Restoration of sphincter function. Surgery for anal fissure: indications, methods, progress, rehabilitation. What should rehabilitation after surgery for bowel cancer include?
To the cells immune system include lymphocytes, macrophages and other antigen-presenting cells(A - cells, from the English accessory - auxiliary), as well as the so-called third population of cells(i.e. cells that do not have the main surface markers of T- and B-lymphocytes, A-cells).
According to their functional properties, all immunocompetent cells are divided into effector and regulatory. The interaction of cells in the immune response is carried out with the help of humoral mediators - cytokines. The main cells of the immune system are T and B lymphocytes.
Lymphocytes.
In the body, lymphocytes constantly recirculate between areas of accumulation of lymphoid tissue. The location of lymphocytes in lymphoid organs and their migration along the bloodstream and lymphatic beds are strictly ordered and associated with the functions of various subpopulations.
Lymphocytes have a common morphological characteristics, however, their functions, surface CD (from clusterdifferentiation) markers, individual (clonal) origin are different.
Based on the presence of surface CD markers, lymphocytes are divided into functionally different populations and subpopulations, primarily T- (thymus dependent, having undergone primary differentiation in the thymus) lymphocytes and B - (bursa-dependent, having undergone maturation in the bursa of Fabricius in birds or its analogues in mammals) lymphocytes.
T-lymphocytes.
Localization.
Usually localized in the so-called T-dependent zones of peripheral lymphoid organs (periarticular in the white pulp of the spleen and paracortical zones of the lymph nodes).
Functions.
T lymphocytes recognize the antigen processed and presented on the surface of antigen-presenting (A) cells. They are responsible for cellular immunity, immune reactions cell type. Distinct subpopulations help B lymphocytes respond to T-dependent antigens production of antibodies.
Origin and maturation.
The ancestor of all blood cells, including lymphocytes, is a single bone marrow stem cell. It generates two types of progenitor cells - lymphoid stem cell and the precursor of red blood cells, from which the precursor cells of leukocytes and macrophages originate.
The formation and maturation of immunocompetent cells occurs in the central organs of the immune system (for T-lymphocytes, in the thymus). Precursor cells of T lymphocytes enter the thymus, where pre-T cells (thymocytes) mature, proliferate and differentiate into separate subclasses as a result of interaction with epithelial and dendritic cells of the stroma and the influence of hormone-like polypeptide factors secreted by epithelial cells of the thymus (alpha1- thymosin, thymopoietin, thymulin, etc.).
During differentiation, T lymphocytes acquire a specific set of membrane CD markers. T cells are divided into subpopulations according to their function and CD marker profile.
T lymphocytes recognize antigens using two types of membrane glycoproteins - T cell receptors(family of Ig-like molecules) and CD3, non-covalently linked to each other. Their receptors, unlike antibodies and B-lymphocyte receptors, do not recognize freely circulating antigens. They recognize peptide fragments presented to them by A-cells through a complex of foreign substances with the corresponding protein of the major histocompatibility system of classes 1 and 2.
There are three main groups of T-lymphocytes: helpers (activators), effectors, regulators.
The first group is assistants ( activators) , which include T-helpers1, T-helpers2, inducers of T-helpers, inducers of T-suppressors.
1. T-helpers1 carry receptors CD4 (as well as T-helper2) and CD44, are responsible for maturation T-cytotoxic lymphocytes (T-killers), activate T-helpers2 and the cytotoxic function of macrophages, secrete IL-2, IL-3 and other cytokines.
2. T-helpers2 have common CD4 and specific CD28 receptors for helpers, ensure proliferation and differentiation of B lymphocytes into antibody-producing (plasma) cells, antibody synthesis, inhibit the function of T helper1, secrete IL-4, IL-5 and IL-6.
3. T-helper inducers carry CD29 and are responsible for the expression of HLA class 2 antigens on macrophages and other A cells.
4. Inducers of T-suppressors carry a CD45 specific receptor, are responsible for the secretion of IL-1 by macrophages, activation of the differentiation of T-suppressor precursors.
The second group is T-effectors. It includes only one subpopulation.
5. T-cytotoxic lymphocytes (T-killers). They have a specific CD8 receptor and lyse target cells carrying foreign antigens or altered autoantigens (transplant, tumor, virus, etc.). CTLs recognize a foreign epitope of a viral or tumor antigen in complex with an HLA class 1 molecule in the plasma membrane of the target cell.
The third group is T-cells-regulators. Represented by two main subpopulations.
6. T-suppressors are important in the regulation of immunity, providing suppression of the functions of T-helper 1 and 2, B-lymphocytes. They have receptors CD11, CD8. The group is functionally heterogeneous. Their activation occurs as a result of direct stimulation by antigen without significant participation of the major histocompatibility system.
7. T-consupressors. They do not have CD4, CD8, they have a receptor for a special leukine. They help suppress the functions of T-suppressors, develop resistance of T-helpers to the effect of T-suppressors.
B lymphocytes.
There are several subtypes of B lymphocytes. The main function of B cells is effector participation in humoral immune reactions, differentiation as a result of antigenic stimulation into plasma cells that produce antibodies.
The formation of B cells in the fetus occurs in the liver, and subsequently in the bone marrow. The process of B cell maturation occurs in two stages - antigen - independent and antigen - dependent.
Antigen-independent phase. In the process of maturation, the B lymphocyte goes through the stage pre-B-lymphocyte- an actively proliferating cell having cytoplasmic H-chains of type C mu (i.e. IgM). Next stage- immature B lymphocyte characterized by the appearance of membrane (receptor) IgM on the surface. The final stage of antigen-independent differentiation is the formation mature B lymphocyte, which can have two membrane receptors with the same antigen specificity (isotype) - IgM and IgD. Mature B lymphocytes leave Bone marrow and populate the spleen, lymph nodes and other accumulations of lymphoid tissue, where their development is delayed until they meet “their” antigen, i.e. before antigen-dependent differentiation occurs.
Antigen-dependent differentiation involves the activation, proliferation, and differentiation of B cells into plasma cells and memory B cells. Activation is carried out in various ways, which depends on the properties of antigens and the participation of other cells (macrophages, T-helpers). Most antigens that induce antibody synthesis require the participation of T cells to induce an immune response. Thymus-dependent antigens. Thymus-independent antigens(LPS, high molecular weight synthetic polymers) are able to stimulate the synthesis of antibodies without the help of T lymphocytes.
The B lymphocyte, using its immunoglobulin receptors, recognizes and binds the antigen. Simultaneously with the B cell, the antigen, presented by the macrophage, is recognized by the T helper (T helper 2), which is activated and begins to synthesize growth and differentiation factors. Activated by these factors, the B lymphocyte undergoes a series of divisions and simultaneously differentiates into plasma cells that produce antibodies.
The pathways of B cell activation and cell cooperation in the immune response to various antigens and with the participation of B cell populations with and without the Lyb5 antigen differ. Activation of B lymphocytes can be carried out:
T-dependent antigen with the participation of MHC class 2 T-helper proteins;
T-independent antigen containing mitogenic components;
Polyclonal activator (LPS);
Anti-mu immunoglobulins;
T-independent antigen that does not have a mitogenic component.
Cooperation of cells in the immune response.
In the formation of an immune response, all parts of the immune system are included systems-systems macrophages, T- and B-lymphocytes, complement, interferons and the major histocompatibility system.
IN in brief The following stages can be distinguished.
1. Uptake and processing of antigen by a macrophage.
2. Presentation of the processed antigen by the macrophage using the major histocompatibility system class 2 protein to T helper cells.
3. Antigen recognition by T-helpers and their activation.
4. Antigen recognition and activation of B lymphocytes.
5. Differentiation of B lymphocytes into plasma cells, synthesis of antibodies.
6. Interaction of antibodies with antigen, activation of complement systems and macrophages, interferons.
7. Presentation of foreign antigens to T-killers with the participation of MHC class 1 proteins, destruction of cells infected with foreign antigens by T-killers.
8. Induction of T- and B-immune memory cells capable of specifically recognizing the antigen and participating in the secondary immune response (antigen-stimulated lymphocytes).
Immune memory cells. Maintaining long-lived and metabolically inactive memory cells recirculating in the body is the basis for the long-term preservation of acquired immunity. The state of immune memory is determined not only by the lifespan of T- and B-memory cells, but also by their antigenic stimulation. Long-term preservation of antigens in the body is ensured by dendritic cells (antigen depot), which store them on their surface.
Dendritic cells- a population of growing cells of lymphoid tissue of bone marrow (monocyte) origin, presenting antigenic peptides to T lymphocytes and retaining antigens on their surface. These include follicular process cells of the lymph nodes and spleen, Langerhans cells of the skin and respiratory tract, M-cells of lymphatic follicles digestive tract, dendritic epithelial cells of the thymus.
CD antigens.
Cluster differentiation of surface molecules (antigens) of cells, primarily leukocytes, is making great progress. To date, CD antigens are not abstract markers, but functionally significant receptors, domains and determinants for the cell, including those that are not initially specific for leukocytes.
The most important differentiation antigens of T lymphocytes people are as follows.
1. CD2 is an antigen characteristic of T-lymphocytes, thymocytes, NK cells. It is identical to the receptor of sheep erythrocytes and ensures the formation of rosettes with them (method for determining T cells).
2. CD3 - necessary for the functioning of any T-cell receptors (TCRs). All subclasses of T lymphocytes have CD3 molecules. The interaction of TCR-CD3 (it consists of 5 subunits) with the antigen-presenting MHC class 1 or 2 molecule determines the nature and implementation of the immune response.
3. CD4. These receptors have T-helpers 1 and 2 and T-inducers. They are a coreceptor (binding site) for the determinants of MHC class 2 protein molecules. It is a specific receptor for the envelope proteins of the human immunodeficiency virus HIV-1 (gp120) and HIV-2.
4. CD8. The population of CD8+ T lymphocytes includes cytotoxic and suppressor cells. Upon contact with target cell CD8 acts as a coreceptor for HLA class 1 proteins.
Differentiation receptors of B-lymphocytes.
On the surface of B lymphocytes there can be up to 150 thousand receptors, among which more than 40 types have been described. various functions. Among them are receptors for the Fc component of immunoglobulins, for the C3 component of complement, antigen-specific Ig receptors, receptors for various growth and differentiation factors.
Brief description of methods for assessing T- and B-lymphocytes.
To identify B-lymphocytes, the method of rosette formation with erythrocytes treated with antibodies and complement (EAC-ROC), spontaneous rosette formation with mouse erythrocytes, the method of fluorescent antibodies with monoclonal antibodies (MAbs) to B-cell receptors (CD78, CD79a,b, membrane Ig) are used ).
To quantify T-lymphocytes, the method of spontaneous rosette formation with sheep erythrocytes (E-ROC) is used, to identify subpopulations (for example, T-helpers and T-suppressors) - an immunofluorescent method with mAbs to CD receptors, to determine T-killers - cytotoxicity tests .
The functional activity of T and B cells can be assessed in the response of blast transformation of lymphocytes (RBTL) to various T and B mitogens.
Sensitized T-lymphocytes involved in delayed-type hypersensitivity reactions (DTH) can be determined by the release of one of the cytokines - MIF (migration inhibitory factor) in the reaction of inhibition of leukocyte (lymphocyte) migration - RTML. Read more about methods for assessing the immune system in lectures on clinical immunology.
One of the features of immunocompetent cells, especially T-lymphocytes, is the ability to produce a large number of soluble substances - cytokines (interleukins) that perform regulatory functions. They ensure the coordinated operation of all systems and factors of the immune system; thanks to direct and feedback connections between various systems and subpopulations of cells, they ensure stable self-regulation of the immune system. Their determination provides additional insight into the state of the immune system.
The first study is always counting leukocyte formula(see chapter “Hematological studies”). Both relative and absolute values of the number of peripheral blood cells are assessed.
Determination of the main populations (T-cells, B-cells, natural killer cells) and subpopulations of T-lymphocytes (T-helpers, T-CTLs). For primary research immune status and detection of severe immune system disorders WHO recommended determination of CD3, CD4, CD8, CD19, CD16+56, CD4/CD8 ratio. The study allows us to determine the relative and absolute number of the main populations of lymphocytes: T cells - CD3, B cells - CD19, natural killer (NK) cells - CD3- CD16++56+, subpopulations of T lymphocytes (T helper cells CD3+ CD4+, T-cytotoxic CD3+ CD8+ and their ratio).
Research method
Immunophenotyping of lymphocytes is carried out using monoclonal antibodies to superficial differentiation tonsillitis on cells of the immune system, using flow laser cytofluorometry on flow cytometers.
The selection of the lymphocyte analysis zone is made based on the additional marker CD45, which is present on the surface of all leukocytes.
Conditions for taking and storing samples
Venous blood taken from the ulnar vein in the morning, strictly on an empty stomach, into a vacuum system to the mark indicated on the tube. K2EDTA is used as an anticoagulant. After collection, the sample tube is slowly inverted 8-10 times to mix the blood with the anticoagulant. Storage and transportation strictly at 18–23°C in vertical position no more than 24 hours
Failure to meet these conditions leads to incorrect results.
Interpretation of results
T lymphocytes (CD3+ cells). Increased quantity indicates hyperactivity of the immune system, observed in acute and chronic lymphocytic leukemia. An increase in the relative indicator occurs with some virus and bacterial infections at the onset of the disease, exacerbations of chronic diseases.
A decrease in the absolute number of T-lymphocytes indicates a failure of cellular immunity, namely a failure of the cellular-effector component of immunity. It is detected in inflammations of various etiologies, malignant neoplasms, after injury, surgery, heart attack, smoking, taking cytostatics. An increase in their number in the dynamics of the disease is a clinically favorable sign.
B lymphocytes (CD19+ cells) A decrease is observed with physiological and congenital hypogammaglobulinemia and agammaglobulinemia, with neoplasms of the immune system, treatment with immunosuppressants, acute viral and chronic bacterial infections, and the condition after removal of the spleen.
NK lymphocytes with the CD3-CD16++56+ phenotype Natural killer cells (NK cells) are a population of large granular lymphocytes. They are capable of lysing target cells infected with viruses and other intracellular antigens, tumor cells, as well as other cells of allogeneic and xenogeneic origin.
An increase in the number of NK cells is associated with activation of anti-transplantation immunity, in some cases observed with bronchial asthma, occurs when viral diseases, increases in malignant neoplasms and leukemia, during the period of convalescence.
Helper T-lymphocytes with the CD3+CD4+ phenotype An increase in absolute and relative amounts is observed in autoimmune diseases, perhaps with allergic reactions, some infectious diseases. This increase indicates stimulation of the immune system to the antigen and serves as confirmation of hyperreactive syndromes.
A decrease in the absolute and relative number of T cells indicates a hyporeactive syndrome with a violation of the regulatory component of immunity and is a pathognomic sign for HIV infection; occurs when chronic diseases(bronchitis, pneumonia, etc.), solid tumors.
T-cytotoxic lymphocytes with the CD3+ CD8+ phenotype An increase is detected in almost all chronic infections, viral, bacterial, protozoal infections. Is characteristic of HIV infection. A decrease is observed when viral hepatitis, herpes, autoimmune diseases.
CD4+/CD8+ ratio The study of the CD4+/CD8+ ratio (CD3, CD4, CD8, CD4/CD8) is recommended only for monitoring HIV infection and monitoring the effectiveness of ARV therapy. Allows you to determine the absolute and relative number of T-lymphocytes, subpopulations of T-helpers, CTLs and their ratio.
The range of values is 1.2–2.6. A decrease is observed with congenital immunodeficiencies (DiGeorge, Nezelof, Wiskott-Aldrich syndrome), with viral and bacterial infections, chronic processes, exposure to radiation and toxic chemical substances, multiple myeloma, stress, decreases with age, with endocrine diseases, solid tumors. It is a pathognomic sign for HIV infection (less than 0.7).
An increase in value of more than 3 – in autoimmune diseases, acute T-lymphoblastic leukemia, thymoma, chronic T-leukemia.
The change in the ratio may be associated with the number of helpers and CTLs in of this patient. For example, a decrease in the number of CD4+ T cells with acute pneumonia at the onset of the disease leads to a decrease in the index, but CTL may not change.
For additional research and identifying changes in the immune system in pathologies requiring assessment of the presence of an acute or chronic inflammatory process and the degree of its activity, it is recommended to include a count of the number of activated T-lymphocytes with the CD3+HLA-DR+ phenotype and TNK cells with the CD3+CD16++56+ phenotype.
T-activated lymphocytes with the CD3+HLA-DR+ phenotype A marker of late activation, an indicator of immune hyperreactivity. The expression of this marker can be used to judge the severity and strength of the immune response. Appears on T lymphocytes after day 3 acute illness. With a favorable course of the disease, it decreases to normal. Increased expression on T lymphocytes may occur in many diseases associated with chronic inflammation. Its increase was noted in patients with hepatitis C, pneumonia, HIV infection, solid tumors, and autoimmune diseases.
TNK lymphocytes with the CD3+CD16++CD56+ phenotype T-lymphocytes carrying CD16++ CD 56+ markers on their surface. These cells have properties of both T and NK cells. The study is recommended as an additional marker for acute and chronic diseases.
A decrease in them in the peripheral blood can be observed in various organ-specific diseases and systemic autoimmune processes. An increase was noted in inflammatory diseases of various etiologies and tumor processes.
Study of early and late markers of T-lymphocyte activation (CD3+CD25+, CD3-CD56+, CD95, CD8+CD38+) additionally prescribed to assess changes in IS in acute and chronic diseases, for diagnosis, prognosis, monitoring the course of the disease and therapy.
T-activated lymphocytes with the CD3+CD25+ phenotype, IL2 receptor CD25+ is a marker of early activation. The functional state of T-lymphocytes (CD3+) is indicated by the number of receptors expressing IL2 (CD25+). In hyperactive syndromes, the number of these cells increases (acute and chronic lymphocytic leukemia, thymoma, transplant rejection), in addition, their increase may indicate early stage inflammatory process. In peripheral blood they can be detected in the first three days of illness. A decrease in the number of these cells can be observed with congenital immunodeficiencies, autoimmune processes, HIV infection, fungal and bacterial infections, ionizing radiation, aging, heavy metal poisoning.
T-cytotoxic lymphocytes with the CD8+CD38+ phenotype The presence of CD38+ on CTL lymphocytes was noted in patients with various diseases. An informative indicator for HIV infection and burn disease. An increase in the number of CTLs with the CD8+CD38+ phenotype is observed in chronic inflammatory processes, cancer and some endocrine diseases. During therapy, the indicator decreases.
Subpopulation of natural killer cells with the CD3- CD56+ phenotype The CD56 molecule is an adhesion molecule widely present in nervous tissue. In addition to natural killer cells, it is expressed on many types of cells, including T-lymphocytes.
An increase in this indicator indicates an expansion of the activity of a specific clone of killer cells, which have less cytolytic activity than NK cells with the CD3- CD16+ phenotype. The number of this population increases in hematological tumors (NK-cell or T-cell lymphoma, plasma cell myeloma, aplastic large cell lymphoma), chronic diseases, and some viral infections.
A decrease is observed when primary immunodeficiencies, viral infections, systemic chronic diseases, stress, treatment with cytostatics and corticosteroids.
CD95+ receptor– one of the apoptosis receptors. Apoptosis is a complex biological process necessary to remove damaged, old and infected cells from the body. The CD95 receptor is expressed on all cells of the immune system. He plays important role in the control of the functioning of the immune system, as it is one of the receptors for apoptosis. Its expression on cells determines the cells' readiness for apoptosis.
A decrease in the proportion of CD95+ lymphocytes in the blood of patients indicates a violation of the effectiveness of the last stage of culling defective and infected own cells, which can lead to relapse of the disease, chronicity pathological process, development autoimmune diseases and increasing the likelihood of tumor transformation (for example, cervical cancer with papillomatous infection). Determination of CD95 expression has prognostic significance in myelo- and lymphoproliferative diseases.
An increase in the intensity of apoptosis is observed in viral diseases, septic conditions, and drug use.
Activated lymphocytes CD3+CDHLA-DR+, CD8+CD38+, CD3+CD25+, CD95. The test reflects the functional state of T-lymphocytes and is recommended for monitoring the course of the disease and monitoring immunotherapy for inflammatory diseases of various etiologies.
The anal sphincter is considered one of the important components of the rectum, with the help of which a person can control the process of bowel movement. Various violations in the functioning of the sphincter end up with the development of fecal incontinence, and this becomes the cause of various discomforts.
Problems with tone anus may develop in patients of various ages, but most often this disorder is detected in people with intestinal pathologies. Sphincter exercises increase muscle tone and help avoid involuntary contraction of the organ.
Sphincter anus Helps control bowel movements in the body. The constituent part of the rectum becomes a ring-shaped structure with striated muscles. It covers the anal canal, and the elliptical muscle located on the surface is attached directly to the tailbone itself.
The sphincter controls the movement of substances of varying consistency through the intestines. It takes an active part in the digestive process and holds its contents, preventing it from rising up the esophagus.
When contracting orbicularis muscle The sphincter opening closes, and when it relaxes, on the contrary, it opens.
A person cannot control the work of the internal anal sphincter only with his consciousness. Its relaxation and contraction are carried out reflexively if the feces irritate the nerve endings of the intestine.
The main function of such a sphincter is valve. This means that the sphincter becomes a kind of obstacle that does not allow anything through the anus in the absence of pushing.
Possible violations
Functional insufficiency of the anal sphincter can be expressed in its weakness or spasms.
Weakness
Experts identify several factors that provoke a decrease in the tone of the anus and the development of its insufficiency:
- pregnancy and labor activity among women;
- inflammatory processes in the tissues of the rectum and anus;
- malignant tumors;
- different kinds surgical interventions;
- injuries and damage that are accompanied by violation nerve fibers in the rectum.
Various types of neuropathies often cause damage to nerve fibers in the anal area.. Can cause incontinence when nerves are damaged diabetes, which is accompanied by the development of a pathological condition such as sphincter weakness.
Spasms
In addition, to provoke such pathological condition there may be other diseases gastrointestinal tract. With gastritis, the acidity of the stomach increases greatly and too much hydrochloric acid is produced.
The consequence of this is the passage of food from the stomach into the intestines, in which an excessive acidic environment is formed. The intestines simply cannot cope with such acidity and the result is the development spastic colitis and spasm of the anal sphincter.
Important! The main sign of sphincter spasm is pain in the anal area, which intensifies with defecation. When there is constant damage to the mucous membrane with feces, which becomes the cause.
Exercises
To increase the muscle tone of the anus of the rectum, experts recommend doing simple exercises. Besides, It is possible to achieve a positive effect in the fight against spasms with the help of Kegel exercises.
To strengthen muscles
Sphincter muscle training involves performing various exercises from certain starting positions. The patient needs to lie on his back, sharply squeeze the anal sphincter for a short time, and gradually relax the muscles. This exercise is recommended to be done regularly, as it helps strengthen the sphincter muscles and maintain their normal tone.
When asked how to relax the muscles of the anus, experts prescribe some exercises:
- Iron. You need to lie on your back and hold your raised legs motionless for 30 seconds;
- Cat. You should sit on all fours, alternately bend your lower back down and round your back;
- Birch. You need to lie on your back, raise your legs up at a right angle and slowly lift your pelvis, supporting it with your hands.
Such physical exercise To strengthen the muscles of the anus, it can be done for patients of all ages, regardless of their physical fitness.
Insufficiency of the anal sphincter is detected in 3-7% of patients with diseases of the colon. In reality, there are much more such patients, but out of false shame, many of them do not seek help. This disease does not directly threaten life, but often leads to disability, creating difficult relationships with others.
Etiology. Normally, intestinal contents are retained due to the slit-like shape and sufficient length of the anal canal; activity of the external and internal sphincters; muscles that lift the anus, strengthen the function of the sphincters and form the anorectal flexure, changing the direction of evacuation feces; motor activity of the colon. The work of the muscles and motor activity of the colon is corrected by nerve receptors, the sensitivity of which in the anal canal, the distal rectum and throughout the colon is different. The defeat of one of these links leads to disruption of the coordinated functioning of the obturator apparatus of the rectum and a decrease in the ability to retain intestinal contents.
The damage may be caused by damage muscle tissue and mucous membrane containing nerve endings (wounds, intraoperative injuries, birth injuries, etc.); damage and disease nervous system(Firstly spinal cord); inflammatory diseases and their consequences, reducing the sensitivity of the receptor zone and increasing the motility of the colon (strictures and tumors of the anus and rectum); congenital defects in the development of the anorectal region.
Clinical picture insufficiency of the anal sphincter. Patients report varying degrees of insufficiency of the anal sphincter - from gas incontinence to liquid and even dense feces incontinence. Classification of anal sphincter insufficiency, taking into account the form and etiology of the disease, the degree and nature of the disorders, as well as concomitant diseases.
The main link in the pathogenesis of anal sphincter insufficiency should be considered a decrease or increase in receptor sensitivity, impaired conduction along peripheral nerves and damage to the central nervous system. Decreased sensitivity makes it difficult to control bowel retention, and increased sensitivity causes frequent evacuation of feces even with a small amount in the rectum. Insufficiency of the anal sphincter is aggravated by concomitant dystrophic changes in muscle tissue.
The organic form is characterized by a defect in muscle structures of varying length. There is also a mixed form of sphincter insufficiency, in which disorders of the neuro-reflex activity (characteristic of the inorganic form) and the muscular structures of the obturator apparatus of the rectum (characteristic of the organic form) are combined. Weakness of the anal sphincter is increased by concomitant diseases of the colon, requiring conservative or surgical treatment.
Congenital impairment of the function of holding intestinal contents is observed with various malformations of the rectum. The appearance of insufficiency of the anal sphincter after procto(ano)plasty is most often a consequence of damage to the external sphincter during plastic surgery, but is often combined with a violation of the neuro-reflex activity of the obturator apparatus of the rectum and the motor activity of the colon.
In case of traumatic insufficiency of the anal sphincter, defects of the external anal sphincter prevail. With an increase in the volume of damage and the prevalence of the scar process, the frequency of damage to the internal sphincter and the severity of neuro-reflex disorders increase. The severity of the latter is aggravated by the purulent-inflammatory process.
Diagnosis. The main complaints of patients with anal sphincter insufficiency are incontinence of gases, liquid or solid feces, which approximately corresponds to the 1st, 2nd or 3rd degree of anal incontinence. The severity of incontinence is finally determined using special methods for studying the condition of the obturator apparatus of the rectum. During the survey, they find out the reason for the dysfunction of holding intestinal contents, the frequency and nature of stool, urination, pay attention to the preservation of the feeling of the urge to defecate, the ability to differentiate the nature of the lump contents.
When examining the patient, the size of the anus, its shape, deformations of the perianal skin, and cicatricial changes in the skin are determined. To study the anal reflex, the perianal skin, root of the scrotum, and labia majora are irritated, noting the presence of contraction of the external anal sphincter. The anal reflex is assessed as lively, weakened, or the absence of sphincter contraction. At digital examination assess the tone of the sphincter and its volitional contractions, the length of the anal canal, the safety top edge anorectal angle, the size of the lumen of the anal canal and the distal part of the rectum, the condition of the inner surface of the sacrum, the muscles that lift the ani, and surrounding tissues.
The condition of the mucous membrane and patency of the rectum is assessed during mandatory sigmoidoscopy. X-ray examination of the rectum and pelvic bones is aimed at determining the tone of the colon, the size of the anorectal angle, identifying damage to the sacrum and spine, and spinal bifida. Determine the value of the anorectal angle (the ratio of the direction axes of the anal canal and rectum), which normally is 82-85°; An increase in the anorectal angle should be corrected with surgery.
In addition, the condition of the obturator apparatus of the rectum is assessed by special functional studies. Sphincterometry using a branch sphincterometer with graphical recording of indicators allows you to assess the contractility of the anal sphincter; Both the indicators of tonic tension and volitional contraction themselves, as well as the difference between them, characterizing to a greater extent the contractility of the external sphincter of the rectum, are important. To assess the safety of muscle tissue and its innervation, electromyography is performed. Using a rectal electrode, the function of the external and internal sphincters is assessed, and using a needle electrode, the border of muscle tissue, the muscles that lift the ani, is assessed. A cutaneous plate electrode allows you to determine the condition of the muscles of the perineum and gluteal muscle. Manometric methods are used to study the pressure in the anal canal in the projections of the external and internal sphincter, the threshold of the rectoanal reflex, adaptive capacity, the maximum volume of filling and the sensitivity threshold of the rectum. Dilatometry allows you to determine the degree of elasticity and distensibility of the anal sphincter.
It should be noted that the patient’s complaints about gas incontinence, the presence of unpleasant odor, the dismissive or suspicious attitude of others may be a manifestation of dysmorphophobia. In such cases, you should, after making sure that there is no decrease in the function of the obturator apparatus of the rectum by objective methods, consult the patient with.
Treatment in patients with anal sphincter insufficiency, it is carried out taking into account violations of continence mechanisms. As a rule, it combines conservative and surgical methods.
Conservative treatment of anal sphincter insufficiency is aimed at improving the neuro-reflex activity and contractility of the obturator apparatus of the rectum. It is included in the complex of preoperative preparation and postoperative treatment patients with organic and mixed forms of anal sphincter insufficiency. Conservative treatment of anal sphincter insufficiency is the main one for patients with an inorganic form of incontinence, as well as with an organic form of incontinence of the first degree with linear sphincter defects not exceeding the circumference, in the absence of anal deformity. In addition to a diet with restriction of toxins and liquids, rectal lavages and treatment inflammatory diseases, electrical stimulation of the sphincter and perineal muscles is of great importance, as well as physical therapy and drug therapy.
Electrical stimulation of the anal sphincter and perineal muscles is carried out intermittently daily (course 10-15 days). This method is limited if there is general contraindications to electrotherapy, as well as for incontinence with increased threshold irritation of the rectum, since in this case electrical stimulation leads to increased irritation of the receptor zone.
Includes exercises for the abdominal and pelvic floor muscles, gluteal region, hip adductors, as well as breathing exercises. The duration of the lesson (30-40 minutes) depends on age and general condition sick. Strength exercises are contraindicated.
Drug therapy is aimed at treating inflammatory diseases of the colon and dysbiosis. Improvement of neuro-reflex activity is facilitated by the use of anabolic drugs (Nerobol, Retabolil, potassium orotate, etc.), proserin, ATP, B vitamins.
Mechanical dysfunction of the sphincter apparatus is the main indication for surgical treatment.
For defects of the anal sphincter equal to or slightly exceeding 1/4 of the circumference, accompanied by deformation of the wall of the anal canal, when the scar process does not extend to the pelvic floor muscles and there is a II degree of insufficiency, sphincteroplasty is performed. It is made from an arcuate incision 3 cm long, retreating from the edge of the anus by 2-3 cm. After exposing the sphincter muscle and the scar tissue replacing it, the sphincter areas adjacent to the scar are mobilized for 1.5-2 cm in each direction, the scar excised. The ends of the sphincter are brought together with two or three U-shaped catgut sutures or the sphincter is sutured side-to-side; The subcutaneous portion of the pulp is carefully isolated and sutured. The wound is sutured in the radial direction with rare interrupted sutures; sometimes excision of the skin scar and plastic surgery of the perianal skin are required.
In case of a defect of the anal sphincter from 1/4 to half a circle with its localization along the anterior or posterior semicircle, or insufficiency of the anal sphincter of II-III degree, sphincterolevatoroplasty is performed. The operation involves isolating scarred tissue of the sphincter and the anterior or posterior semicircle of the rectum to a height of up to 6 cm. Corrugated sutures are placed on the rectum, narrowing its lumen. Then, the levator ani muscles are sutured with three to four sutures, the presence of the anorectal angle on the side of the rectal lumen is controlled, and sphincterolevatoplasty is performed.
Damage to the lateral semicircle of the sphincter is usually accompanied by injury and cicatricial degeneration of the levator ani muscles, which does not allow sphincterolevatoplasty. In such cases, sphincterogluteoplasty is performed - a flap cut from the medial edge of the gluteus maximus muscle (7-8 cm long) is sutured to the edges of the mobilized sphincter.
If the muscles of the obturator apparatus of the rectum are damaged, occupying 1/4 or its entire circumference, surgical correction using the gluteus maximus muscles (gluteoplasty) or the medial portion of the adductor magnus muscle of the thigh. Sphincter correction using fascial strips is less effective.
When insufficiency of the anal sphincter is combined with rectal fistulas or strictures of the anal canal, it is possible to simultaneously perform an operation to eliminate the fistula or stricture with plastic surgery of the obturator apparatus using one of the described methods.
Success plastic surgery with insufficiency of the anal sphincter, it sharply decreases with the development of wound infection. Its prevention is achieved by careful hemostasis, careful handling of tissues, adequate wound care and the use of antibiotics. For these reasons, correction of anal insufficiency is carried out only after the disappearance of purulent-inflammatory processes in the perianal zone and pararectal tissue, with severe course which sometimes require a preventive colostomy. The latter is also indicated for patients preparing for complex reconstructive interventions using the gluteal or thigh muscles. The frequency of wound suppuration in these cases decreases significantly.
Postoperative treatment is aimed at preventing wound infection and limiting the motor activity of the colon muscles. Stool retention is achieved through dietary restrictions; the first chair is called by appointment Vaseline oil and a high cleansing enema on the 7-10th day, after which the food regimen is expanded. After the wound has healed, it is carried out conservative treatment insufficiency of the anal sphincter.
Physical activity is limited for 2-3 months. after sphinctero- and sphincterolevatoroplasty and up to 4-6 months. after reconstruction of the sphincter using the muscles of the gluteal region and thigh. Clinical observation for up to 2 years after surgery is aimed at assessing the function of the obturator apparatus (every 6 months) and conducting courses of conservative therapy.
It should be noted that in some severe cases of incontinence, a colostomy may be more tolerable than being unable to close. Recently, methods have been developed to eliminate anal incontinence using sphincteroplasty of autologous, freely transplanted colonic muscle.
The article was prepared and edited by: surgeon