p>dziejczak m, sudo-szopiska i (red.): diagnostyka i lecze-nie ropni i przetok odbytu. wydawnictwo Borgis, warszawa 2008.</p> <p>14. jorge jmn, wexner sd: a practical guide to basic anorectal physiology investigations. contemporary surgery 1993 oct; 43: 214-224.</p> <p>15. stefaski l: anatomia kliniczna okolicy odbytowo-odbytniczej. Pol Przegl chirurg 2012; 84(5): 466-476.</p> <p>16. tylicki m: zarys proktologii. Biblioteka lekarza Praktyka, seria ii, tom 74, Pzwl, warszawa 1972.</p> <p>17. tylicki m: operacje proktologiczne. Pzwl, warszawa 1973.18. koodziejczak m, sudo-szopiska i: diagnostyka i leczenie </p> <p>ropni i przetok odbytu. wydawnictwo medyczne Borgis, war-szawa 2008.</p> <p>19. Parks aG, Gordon PH, Hardcastle jd: a classification of fistula---in-ano. Br j surg 1976; 63: 1-12.</p> <p>adres/address: *krzysztof Bielecki</p> <p>oddzia chirurgii oglnej z Pododdziaem Proktologii szpital na solcu</p> <p>ul. solec 93, 00-382 warszawatel.: +48 (22) 250-62-68</p> <p>e-mail: prof.bielecki@gmail.com</p> <p>otrzymano/received: 15.05.2013 zaakceptowano/accepted: 26.06.2013</p> <p>Postpy Nauk Medycznych, t. XXVI, nr 8, 2013</p> <p>531</p> <p>Borgis</p> <p>p r a c E o r y g i n a l n E o r i g i n a l p a p E r S</p> <p>*agnieszka Brodzisz1, czesaw cielecki2, Pawe nachulewicz2, Pawe wieczorek1</p> <p>the use of transperineal ultrasound and endosonography using H2o2 in the diagnosis of perianal abscesses and fistulas in children</p> <p>zastosowanie ultrasonografii przezkroczowej i endosonografii z zastosowaniem H2o2 w diagnostyce ropni i przetok okooodbytniczych u dzieci</p> <p>1department of Pediatric radiology, medical university, lublin Head of department: prof. Pawe wieczorek, md, Phd 2department of surgery and Pediatric traumatology, medical university, lublin Head of department: Pawe nachulewicz, md, Phd</p> <p>s u m m a r y</p> <p>Introduction. Perianal abscesses are not uncommon pathology in children, while the ethiopathology of perianal fistula still need to be determined. surgical treatment involves abscess incision and evacuation usually without the need for imaging. transperineal ultrasound (tPus) and endorectal ultrasound (erus) enable the assessment of the distribution and penetra-tion of perianal abscesses and fistulas.</p> <p>Aim. aim of this study is the evaluation of usefulness of the intrasurgical tPus and H2o2 enhanced endosonography in the assessment of the distribution and penetration of perianal abscesses and fistulas in children.</p> <p>Material and methods. us examination was performed in 9 children (aged 2 month to 8 years old) with perianal abscess and fistula. the examination was performed before abscess incision in order to assess its distribution, as well as after surgical incision, and H2o2 injection to visualise fistulous tract. the us examinations were performed with the use of Philips iu22 ultra-sound scanner with high frequency transducers (l 12-5 mHz and l 15-7 mHz) and Bk-medical Profocus ultrasound scanner with high frequency (16-9 mHz) 360 degrees rotational transducer with automatic 3d data acquisition (type 2050).</p> <p>Results. the measurements of perianal abscesses and fistulas in all patients taken at B-mode us were statistically signifi-cantly lower than that ones taken after H2o2 injection. H2o2 enhanced us examination enabled precise assessment of ana-tomical relations between abscesses and fistulous tracts towards external and internal anal sphincters influencing widening of the extent of surgery. surgical treatment was successful in all patients. no recurrence was noticed in short time follow-up.</p> <p>Conclusions. transperineal and transanal us with the use of high frequency transducers and H2o2 injection enabled pre-cise assessment of the distribution of perianal abscesses and fistulas, and had an impact on the surgery extent.</p> <p>key words: transperineal ultrasound, endorectal ultrasound, perianal abscesses and fistula in children</p> <p>s t r e s z c z e n i e</p> <p>Wstp. ropnie okooodbytnicze u dzieci nie s zmianami rzadkimi, a patogeneza przetoki nie jest do koca wyjaniona. najczciej leczenie chirurgiczne polega na naciciu ropnia i ewakuacji jego treci oraz rewizji jamy ropnia bez stosowania metod obrazowych. ultrasonografia przezkroczowa, jak i badanie endosonograficzne wysokiej czstotliwoci w trybie obra-zowania 3d pozwalaj na ocen rozlegoci i penetracji ropni oraz przetok okooodbytniczych.</p> <p>Cel. celem pracy jest ocena przydatnoci ultrasonografii przezkroczowej oraz endosonografii z zastosowaniem wody utlenionej w ocenie rozlegoci ropni i przetok okooodbytniczych u dzieci.</p> <p>Materia i metody. Badanie usG wykonano u 9 dzieci w wieku od 2 miesica do 8 lat z ropniem i przetok okooodbyt-nicz. Badanie wykonywano przed naciciem ropnia, oceniajc jego rozlego oraz po jego naciciu po podaniu wody utlenionej w celu oceny kanau przetoki. Badanie wykonywano aparatami usG: Philips iu22 gowicami wysokiej czstotliwo-ci l 12-5 mhz i l 15-7 mhz oraz Bk profocus gowic rotacyjn 20-52 o czstotliwoci 16-9 mhz z 360-stopniow akwizycj danych pracujc w trybie 3d.</p> <p>Wyniki. u wszystkich badanych pacjentw ropnie i przetoki okooodbytnicze w badaniu usG w skali szaroci byy sta-tystycznie istotnie mniejsze anieli po badaniu z uyciem H2o2. Badanie kontrastowe u wszystkich badanych pozwolio na </p> <p>532</p> <p>Agnieszka Brodzisz et al.</p> <p>introductionthe exact incidence of perianal abscesses (perineal-</p> <p>abscess, Pa) and fistulas (fistula-in-ano, fia) in the pe-diatric population is not known. large statistical reports, including both adults and children indicate that children constitute between 0.5 and 4% of all patients (1). more than 80% of all patients with Pa/and the fia are children under one year of age, boys: girls 9:1 (1). the etiol-ogy of perianal abscesses/fistulas is not entirely clear. there are several theories explaining the development of the Pa/fia: anal gland inflammation, anoderm infec-tion, anal fissure infection, congenital abnormal cells of the intestinal wall anchor in the anoderm (2). the pres-ence of perianal abscesses and fistulas in childhood almost exclusively concern boys to 1 year of age, and therefore emphasizes the influence of prenatal andro-gens on the development of abnormal glands of mor-gagni of the anal canal designed to deepen and cause thinning of the anal crypts (3). compared to adults, there are significant differences in anatomy, etiology, statistics or treatments for Pa/fia. during infancy pel-vis is shallower in the longitudinal dimension, and the length of the anal canal is approximately 5 mm. fistula is a straight line according to Goodsalls rule, almost all of them are of a low intersphincteric type, according to Parks classification in adults, this type constitutes 70% (4), external parts of fistulas are usually located at 9 and 3and lying in litothomy position. in children, the disease was only local, with no signs of systemic infection. factors predisposing to the development of Pa/fia are: lowered immunity, diabetes, hematologic malignancies, granulomatous disease (5, 6).</p> <p>all these factors determine the diversity of not only therapeutic but also diagnostic conduct in children at this age. in diagnostic imaging of perianal abscesses and fistulas great role is played by ultrasound (7). with access through the perineum transperineal ultra-sound (tPus) and endoscopic (endorectal) examina-tion (erus). the use of conventional endorectal probes in infants is limitedby the above-mentioned anatomical conditions, and therefore transperineal ultrasound ex-aminations are carried out (8). tPus examinations can be performed with conventional probes with frequency 2-6 mH, linear probe with frequency 5-10 mHz or end-fire probes used for endosonography. erus examina-tion is performed in older children (sometimes in seda-tion) using a radial electronic probe or a mechanical rotationalhead. tPus and erus examinations allow to evaluate the anatomy of the anal canal and perianal </p> <p>area area, as well as anatomy of sphincters, and in the presence of a fistula, their relationship (9). spatial imag-ing (3d) in erus and tPus examinations allows better assessment of the extent and penetration of perianal abscesses and fistulas (10). But not always performing a gray-scale ultrasound allows the assessment of the extent of the abscess and the course of the canal or multiple canals of fistula. therefore the administration of hydrogen peroxide (H2o2) is helpful in confirming the diagnosis, in determining the course of the canal or multiple canals of fistula and in the assessment of the internal opening of fistulas (11).</p> <p>aim</p> <p>the purpose of this paper is to evaluate the use-fulness of ultrasonography and transperineal endo-sonography using hydrogen peroxide (H2o2) in as-sessing the extent of perineal abscesses and fistulas in children.</p> <p>material and metHods</p> <p>the study group consisted of nine children with ab-scess and/or perianal fistula diagnosed and treated in the department of Pediatric surgery and depart-ment of children radiology of the medical university in lublin. the age of children ranged from 2 to 8 years (the mean 4 years), including 5 children in infancy, all boys. in all children an ultrasound examination of soft tissues around the abscess and transperineal ex-aminations were performed. in addition, endoscopic ultrasound of the anal canal was performed in four children aged 3 to 8 years. surgery was performed under general intravenous anesthesia, using periop-erative intravenous antibiotics. in the litothomy pa-tient positioning after the identification and location of the lesion (Pa/fia) in ultrasound examination inci-sion and evacuation of the contents of the abscess were performed. then, under ultrasound guidance, and the administration of hydrogen peroxide (H2o2) the presence and extent of the fistula canal or canals were assessed. in the presence of abscess and fis-tula, fistulotomy on the probe ring canal set under ultrasound guidance was performed simultaneously with the evacuation of the abscess.</p> <p>ultrasonography was performed with ultrasound systems: Philips and u22, high frequency probes l 12-5 mHz and l 15-7 mHz, convex 5-8 mHz and Bk Pro-focus rotationalhead 2050 with frequency 16-9 mHz with 360 degrees data acquisition in 3d mode.</p> <p>uwidocznienie dystrybucji i relacji anatomicznych do zwieraczy wewntrznego i zewntrznego odbytu i poszerzenie rozle-goci zabiegu operacyjnego. u wszystkich pacjentw uzyskano ustpienie ropnia, zagojenie przetoki oraz brak nawrotu w krtkotrwaej obserwacji.</p> <p>Wnioski. Badanie usG z dojcia przezkroczowego i przezodbytniczego pozwolio na ocen rozlegoci ropni i przetok okooodbytniczych i rozszerzenie zabiegu.</p> <p>sowa kluczowe: ultrasonografia przezkroczowa, endosonografia, ropie i przetoka okooodbytnicza u dzieci</p> <p>The use of transperineal ultrasound and endosonography using H2O2 in the diagnosis of perianal abscesses...</p> <p>533</p> <p>results</p> <p>in the analyzed group of nine children, the ultra-sound abscess and fistula (Pa/fia) were observed in 6 of them (67%), in 3 patients (33%) only the abscess was observed. in all patients perianal abscess was lo-cated under the skin at the anal verge, in five children on the right side, in four on the left side. in patients with the presence of perianal abscess and fistula in 5 of them opening of the fistula was located at 9, in 1 patient at 3 hours. in the ultrasound examination, all patients had the typical hipoechogenic appearance of the ab-scess area, in 6 subjects with an irregular outline. in the largest cross-sectional size the abscesses ranged from 8 x 7 mm to 25 x 30 mm. in three subjects soft tissue swelling was present around the abscess showing no blood flow signal. in 3 (50%)...</p>