VIDEO-ASSISTED TREATMENT OF RECURRENT AND COMPLICATED FISTULOUS FORMS OF CHRONIC PARAPROCTITIS

Aims. The aim of the study was to evaluate the efficacy and finding benefits of the video-assisted fistula treatment method using fistuloscopy compared to conventional surgical treatment methods for complex forms of chronic paraproctitis, and transsphincteric and extrasphincteric, relapsing rectal fistulas. Materials and methods. A comprehensive analysis was carried out of the results of surgical treatment of 228 patients with chronic paraproctitis, transsphincteric, extrasphincteric, including relapsing, rectal fistulas, subdivided into three groups (the main and two control ones) depending on the applied methods of surgical treatment of chronic paraproctitis. The results of surgical treatment of pararectal fistulas in the three study groups were compared. The treatment efficacy was assessed based on the results of early and late postoperative period. Results. It is found that the use of video-assisted fistula treatment method with fistuloscopy excludes an extensive surgical wound in the perianal region, which greatly reduces the probability of its secondary infection and trauma of the sphincter, thereby actually excludes the occurrence of insufficiency. The use of video-assisted fistula treatment method helped reduce the number of postoperative complications.


INTRODUCTION.
Fistulas occupy the first place in the rank of complications of chronic paraproctitis [1 ; 2]. At the present stage of coloproctology development, the final treatment of this pathology is surgical fistula dissection [2; 3]. Leading surgeons in this area proposed numerous methods for rectal fistula surgery [4]. However, such surgery is often associated with complications in pararectal intercellular space, which are accompanied by continuous development and often relapse of the inflammatory process [5; 6].
The most severe post-surgical complication is anal sphincter failure after incompletely radical surgery and long-term treatment [7; 8]. Unfortunately, the formed scars in the pararectal area often do not allow for the complete dissection of pathologically altered tissues [9; 10]. Thus, any surgical method of treatment intended for the reinforcement of rectal walls and the wound has its advantages and disadvantages.
The implementation of new effective surgical methods for the treatment of rectal fistulas, especially in cases of relapse, is an acute task in modern surgery.
The study was aimed at evaluating the effectiveness and identifying the benefits of the video-assisted method of fistula treatment using fistuloscopy in comparison with traditional methods of surgical treatment for complicated forms of chronic paraproctitis and transsphincteric and extrasphincteric, relapsing rectal fistula.

MATERIALS AND METHODS.
A prospective blind randomized study (with preliminary stratification of cases by the severity of pathological process) on the effectiveness of the treatment of 228 patients with chronic paraproctitis fistulas was performed at the surgical department of the clinics at Rostov State Medical University in 2012-2017. The study included patients with transsphincteric and extrasphincteric fistulas, including relapse forms (156 men (67.8%) and 72 women (31.2%)). The mean age of men was 31.5±7.9 years old and the mean age of women was 47.1±9.4 years old. By the duration of the disease, patients were divided as follows: less than 6 months -26 patients (11.4%), from 6 months to 1 year -86 patients (37.7%), from 1 to 3 years -46 patients (20.2%), from 3 to 5 years -45 patients (19.7%), more than 5 years -25 patients (11%).
The study exclusion criteria were intrasphincteric pararectal fistulas, fistulas associated with specific diseases, and rectal neoplasms (including patients with radical surgery for cancer).
There were 34 patients with transsphincteric fistulas (14.9%), 5 of them had relapse fistulas The authors used the method of parametric statistics (Student's t-test). The differences were statistically significant at (p) > 95% (p < 0.05). In the rest cases, the differences were considered statistically insignificant (p > 0.05).
The study protocol followed guidelines for experimental investigation with human subjects in accordance with the Declaration of Helsinki and was approved by the ethics committee. Written informed consent was obtained from each patient (or an official representative) before the study.

RESULTS.
The treatment results showed that the video-assisted method using fistuloscopy is not only a treatment step but it also has important significance for the choice of intra-operative tactics.
Fistuloscopy provided the precise topical location of the fistula passage, its branches, and blind residual cavities. It allowed the authors to correct preoperative diagnostic discrepancies in topography. Due to the accumulation of clinical experience of the application of VAAFT, the treatment step included electrocoagulation of fistula passage walls, excision of necrotic tissues with a sharpened brush, suturing of internal fistula passage, and sealing of residual canal with twocomponent glue BioGlue. The final postoperative distribution of patients by the degree of severity of fistula in the studied groups is presented in Table 1. It should be noted that using

CONCLUSIONS.
The application of the VAAFT method in patients with complicated and relapse fistulas revealed significant benefits in comparison with traditional methods, which was proved by stable positive results and minimum complications. The method confirmed high clinical effectiveness and high safety achieved due to the minimum injury rates.
In patients with relapse and complicated extrasphincteric fistula, the risk of traumatic injury of earlier discredited and injured components of the sphincter is maximal, which provides a high risk of the development of sphincter failure and, as a result, fecal incontinence.
In the main group, due to the application of the VAAFT method, it was possible to avoid these complications by minimizing the risk of their development. It can be concluded that the best remote results were obtained in the main group (92.7%good, 1.8%satisfactory, 5.5%unsatisfactory) in comparison with Control group I (66.3%good, 14.6%satisfactory, 19.1%unsatisfactory) and Control group II (72.6%good, 14.2%satisfactory, 13.1%unsatisfactory).
The obtained results were achieved in the main group due to the application of a modified VAAFT technology and fistuloscopy techniques that provided a significant decrease in the level of early and remote postoperative complications.
The obtained data provides grounds for the recommendation of VAAFT in the treatment of complicated transsphincteric and extrasphincteric and relapse fistulas.