{"id":5658,"date":"2016-07-19T14:37:52","date_gmt":"2016-07-19T12:37:52","guid":{"rendered":"http:\/\/spital.sf.treime.md\/?p=5658"},"modified":"2016-07-19T14:38:12","modified_gmt":"2016-07-19T12:38:12","slug":"tactica-chirurgicala-in-maladia-hemoroidala-asociata-cu-fisura-anala-cronica","status":"publish","type":"post","link":"https:\/\/treime.md\/ru\/tactica-chirurgicala-in-maladia-hemoroidala-asociata-cu-fisura-anala-cronica\/","title":{"rendered":"Tactica chirurgical\u0103 \u00een maladia hemoroidal\u0103 asociat\u0103 cu fisura anal\u0103 cronic\u0103"},"content":{"rendered":"

Introducere<\/strong><\/p>\n

Boala hemoroidal\u0103 reprezint\u0103 o problem\u0103 actual\u0103 a societ\u0103\u0163ii contemporane, care se manifest\u0103 at\u00e2t prin frecven\u0163a mare, c\u00e2t \u0219i printr-un grad \u00eenalt de afectare a calit\u0103\u0163ii vie\u0163ii pacien\u0163ilor. Dup\u0103 datele cercet\u0103toarei V. D. Fiodorova, inciden\u0163a acestei patologii este de 118-120 de cazuri la 1000 popula\u0163ie [3; 4]. Ponderea bolii hemoroidale \u00een structura patologiilor rectului este de aproximativ 34-41% [5]. \u00cen SUA, boala hemoroidal\u0103 afecteaz\u0103 mai mult de un milion de persoane anual [1].<\/p>\n

Metodele conservative \u0219i minim invazive de tratament \u00een stadiile III \u0219i IV ale patologiei sunt pu\u0163in eficiente. \u00cen stadiile avansate ale afec\u0163iunii se practic\u0103, de regul\u0103, chirurgia invaziv\u0103 \u00een diverse modifica\u0163ii (Milligan-Morgan, Ferguson, Longo, Witehead etc.). Hemoroidectomia relativ frecvent este urmat\u0103 de un sindrom dolor marcat (perioada timpurie), hemoragie, prurit, reten\u0163ie urinar\u0103, stenoz\u0103 anal\u0103, incontinen\u0163\u0103 anal\u0103 etc.<\/p>\n

Un studiu privind frecven\u0163a complica\u0163iilor dup\u0103 hemoroidectomie, efectuat de Universitatea din Minessota pe un lot de 21000 pacien\u0163i, \u00eentr-o perioad\u0103 de aproximativ 66 de luni, a eviden\u0163iat apari\u0163ia complica\u0163iilor la aproximativ 6,8% din pacien\u0163i [2]. Un alt studiu efectuat \u00een Federa\u0163ia Rus\u0103 pe un lot de 700 de bolnavi a eviden\u0163iat apari\u0163ia complica\u0163iilor dup\u0103 hemoroidectomie la aproximativ 23,3% din ei [6]. \u00cen cazul fisurii anale cronice, se impune efectuarea exciziei fisurii cu sfincterotomie dozat\u0103. \u00cens\u0103 asocierea acestor patologii pune o problem\u0103 de tactic\u0103 chirurgical\u0103 \u00een fa\u0163a chirurgilor-proctologi, \u00een special, \u00een vederea deciderii volumului optim al interven\u0163iei chirurgicale la ace\u0219ti pacien\u0163i.<\/p>\n

Material \u0219i metode<\/strong><\/p>\n

Cercetarea este bazat\u0103 pe analiza retrospectiv\u0103 \u0219i prospectiv\u0103 a 582 de fi\u0219e de observa\u0163ie ale pacien\u0163ilor cu maladie hemoroidal\u0103, care s-au aflat la tratament pe parcursul anilor 2013\u20132015 \u00een sec\u0163ia de proctologie a SCM Sf\u00e2nta Treime.<\/p>\n

Din cei 582 de pacien\u0163i cu maladie hemoroidal\u0103, 134 sufereau concomitent \u0219i de o alt\u0103 patologie cronic\u0103 a canalului anal: \u00een 96 de cazuri, maladia hemoroidal\u0103 era asociat\u0103 cu fisura anal\u0103 cronic\u0103, \u00een 24 de cazuri \u2013 cu fistula pararectal\u0103 \u0219i \u00een 14 cazuri \u2013 cu polip anal.<\/p>\n

Pentru omogenizarea materialului clinic, \u00een calitate de material de studiu au fost selecta\u0163i doar bolnavii cu maladie hemoroidal\u0103 asociat\u0103 cu fisur\u0103 anal\u0103 cronic\u0103 (96 pacien\u0163i). Pentru o analiz\u0103 comparativ\u0103 a diferitor tactici chirurgicale, e\u0219antionul de studiu a fost divizat \u00een dou\u0103 loturi.<\/p>\n

Lotul I \u2013 46 de pacien\u0163i la care s-a efectuat he-moroidectomia prin modifica\u0163ia Milligan-Morgan, asociat\u0103 cu excizia fisurii + sfincterotomia dozat\u0103 \u00een modifica\u0163ia Gabriel (\u00een continuare aceast\u0103 tactic\u0103 va fi men\u0163ionat\u0103 ca metoda clasic\u0103).<\/p>\n

Lotul II \u2013 50 de pacien\u0163i la care s-a efectuat excizia fisurii + sfincterotomia dozat\u0103 (procedeul Gabriel), asociat\u0103 cu \u00eenl\u0103turarea submucoas\u0103 a nodulilor hemoroidali localiza\u0163i la ora 3,7 + suturarea pedunculului vascular al nodului hemoroidal plasat la ora 11 (\u00een continuare va fi metoda selectiv\u0103).<\/p>\n

Rezultate ob\u0219inute<\/strong><\/p>\n

Una dintre principalele manifest\u0103ri postoperatorii este prezen\u0163a sindromului algic, care \u00eei provoac\u0103 pacientului un grad pronun\u0163at de disconfort. Ne-am propus s\u0103 grad\u0103m acest sindrom \u00een 4 grade: 0 \u2013 lipsa durerii;1 \u2013 dureri moderate (necesit\u0103 analgezice neopioide ); 2 \u2013 dureri marcate (necesit\u0103 analgezice neopioide \u0219i antiinflamatoare nesteroidiene \u00een asociere cu spasmolitice); 3 \u2013 dureri violente (necesit\u0103 analgezice opioide). Lipsa durerii postoperatorii nu a fost atestat\u0103 la niciun pacient.<\/p>\n

Tabelul 1<\/em><\/p>\n

Gradul sindromului dolor postoperatoriu la pacien\u0163ii din lotul I versus lotul II \u00een primele trei zile<\/em><\/p>\n

\"tab1\"<\/a><\/p>\n

Pentru a obiectiviza grafic aceste date, a fost propus\u0103 calcularea unui coeficient K, ce caracterizea-z\u0103 intensitatea manifest\u0103rii sindromului dolor.<\/p>\n

\"formula\"<\/a><\/p>\n

unde: K \u2013 coeficientul intensit\u0103\u0163ii manifest\u0103rii sindromului dolor; i \u2013 gradul sindromului dolor; n \u2013 num\u0103rul pacien\u0163ilor din fiecare categorie; ntot<\/p>\n

\u2013 num\u0103rul total de pacien\u0163i din lotul I sau lotul II.<\/p>\n

Intensitatea manifest\u0103rii sindromului dolor la pacien\u0163ii din lotul I versus lotul II \u00een primele trei zile<\/p>\n

\"form2\"<\/a><\/p>\n

Astfel, observ\u0103m predominarea sindromului algic pronun\u0163at la pacien\u0163ii din primul lot de studiu, care au urmat tratament chirurgical dup\u0103 metoda clasic\u0103 \u0219i necesit\u0103 administrarea analgezicelor opioide pentru suprimarea durerii. \u00cen lotul al II-lea se poate eviden\u0163ia o frecven\u0163\u0103 mai mic\u0103 de apari\u0163ie a sindromului algic pronun\u0163at, majoritatea pacien\u0163ilor av\u00e2nd dureri moderate.<\/p>\n

Complica\u0163ii postoperatorii timpurii<\/strong><\/p>\n

Tabelul 2<\/em><\/p>\n

Complica\u0163ii postoperatorii timpurii<\/em><\/p>\n

\"tab2\"<\/a>
\nObserv\u0103m o frecven\u0163\u0103 mai mare de apari\u0163ie a complica\u0163iilor postoperatorii timpurii la pacien\u0163ii din primul lot de studiu, \u00een special are loc apari\u0163ia reflex\u0103 a reten\u0163iei de urin\u0103. \u00cen lotul II de studiu atest\u0103m o rat\u0103 sc\u0103zut\u0103 de apari\u0163ie a complica\u0163iilor timpurii.<\/p>\n

Complica\u0163ii postoperatorii tardive<\/strong><\/p>\n

Tabelul 3 <\/em><\/p>\n

Complica\u0163ii postoperatorii tardive<\/em><\/p>\n

\"tab3\"<\/a><\/p>\n

Observ\u0103m o rat\u0103 mai mare de apari\u0163ie a com-plica\u0163iilor postoperatorii tardive la pacien\u0163ii lotului<\/p>\n

I, comparativ cu lotul II de studiu, unde \u00eens\u0103 are loc apari\u0163ia recidivei maladiei hemoroidale, care se mani-fest\u0103 la nivelul nodulului hemoroidal de la ora 11.<\/p>\n

Rezultatele finale ale studiului sunt ilustrate \u00een tabelul 4.<\/p>\n

Tabelul 4<\/em><\/p>\n

Rezultate finale <\/em><\/p>\n

\"tab4\"<\/a><\/p>\n

Concluzii<\/strong><\/p>\n

    \n
  1. La pacien\u0163ii trata\u0163i prin metoda selectiv\u0103 de tratament chirurgical s-a depistat o rat\u0103 mai mic\u0103 de apari\u0163ie a complica\u0163iilor timpurii, comparativ cu pacien\u0163ii trata\u0163i prin metoda clasic\u0103.<\/li>\n
  2. Frecven\u0163a dezvolt\u0103rii complica\u0163iilor postoperatorii tardive \u00een lotul de bolnavi care a beneficiat de interven\u0163ia selectiv\u0103 de tratament al hemoroizilor a constituit 4%, comparativ cu 8,7% \u00een lotul celor care au suportat interven\u0163ie chirurgical\u0103 clasic\u0103.<\/li>\n
  3. Utilizarea metodei selective de tratament chirurgical a permis reducerea duratei de spitalizare la 5 zile, comparativ cu 7 zile care au fost necesare \u00een cazul interven\u0163iei clasice.<\/li>\n
  4. Sindromul dolor marcat postoperatoriu a fost depistat mai frecvent \u00een lotul de studiu tratat prin metoda clasic\u0103, comparativ cu lotul de pacien\u0163i trata\u0163i prin metoda selectiv\u0103.<\/li>\n
  5. A\u0219adar, putem concluziona c\u0103 metoda selectiv\u0103 de tratament chirurgical al patologiei hemoroidale asociate cu fisur\u0103 anal\u0103 cronic\u0103 este una mai eficient\u0103 \u0219i inofensiv\u0103 pentru pacient.<\/li>\n<\/ol>\n

    Bibliografie<\/em><\/p>\n

      \n
    1. Bleday R., Pena J.P., Rothenberger D.A., Goldberg S.M., Buls J.G. Symptomatic hemorrhoids: current incidence and complications of operative therapy. In: Dis. Colon Rectum, 1992; nr. 35(5), p. 477\u2013481. PubMed PMID: 1568400.<\/em><\/li>\n
    2. Scott R. Steele. Complexities in colorectal surgery. 2014, p. 313-333.<\/em><\/li>\n
    3. \u0412\u043e\u0440\u043e\u0431\u044c\u0435\u0432 \u0413.\u0418., \u0428\u0435\u043b\u044b\u0433\u0438\u043d \u042e.\u0410., \u0411\u043b\u0430\u0433\u043e\u0434\u0430\u0440\u043d\u044b\u0439 \u041b.\u0410. \u0413\u0435\u043c\u043e\u0440\u0440\u043e\u0439. \u041c.: \u041c\u0438\u0442\u0440\u0430-\u043f\u0440\u0435\u0441\u0441, 2002, 192 \u0441.<\/em><\/li>\n
    4. \u0424\u0435\u0434\u043e\u0440\u043e\u0432\u0430 \u0412.\u0414., \u0414\u0443\u043b\u044c\u0446\u0435\u0432 \u042e.\u0412. \u041f\u0440\u043e\u043a\u0442\u043e\u043b\u043e\u0433\u0438\u044f. \u041c.: \u041c\u0435\u0434\u0438\u0446\u0438\u043d\u0430, 1984, \u0441. 98-132. <\/em><\/li>\n
    5. \u0424\u0435\u0434\u043e\u0440\u043e\u0432\u0430 \u0412.\u0414., \u0415\u043c\u0435\u043b\u044c\u044f\u043d\u043e\u0432\u0430 \u0415.\u0418. \u0425\u0438\u0440\u0443\u0440\u0433\u0438\u0447\u0435\u0441\u043a\u0438\u0435 \u0431\u043e\u043b\u0435\u0437\u043d\u0438. \u041c\u043e\u0441\u043a\u0432\u0430, 2005, \u0441. 141-145. <\/em><\/li>\n
    6. \u0424\u0438\u043b\u043b\u0438\u043f\u0441 \u0420.\u041a.\u0421. \u041a\u043e\u043b\u043e\u0440\u0435\u043a\u0442\u0430\u043b\u044c\u043d\u0430\u044f \u0445\u0438\u0440\u0443\u0440\u0433\u0438\u044f. 2009, \u0441. 263-280.<\/em><\/li>\n<\/ol>\n

      Oleg Crudu1, Gheorghe Anghelici2, Galina Pavliuc 2, Mihail Erlih1, Elvira Andon1,<\/em><\/strong><\/p>\n

      Dorin Panteleiciuc1, Gheorghe Lupu, \u015etefan Dama\u0219can,<\/em><\/strong><\/p>\n

      1Clinica Chirurgie Constantin \u0162\u00eeb\u00eern\u0103, USMF Nicolae Testemi\u0163anu,<\/em><\/strong><\/p>\n

      2 Spitalul Clinic Municipal \u201dSf\u00e2nta Treime\u201d<\/em><\/strong><\/p>\n

       <\/p>\n

       <\/p>\n","protected":false},"excerpt":{"rendered":"

      Introducere Boala hemoroidal\u0103 reprezint\u0103 o problem\u0103 actual\u0103 a societ\u0103\u0163ii contemporane, care se manifest\u0103 at\u00e2t prin frecven\u0163a mare, c\u00e2t \u0219i printr-un grad \u00eenalt de afectare a calit\u0103\u0163ii vie\u0163ii pacien\u0163ilor. Dup\u0103 datele cercet\u0103toarei V. D. Fiodorova, inciden\u0163a acestei patologii este de 118-120 de cazuri la 1000 popula\u0163ie [3; 4]. Ponderea bolii hemoroidale \u00een structura patologiilor rectului este<\/p>\n","protected":false},"author":2,"featured_media":5663,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[53],"tags":[],"_links":{"self":[{"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/posts\/5658"}],"collection":[{"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/comments?post=5658"}],"version-history":[{"count":2,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/posts\/5658\/revisions"}],"predecessor-version":[{"id":5666,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/posts\/5658\/revisions\/5666"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/media\/5663"}],"wp:attachment":[{"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/media?parent=5658"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/categories?post=5658"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/treime.md\/ru\/wp-json\/wp\/v2\/tags?post=5658"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}