Long-term results of minimally invasive surgical treatment of extra- and transsphincteric perianal fistulas using postoperative rehabilitation programs
Authors:   FSBSI Petrovsky National Research Centre of Surgery (Moscow), FSBEI HE Rostov State Medical University of the Ministry of Health of Russia (Rostov-on-Don), Kovalev S. A. , Kotenko K. V. ,   FSBSI Petrovsky National Research Centre of Surgery, Moscow, Bedzhanyan A. L. ,   FSBSI Petrovsky National Research Centre of Surgery, Moscow, Khitaryan A. G. ,   FSBEI HE Rostov State Medical University of the Ministry of Health of Russia, Rostov-on-Don, Alibekov A. Z. ,   FSBEI HE Rostov State Medical University of the Ministry of Health of Russia, Rostov-on-Don
Published: June 2022

Introduction. A modern promising trend in coloproctology is the use of minimally invasive surgical technologies in the surgical treatment of extra- and transsphincteric perianal fistulas, in particular laser technology FiLaC (Fistula Laser Closure). Surgical treatment of patients with extra- and transsphincteric perianal fistulas requires proper routing, stratification of the used methods of surgical treatment, postoperative rehabilitation and dynamic evaluation of the obtained results, including in the long-term period. Purpose of the study. In a comparative aspect, to evaluate the long-term results of surgical treatment of trans- and extrasphincteric perianal fistulas using the standard FiLaC technology and the developed modified FiLaC technology and the use of 2 or 4-component complex programs of physiotherapeutic postoperative rehabilitation. Material and methods. The study included 180 operated patients with trans- and extrasphincteric perianal fistulas, who were divided into two groups depending on the method of surgical intervention. In the 1st group (90 patients), the standard FiLaC technology was used for minimally invasive surgical treatment of fistulas; in the 2nd group (90 patients), a modified FiLaC technology, which provides for the opening of purulent streaks and laser coagulation of the intrasphincteric part of the fistula with a Biolitec laser (power 12 W, 100 J/cm), was applied. Each group was divided into 3 subgroups depending on the postoperative rehabilitation program used: in the 1st (main group), a 4-component program of postoperative rehabilitation was used, in the 2nd (comparison group) — a 2-component program, and in the 3rd (control group), the program of postoperative rehabilitation was not used. To evaluate the results obtained, the authors used a basic set (clinical examination with an assessment of the general condition, laboratory tests, high-resolution anoscopy, examination of the fistula tract with a button probe), additional instrumental methods (transrectal ultrasound (TRUS) with sonoelastometry, examination of the functional state of the rectal obturator), as well as a subjective assessment of the degree of improvement after treatment on the Clinical Global Impression Scale (Srikrishna S., Robinson D., Cardozo L. (2010)) and an assessment of the quality of life according to the SF-36 questionnaire (Ware JE et al. SF-36 Health Survey. Manual and interpretation guide. The Health Institute, New England Medical Center. Boston, Mass. 1993), which allow assessing the dynamics of the patient’s clinical and functional status in the process of rehabilitation, which is an urgent topic of scientific research. Long-term results were tracked over a period of 19 months up to 3 years (median 31 months). Results and discussion. The comparative analysis of the long-term results (up to 3 years), depending on the type of minimally invasive surgical treatment and the postoperative rehabilitation program used, showed that in the group of patients operated on using the FiLaC technology, the majority had good results — 96.7% of patients in the main group, 90,1% in the comparison group and 84% in the control group. In the comparative analysis of the long-term results of treatment (up to 3 years) in the patients with chronic paraproctitis after performing surgery using a modified FiLaC technology under the influence of the developed postoperative rehabilitation programs, it was found that: 59 people (65,5%) had good characteristics, 19 people (21.1%) had satisfactory characteristics, and 12 people (13,4%) had unsatisfactory characteristics. The differences were statistically significant p=0,002, which indicates that the long-term results were statistically significantly better in the main group than in patients of the control group who did not have rehabilitation measures. Conclusions. The obtained results demonstrated the benefits of using the modified FiLaC technology in the surgical treatment of transsphincteric and extrasphincteric fistulas of the rectum, which was confirmed by a 1,3-fold decrease in the incidence of relapses compared with the data obtained using the traditional FiLaC technology. The proportion of relapses in the main group of patients (when using a 4-component program of postoperative rehabilitation) decreased by 5,8 (comparison group) and 16,1 (control group) times, respectively (median observations 31 months), which allows us to recommend the developed modified FiLaC technology and comprehensive postoperative rehabilitation programs for wide introduction into the clinical practice of coloproctologists in the surgical treatment of transsphincteric and extrasphincteric perianal fistulas.