Check-up and treatment of chronic postoperative wounds of the anal canal and perineum

AIM: to work out the algorithm for diagnosis and treatment of non-healing postoperative wounds of the perineum and anal canal.
PATIENTS AND METHODS: the prospective cohort study included 119 people which underwent surgery for chronic anal fissure, hemorrhoids and anal fistula. The main group included 63 patients with long-term non-healing chronic wounds (46-159 days after surgery, mean 106.0 ± 44.8 days). The control group included 56 patients, whose postoperative period was uneventful and whose wounds healed on the 38.0 ± 10.4 days (p = 0.001).The wound healing and possible deviations in its course were assessed in all the patients using clinical, microbiological, cytological, pathomorphological pathophysiological tests, as well as molecular diagnostics (PCR). The main and control groups of the patients were homogenous in the main parameters (age, sex, the nature of surgical treatment), with the exception of the history of the disease. In the patients with a history of non-healing postoperative wounds, the incidence of sexually transmitted infections (STI) and inflammatory diseases of the pelvic organs, possibly caused by STI, was 44.4%, and in the patients of the control group — 10.7%, (p = 0.002).
RESULTS: in all patients of the main group at the time of admission and in 85.7% of the control group on the 30th day after the surgery, the wounds were contaminated with various microorganisms during bacteriological examination. Clinically significant microorganisms were found in 71.4% of the patients in the main group and in 12.5% of the control group (p = 0.0001). Associations of microorganisms were found in 73.0% in the main group and only in 33.9% in the controls (p = 0.01). During PCR in wounds of the perineum and anal canal STI were found in 34.9% in the main group, while in the control — 7.1% (p = 0.003). Histological examination of tissues taken from the area of non-healing wounds revealed papillomavirus infection (koilocytosis) in 11 (17.5%) patients. The patients with non-healing wounds were treated depending on the isolated pathogen and sensitivity to antibiotics, as well as appropriate treatment if an STI was detected. In 6.3% in the main group, the wounds did not heal and a spasm of the internal sphincter was detected. These patients got injection of botulinum toxin type A (BTA) into the internal sphincter (40 U). After 9.4 days after the BTA complete wound healing was noted. A control test (profilometry) on the 7th day after the BTA showed no spasm of the internal sphincter in all cases.
CONCLUSION: healing processes in patients after anal surgery may slow down due to the presence of infectious agents, opportunistic pathogens and STI, which support the inflammatory wound reaction in the postoperative period, as well as due to spasm of the anal sphincter. It is necessary to carry out targeted diagnostics, to prescribe appropriate treatment, and in the presence of anal sphincter spasm, to eliminate it.

1. Vinnik Yu.S., Markelova N.M., Tyuryumin V.S. Modern methods for treatment of purulent wounds Siberian Medical Review. 2013;1:18–24. (in Russ.).

2. Lewis S. Pilcher. The Treatment of Wounds. 2015:10–15.

3. Frolov S.A., Kuzminov A.M., Vyshegorodtsev D.V., Korolik V.Yu., et al. Low-temperature argon plasma in the wounds treatment after hemorrhoidectomy. Koloproktologia. 2021;20(3):51–61. (in Russ.). DOI:10.33878/2073-7556-2021-20-3-51-61

4. Sheets AR, Massey CJ, Cronk SM, Iafrati MD, et al. J Matrix- and plasma-derived peptides promote tissue-specific injury responses and wound healing in diabetic swine. Transl Med. 2016;Jul 214(1):197.

5. George Han 1 , Roger Ceilley Chronic Wound Healing: A Review of Current Management and Treatments. Adv Ther. 2017;Mar 34(3):599–610.

6. Potekaev N.N., Frigo N.V., Michenko A.V., Lvov A.N. et al. Chronic ulcers and wounds of the skin and subcutaneous tissue that do not heal for a long time. Clinical Dermatology and Venereology. 2018;17(6):7–12. (in Russ.).

7. Nekhrikova S.V., Titov A.Yu., Korneva T.K., Markova E.V., Vorobieva I.V. Treatment of non-healing wounds of the perineum and anal canal. RMZh. 2014;17:1242 -1247. (in Russ.).

8. Obolensky V.N. Modern methods of treating chronic wounds. Surgery. 2016;10:148–154. (in Russ.).

9. Nekhrikova S.V., Titov A.Yu., Kashnikov V.N., Romanov R.I. et al. Anal canal and perianal diseases treatment in an outpatient setting. Evidence-Based Gastroenterology. 2019;8(3):27–37. (in Russ.).

10. Tkalich O.V., Ponomarenko A.A., Fomenko O. Yu., ArslanbekovaK.I. et al. The treatment of chronic anal fissures with fissure excision and botulinum toxin type A injection (ISRCTN97413456). Koloproktologia. 2020;19(1):80–99. (in Russ.). DOI:10.33878/2073-7556-2020-19-1-80-99

11. Ribeiro DML, Carvalho Júnior AR, Vale de Macedo GHR, Chagas VL, et al. Polysaccharide-Based Formulations for Healing of Skin-Related Wound Infections: Lessons from Animal Models and Clinical Trials. Biomolecules. 2019; Dec 3010(1):63.

12. Nekhrikova S. Chronic wounds perineum and anal canal. Colorectal Disease. (ESCP), Berlin.2017;19(Suppl.2): 33.

13. Khairullina G.A., Konovalov A.S., Zueva A.G., Surovtsev V.V. et al. Prevalence of sexually transmitted infections, Difficult patient.2018;16(6):67–70. (in Russ.).

14. Wagenlehner Florian M.E. , Brockmeyer N.H., Thomas Discher, Klaus Friese, et al. The Presentation, Diagnosis, and Treatment of Sexually Transmitted Infections. Dtsch Arztebl Int. 2016; Jan 11;113(1-02):11–22.

15. Marin V, Bertoncello C.Marin V, et al. Sexually transmitted diseases: epidemiological and social aspects. Ann Ig. 2002; MarApr;14(2):163–9.

16. McMurray M, Armstrong M, Paulson J. Addressing the Increased Incidence of Common Sexually Transmitted Infections. J Am Osteopath Assoc. 2018; Aug 1;118(8):51–55.

17. Jensen JS, Cusini M, Gomberg M, Moi H.Jensen JS, et al. 2016 European guideline on Mycoplasma genitalium infections. J Eur Acad Dermatol Venereol. 2016; Oct 30(10):1650–1656.

18. Ershov V.A., Vyazovaya A.A., Narvskaya O.V. Immunomorphological criteria for coylocytes. Bulletin of St. Petersburg State University. 2014;2:171–174. (in Russ.).

19. Khryukin R.Yu., Kostarev I.V., Arslanbekova K.I., Nagudov M.A. et al. Botulinum toxin type A and lateral subcutaneous sphincterotomy for chronic anal fissure with the sphincter spasm. What to choose? (systematic literature review and meta-analysis). Koloproktologia. 2020;19(2):113–128. (in Russ.). DOI:10.33878/2073-7556-2020-19-2-113-128

20. Shelygin Yu.A., Tkalich O.V., Ponomarenko A.A. Follow-Up Results of Combination Treatment of Chronic Anal Fissure. International Journal of Pharmaceutical Research. 2020;12(2):244–249.