Local microcirculation changes in different anal canal layers in case of chronic paraproctitis

Makarov Nikolay Viktorovich

SI “Crimea State Medical University named after S. I. Georgievsky”

Local microcirculation changes in different anal canal layers in case of chronic paraproctitis

As of today there is a certain algorithm of examination in case of chronic paraproctitis, which includes number of diagnostic events. The diagnosis is established on the grounds of anamnesis morbi, perianal area examination (detection of external fistula foramen), fistula sounding, staining with subsequent anoscopy for the detection of internal foramen localization and its assessment, sigmoidoscopy, fistulography for assessment of fistula complexity degree and its location relation to anal sphincter. For the measurement of sphincter’s contractile force sphincteromanography, manometry and electromyography are used. We measured maximal and average anal sphincter compression pressure, sphincter contraction asymmetry, sphincter length, inhibiting rectoanal reflux and vector size. Anal canal perfusing was measured by laser flowmetry but this method is quite expensive.

The results of chronic paraproctitis treatment cannot be considered satisfactory, ‘cause the frequency of disease’s relapses is about 14% according to data of different authors and the frequency of anal incontinence is about 63% (Christensen A., Lisbeth N., 1984).

We suppose that these complications are the results of insufficient diagnostics in preoperative period.

The target of this work is quantitative and qualitative assessment of microcirculation rates in mucous-submucous layer of anal canal wall in case of varying difficulty chronic paraproctitis.

We performed the investigation of anal canal mucous-submucous microcirculation condition in anal crypt area in III, VI, IX, XI, XII hour points of conventional dial. We composed three groups of patients (45 persons) in age from 26 to 67, among them 18 females (40%) and 27 males (60%). First group (15 persons) was composed of patients with extrasphincteral paraproctitis: 7 persons with first degree of complexity by Dultzev-Salamanov classification, 5 persons with second degree and 3 persons with fourth degree. In all the 15 patients VI hour anal crypt was the internal foramen of pararectal fistula. The second group (15 persons) was composed of patients with chronic hemorrhoids of second-fourth degree of complexity. The third (control) group of 15 patients was the group of patients without any rectal pathology.

The investigation was performed on MyLab 20 plus apparatus with spectral Doppler pulse-wave detector PW/(HighPRF). We measured speed of blood flow (V, meters per second) and resistivity index (RI) – the ratio of difference between maximal systolic and final diastolic speed to maximal systolic blood flow speed.

The results are shown in Tables 1 and 2.

Table 1. Rates of blood flow in anal area in first group of patients.

		III h.	VI h.	VII h.	XI h.
first stage, n=7	Blood flow speed, m/s*10^-2	6,04±0,07	5±0,06	5,98±0,09	6,01±0,07
first stage, n=7	Resistivity index	0,728±0,0125	0,691±0,0125	0,719±0,0165	0,741±0,033
second stage, n=5	Blood flow speed, m/s*10^-2	5,98±0,012	3,98±0,012	5,89±0,016	6,03±0,01
second stage, n=5	Resistivity index	0,74±0,0125	0,609±0,01	0,71±0,0085	0,74±0,0125
fourth stage, n=3	Blood flow speed, m/s*10^-2	5,98±0,017	3,88±0,017	4,88±0,017	6,2±0,012
fourth stage, n=3	Resistivity index	0,742±0,0125	0,589±0,0125	0,632±0,0125	0,71±0,0125
Control group	Blood flow speed, m/s*10^-2	6,01±0,017	5,015±0,008	6,12±0,01	6,051±0,033
Control group	Resistivity index	0,741±0,033	0,701±0,125	0,731±0,01	0,73±0,01

Table 2. Rates of blood flow in anal area in second group of patients.

		III h.	VI h.	VII h.	XI h.
second stage, n=6	Blood flow speed, m/s*10^-2	6,23±0,0125	5,09±0,033	6,3±0,01	6,32±0,01
second stage, n=6	Resistivity index	0,74±0,0125	0,698±0,01	0,741±0,008	0,749±0,008
third stage, n=5	Blood flow speed, m/s*10^-2	8,108±0,033	5,298±0,0125	8,31±0,016	8,211±0,017
third stage, n=5	Resistivity index	0,744±0,01	0,71±0,0125	0,71±0,0216	0,751±0,008
fourth stage, n=4	Blood flow speed, m/s*10^-2	8,41±0,01	5,498±0,018	8,4±0,02	8,298±0,018
fourth stage, n=4	Resistivity index	0,726±0,008	0,72±0,01	0,74±0,017	0,74±0,0125
Control group	Blood flow speed, m/s*10^-2	6,01±0,017	5,015±0,008	6,12±0,01	6,051±0,033
Control group	Resistivity index	0,741±0,033	0,701±0,125	0,731±0,01	0,73±0,01

Conclusions:

1. Patients with first stage chronic paraproctitis have no difference in microcirculation relative to control group, whereas at pararectal fistulas of second and fourth degree of complexity that is when cicatricle changes in internal foramen area are present a significant decrease of blood flow is marked.

2. In case of chronic hemorrhoid of second and fourth stages the increase of blood flow in mucous-submucous layer of anal canal is marked in III, VII and XI hours’ zone.

3. In case of plastic repair methods of chronic paraproctitis of second and fourth stages operative treatment for the excision of inner foramen it’s necessary to recede not less than 2-3 mm from cicatricial changed tissues.

We think that this characteristics are important both for the choice of surgical treatment method and for prediction of postoperative period and recovery of patient.