{"id":2747,"date":"2013-05-21T09:54:52","date_gmt":"2013-05-21T09:54:52","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2747"},"modified":"2013-06-08T09:37:00","modified_gmt":"2013-06-08T09:37:00","slug":"9-nejcastejsi-onemocneni-v-proktologii","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2747","title":{"rendered":"9 Nej\u010dast\u011bj\u0161\u00ed onemocn\u011bn\u00ed v proktologii"},"content":{"rendered":"<h6>\u00davod<\/h6>\n<p style=\"text-align: justify;\">Terminologicky rozum\u00edme kone\u010dn\u00edkem (rektem) kone\u010dnou \u010d\u00e1st tlust\u00e9ho st\u0159eva od sigmatu a\u017e k \u0159itn\u00edmu (an\u00e1ln\u00edmu) otvoru. Tato \u010d\u00e1st za\u017e\u00edvac\u00edho traktu, ozna\u010dovan\u00e1 tak\u00e9 jako anorekt\u00e1ln\u00ed oblast, se skl\u00e1d\u00e1 z \u010d\u00e1sti p\u00e1nevn\u00ed a an\u00e1ln\u00ed. Toto rozli\u0161ov\u00e1n\u00ed \u010dasto neb\u00fdv\u00e1 u\u017e\u00edv\u00e1no zcela p\u0159esn\u011b. V klinick\u00e9 praxi by pojem kone\u010dn\u00edk m\u011bl b\u00fdt u\u017e\u00edv\u00e1n jen pro p\u00e1nevn\u00ed \u010d\u00e1st. V\u00fdvojov\u011b je an\u00e1ln\u00ed oblast p\u016fvodu ektoderm\u00e1ln\u00edho s citlivou somatickou inervac\u00ed a oblast kone\u010dn\u00edku m\u00e1 p\u016fvod entoderm\u00e1ln\u00ed s viscer\u00e1ln\u00ed inervac\u00ed necitlivou na bolestiv\u00e9 podn\u011bty. Hranic\u00ed obou \u010d\u00e1st\u00ed je linea dentata. Diagnostika a l\u00e9\u010dba onemocn\u011bn\u00ed anorekt\u00e1ln\u00ed oblasti je na pomez\u00ed chirurgie a gastroenterologie a vy\u017eaduje speci\u00e1ln\u00ed znalosti a \u0161kolen\u00ed. Proto se vytvo\u0159il zvl\u00e1\u0161tn\u00ed podobor naz\u00fdvan\u00fd proktologie, kter\u00fdm se ze sv\u00e9ho pohledu zab\u00fdvaj\u00ed ob\u011b odbornosti. V n\u00e1sleduj\u00edc\u00edch kapitol\u00e1ch se pojedn\u00e1v\u00e1 o nej\u010dast\u011bj\u0161\u00edch onemocn\u011bn\u00edch a v\u00fdkonech v proktologii.<\/p>\n<p style=\"text-align: justify;\">Problematika nej\u010dast\u011bj\u0161\u00edch proktologick\u00fdch onemocn\u011bn\u00ed je \u010dastou n\u00e1pln\u00ed pr\u00e1ce v\u0161eobecn\u00e9ho chirurga a rozd\u011blili jsme ji do n\u00e1sleduj\u00edc\u00edch kapitol:<\/p>\n<ol>\n<li>an\u00e1ln\u00ed absces a an\u00e1ln\u00ed p\u00ed\u0161t\u011bl,<\/li>\n<li>sinus pilonidalis,<\/li>\n<li>\u0159itn\u00ed trhliny,<\/li>\n<li>hemoroidy.<\/li>\n<\/ol>\n<h4>9.1 An\u00e1ln\u00ed absces a an\u00e1ln\u00ed p\u00ed\u0161t\u011bl<\/h4>\n<h6>Obecn\u011b<\/h6>\n<p style=\"text-align: justify;\">Klinick\u00e9 obrazy an\u00e1ln\u00edho abscesu a an\u00e1ln\u00ed p\u00ed\u0161t\u011ble jsou spolu \u00fazce spjaty a vych\u00e1zej\u00ed ze stejn\u00e9ho z\u00e1kladu. T\u00e9m\u011b\u0159 v\u017edy je absces p\u0159edch\u00e1zej\u00edc\u00edm akutn\u00edm jevem a p\u00ed\u0161t\u011bl p\u0159\u00edm\u00fdm d\u016fsledkem. Anorekt\u00e1ln\u00ed abscesy a p\u00ed\u0161t\u011ble jsou t\u0159ikr\u00e1t \u010dast\u011bj\u0161\u00ed u mu\u017e\u016f ne\u017e u \u017een.<\/p>\n<p style=\"text-align: justify;\">Abscesy jsou nej\u010dast\u011bj\u0161\u00ed mezi 20. a 40. rokem \u017eivota a p\u00ed\u0161t\u011ble mezi 20. a 50. rokem \u017eivota.<\/p>\n<h6>Etiopatogeneza<\/h6>\n<p style=\"text-align: justify;\">Periprokt\u00e1ln\u00ed abscesy jsou zp\u016fsobeny nespecifickou infekc\u00ed rudiment\u00e1rn\u011b ulo\u017een\u00fdch proktode\u00e1ln\u00edch \u017el\u00e1zek \u2013 nej\u010dast\u011bji v oblasti zadn\u00ed komisury. Tento prim\u00e1rn\u00ed absces se klinicky nemus\u00ed projevit a m\u016f\u017ee se spont\u00e1nn\u011b zase zhojit. Absces se tak\u00e9 m\u016f\u017ee vypr\u00e1zdnit p\u0159es kryptu do \u0159itn\u00edho kan\u00e1lu. Pokud se v\u0161ak \u0161\u00ed\u0159\u00ed infekce pod\u00e9l existuj\u00edc\u00edch \u0161t\u011brbin submuk\u00f3zn\u011b, subanoderm\u00e1ln\u011b, intersfinktericky, transsfinktericky nebo v\u016fbec suprasfinktericky, je v\u00fdsledkem klinicky v\u00fdrazn\u00fd sekund\u00e1rn\u00ed absces, vlastn\u00ed periprokt\u00e1ln\u00ed absces. Zde u\u017e spont\u00e1nn\u00ed reverze nen\u00ed mo\u017en\u00e1. Bez l\u00e9\u010dby doch\u00e1z\u00ed podle polohy abscesu k jeho perforaci do rekta, do \u0159itn\u00edho kan\u00e1lu nebo vn\u011b do oblasti perian\u00e1ln\u00ed.<\/p>\n<h6>Klinick\u00fd obraz abscesu<\/h6>\n<p style=\"text-align: justify;\">Symptomatika periprokt\u00e1ln\u00edch absces\u016f z\u00e1vis\u00ed na jejich um\u00edst\u011bn\u00ed. Zpravidla se v\u0161ak vyskytuj\u00ed po n\u011bkolik dn\u00ed intenzivn\u00ed, pulzuj\u00edc\u00ed bolesti, kter\u00e9 jsou mnohdy k nevydr\u017een\u00ed, \u010d\u00e1ste\u010dn\u011b s hore\u010dkou a z\u0159ejm\u00fdm pocitem nemoci. P\u0159i spont\u00e1nn\u00ed perforaci bolesti zna\u010dn\u011b polev\u00ed, av\u0161ak nevymiz\u00ed \u00fapln\u011b. D\u016fvodem je nedostate\u010dn\u00e1 dren\u00e1\u017e. Op\u011btovn\u00e9 zadr\u017eov\u00e1n\u00ed sekretu s nov\u00fdm n\u00e1r\u016fstem obt\u00ed\u017e\u00ed nen\u00ed v\u00fdjimkou. Po spont\u00e1nn\u00ed perforaci (nebo chirurgick\u00e9 incizi) abscesu pak z\u016fst\u00e1v\u00e1 \u2013 podle pr\u016fb\u011bhu \u2013 jedna z n\u00ed\u017ee popsan\u00fdch p\u00ed\u0161t\u011bl\u00ed. Klinick\u00e1 symptomatika abscesu je mnohdy m\u00e9n\u011b dramatick\u00e1, kdy\u017e se absces rozv\u00edj\u00ed nejprve krani\u00e1ln\u011b: ischiorekt\u00e1ln\u011b, pelvirekt\u00e1ln\u011b, supralevatorn\u011b. Zpo\u010d\u00e1tku se objevuje pouze nep\u0159\u00edjemn\u00fd tlak nebo pocit p\u0159\u00edtomnosti ciz\u00edho t\u011blesa, s rostouc\u00ed expanz\u00ed brzy n\u00e1sleduj\u00ed siln\u011bj\u0161\u00ed bolesti, hore\u010dka nebo zimnice se siln\u00fdm pocitem nemoci.<\/p>\n<p style=\"text-align: justify;\">Obzvl\u00e1\u0161t\u011b u stavu sn\u00ed\u017een\u00e9 imunity by se z ischioa pelvirekt\u00e1ln\u00edch absces\u016f mohly vyvinout flegm\u00f3ny p\u00e1nevn\u00edho dna nebo a\u017e \u017eivot ohro\u017euj\u00edc\u00ed gangr\u00e9na.<\/p>\n<h6>N\u00e1lez u abscesu<\/h6>\n<p>Pro praxi se doporu\u010duje n\u00e1sleduj\u00edc\u00ed rozd\u011blen\u00ed absces\u016f;je orientov\u00e1no podle anatomick\u00fdch struktur.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Ischiorekt\u00e1ln\u00ed absces<\/strong><br \/>\nAbscesy ulo\u017een\u00e9 v ischiorekt\u00e1ln\u00ed j\u00e1m\u011b jsou ohrani\u010deny dovnit\u0159 svalstvem sv\u011bra\u010de, krani\u00e1ln\u011b zdviha\u010dem kone\u010dn\u00edku a vn\u011b kost\u00ed sedac\u00ed. Mohou se vyskytovat jedno-, ale i oboustrann\u011b.<\/li>\n<li style=\"text-align: justify;\"><strong>Intersfinkterick\u00fd absces<\/strong><br \/>\nAbscesy nach\u00e1zej\u00edc\u00ed se mezi sv\u011bra\u010di se vyprazd\u0148uj\u00ed p\u0159ev\u00e1\u017en\u011b prost\u0159ednictv\u00edm v\u00fdvod\u016f infikovan\u00fdchproktode\u00e1ln\u00edch \u017el\u00e1zek a pot\u00e9 \u010dasto vystupuj\u00ed jakone\u00fapln\u00e9 vnit\u0159n\u00ed p\u00ed\u0161t\u011ble, z nich\u017e se nap\u0159. p\u0159i vy\u0161et\u0159en\u00ed n\u00e1razov\u011b uvol\u0148uje hnis; jin\u00e9 perforuj\u00ed dist\u00e1ln\u011b. Tyto abscesy se v\u0161ak mohou vyskytovat tak\u00e9v supralev\u00e1torov\u00e9 oblasti, z n\u00ed\u017e vedou k suprasfinkterick\u00fdm p\u00ed\u0161t\u011bl\u00edm.<\/li>\n<li style=\"text-align: justify;\"><strong>Subanoderm\u00e1ln\u00ed \u2013 submuk\u00f3zn\u00ed absces<br \/>\n<\/strong>Jejich v\u00fdskyt je pom\u011brn\u011b \u0159\u00eddk\u00fd, le\u017e\u00ed na povrchu mezi svalstvem sv\u011bra\u010de a an\u00e1ln\u00edm, p\u0159\u00edp. rekt\u00e1ln\u00edm epitelem. Podle toho se zde rozli\u0161uj\u00ed submuk\u00f3zn\u00eda subanoderm\u00e1ln\u00ed abscesy. U subkut\u00e1nn\u00edho roz\u0161\u00ed\u0159en\u00ed je z pohledu diferenci\u00e1ln\u00ed diagnostiky pot\u0159eba pom\u00fd\u0161let na an\u00e1ln\u00ed acne inversa.<\/li>\n<li style=\"text-align: justify;\"><strong>Pelvirekt\u00e1ln\u00ed absces<\/strong><br \/>\nTyto abscesy mezi st\u011bnou rekta a svalstvem zdviha\u010de se ozna\u010duj\u00ed tak\u00e9 jako supralevatorn\u00ed abscesy.<\/li>\n<\/ul>\n<p><span style=\"text-align: justify;\">Klasifikace absces\u016f dle Nov\u00e1ka (Nov\u00e1k 1985) je zn\u00e1zorn\u011bna na obr\u00e1zc\u00edch 1 a\u017e 6.<\/span><\/p>\n<h6>Klinick\u00fd obraz \u201ep\u00ed\u0161t\u011ble\u201c<\/h6>\n<p style=\"text-align: justify;\">Na rozd\u00edl od abscesu je klinick\u00e1 symptomatika perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed m\u00e9n\u011b dramatick\u00e1. V pop\u0159ed\u00ed je r\u016fzn\u011b siln\u00e9 vym\u011b\u0161ov\u00e1n\u00ed hnisav\u011b-ser\u00f3zn\u00edho sekretu, nez\u0159\u00eddka s v\u00fdrazn\u00fdm an\u00e1ln\u00edm ekz\u00e9mem. Epitelizace a n\u00e1sledn\u00fd uz\u00e1v\u011br vn\u011bj\u0161\u00edho \u00fast\u00ed p\u00ed\u0161t\u011ble m\u016f\u017ee zp\u016fsobit p\u0159echodn\u00e9 zadr\u017eov\u00e1n\u00ed sekretu, ani\u017e by se v\u0161ak p\u00ed\u0161t\u011bl zhojila. Pot\u00e9 je ot\u00e1zkou \u010dasu, kdy se p\u00ed\u0161t\u011bl nebo nov\u00fd absces op\u011bt rozvinou.<\/p>\n<h6>Klinick\u00fd n\u00e1lez u p\u00ed\u0161t\u011ble<\/h6>\n<p style=\"text-align: justify;\">U perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed se rozli\u0161uje p\u011bt typ\u016f \u2013 podle jejich pr\u016fb\u011bhu. Vnit\u0159n\u00ed, tak\u00e9 prim\u00e1rn\u00ed, otvor je v\u00fdvodem proktode\u00e1ln\u00ed \u017el\u00e1zky, tedy krypty. Vn\u011bj\u0161\u00ed otvor je v\u011bt\u0161inou um\u00edst\u011bn perian\u00e1ln\u011b. Po spont\u00e1nn\u00ed perforaci abscesu do rekta le\u017e\u00ed sekund\u00e1rn\u00ed otvor p\u00ed\u0161t\u011ble v horn\u00ed \u010d\u00e1sti \u0159itn\u00edho kan\u00e1lu, p\u0159\u00edp. ve spodn\u00ed \u010d\u00e1sti rekta. Dva otvory p\u00ed\u0161t\u011ble \u2013 v\u017edy po obou stran\u00e1ch \u0159itn\u00edho otvoru \u2013 poukazuj\u00ed na tzv. podkovovitou p\u00ed\u0161t\u011bl. U siln\u011b rozv\u011btven\u00fdch p\u00ed\u0161t\u011bl\u00ed s v\u00edce otvory hovo\u0159\u00edme o p\u00ed\u0161t\u011bl\u00edch ve tvaru \u201eli\u0161\u010d\u00ed nory\u201c.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_343.png\"><img decoding=\"async\" title=\"Obr. 1 \u2013 Podslizni\u010dn\u00ed absces\" alt=\"Obr. 1 \u2013 Podslizni\u010dn\u00ed absces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_343.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1 \u2013 Podslizni\u010dn\u00ed absces<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_346.png\"><img decoding=\"async\" title=\"Obr. 2 \u2013 Pelvirekt\u00e1ln\u00ed absces\" alt=\"Obr. 2 \u2013 Pelvirekt\u00e1ln\u00ed absces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_346.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2 \u2013 Pelvirekt\u00e1ln\u00ed absces<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_344.png\"><img decoding=\"async\" title=\"Obr. 3 \u2013 Podko\u017en\u00ed perian\u00e1ln\u00ed absces\" alt=\"Obr. 3 \u2013 Podko\u017en\u00ed perian\u00e1ln\u00ed absces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_344.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3 \u2013 Podko\u017en\u00ed perian\u00e1ln\u00ed absces<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_345.png\"><img loading=\"lazy\" decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 4 \u2013 Intersfinkterick\u00fd absces\" alt=\"Obr. 4 \u2013 Intersfinkterick\u00fd absces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_345.png\" width=\"200\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 4 \u2013 Intersfinkterick\u00fd absces<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_347.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 5 \u2013 Podko\u017en\u00ed margin\u00e1ln\u00ed absces\" alt=\"Obr. 5 \u2013 Podko\u017en\u00ed margin\u00e1ln\u00ed absces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_347.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5 \u2013 Podko\u017en\u00ed margin\u00e1ln\u00ed absces<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_348.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 6 \u2013 Ischiorekt\u00e1ln\u00ed absces\" alt=\"Obr. 6 \u2013 Ischiorekt\u00e1ln\u00ed absces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_348.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6 \u2013 Ischiorekt\u00e1ln\u00ed absces<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\"><strong>Submuk\u00f3zn\u00ed (subanoderm\u00e1ln\u00ed) subkut\u00e1nn\u00ed p\u00ed\u0161t\u011bl<\/strong><br \/>\nProb\u00edhaj\u00ed pod sliznic\u00ed rekta nebo anodermu, p\u0159\u00edp. vn\u011bj\u0161\u00ed k\u016f\u017e\u00ed a jsou \u010dasto d\u016fsledkem kryptitidy nebo trhliny.<\/li>\n<li style=\"text-align: justify;\"><strong>Intersfinkterick\u00e1 p\u00ed\u0161t\u011bl<\/strong><br \/>\nPov\u011bt\u0161inou se jedn\u00e1 o dist\u00e1ln\u00ed pr\u016fb\u011bh mezi vnit\u0159n\u00edm a vn\u011bj\u0161\u00edm sv\u011bra\u010dem, \u010dasto u chronick\u00fdch trhlin. Mohou m\u00edt proxim\u00e1ln\u011b ne\u00fapln\u00e9 postrann\u00ed v\u011btve a\u017e hluboko retrorekt\u00e1ln\u00edm sm\u011brem.<\/li>\n<li style=\"text-align: justify;\"><strong>Transsfinkterick\u00e1 p\u00ed\u0161t\u011bl<\/strong><br \/>\nTyto p\u00ed\u0161t\u011ble pronikaj\u00ed vnit\u0159n\u00edm a vn\u011bj\u0161\u00edm sv\u011bra\u010dem,\u00fast\u00ed v oblasti perian\u00e1ln\u00ed k\u016f\u017ee a nez\u0159\u00eddka maj\u00ed proxim\u00e1ln\u011b slep\u00e1 vedlej\u0161\u00ed ramena v prostoru uvnit\u0159sv\u011bra\u010de.<\/li>\n<li style=\"text-align: justify;\"><strong>Suprasfinkterick\u00e1 p\u00ed\u0161t\u011bl<\/strong><br \/>\nTento velmi ojedin\u011bl\u00fd typ p\u00ed\u0161t\u011ble sestupuje v prostoru uvnit\u0159 sv\u011bra\u010de, zahrnuje cel\u00fd vn\u011bj\u0161\u00ed sv\u011bra\u010d \u0159itn\u00ed, obloukovit\u011b dosahuje p\u0159es puborekt\u00e1ln\u00ed kli\u010dkuk fosse ischiorectalis a odtud k vn\u011bj\u0161\u00ed k\u016f\u017ei. Tak\u00e9 zdese \u010dasto vyskytuj\u00ed slep\u00e9 vedlej\u0161\u00ed chodbi\u010dky v\u011btv\u00edc\u00edse z hlavn\u00ed chodby p\u00ed\u0161t\u011ble.<\/li>\n<li style=\"text-align: justify;\"><strong>Extrasfinkterick\u00e1 p\u00ed\u0161t\u011bl<\/strong><br \/>\nP\u00ed\u0161t\u011ble tohoto druhu se vymykaj\u00ed v\u00fd\u0161e uveden\u00e9mu sch\u00e9matu, proto\u017ee nevych\u00e1zej\u00ed z proktode\u00e1ln\u00ed \u017el\u00e1zky, \u010d\u00edm\u017e chyb\u00ed jinak b\u011b\u017en\u00e9 spojen\u00ed s \u0159itn\u00edm kan\u00e1lem na \u00farovni zubat\u00e9 linie. Tyto p\u00ed\u0161t\u011ble jsou v\u011bt\u0161inou d\u016fsledkem jin\u00e9ho onemocn\u011bn\u00ed (nap\u0159. an\u00e1ln\u00ed formy Crohnovy nemoci) nebo iatrogenn\u00edch z\u00e1sah\u016f.Prob\u00edhaj\u00ed od vnit\u0159n\u00edho otvoru nad zubatou lini\u00ed v roz\u0161\u00ed\u0159en\u00e9 \u010d\u00e1sti kone\u010dn\u00edku p\u0159es zdviha\u010d ke k\u016f\u017ei.<br \/>\nObdobn\u00e1 je situace u p\u00ed\u0161t\u011bl\u00ed rektovagin\u00e1ln\u00edch. Ani tyto nelze p\u0159i\u0159adit k v\u00fd\u0161e popsan\u00e9mu sch\u00e9matu; jsou nej\u010dast\u011bji n\u00e1sledkem porodn\u00edch traumatick\u00fdch l\u00e9z\u00ed, n\u00e1sledkem resek\u010dn\u00edch v\u00fdkon\u016f v oblasti rekta, n\u00e1sledkem aktinoterapie nebo Crohnovy choroby. 85\u201395 % v\u0161ech p\u00ed\u0161t\u011bl\u00ed prob\u00edh\u00e1 intera transsfinktericky.<\/li>\n<\/ul>\n<h6>Pr\u016fb\u011bh<\/h6>\n<p style=\"text-align: justify;\">Reverze periprokt\u00e1ln\u00edho abscesu nen\u00ed mo\u017en\u00e1. Nen\u00ed-li vypr\u00e1zdn\u011bn chirurgicky, doch\u00e1z\u00ed zpravidla k jeho spont\u00e1nn\u00ed perforaci. Ta prob\u011bhne \u2013 bez ohledu na um\u00edst\u011bn\u00ed \u2013 vn\u011b, do \u0159itn\u00edho kan\u00e1lu nebo tak\u00e9 do rekta. S t\u00edm se poj\u00ed rychl\u00e1 zm\u011bna klinick\u00e9 symptomatologie (bolesti, hore\u010dka, zimnice, obecn\u00fd pocit nemoci). V\u011bt\u0161inou se ov\u0161em mus\u00ed po\u010d\u00edtat s d\u016fsledkem v podob\u011b perian\u00e1ln\u00ed p\u00ed\u0161t\u011ble. Ta nez\u00e1vis\u00ed na um\u00edst\u011bn\u00ed nebo rozsahu abscesu. Pouze tehdy, je-li absces chirurgicky evakuov\u00e1n a z\u00e1rove\u0148 exstirpov\u00e1na k n\u011bmu pat\u0159\u00edc\u00ed p\u00ed\u0161t\u011bl, lze o\u010dek\u00e1vat nekomplikovan\u00e9 zhojen\u00ed.<\/p>\n<p style=\"text-align: justify;\">Ani u perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed nelze o\u010dek\u00e1vat spont\u00e1nn\u00ed reverzi. Setrval\u00e9 vylu\u010dov\u00e1n\u00ed hnisav\u00e9ho, ser\u00f3zn\u00edho sekretu, kter\u00e9 m\u00e1 mnohdy r\u016fznou intenzitu, je projevem perzistuj\u00edc\u00edho z\u00e1n\u011btliv\u00e9ho infiltr\u00e1tu. Bez l\u00e9\u010dby se mus\u00ed po\u010d\u00edtat s progres\u00ed onemocn\u011bn\u00ed s nov\u00fdmi abscesy a dal\u0161\u00edmi p\u00ed\u0161t\u011blemi. Nutn\u00fdm n\u00e1sledkem je naru\u0161en\u00ed a omezen\u00ed funk\u010dnosti org\u00e1nu kontinence. U imunologick\u00fdch poruch se mohou i zde vyskytnout gangren\u00f3zn\u00ed flegm\u00f3ny se stavy sepse, p\u0159edstavuj\u00edc\u00ed ohro\u017een\u00ed \u017eivota. U pr\u016fb\u011bhu v \u0159\u00e1du let jsou pops\u00e1ny i p\u00ed\u0161t\u011blov\u00e9 karcinomy.<\/p>\n<p style=\"text-align: justify;\">Klasifikace perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed podle Nov\u00e1ka (Nov\u00e1k 1985) je zobrazena na obr\u00e1zc\u00edch 7 a\u017e 13. Klasifikujeme je dle toho, zda maj\u00ed jedno \u010di dv\u011b \u00fast\u00ed (\u00faplnost) a dle vztahu ke sfikter\u016fm a lev\u00e1tor\u016fm.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_350.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 7 \u2013 P\u00ed\u0161t\u011ble \u00fapln\u00e9 (podle \u00faplnosti)\" alt=\"Obr. 7 \u2013 P\u00ed\u0161t\u011ble \u00fapln\u00e9 (podle \u00faplnosti)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_350.png\" width=\"200\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 7 \u2013 P\u00ed\u0161t\u011ble \u00fapln\u00e9 (podle \u00faplnosti)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_353.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 8 \u2013 P\u00ed\u0161t\u011ble ne\u00fapln\u00e9\" alt=\"Obr. 8 \u2013 P\u00ed\u0161t\u011ble ne\u00fapln\u00e9\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_353.png\" width=\"201\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 8 \u2013 P\u00ed\u0161t\u011ble ne\u00fapln\u00e9<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_351.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 9 \u2013 P\u00ed\u0161t\u011ble intrasfinkterick\u00e9 (podle vztahu k sfinkter\u016fm)\" alt=\"Obr. 9 \u2013 P\u00ed\u0161t\u011ble intrasfinkterick\u00e9 (podle vztahu k sfinkter\u016fm)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_351.png\" width=\"200\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 9 \u2013 P\u00ed\u0161t\u011ble intrasfinkterick\u00e9 (podle vztahu k sfinkter\u016fm)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_352.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 10 \u2013 P\u00ed\u0161t\u011ble transsfinkterick\u00e9\" alt=\"Obr. 10 \u2013 P\u00ed\u0161t\u011ble transsfinkterick\u00e9\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_352.png\" width=\"201\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 10 \u2013 P\u00ed\u0161t\u011ble transsfinkterick\u00e9<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 212px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_354.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 11 \u2013 P\u00ed\u0161t\u011ble intersfinkterick\u00e9\" alt=\"Obr. 11 \u2013 P\u00ed\u0161t\u011ble intersfinkterick\u00e9\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_354.png\" width=\"202\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 11 \u2013 P\u00ed\u0161t\u011ble intersfinkterick\u00e9<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_355.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 12 \u2013 P\u00ed\u0161t\u011ble supralev\u00e1torov\u00e9 (podle vztahu k lev\u00e1tor\u016fm)\" alt=\"Obr. 12 \u2013 P\u00ed\u0161t\u011ble supralev\u00e1torov\u00e9 (podle vztahu k lev\u00e1tor\u016fm)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_355.png\" width=\"201\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 12 \u2013 P\u00ed\u0161t\u011ble supralev\u00e1torov\u00e9 (podle<br \/>vztahu k lev\u00e1tor\u016fm)<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 212px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_358.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 13 \u2013 P\u00ed\u0161t\u011ble infralev\u00e1torov\u00e9\" alt=\"Obr. 13 \u2013 P\u00ed\u0161t\u011ble infralev\u00e1torov\u00e9\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_358.png\" width=\"202\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 13 \u2013 P\u00ed\u0161t\u011ble infralev\u00e1torov\u00e9<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_357.png\"><img decoding=\"async\" title=\"Obr. 14 \u2013 Absces perian\u00e1ln\u00ed \u2013 endosonografick\u00fd obraz\" alt=\"Obr. 14 \u2013 Absces perian\u00e1ln\u00ed \u2013 endosonografick\u00fd obraz\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_357.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 14 \u2013 Absces perian\u00e1ln\u00ed \u2013 endosonografick\u00fd obraz<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Diagnostika<\/h6>\n<p style=\"text-align: justify;\">Tzv. zral\u00fd absces nen\u00ed obt\u00ed\u017en\u00e9 diagnostikovat na z\u00e1klad\u011b anamn\u00e9zy, klinick\u00e9 symptomatologie, aspekce a palpace. Ischiorekt\u00e1ln\u00ed abscesy maj\u00ed p\u0159i um\u00edst\u011bn\u00ed na povrchu v\u011bt\u0161inou na\u010dervenale lividn\u00ed zbarven\u00ed s jasn\u011b viditelnou prominenc\u00ed. Roz\u0161\u00ed\u0159en\u00e9 abscesy mohou zp\u016fsobit deformaci \u0161t\u011brbiny an\u00e1ln\u00ed a p\u0159\u00edpadn\u011b je potom mo\u017en\u00e9 rozpoznat fluktuaci. V po\u010d\u00e1te\u010dn\u00edm stadiu m\u016f\u017ee b\u00fdt nesnadn\u00e9 s jistotou objektivizovat pelvirekt\u00e1ln\u00ed i ischiorekt\u00e1ln\u00ed abscesy. V t\u011bchto p\u0159\u00edpadech \u010dasto pom\u016f\u017ee digit\u00e1ln\u00ed vy\u0161et\u0159en\u00ed rekta s otoky a bolestivost\u00ed p\u0159i palpaci v \u0159itn\u00edm kan\u00e1lu nebo spodn\u00ed \u010d\u00e1sti rekta. P\u0159esn\u00e1 diagnostika perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed je spojena s v\u011bt\u0161\u00edmi probl\u00e9my pouze u komplikovan\u00fdch pr\u016fb\u011bh\u016f. U nej\u010dast\u011bj\u0161\u00edch intersfinkterick\u00fdch a transsfinkterick\u00fdch p\u00ed\u0161t\u011bl\u00ed lze v\u011bt\u0161inou rozpoznat dob\u0159e viditeln\u00fd vn\u011bj\u0161\u00ed otvor p\u00ed\u0161t\u011ble v r\u016fzn\u00fdch vzd\u00e1lenostech od \u0159itn\u00edho otvoru a ve stejn\u00e9 oblasti \u0159itn\u00edho kan\u00e1lu i vnit\u0159n\u00ed otvor. Podle Goodsallova pravidla je pr\u016fb\u011bh t\u011bchto p\u00ed\u0161t\u011bl\u00ed s vn\u011bj\u0161\u00edm otvorem pod lini\u00ed mezi t\u0159et\u00ed a dev\u00e1tou hodinou v litotomick\u00e9 poloze p\u0159ev\u00e1\u017en\u011b obloukovit\u00fd a naho\u0159e p\u0159\u00edmo\u010dar\u00fd. Jejich pr\u016fb\u011bh lze dob\u0159e vysledovat pomoc\u00ed pali\u010dkov\u00e9 sondy. Ov\u0161em u v\u00fdrazn\u00fdch z\u00e1n\u011btliv\u00fdch infiltr\u00e1t\u016f nen\u00ed sondov\u00e1n\u00ed v\u017edy snadn\u00e9 a m\u016f\u017ee doj\u00edt ke stanoven\u00ed fale\u0161n\u00e9 cesty. Toto nebezpe\u010d\u00ed je nutn\u00e9 m\u00edt na pam\u011bti p\u0159edev\u0161\u00edm u komplikovan\u00fdch pr\u016fb\u011bh\u016f p\u00ed\u0161t\u011bl\u00ed s vedlej\u0161\u00edmi chodbi\u010dkami. Sondov\u00e1n\u00ed by proto nem\u011blo b\u00fdt n\u00e1siln\u00e9, ale m\u011blo by prob\u011bhnout v anestezii p\u0159i p\u0159\u00edprav\u011b k operaci. Rentgenov\u00e9 zobrazov\u00e1n\u00ed p\u00ed\u0161t\u011bl\u00ed (fistulografie) se d\u0159\u00edve vyu\u017e\u00edvalo pouze ve v\u00fdjime\u010dn\u00fdch p\u0159\u00edpadech, dnes se sp\u00ed\u0161e uplatn\u00ed endosonografie, po\u010d\u00edta\u010dov\u00e1 tomografie nebo magnetick\u00e1 rezonance (obr. 14).<\/p>\n<h6>Diferenci\u00e1ln\u00ed diagn\u00f3za<\/h6>\n<p style=\"text-align: justify;\">U an\u00e1ln\u00edch absces\u016f a p\u00ed\u0161t\u011bl\u00ed je v\u017edy nutn\u00e9 pomyslet na Crohnovu nemoc: 10\u201330% pacient\u016f s Crohnovou chorobou m\u00e1 sv\u00e9 prvotn\u00ed projevy v an\u00e1ln\u00ed oblasti. Ty mohou vykazovat v\u00fd\u0161e popsan\u00e9 formy a pr\u016fb\u011bhy, ale tak\u00e9 nemus\u00ed m\u00edt \u017e\u00e1dn\u00e9 spojen\u00ed s p\u0159edchoz\u00edmi org\u00e1nov\u00fdmi strukturami. Typick\u00e9 p\u00ed\u0161t\u011ble p\u0159i Crohnov\u011b nemoci se mohou vyskytovat n\u00e1hodn\u011b ve v\u0161ech oblastech \u0159itn\u00edho kan\u00e1lu nebo rekta. U acne inversa se objevuj\u00ed nahodil\u00e1, ve velk\u00e9 rozloze po obou stran\u00e1ch \u0159itn\u00edho otvoru v\u00edce\u010detn\u00e1 a navz\u00e1jem spl\u00fdvaj\u00edc\u00ed absceduj\u00edc\u00ed m\u00edsta, v\u011bt\u0161inou s mnoha hnisaj\u00edc\u00edmi otvory p\u00ed\u0161t\u011bl\u00ed. Nen\u00ed zde spojen\u00ed t\u011bchto p\u00ed\u0161t\u011bl\u00ed s \u0159itn\u00edm kan\u00e1lem nebo rektem. Tak\u00e9 sinus pilonidalis se m\u016f\u017ee vyskytnout ve form\u011b s akutn\u00edm abscesem nebo chronickou p\u00ed\u0161t\u011bl\u00ed. Um\u00edst\u011bn\u00ed v bezprost\u0159edn\u00ed bl\u00edzkosti \u0159itn\u00ed \u0161t\u011brbiny v\u0161ak z pohledu diferenci\u00e1ln\u00ed diagnostiky z\u0159\u00eddka zanech\u00e1 pochyby. Ve v\u00fdrazn\u011b men\u0161\u00edm po\u010dtu (1\u20133 %) lze perian\u00e1ln\u00ed p\u00ed\u0161t\u011ble o\u010dek\u00e1vat u tuberkul\u00f3zy. Vych\u00e1z\u00ed se z kontaminace proktode\u00e1ln\u00edch \u017el\u00e1zek ze spolknut\u00fdch tuberkul\u00f3zn\u00edch bakteri\u00ed. Tyto p\u00ed\u0161t\u011ble p\u0159itom nen\u00ed v\u017edy lehk\u00e9 odli\u0161it od klasick\u00fdch p\u00ed\u0161t\u011bl\u00ed. Relevantn\u00ed je to v zem\u00edch t\u0159et\u00edho sv\u011bta.<\/p>\n<h6>L\u00e9\u010dba<\/h6>\n<p style=\"text-align: justify;\">U periprokt\u00e1ln\u00edch absces\u016f i perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed je nutn\u00e9 ch\u00e1pat chirurgick\u00e1 opat\u0159en\u00ed p\u0159i l\u00e9\u010db\u011b jako prioritn\u00ed.<\/p>\n<h6>L\u00e9\u010dba absces\u016f<\/h6>\n<p style=\"text-align: justify;\">Anorekt\u00e1ln\u00ed absces by m\u011bl b\u00fdt v z\u00e1sad\u011b ihned po stanoven\u00ed diagn\u00f3zy incidov\u00e1n a dostate\u010dn\u011b drenov\u00e1n. Proto\u017ee v\u017edy hroz\u00ed nebezpe\u010d\u00ed progrese do okoln\u00edch struktur, je \u010dasov\u00fd odklad kontraindikov\u00e1n; \u010dasov\u00e9 odd\u00e1len\u00ed a\u017e do v\u00fdskytu fluktuace nebo zku\u0161ebn\u00ed l\u00e9\u010dba pomoc\u00ed \u201ehojiv\u00e9 masti\u201c jsou v\u017edy \u0161patn\u00e9. V\u00fdlu\u010dn\u00e9 pod\u00e1n\u00ed antibiotik se pova\u017euje za chybu l\u00e9ka\u0159e. L\u00e9\u010debn\u00fd\u00a0postup by m\u011bl zahrnovat \u0161irokou trycht\u00fd\u0159ovitou ko\u017en\u00ed incizi a n\u00e1slednou sekund\u00e1rn\u00ed l\u00e9\u010dbu. Men\u0161\u00ed perian\u00e1ln\u00ed abscesy lze zpravidla otev\u0159\u00edt ambulantn\u011b. Dopl\u0148kov\u00e1 l\u00e9\u010dba antibiotiky m\u00e1 smysl pouze v ojedin\u011bl\u00fdch p\u0159\u00edpadech, nap\u0159. p\u0159i imunosupresi, doprovodn\u00e9 flegm\u00f3n\u011b m\u011bkk\u00fdch tk\u00e1n\u00ed nebo doprovodn\u00e9 septick\u00e9 reakci. Intersfinkterick\u00fd absces b\u00fdv\u00e1 kv\u016fli chyb\u011bj\u00edc\u00edmu typick\u00e9mu za\u010derven\u00e1n\u00ed na povrchu a zdu\u0159en\u00ed mnohdy \u0161patn\u011b diagnostikovateln\u00fd a obvykle jej lze rozpoznat pouze podle akutn\u00ed, siln\u00e9 a lokalizovan\u00e9 bolesti. P\u0159i pochyb\u00e1ch u diagn\u00f3zy se doporu\u010duje nejprve vy\u0161et\u0159en\u00ed v nark\u00f3ze a navazuj\u00edc\u00ed \u00fapln\u00e9 odkryt\u00ed dutiny abscesu \u2013 v\u011bt\u0161inou se zahrnut\u00edm dist\u00e1ln\u00edch \u010d\u00e1st\u00ed vnit\u0159n\u00edho sv\u011bra\u010de \u0159itn\u00edho. U ka\u017ed\u00e9 operace anorekt\u00e1ln\u00edho abscesu by se m\u011blo p\u00e1trat po p\u0159\u00ed\u010din\u011b. Ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f je kryptoglandul\u00e1rn\u00ed. Lze-li nal\u00e9zt spojen\u00ed p\u00ed\u0161t\u011ble s \u0159itn\u00edm kan\u00e1lem, je p\u00ed\u0161t\u011bl prim\u00e1rn\u011b operov\u00e1na nebo nejprve pomoc\u00ed vl\u00e1kna napojena k n\u011bkolikat\u00fddenn\u00ed dren\u00e1\u017ei a pot\u00e9 chirurgicky o\u0161et\u0159ena. Nelze-li p\u00ed\u0161t\u011bl prim\u00e1rn\u011b nal\u00e9zt, m\u011blo by se postupovat velice \u0161etrn\u011b z d\u016fvodu nebezpe\u010d\u00ed vytvo\u0159en\u00ed fale\u0161n\u00e9 cesty (obr. 15 a\u017e 21).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_360.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 15 \u2013 Digit\u00e1ln\u00ed revize abscesov\u00e9 dutiny\" alt=\"Obr. 15 \u2013 Digit\u00e1ln\u00ed revize abscesov\u00e9 dutiny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_360.png\" width=\"201\" height=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 15 \u2013 Digit\u00e1ln\u00ed revize abscesov\u00e9 dutiny<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_361.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 16 \u2013 K\u0159\u00ed\u017eov\u00e9 incize pro periprokt\u00e1ln\u00ed absces podkovovit\u00fd\" alt=\"Obr. 16 \u2013 K\u0159\u00ed\u017eov\u00e9 incize pro periprokt\u00e1ln\u00ed absces podkovovit\u00fd\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_361.png\" width=\"201\" height=\"149\" \/><\/a><p class=\"wp-caption-text\">Obr. 16 \u2013 K\u0159\u00ed\u017eov\u00e9 incize pro periprokt\u00e1ln\u00ed absces podkovovit\u00fd<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Typy inciz\u00ed perian\u00e1ln\u00edch<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_364.png\"><img loading=\"lazy\" decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px;\" title=\"Obr. 17 \u2013 K\u0159\u00ed\u017eov\u00e9 a radi\u00e1ln\u00ed \u0159ezy\" alt=\"Obr. 17 \u2013 K\u0159\u00ed\u017eov\u00e9 a radi\u00e1ln\u00ed \u0159ezy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_364.png\" width=\"201\" height=\"182\" \/><\/a><p class=\"wp-caption-text\">Obr. 17 \u2013 K\u0159\u00ed\u017eov\u00e9 a radi\u00e1ln\u00ed \u0159ezy<\/p><\/div>\n<p style=\"text-align: start;\">\n<\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_362.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 18 \u2013 Pod\u00e9ln\u00e9 a obloukovit\u00e9 \u0159ezy\" alt=\"Obr. 18 \u2013 Pod\u00e9ln\u00e9 a obloukovit\u00e9 \u0159ezy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_362.png\" width=\"201\" height=\"182\" \/><\/a><p class=\"wp-caption-text\">Obr. 18 \u2013 Pod\u00e9ln\u00e9 a obloukovit\u00e9 \u0159ezy<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_363.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 19 \u2013 \u0158ezy tvaru T\" alt=\"Obr. 19 \u2013 \u0158ezy tvaru T\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_363.png\" width=\"201\" height=\"182\" \/><\/a><p class=\"wp-caption-text\">Obr. 19 \u2013 \u0158ezy tvaru T<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 212px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_366.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 20 \u2013 \u0158ezy podle Ulanovsk\u00e9ho\" alt=\"Obr. 20 \u2013 \u0158ezy podle Ulanovsk\u00e9ho\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_366.png\" width=\"202\" height=\"181\" \/><\/a><p class=\"wp-caption-text\">Obr. 20 \u2013 \u0158ezy podle Ulanovsk\u00e9ho<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_365.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 21 \u2013 \u0158ezy podle Reifferscheida\" alt=\"Obr. 21 \u2013 \u0158ezy podle Reifferscheida\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_365.png\" width=\"201\" height=\"181\" \/><\/a><p class=\"wp-caption-text\">Obr. 21 \u2013 \u0158ezy podle Reifferscheida<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">L\u00e9\u010dba anorekt\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed<\/h6>\n<p style=\"text-align: justify;\">An\u00e1ln\u00ed p\u00ed\u0161t\u011bl p\u0159edstavuje indikaci pro operaci, proto\u017ee spont\u00e1nn\u00ed zhojen\u00ed je popisovan\u00e9 pouze ve v\u00fdjime\u010dn\u00fdch p\u0159\u00edpadech a je nutn\u00e9 po\u010d\u00edtat s recidivuj\u00edc\u00edmi abscesy. U dlouhotrvaj\u00edc\u00edch chronick\u00fdch pr\u016fb\u011bh\u016f jsou pops\u00e1ny i p\u0159\u00edpady vzniku malignom\u016f. C\u00edlem ka\u017ed\u00e9ho chirurgick\u00e9ho v\u00fdkonu u p\u00ed\u0161t\u011bl\u00ed je vyhojen\u00ed bez po\u0161kozen\u00ed kontinence a bez recidivy. Operativn\u00ed \u0159e\u0161en\u00ed se orientuje podle pr\u016fb\u011bhu p\u00ed\u0161t\u011ble, tedy podle jej\u00edho vztahu k apar\u00e1tu sv\u011bra\u010de. Subanoderm\u00e1ln\u00ed, submuk\u00f3zn\u00ed, subkut\u00e1nn\u00ed, intersfinkterick\u00e9 a dist\u00e1ln\u00ed transsfinketrick\u00e9 p\u00ed\u0161t\u011ble, kter\u00e9 zahrnuj\u00ed jen malou \u010d\u00e1st svalstva sv\u011bra\u010de, lze \u00fapln\u011b discidovat bez omezen\u00ed kontinence. M\u00edra recidivy se pohybuje okolo 10 %, p\u0159i\u010dem\u017e naru\u0161en\u00ed kontinence p\u0159\u00edmo z\u00e1vis\u00ed na m\u00ed\u0159e zasa\u017een\u00ed sv\u011bra\u010de. Zat\u00edmco v d\u0159\u00edv\u011bj\u0161\u00edch dob\u00e1ch se odd\u011blovaly a\u017e dv\u011b t\u0159etiny svalov\u00e9 hmoty, dnes se postupuje \u0161etrn\u011bji. V literatu\u0159e se tedy objevuj\u00ed \u00fadaje o poopera\u010dn\u00ed poru\u0161e kontinence se \u0161irok\u00fdm rozptylem 5\u201340 %. U ji\u017e p\u0159edem po\u0161kozen\u00e9ho sv\u011bra\u010de jsou proto zapot\u0159eb\u00ed alternativn\u00ed opat\u0159en\u00ed. V t\u011bchto p\u0159\u00edpadech se zav\u00e1d\u00ed voln\u00e9 dren\u00e1\u017en\u00ed vl\u00e1kno a po n\u011bkolika t\u00fddnech se p\u0159i \u00fapln\u00e9 nep\u0159\u00edtomnosti infekce provede rozt\u011bt\u00ed nebo vytvo\u0159\u00ed plastick\u00fd uz\u00e1v\u011br p\u00ed\u0161t\u011ble. Proxim\u00e1ln\u00ed (vysok\u00e9) transsfinkterick\u00e9, suprasfinkterick\u00e9 a extrasfinkterick\u00e9 pr\u016fb\u011bhy p\u00ed\u0161t\u011bl\u00ed proch\u00e1zej\u00edc\u00ed hlavn\u00edmi \u010d\u00e1stmi sval\u016f se prim\u00e1rn\u011b dr\u00e9nuj\u00ed vl\u00e1knem a po zklidn\u011bn\u00ed se v druh\u00e9 dob\u011b \u0159e\u0161\u00ed plastikou. K tomu se po \u00fapln\u00e9 exstirpaci p\u00ed\u0161t\u011ble p\u0159edev\u0161\u00edm v kryptoglandul\u00e1rn\u00ed oblasti provede p\u0159\u00edm\u00e1 sutura sv\u011bra\u010de s plastikou pomoc\u00ed posuvn\u00e9ho lal\u016f\u010dku ve tvaru U z muk\u00f3zy a submuk\u00f3zy, \u010d\u00edm\u017e se uzav\u0159e vnit\u0159n\u00ed \u00fast\u00ed p\u00ed\u0161t\u011ble. Ko\u017en\u00ed r\u00e1na se \u0161iroce otev\u0159e, aby mohl odt\u00e9kat sekret. Toto kulisovit\u00e9 uspo\u0159\u00e1d\u00e1n\u00ed steh\u016f nab\u00edz\u00ed nejlep\u0161\u00ed \u0161ance na zhojen\u00ed. Bezprost\u0159edn\u00ed insuficience sutury plastiky se vyskytne a\u017e u 20% p\u0159\u00edpad\u016f, m\u00edra recidivy se pohybuje mezi 5 a\u017e 30 %. Nen\u00e1padn\u00e9 poruchy kontinence se zde uv\u00e1d\u011bj\u00ed a\u017e u 40%, inkontinence pevn\u00e9 stolice se v\u0161ak vyskytuje pouze v ojedin\u011bl\u00fdch p\u0159\u00edpadech. V posledn\u00edch letech se na specializovan\u00fdch pracovi\u0161t\u00edch st\u00e1le \u010dast\u011bji prov\u00e1d\u00ed u proxim\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed jejich rozt\u011bt\u00ed s prim\u00e1rn\u00ed okam\u017eitou rekonstrukc\u00ed svalu. Nemnoh\u00e9 dosavadn\u00ed zku\u0161enosti ud\u00e1vaj\u00ed m\u00edru vyhojen\u00ed v 80\u201390%, av\u0161ak tak\u00e9 5\u201310% m\u00edru dehiscence. V n\u00e1sleduj\u00edc\u00edch letech bude nutn\u00e9 dal\u0161\u00ed vyhodnocen\u00ed. V roce 2009 se do \u010cesk\u00e9 republiky roz\u0161\u00ed\u0159ila z USA tak\u00e9 \u201eAnal-Fistula-Plug\u201c (z\u00e1tka). Pomoc\u00ed \u00fazk\u00e9ho cylindru vyroben\u00e9ho z vep\u0159ov\u00e9ho kolagenu se kan\u00e1lek p\u00ed\u0161t\u011ble uzav\u0159e zevnit\u0159. Rozs\u00e1hlej\u0161\u00ed odstran\u011bn\u00ed tk\u00e1n\u011b p\u00ed\u0161t\u011ble se zde na rozd\u00edl od jin\u00fdch technik neprov\u00e1d\u00ed, co\u017e tuto operaci usnad\u0148uje. Po po\u010d\u00e1te\u010dn\u00edch vysoce euforick\u00fdch \u00fadaj\u00edch o \u00fasp\u011b\u0161nosti s m\u00edrami vyhojen\u00ed p\u0159esahuj\u00edc\u00edmi 85 % uv\u00e1d\u011bj\u00ed nov\u011bj\u0161\u00ed publikace m\u00edry zhojen\u00ed mezi30 a\u017e 70%. Kone\u010dn\u00e9 posouzen\u00ed nyn\u00ed je\u0161t\u011b nen\u00ed mo\u017en\u00e9. Jsou napl\u00e1nov\u00e1ny multicentrick\u00e9 randomizovan\u00e9 studie. Vedle v\u00fd\u0161e popsan\u00fdch metod se v n\u011bkter\u00fdch p\u0159\u00edpadech uplat\u0148uj\u00ed tak\u00e9 jin\u00e9 techniky: p\u0159\u00edm\u00e9 \u00fapln\u00e9 rozt\u011bt\u00ed a jednodob\u00e1 nebo dvoudob\u00e1 rekonstrukce a svalov\u00fd interpozit. Zvl\u00e1\u0161tn\u00ed formu anorekt\u00e1ln\u00ed p\u00ed\u0161t\u011ble p\u0159edstavuje rekto-, p\u0159\u00edp. anovagin\u00e1ln\u00ed p\u00ed\u0161t\u011bl. Jej\u00ed diagnostika a l\u00e9\u010dba prob\u00edh\u00e1 analogicky dle v\u00fd\u0161e uveden\u00fdch postup\u016f. Kv\u016fli jej\u00ed poloze je v\u0161ak nej\u010dast\u011bji nutn\u00fd plastick\u00fd z\u00e1sah. V d\u016fsledku toho, \u017ee v t\u00e9to oblasti chyb\u00ed u rektovagin\u00e1ln\u00edho septa okoln\u00ed vazivov\u00e1 a svalov\u00e1 tk\u00e1\u0148, jsou m\u00edry \u00fasp\u011b\u0161nosti ni\u017e\u0161\u00ed ne\u017e u ostatn\u00edch anorekt\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed. U an\u00e1ln\u00edch Crohnov\u00fdch p\u00ed\u0161t\u011bl\u00ed je 75% stejn\u011b jako u jin\u00fdch p\u00ed\u0161t\u011bl\u00ed kryptoglandul\u00e1rn\u00edho p\u016fvodu a m\u00e1 stejn\u00e9 pr\u016fb\u011bhy. Oproti tomu 25% nesleduje anatomick\u00e9 struktury a pronik\u00e1 tk\u00e1n\u011bmi destruktivn\u00edm zp\u016fsobem. Jejich l\u00e9\u010dba prob\u00edh\u00e1 rovn\u011b\u017e podle v\u00fd\u0161e popsan\u00fdch strategi\u00ed. Proto\u017ee jsou kv\u016fli vysok\u00e9 m\u00ed\u0159e recidivy z\u00e1kladn\u00edho onemocn\u011bn\u00ed v mnoha p\u0159\u00edpadech nutn\u00e9 opakovan\u00e9 chirurgick\u00e9 z\u00e1sahy, m\u011blo by se obzvl\u00e1\u0161t\u011b db\u00e1t na \u0161etrn\u00e9 zach\u00e1zen\u00ed se svalstvem sv\u011bra\u010de. P\u0159ed ka\u017ed\u00fdm rekonstruktivn\u00edm z\u00e1sahem u p\u00ed\u0161t\u011ble mus\u00ed b\u00fdt syst\u00e9mov\u00e9 abdomin\u00e1ln\u00ed onemocn\u011bn\u00ed pod kontrolou a lok\u00e1ln\u00ed n\u00e1lez mus\u00ed b\u00fdt bez p\u0159\u00edtomnosti infekce. U slo\u017eit\u00fdch p\u00ed\u0161t\u011bl\u00ed se s\u00e9riemi recidiv je voln\u00e1 dlouhodob\u00e1 dren\u00e1\u017e vl\u00e1knem opat\u0159en\u00edm, kter\u00e9 pacient zpravidla velmi dob\u0159e sn\u00e1\u0161\u00ed a kter\u00e9 m\u016f\u017ee zamezit zaveden\u00ed stomie nebo jej p\u0159inejmen\u0161\u00edm odd\u00e1lit.<\/p>\n<h6>VAAFT \u2013 video assisted anal fistula treatment<\/h6>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o mininvazivn\u00ed techniku, kter\u00e1 vyu\u017e\u00edv\u00e1 k nasondov\u00e1n\u00ed p\u00ed\u0161t\u011ble speci\u00e1ln\u011b upraven\u00e9ho ureteroskopu \u2013 fistuloskopu, kter\u00fdm, po pr\u016fvleku fistulou, je zavedeno vl\u00e1kno bipol\u00e1rn\u00ed koagulace nebo vl\u00e1kno diodov\u00e9ho laseru a v pr\u016fb\u011bhu fistulace je provedena fotokoagula\u010dn\u00ed \u010di elektrokoagula\u010dn\u00ed syringotomie. P\u0159edpokladem \u00fasp\u011b\u0161n\u00e9ho vyhojen\u00ed fistulace je samoz\u0159ejm\u011b pe\u010dliv\u00fd uz\u00e1v\u011br vnit\u0159n\u00edho \u00fast\u00ed p\u00ed\u0161t\u011ble, kter\u00fd lze prov\u00e9st klasicky suturou, posuvn\u00fdm slizni\u010dn\u00edm lalokem \u010di suturou staplerem. V\u00fdkon m\u016f\u017ee b\u00fdt dopln\u011bn aplikac\u00ed tk\u00e1\u0148ov\u00e9ho lepidla nebo aplikac\u00ed k\u00f3nick\u00e9 z\u00e1tky, tzv. plugu. L\u00e9\u010debn\u00e9 postupy u p\u00ed\u0161t\u011bl\u00ed jsou zn\u00e1zorn\u011bny na obr. 22\u201337.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_369.png\"><img decoding=\"async\" title=\"Obr. 22 \u2013 Fistuloskop\" alt=\"Obr. 22 \u2013 Fistuloskop\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_369.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22 \u2013 Fistuloskop<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_370.png\"><img decoding=\"async\" title=\"Obr. 23 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed fistuly\" alt=\"Obr. 23 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed fistuly\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_370.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 23 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed fistuly<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_371.png\"><img decoding=\"async\" title=\"Obr. 24 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed nasondov\u00e1no fistuloskopem, zachyceno suturou\" alt=\"Obr. 24 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed nasondov\u00e1no fistuloskopem, zachyceno suturou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_371.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 24 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed nasondov\u00e1no fistuloskopem, zachyceno suturou<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_372.png\"><img decoding=\"async\" title=\"Obr. 25 \u2013 Pohled do fistuly protahovan\u00e9 laserov\u00fdm vl\u00e1knem nebo monopol\u00e1rn\u00ed elektrokoagula\u010dn\u00ed elektrodou\" alt=\"Obr. 25 \u2013 Pohled do fistuly protahovan\u00e9 laserov\u00fdm vl\u00e1knem nebo monopol\u00e1rn\u00ed elektrokoagula\u010dn\u00ed elektrodou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_372.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 25 \u2013 Pohled do fistuly protahovan\u00e9 laserov\u00fdm vl\u00e1knem nebo monopol\u00e1rn\u00ed elektrokoagula\u010dn\u00ed elektrodou<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_373.png\"><img decoding=\"async\" title=\"Obr. 26 \u2013 Uz\u00e1v\u011br vnit\u0159n\u00edho \u00fast\u00ed staplerem Trans STAR\" alt=\"Obr. 26 \u2013 Uz\u00e1v\u011br vnit\u0159n\u00edho \u00fast\u00ed staplerem Trans STAR\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_373.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 26 \u2013 Uz\u00e1v\u011br vnit\u0159n\u00edho \u00fast\u00ed staplerem Trans STAR<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_374.png\"><img decoding=\"async\" title=\"Obr. 27 \u2013 Staplerov\u00e1 sutura\" alt=\"Obr. 27 \u2013 Staplerov\u00e1 sutura\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_374.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 27 \u2013 Staplerov\u00e1 sutura<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_377.png\"><img decoding=\"async\" title=\"Obr. 28 \u2013 Fistuloskop\" alt=\"Obr. 28 \u2013 Fistuloskop\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_377.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 28 \u2013 Fistuloskop<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_376.png\"><img decoding=\"async\" title=\"Obr. 29 \u2013 Elektrokoagula\u010dn\u00ed monopol\u00e1rn\u00ed elektroda\" alt=\"Obr. 29 \u2013 Elektrokoagula\u010dn\u00ed monopol\u00e1rn\u00ed elektroda\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_376.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 29 \u2013 Elektrokoagula\u010dn\u00ed monopol\u00e1rn\u00ed elektroda<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_379.png\"><img decoding=\"async\" title=\"Obr. 30 \u2013 P\u00ed\u0161t\u011bl nasodovan\u00e1 fistuloskopem\" alt=\"Obr. 30 \u2013 P\u00ed\u0161t\u011bl nasodovan\u00e1 fistuloskopem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_379.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 30 \u2013 P\u00ed\u0161t\u011bl nasodovan\u00e1 fistuloskopem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_378.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\" Obr. 31 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed p\u00ed\u0161t\u011ble\" alt=\" Obr. 31 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed p\u00ed\u0161t\u011ble\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_378.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 31 \u2013 Vnit\u0159n\u00ed \u00fast\u00ed p\u00ed\u0161t\u011ble<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_381.png\"><img decoding=\"async\" title=\"Obr. 32 \u2013 Sada pro syringotomii \" alt=\"Obr. 32 \u2013 Sada pro syringotomii \" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_381.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 32 \u2013 Sada pro syringotomii<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_380.png\"><img decoding=\"async\" title=\"Obr. 33 \u2013 Sonda s mandr\u00e9nem\" alt=\"Obr. 33 \u2013 Sonda s mandr\u00e9nem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_380.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 33 \u2013 Sonda s mandr\u00e9nem<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_383.png\"><img decoding=\"async\" title=\"Obr. 34 \u2013 Sonda s elektrokoagula\u010dn\u00ed elektrodou\" alt=\"Obr. 34 \u2013 Sonda s elektrokoagula\u010dn\u00ed elektrodou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_383.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 34 \u2013 Sonda s elektrokoagula\u010dn\u00ed elektrodou<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_384.png\"><img decoding=\"async\" title=\"Obr. 35 \u2013 Mandr\u00e9n prota\u017een\u00fd fistulac\u00ed\" alt=\"Obr. 35 \u2013 Mandr\u00e9n prota\u017een\u00fd fistulac\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_384.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 35 \u2013 Mandr\u00e9n prota\u017een\u00fd fistulac\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_386.png\"><img decoding=\"async\" title=\"Obr. 36 \u2013 Sonda prota\u017een\u00e1 fistulac\u00ed\" alt=\"Obr. 36 \u2013 Sonda prota\u017een\u00e1 fistulac\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_386.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 36 \u2013 Sonda prota\u017een\u00e1 fistulac\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_385.png\"><img decoding=\"async\" title=\"Obr. 37 \u2013 Zaveden\u00e1 monopol\u00e1rn\u00ed elektroda\" alt=\"Obr. 37 \u2013 Zaveden\u00e1 monopol\u00e1rn\u00ed elektroda\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_385.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 37 \u2013 Zaveden\u00e1 monopol\u00e1rn\u00ed elektroda<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Anal-fistula-plug, an\u00e1ln\u00ed z\u00e1tka<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_388.png\"><img loading=\"lazy\" decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 38 \u2013 Extracelul\u00e1rn\u00ed stroma\" alt=\"Obr. 38 \u2013 Extracelul\u00e1rn\u00ed stroma\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_388.png\" width=\"201\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 38 \u2013 Extracelul\u00e1rn\u00ed stroma<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 212px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_389.png\"><img loading=\"lazy\" decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 39 \u2013 Neovaskularizace s inici\u00e1ln\u00ed bun\u011b\u010dnou implantac\u00ed\" alt=\"Obr. 39 \u2013 Neovaskularizace s inici\u00e1ln\u00ed bun\u011b\u010dnou implantac\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_389.png\" width=\"202\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 39 \u2013 Neovaskularizace s inici\u00e1ln\u00ed bun\u011b\u010dnou<br \/>implantac\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_390.png\"><img loading=\"lazy\" decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 40 \u2013 Neovaskularizace s pokro\u010dilou bun\u011b\u010dnou implantac\u00ed\" alt=\"Obr. 40 \u2013 Neovaskularizace s pokro\u010dilou bun\u011b\u010dnou implantac\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_390.png\" width=\"201\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 40 \u2013 Neovaskularizace s pokro\u010dilou bun\u011b\u010dnou implantac\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 211px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_391.png\"><img loading=\"lazy\" decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 41 \u2013 Tk\u00e1\u0148ov\u00e1 p\u0159estavba\" alt=\"Obr. 41 \u2013 Tk\u00e1\u0148ov\u00e1 p\u0159estavba\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_391.png\" width=\"201\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 41 \u2013 Tk\u00e1\u0148ov\u00e1 p\u0159estavba<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_392.png\"><img decoding=\"async\" title=\"Obr. 42 \u2013 Provle\u010den\u00ed kart\u00e1\u010dku\" alt=\"Obr. 42 \u2013 Provle\u010den\u00ed kart\u00e1\u010dku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_392.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 42 \u2013 Provle\u010den\u00ed kart\u00e1\u010dku<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_393.png\"><img decoding=\"async\" title=\"Obr. 43 \u2013 Provle\u010den\u00ed z\u00e1tky\" alt=\"Obr. 43 \u2013 Provle\u010den\u00ed z\u00e1tky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_393.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 43 \u2013 Provle\u010den\u00ed z\u00e1tky<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_395.png\"><img decoding=\"async\" title=\"Obr. 44 \u2013 Fixace z\u00e1tky ke svalov\u00fdm struktur\u00e1m st\u011bny rekta\" alt=\"Obr. 44 \u2013 Fixace z\u00e1tky ke svalov\u00fdm struktur\u00e1m st\u011bny rekta\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_395.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 44 \u2013 Fixace z\u00e1tky ke svalov\u00fdm struktur\u00e1m st\u011bny rekta<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_394.png\"><img decoding=\"async\" title=\"Obr. 45 \u2013 Se\u0159\u00edznut\u00ed z\u00e1tky pod \u00farovn\u00ed muk\u00f3zy\" alt=\"Obr. 45 \u2013 Se\u0159\u00edznut\u00ed z\u00e1tky pod \u00farovn\u00ed muk\u00f3zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_394.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 45 \u2013 Se\u0159\u00edznut\u00ed z\u00e1tky pod \u00farovn\u00ed muk\u00f3zy<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_397.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 46 \u2013 Sutura vnit\u0159n\u00edho \u00fast\u00ed \" alt=\"Obr. 46 \u2013 Sutura vnit\u0159n\u00edho \u00fast\u00ed \" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_397.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 46 \u2013 Sutura vnit\u0159n\u00edho \u00fast\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_398.png\"><img decoding=\"async\" title=\"Obr. 47 \u2013 Sest\u0159i\u017een\u00ed zevn\u00edho konce z\u00e1tky\" alt=\"Obr. 47 \u2013 Sest\u0159i\u017een\u00ed zevn\u00edho konce z\u00e1tky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_398.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 47 \u2013 Sest\u0159i\u017een\u00ed zevn\u00edho konce z\u00e1tky<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_400.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 48a \u2013 Provle\u010den\u00ed z\u00e1tky\" alt=\"Obr. 48a \u2013 Provle\u010den\u00ed z\u00e1tky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_400.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 48a \u2013 Provle\u010den\u00ed z\u00e1tky<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_399.png\"><img decoding=\"async\" title=\"Obr. 48b \u2013 Excize zevn\u00edho \u00fast\u00ed fistulace a odst\u0159i\u017een\u00ed zevn\u00edho konce z\u00e1tky\" alt=\"Obr. 48b \u2013 Excize zevn\u00edho \u00fast\u00ed fistulace a odst\u0159i\u017een\u00ed zevn\u00edho konce z\u00e1tky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_399.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 48b \u2013 Excize zevn\u00edho \u00fast\u00ed fistulace a odst\u0159i\u017een\u00ed zevn\u00edho konce z\u00e1tky<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_401.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 49 \u2013 Periprokt\u00e1ln\u00ed p\u00ed\u0161t\u011bl chybn\u011b sanovan\u00e1 elastickou ligaturou\" alt=\"Obr. 49 \u2013 Periprokt\u00e1ln\u00ed p\u00ed\u0161t\u011bl chybn\u011b sanovan\u00e1 elastickou ligaturou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_401.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 49 \u2013 Periprokt\u00e1ln\u00ed p\u00ed\u0161t\u011bl chybn\u011b sanovan\u00e1 elastickou ligaturou<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_404.png\"><img decoding=\"async\" title=\"Obr. 50 \u2013 Kompletn\u00ed excize fistulace s plastikou dle Limberga\" alt=\"Obr. 50 \u2013 Kompletn\u00ed excize fistulace s plastikou dle Limberga\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_404.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 50 \u2013 Kompletn\u00ed excize fistulace s plastikou dle Limberga<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_403.png\"><img decoding=\"async\" title=\"Obr. 51 \u2013 P\u0159eto\u010den\u00ed Limbergova laloku\" alt=\"Obr. 51 \u2013 P\u0159eto\u010den\u00ed Limbergova laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_403.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 51 \u2013 P\u0159eto\u010den\u00ed Limbergova laloku<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_406.png\"><img decoding=\"async\" title=\"Obr. 52 \u2013 Fixace z\u00e1dr\u017en\u00fdmi stehy a zevn\u00ed plastika\" alt=\"Obr. 52 \u2013 Fixace z\u00e1dr\u017en\u00fdmi stehy a zevn\u00ed plastika\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_406.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 52 \u2013 Fixace z\u00e1dr\u017en\u00fdmi stehy a zevn\u00ed plastika<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_405.png\"><img decoding=\"async\" title=\"Obr. 53 \u2013 Sanace zevn\u00edho \u00fast\u00ed technikou laloku dle Schimanowsk\u00e9ho\" alt=\"Obr. 53 \u2013 Sanace zevn\u00edho \u00fast\u00ed technikou laloku dle Schimanowsk\u00e9ho\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_405.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 53 \u2013 Sanace zevn\u00edho \u00fast\u00ed technikou laloku dle Schimanowsk\u00e9ho<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_408.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 54 \u2013 Excidovan\u00e1 fistula s p\u0159ipraven\u00fdm lalokem\" alt=\"Obr. 54 \u2013 Excidovan\u00e1 fistula s p\u0159ipraven\u00fdm lalokem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_408.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 54 \u2013 Excidovan\u00e1 fistula s p\u0159ipraven\u00fdm lalokem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_407.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 55 \u2013 Fixace laloku z\u00e1dr\u017en\u00fdmi stehy\" alt=\"Obr. 55 \u2013 Fixace laloku z\u00e1dr\u017en\u00fdmi stehy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_407.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 55 \u2013 Fixace laloku z\u00e1dr\u017en\u00fdmi stehy<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_410.png\"><img decoding=\"async\" title=\"Obr. 56 \u2013 Schimanowsk\u00e9ho plastika\" alt=\"Obr. 56 \u2013 Schimanowsk\u00e9ho plastika\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_410.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 56 \u2013 Schimanowsk\u00e9ho plastika<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_411.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 57 \u2013 Technika monodren\u00e1\u017ee fistulac\u00ed p\u0159i rekt\u00e1ln\u00ed form\u011b Crohnovy choroby\" alt=\"Obr. 57 \u2013 Technika monodren\u00e1\u017ee fistulac\u00ed p\u0159i rekt\u00e1ln\u00ed form\u011b Crohnovy choroby\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_411.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 57 \u2013 Technika monodren\u00e1\u017ee fistulac\u00ed p\u0159i rekt\u00e1ln\u00ed form\u011b Crohnovy choroby<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Je modern\u00ed metoda l\u00e9\u010dby periprokt\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed implantac\u00ed biologick\u00e9 z\u00e1tky, kter\u00e1 je vyrobena tak zvanou SIS biotechnologi\u00ed\u00a0(small intestinal submucosis). Jedn\u00e1 se o z\u00e1tku vytvo\u0159enou srolov\u00e1n\u00edm biologick\u00e9ho materi\u00e1lu, z\u00edskan\u00e9ho ze submuk\u00f3zy\u00a0tenk\u00e9ho st\u0159eva prasete. Z t\u00e9to tk\u00e1n\u011b jsou speci\u00e1ln\u00edmi postupy odstran\u011bny bun\u011b\u010dn\u00e9 struktury muk\u00f3zy se zachov\u00e1n\u00edm intaktn\u00ed struktury submuk\u00f3zn\u00ed matrix. Kone\u010dn\u00fdm produktem je prostorov\u00e1 extracelul\u00e1rn\u00ed matrix. Z\u00e1tka je tedy snadno manipulovateln\u00e1, steriln\u00ed, pln\u011b biologicky degradabiln\u00ed. Nedoch\u00e1z\u00ed u n\u00ed k rejekci nebo zapouzd\u0159en\u00ed. Po implantaci SIS doch\u00e1z\u00ed k intenzivn\u00ed angiogenezi, n\u00e1sledn\u00e9mu os\u00eddlen\u00ed stromatu bun\u011b\u010dn\u00fdmi elementy a ke tk\u00e1\u0148ov\u00e9 p\u0159estavb\u011b (obr. 38 a\u017e 41).<\/p>\n<h6>Postup operace<\/h6>\n<p style=\"text-align: justify;\">An\u00e1ln\u00ed fisurou se provle\u010de zav\u00e1d\u011b\u010d, pomoc\u00ed kter\u00e9ho je n\u00e1sledn\u011b prota\u017een speci\u00e1ln\u00ed kart\u00e1\u010dek, j\u00edm\u017e provedeme rozru\u0161en\u00ed st\u011bny fistuly se snahou obna\u017eit okoln\u00ed zdravou tk\u00e1\u0148. Prov\u00e1d\u00edme vy\u010dist\u011bn\u00ed kan\u00e1lu od tk\u00e1\u0148ov\u00e9ho detritu proplachem a pot\u00e9 pomoc\u00ed prota\u017een\u00e9 ligatury provl\u00e9k\u00e1me takto vznikl\u00fdm kan\u00e1lem k\u00f3nickou z\u00e1tku z materi\u00e1lu SIS. Z\u00e1tku fixujeme ke svalov\u00fdm struktur\u00e1m st\u011bny rekta a kryjeme plastikou sliznice. Zevn\u00ed konec z\u00e1tky odst\u0159ihneme v \u00farovni okoln\u00ed k\u016f\u017ee(obr. 42 a\u017e 48).<\/p>\n<p style=\"text-align: justify;\">U\u00a0obt\u00ed\u017en\u011b se hoj\u00edc\u00edch fistulac\u00ed perian\u00e1ln\u00edch \u010di u nedob\u0159e technicky sanovan\u00fdch fistul lze vyu\u017e\u00edt metody T.E.M. Double flap. Metoda spo\u010d\u00edv\u00e1 v kompletn\u00ed excizi fistuly v cel\u00e9 d\u00e9lce ve zdrav\u00e9 perirekt\u00e1ln\u00ed tk\u00e1ni a uz\u00e1v\u011bru obou \u00fast\u00ed posunut\u00fdm lalokem. Metodu lze \u00fasp\u011b\u0161n\u011b pou\u017e\u00edt u kompletn\u00edch vysoce komunikuj\u00edc\u00edch p\u00ed\u0161t\u011bl\u00ed, kde vnit\u0159n\u00ed advancement flap vytv\u00e1\u0159\u00edme technikou T.E.M., zevn\u00ed \u00fast\u00ed pak o\u0161et\u0159ujeme n\u011bkterou z technik posunu \u010di p\u0159eto\u010den\u00ed ko\u017en\u00edho laloku. Plastiku je nutno pojistit ileostomi\u00ed (obr. 50 a\u017e 56).Po tot\u00e1ln\u00ed excizi p\u00ed\u0161t\u011ble, plastiky zevn\u00edho defektu dle Limberga nebo Schimanowsk\u00e9ho uzav\u00edr\u00e1me vnit\u0159n\u00ed \u00fast\u00ed posunut\u00fdm lalokem technikou T.E.M. advancement flap nebo pomoc\u00ed stapleru Trans STARR.<\/p>\n<h6>Dlouhodob\u00e1 dren\u00e1\u017e vl\u00e1knem<\/h6>\n<p style=\"text-align: justify;\">Na rozd\u00edl od v\u00fd\u0161e zm\u00edn\u011bn\u00e9 dren\u00e1\u017ee vl\u00e1knem p\u0159i chirurgick\u00e9m o\u0161et\u0159en\u00ed absces\u016f p\u0159edstavuje dlouhodob\u00e1 dren\u00e1\u017e vl\u00e1knem mo\u017enost l\u00e9\u010dby u vybran\u00fdch p\u0159\u00edpad\u016f perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed. C\u00edlem dlouhodob\u00e9 dren\u00e1\u017ee vl\u00e1knem je dos\u00e1hnout v \u0159\u00e1dech n\u011bkolika t\u00fddn\u016f a\u017e m\u011bs\u00edc\u016f epitelizace cel\u00e9ho pr\u016fb\u011bhu p\u00ed\u0161t\u011ble. Za t\u00edmto \u00fa\u010delem jsou pr\u016fb\u011bhy p\u00ed\u0161t\u011ble \u2013 p\u0159\u00edpadn\u011b tak\u00e9 v\u00edce p\u00ed\u0161t\u011bl\u00ed \u2013 dr\u00e9nov\u00e1ny pomoc\u00ed latexov\u00e9ho nebo silikonov\u00e9ho vl\u00e1kna a konce jsou zav\u00e1z\u00e1ny do voln\u00e9 smy\u010dky. T\u00edmto zp\u016fsobem se p\u00ed\u0161t\u011bl udr\u017euje neust\u00e1le otev\u0159en\u00e1 a zabra\u0148uje se hromad\u011bn\u00ed sekretu (obr. 57). V minulosti prov\u00e1d\u011bn\u00e1 dren\u00e1\u017e vl\u00e1knem podle Hippokrata s c\u00edlem postupn\u00e9ho prot\u011bt\u00ed a jizven\u00ed apar\u00e1tu sv\u011bra\u010de se dnes kv\u016fli vysok\u00e9 m\u00ed\u0159e inkontinence, siln\u00fdch bolest\u00ed v pr\u016fb\u011bhu t\u00fddn\u016f trvaj\u00edc\u00ed l\u00e9\u010dby a dal\u0161\u00edm komplikac\u00edm nepou\u017e\u00edv\u00e1.<\/p>\n<h6>Fibrinov\u00e9 lepidlo<\/h6>\n<p style=\"text-align: justify;\">Dal\u0161\u00ed mo\u017enost konzervativn\u00ed l\u00e9\u010dby p\u0159edstavuje v posledn\u00ed dob\u011b st\u00e1le v\u00edce propagovan\u00e9 o\u0161et\u0159en\u00ed perian\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed pomoc\u00ed nov\u00e9ho typu fibrinov\u00e9ho lepidla, u n\u011bho\u017e ji\u017e m\u00e1me k dispozici spolehliv\u00e9 posouzen\u00ed. Tato autologn\u00ed fibrinov\u00e1 lepidla (autologous fibrin tissue adhesive = AFTA) se ve srovn\u00e1n\u00ed s d\u0159\u00edve pou\u017e\u00edvan\u00fdmi jin\u00fdmi lepidly vyzna\u010duj\u00ed obzvl\u00e1\u0161t\u011b dobrou p\u0159ilnavost\u00ed tk\u00e1n\u00ed. Z\u00e1kladn\u00edm p\u0159edpokladem hojen\u00ed je ale eliminace infektu. K tomu je ide\u00e1ln\u00ed p\u0159\u00edpravou dlouhodob\u00e1 dren\u00e1\u017e vl\u00e1knem.<\/p>\n<h4>9.2 Sinus pilonidalis<\/h4>\n<h6>V\u0161eobecn\u011b<\/h6>\n<p style=\"text-align: justify;\">Sinus pilonidalis (pilus = vlasy, chloupky, nidus = hn\u00edzdo) je akutn\u00ed nebo chronicky prob\u00edhaj\u00edc\u00ed z\u00e1n\u011bt v subkut\u00e1nn\u00ed tukov\u00e9 tk\u00e1ni, p\u0159ev\u00e1\u017en\u011b v oblasti kostr\u010de. Nespr\u00e1vn\u011b b\u00fdv\u00e1 ozna\u010dov\u00e1n dermou kostr\u010de \u2013 sakr\u00e1ln\u00ed dermou, jako dermoidn\u00ed cysta, kostr\u010dov\u00e1 p\u00ed\u0161t\u011bl, raphefistule, pilonid\u00e1ln\u00ed cysta a sakrokokcyge\u00e1ln\u00ed cysta. Dermoidn\u00ed cysta je toti\u017e onemocn\u011bn\u00ed vrozen\u00e9, b\u00fdv\u00e1 nej\u010dast\u011bji diagnostikov\u00e1no v d\u011btsk\u00e9m v\u011bku, m\u016f\u017ee obsahovat zbytky embryon\u00e1ln\u00ed tk\u00e1n\u011b (vlasy, zuby) a \u010dasto komunikuje s p\u00e1te\u0159n\u00edm kan\u00e1lem. Jsou rozli\u0161ov\u00e1ny t\u0159i obrazy pilonid\u00e1ln\u00edho sinu: asymptomatick\u00e1, akutn\u011b absceduj\u00edc\u00ed a chronick\u00e1 forma.<\/p>\n<h6>Incidence<\/h6>\n<p style=\"text-align: justify;\">Obraz nemoci se vyskytuje \u010dasto mezi 20. a\u017e 30. rokem \u017eivota, p\u0159ev\u00e1\u017en\u011b u mu\u017e\u016f. Menzel a spolupracovn\u00edci referovali o 103 pacientech; z toho bylo 84 mu\u017e\u016f a 19 \u017een. B\u011bhem 2. sv\u011btov\u00e9 v\u00e1lky se muselo podrobit operaci pilonid\u00e1ln\u00edho sinu 77 637 americk\u00fdch voj\u00e1k\u016f, u dal\u0161\u00edch 9000 mu\u017e\u016f byla diagn\u00f3za zji\u0161t\u011bna jako vedlej\u0161\u00ed n\u00e1lez \u2013 d\u017e\u00edpov\u00e1 nemoc. Sondenaa et al. vypo\u010d\u00edtali ze skupiny nemocn\u00fdch v po\u010dtu 322 pacient\u016f nahodilost 26 na 100 000 obyvatel; mu\u017e\u016f bylo posti\u017eeno 2,2kr\u00e1t v\u00edce ne\u017e \u017een.<\/p>\n<h6>Etiopatogeneze<\/h6>\n<p style=\"text-align: justify;\">Sinus pilonidalis je charakterizov\u00e1n jako z\u00edskan\u00e1 i d\u011bdi\u010dn\u011b predisponuj\u00edc\u00ed choroba. Zd\u00e1 se, \u017ee z\u00e1kladem jeho vzniku je multifaktori\u00e1ln\u00ed d\u011bn\u00ed, vyvolan\u00e9 n\u00e1sleduj\u00edc\u00edmi mechanismy: t\u0159ec\u00ed pohyby h\u00fd\u017ed\u00ed tla\u010d\u00ed pol\u00e1man\u00e9 chloupky s jejich ko\u0159enov\u00fdmi konci do k\u016f\u017ee.<\/p>\n<p style=\"text-align: justify;\">Proto\u017ee rohovit\u00e9 \u0161upiny chloupk\u016f funguj\u00ed jako zp\u011btn\u00e9 h\u00e1\u010dky, pronik\u00e1 chloupek st\u00e1le hloub\u011bji do subkut\u00e1nn\u00ed tukov\u00e9 tk\u00e1n\u011b. Tam dojde k rozvoji granulom\u016f, kter\u00e9 perzistuj\u00ed (asymptomatick\u00e1 forma), mohou se ale infikovat (abscesuj\u00edc\u00ed a chronick\u00e1 forma). Siln\u00e9 ochlupen\u00ed, adipozita, nadm\u011brn\u00e1 sekrece potu a nedostate\u010dn\u00e1 hygiena t\u011bla napom\u00e1haj\u00ed vzniku pilonid\u00e1ln\u00edho sinu. Je pops\u00e1na tak\u00e9 rodinn\u00e1 predispozice.<\/p>\n<h6>Klinick\u00fd obraz<\/h6>\n<p style=\"text-align: justify;\">Sinus pilonidalis se vyskytuje z p\u0159ev\u00e1\u017en\u00e9 \u010d\u00e1sti v rima ani, ale tak\u00e9 b\u00fdv\u00e1 v oblasti pupku, za u\u0161ima, na penisu a interdigit\u00e1ln\u011b u holi\u010d\u016f. Pot\u00ed\u017ee jsou z\u00e1visl\u00e9 na klinick\u00e9m vzhledu: symptomatick\u00e1 forma je charakteristick\u00e1 n\u00e1lezem v\u011bt\u0161\u00edho mno\u017estv\u00ed dilatovan\u00fdch p\u00f3r\u016f v rima ani a takto je tak\u00e9 diagnostikov\u00e1na. Akutn\u011b abscesuj\u00edc\u00ed forma imponuje otoky a bolestmi \u010dasto paramedi\u00e1ln\u011b rima ani. Po spont\u00e1nn\u00ed perforaci odte\u010de hnis. V chronick\u00e9m stadiu trp\u00ed pacienti permanentn\u00ed nebo ob\u010dasnou ser\u00f3zn\u011b-hnisovou sepurac\u00ed z dilatovan\u00e9ho p\u00f3ru (prim\u00e1rn\u00edho otvoru), p\u0159\u00edpadn\u011b z later\u00e1ln\u00edch sekund\u00e1rn\u00edch otvor\u016f. Neexistuje spont\u00e1nn\u00ed vyl\u00e9\u010den\u00ed. Asymptomatick\u00fd sinus dlouhodob\u011b perzistuje, m\u016f\u017ee tak\u00e9 p\u0159ej\u00edt do akutn\u00ed (absceduj\u00edc\u00ed) formy nebo do chronick\u00e9ho stadia. Po del\u0161\u00edm nel\u00e9\u010den\u00ed m\u016f\u017ee doj\u00edt k malign\u00ed degeneraci. Davis et al., Kulaylat et al. na\u0161li do roku 1966 v\u00edce ne\u017e 40 takov\u00fdch p\u0159\u00edpad\u016f; v 80 % se jednalo o dla\u017edico-bun\u011b\u010dn\u00fd karcinom (obr. 58 a 59).<\/p>\n<h6>Diagnostika<\/h6>\n<p style=\"text-align: justify;\">Diagnostika se prov\u00e1d\u00ed prost\u0159ednictv\u00edm inspekce, palpace a sond\u00e1\u017e\u00ed. P\u0159i tlaku na chronick\u00fd sinus vyte\u010de \u010dasto krvav\u011b-ser\u00f3zn\u00ed tekutina z prim\u00e1rn\u00edho otvoru le\u017e\u00edc\u00edho v rima ani. Dal\u0161\u00ed diagnostick\u00e9 prost\u0159edky nejsou pot\u0159ebn\u00e9. Dahl a Henrich vid\u011bli v sinu vystlan\u00e9m epitelem fragmenty chloupk\u016f a granula\u010dn\u00edtk\u00e1n\u011b s p\u0159\u00edm\u011bs\u00ed obrovsk\u00fdch bun\u011bk. Elektronov\u011b-mikroskopicky se daly prok\u00e1zat trny nebo do proti h\u00e1k\u016f formovan\u00e9 vlasov\u00e9 elementy. Sendenaa et al. vy\u0161et\u0159ili 53 pacient\u016f se sinem pilonid\u00e1ln\u00edm; prok\u00e1zali chronickou z\u00e1n\u011btlivou reakci k\u016f\u017ee na z\u00e1klad\u011b shlukov\u00e1n\u00ed keratinu a bun\u011b\u010dn\u00e9ho detritu. Diferenci\u00e1ln\u011b diagnosticky vz\u00e1cn\u011b p\u0159ich\u00e1zej\u00ed v \u00favahu an\u00e1ln\u00ed Crohnovy p\u00ed\u0161t\u011ble a acne inversa.<\/p>\n<h6>Terapie<\/h6>\n<ul>\n<li><strong style=\"text-align: justify;\">Konzervativn\u00ed terapie chronick\u00e9ho sinus pilonidalis<br \/>\n<\/strong>Lok\u00e1ln\u00ed nebo syst\u00e9mov\u00e9 pod\u00e1v\u00e1n\u00ed antibiotik se nedoporu\u010duje, nebo\u0165 nep\u016fsob\u00ed definitivn\u011b na vyl\u00e9\u010den\u00ed sinu. Injekce fenolu v roztoku se kv\u016fli vysok\u00e9 toxicit\u011b a mo\u017en\u00e9 resorpci fenolu ji\u017e nepou\u017e\u00edv\u00e1.<\/li>\n<li><strong style=\"text-align: justify;\">Chirurgick\u00e1 terapie chronick\u00e9ho sinus pilonidalis<br \/>\n<\/strong>P\u0159i kyret\u00e1\u017ei p\u00ed\u0161t\u011blov\u00e9ho syst\u00e9mu dle Lorda a Millara, kter\u00e1 se dnes pou\u017e\u00edv\u00e1 jen z\u0159\u00eddka, jsou nejd\u0159\u00edv vy\u0159\u00edznut\u00edm zv\u011bt\u0161eny prim\u00e1rn\u00ed a sekund\u00e1rn\u00ed otvory a subkut\u00e1nn\u00ed chodby jsou pomoc\u00ed kart\u00e1\u010dku \u010di exkochlea\u010dn\u00ed l\u017ei\u010dky vy\u0161krab\u00e1ny a vy\u010di\u0161t\u011bny. Tento z\u00e1sah vy\u017eaduje profylaktickou d\u00e1vku \u0161irokospek\u00e9ho antibiotika. U tohoto postupu byla pops\u00e1na recidiva v 6%. Metodou volby p\u0159i akutn\u011b absceduj\u00edc\u00ed form\u011b je operace. Absces je nejd\u0159\u00edve otev\u0159en a t\u00edmto je vytvo\u0159ena \u00fa\u010dinn\u00e1 dren\u00e1\u017e. Definitivn\u00ed o\u0161et\u0159en\u00ed sinu pilonidalis n\u00e1sleduje sekund\u00e1rn\u011b n\u00e1sleduj\u00edc\u00edmi zp\u016fsoby:<\/p>\n<ul>\n<li style=\"text-align: justify;\">Excize a sekund\u00e1rn\u00ed hojen\u00ed<br \/>\nJe provedena kompletn\u00ed excize lo\u017eiska se v\u0161emi\u00a0fistulacemi a\u017e k fascii sakr\u00e1ln\u00ed. Okraje r\u00e1ny\u00a0ploch\u00e1 jizva. Pe\u010dliv\u00fdm vyholen\u00edm mus\u00edme p\u0159ed\u00a0v\u00fdkonem p\u0159ipravit z\u00f3nu bez ochlupen\u00ed. Bascom\u00a0prok\u00e1zal, \u017ee v poko\u017ece bez folikul\u016f se onemocn\u011bn\u00ed\u00a0nevyskytne. Pe\u010dliv\u00e1 p\u00e9\u010de o vytvo\u0159enou jizvu\u00a0je podstatnou sou\u010d\u00e1st\u00ed konceptu terapie.<\/li>\n<li style=\"text-align: justify;\">Excize s prim\u00e1rn\u00edm uzav\u0159en\u00edm r\u00e1ny<br \/>\nPo excizi je r\u00e1na prim\u00e1rn\u011b o\u0161et\u0159ena suturou, p\u0159\u00edpadn\u011b je plasticky rekonstruov\u00e1na. Pro posledn\u00ed jmenovan\u00fd operativn\u00ed postup jsou doporu\u010deny r\u016fzn\u00e9 metody. Plastika by m\u011bla b\u00fdt provedena p\u0159i ATB profylaxi.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_414.png\"><img decoding=\"async\" title=\"Obr. 58 \u2013 Zevn\u00ed prim\u00e1rn\u00ed \u00fast\u00ed pilonid\u00e1ln\u00edho sinu\" alt=\"Obr. 58 \u2013 Zevn\u00ed prim\u00e1rn\u00ed \u00fast\u00ed pilonid\u00e1ln\u00edho sinu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_414.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 58 \u2013 Zevn\u00ed prim\u00e1rn\u00ed \u00fast\u00ed pilonid\u00e1ln\u00edho sinu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_413.png\"><img decoding=\"async\" title=\"Obr. 59 \u2013 Excidovan\u00fd sinus pilonidalis\" alt=\"Obr. 59 \u2013 Excidovan\u00fd sinus pilonidalis\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_413.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 59 \u2013 Excidovan\u00fd sinus pilonidalis<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>\u00a0Operace pilonid\u00e1ln\u00edho sinu posuvn\u00fdm lalokem dle Karydakise<\/h6>\n<p style=\"text-align: justify;\">Dr. George Karydakis publikoval svou metodu chirurgick\u00e9 excize pilonid\u00e1ln\u00edho sinu v roce 1973. Podstata jeho origin\u00e1ln\u00edho \u0159e\u0161en\u00ed spo\u010d\u00edv\u00e1 v jednoduch\u00e9m odstran\u011bn\u00ed lo\u017eiska sinu bikonvexn\u00edm eliptick\u00fdm excentrick\u00fdm vy\u0159\u00edznut\u00edm m\u011bkk\u00fdch tk\u00e1n\u00ed a\u017e k sakr\u00e1ln\u00ed fascii. Technikou later\u00e1ln\u00edho podminov\u00e1n\u00ed je pak vytvo\u0159en ko\u017en\u011b-podko\u017en\u00ed lalok, kter\u00fd je p\u0159eta\u017een excentricky medi\u00e1ln\u011b. Dojde tak k plastice defektu se zm\u011bl\u010den\u00edm rima ani bez nap\u011bt\u00ed.Po dezinfekci a zarou\u0161kov\u00e1n\u00ed opera\u010dn\u00edho pole v poloze Jack Knife s rozta\u017een\u00fdmi p\u016flkami, kter\u00e9 jsou v t\u00e9to poloze fixov\u00e1ny p\u00e1sy n\u00e1plasti, jsou hlavn\u00ed kan\u00e1l a p\u0159\u00edpadn\u00e1 vedlej\u0161\u00ed \u00fast\u00ed sinu nast\u0159\u00edknuty patentn\u00ed mod\u0159\u00ed. N\u011bkte\u0159\u00ed operat\u00e9\u0159i prov\u00e1d\u011bj\u00ed v\u00fdkon bez n\u00e1st\u0159iku. Eliptick\u00e1 excize je pak situov\u00e1na excentricky k rima ani tak, aby osa elipsy byla vedena cca 1,5 a\u017e 2 cm paraleln\u011b s rima ani na zdravou stranu, tedy stranu bez vy\u00fast\u011bn\u00ed hlavn\u00edho v\u00fdvodu a v\u00fdvod\u016f sekund\u00e1rn\u00edch. Jsou-li hlavn\u00ed v\u00fdvod a p\u0159\u00edpadn\u00e9 v\u00fdvody sekund\u00e1rn\u00ed um\u00edst\u011bny v rima ani, p\u0159esv\u011bd\u010d\u00edme se p\u00e1tradlem o um\u00edst\u011bn\u00ed vlastn\u00edho lo\u017eiska sinu. Elipsu pak excentricky um\u00eds\u0165ujeme na \u201estranu zdravou\u201c. Excizi k\u016f\u017ee a podko\u017e\u00ed se sinem prov\u00e1d\u00edme kolmo ke spodin\u011b a\u017e k fascii sakr\u00e1ln\u00ed. Pamatujeme na ulo\u017een\u00ed an\u00e1ln\u00edho kan\u00e1lu s lev\u00e1tory a sv\u011bra\u010dov\u00fdm syst\u00e9mem. B\u011bhem excize sledujeme p\u0159\u00edpadn\u00fd v\u00fdskyt modr\u00e9ho zbarven\u00ed, kter\u00e9 prokazuje caro luxurians a pyogenn\u00ed membr\u00e1nu p\u0159\u00edpadn\u00fdch chobot\u016f sinu. Exaktn\u011b stav\u00edme krv\u00e1cen\u00ed elektrokoagulac\u00ed. V polovin\u011b tlou\u0161\u0165ky podko\u017e\u00ed pak\u00a0rovnom\u011brn\u011b se spodinou nat\u00edn\u00e1me podko\u017e\u00ed na stran\u011b bl\u00ed\u017ee k rima ani, a vytv\u00e1\u0159\u00edme tak lalok pro budouc\u00ed posuvnou plastiku. Takto provedenou discizi rozev\u0159eme a v jej\u00edm vrcholu nakl\u00e1d\u00e1me jednotliv\u00e9 stehy, kter\u00e9 fixujeme ke spodin\u011b vznikl\u00e9ho defektu, tedy k fascii sakr\u00e1ln\u00ed, a d\u00e1le do podko\u017e\u00ed strany prot\u011bj\u0161\u00ed. Stehy nedotahujeme, ale v\u011b\u0161\u00edme. V z\u00e1v\u011bre\u010dn\u00e9 f\u00e1zi operace povolujeme n\u00e1plas\u0165ov\u00e9 fixace. Vkl\u00e1d\u00e1me tenk\u00fd Redon\u016fv dr\u00e9n na spodinu defektu a po p\u0159eta\u017een\u00ed ko\u017en\u011b-podko\u017en\u00edho laloku ke stran\u011b prot\u011bj\u0161\u00ed jednotliv\u00e9 stehy uzl\u00edme. Dokon\u010dujeme suturu k\u016f\u017ee, Redon\u016fv dr\u00e9n napojujeme na aktivn\u00ed s\u00e1n\u00ed. Po toalet\u011b r\u00e1ny tuto kryjeme bu\u010f lep\u00edc\u00edm kryt\u00edm, \u010di do rima ani vkl\u00e1d\u00e1me nevelk\u00e9 mulov\u00e9 hypomochlion ve tvaru v\u00e1le\u010dku o pr\u016fm\u011bru asi tak 2 cm (obr. 60\u201363). V poopera\u010dnm\u00edm obdob\u00ed by m\u011bl pacient le\u017eet na z\u00e1dech.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_416.png\"><img decoding=\"async\" title=\"Obr. 60 \u2013 Excentrick\u00fd eliptick\u00fd \u0159ez\" alt=\"Obr. 60 \u2013 Excentrick\u00fd eliptick\u00fd \u0159ez\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_416.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 60 \u2013 Excentrick\u00fd eliptick\u00fd \u0159ez<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_417.png\"><img decoding=\"async\" title=\"Obr. 61 \u2013 Podminov\u00e1n\u00ed later\u00e1ln\u00edho okraje \u2013 vytvo\u0159en\u00ed Karydakisova laloku\" alt=\"Obr. 61 \u2013 Podminov\u00e1n\u00ed later\u00e1ln\u00edho okraje \u2013 vytvo\u0159en\u00ed Karydakisova laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_417.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 61 \u2013 Podminov\u00e1n\u00ed later\u00e1ln\u00edho okraje \u2013 vytvo\u0159en\u00ed Karydakisova laloku<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_418.png\"><img decoding=\"async\" title=\"Obr. 62 \u2013 Sutura laloku ke spodin\u011b a kontralater\u00e1ln\u00ed stran\u011b \u2013 p\u0159eta\u017een\u00ed laloku\" alt=\"Obr. 62 \u2013 Sutura laloku ke spodin\u011b a kontralater\u00e1ln\u00ed stran\u011b \u2013 p\u0159eta\u017een\u00ed laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_418.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 62 \u2013 Sutura laloku ke spodin\u011b a kontralater\u00e1ln\u00ed stran\u011b \u2013 p\u0159eta\u017een\u00ed laloku<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_419.png\"><img decoding=\"async\" title=\"Obr. 63 \u2013 Sutura k\u016f\u017ee po nalo\u017een\u00ed Redonova dr\u00e9nu ke spodin\u011b plastiky\" alt=\"Obr. 63 \u2013 Sutura k\u016f\u017ee po nalo\u017een\u00ed Redonova dr\u00e9nu ke spodin\u011b plastiky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_419.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 63 \u2013 Sutura k\u016f\u017ee po nalo\u017een\u00ed Redonova dr\u00e9nu ke spodin\u011b plastiky<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Operace pilonid\u00e1ln\u00edho sinu p\u0159eto\u010den\u00fdm lalokem dle Limberga<\/h6>\n<p style=\"text-align: justify;\">Podstata v\u00fdkonu spo\u010d\u00edv\u00e1 op\u011btovn\u011b v kompletn\u00ed excizi lo\u017eiska sinu, tentokr\u00e1t v\u0161ak ve tvaru koso\u010dtverce \u010di l\u00e9pe rhomboidu a kryt\u00edm defektu p\u0159eto\u010den\u00edm rotovan\u00e9ho laloku dle Limberga (obr. 64\u201367).Po dezinfekci a zarou\u0161kov\u00e1n\u00ed opera\u010dn\u00edho pole v poloze Jack Knife, po n\u00e1st\u0159iku hlavn\u00edho v\u00fdvodu a p\u0159\u00edpadn\u00fdch v\u00fdvod\u016f sekund\u00e1rn\u00edch patentn\u00ed mod\u0159\u00ed prov\u00e1d\u00edme excizi lo\u017eiska sinu ve tvaru rhomboidu a\u017e k fascii sakr\u00e1ln\u00ed. Exaktn\u011b stav\u00edme krv\u00e1cen\u00ed koagulac\u00ed. Na n\u00e1mi zvolen\u00e9 stran\u011b vym\u011b\u0159ujeme budouc\u00ed Limberg\u016fv lalok ko\u017en\u011b-podko\u017en\u00ed, incize vedeme kolmo ke spodin\u011b, k pov\u00e1zce m. gluteus maximus. Podko\u017e\u00ed ost\u0159e odpreparov\u00e1v\u00e1me od pov\u00e1zky, a z\u00edsk\u00e1v\u00e1me tak voln\u00fd ko\u017en\u011b-podko\u017en\u00ed lalok. Na spodinu defektu um\u00edst\u00edme Redon\u016fv dr\u00e9n, nakl\u00e1d\u00e1me jednotliv\u00e9 stehy, kter\u00e9 uzl\u00edme postupn\u011b po nalo\u017een\u00ed v\u0161ech. V\u00fdkon dokon\u010dujeme suturou k\u016f\u017ee a napojen\u00edm Redonova dr\u00e9nu na aktivn\u00ed s\u00e1n\u00ed. Po toalet\u011b kryjeme suturu, po v\u00fdkonu pacient z\u016fst\u00e1v\u00e1 v poloze na z\u00e1dech.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_421.png\"><img decoding=\"async\" title=\"Obr. 64 \u2013 Ko\u017en\u00ed incize rhomboidn\u00edho tvaru\" alt=\"Obr. 64 \u2013 Ko\u017en\u00ed incize rhomboidn\u00edho tvaru\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_421.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 64 \u2013 Ko\u017en\u00ed incize rhomboidn\u00edho tvaru<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_422.png\"><img decoding=\"async\" title=\"Obr. 65 \u2013 P\u0159eta\u017een\u00ed Limbergova laloku\" alt=\"Obr. 65 \u2013 P\u0159eta\u017een\u00ed Limbergova laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_422.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 65 \u2013 P\u0159eta\u017een\u00ed Limbergova laloku<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_424.png\"><img decoding=\"async\" title=\"Obr. 66 \u2013 Sutura p\u0159\u00eddr\u017en\u00fdmi stehy\" alt=\"Obr. 66 \u2013 Sutura p\u0159\u00eddr\u017en\u00fdmi stehy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_424.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 66 \u2013 Sutura p\u0159\u00eddr\u017en\u00fdmi stehy<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_423.png\"><img decoding=\"async\" title=\"Obr. 67 \u2013 V\u00fdsledn\u00fd stav plastiky\" alt=\"Obr. 67 \u2013 V\u00fdsledn\u00fd stav plastiky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_423.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 67 \u2013 V\u00fdsledn\u00fd stav plastiky<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_427.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 68 \u2013 Ko\u017en\u00ed incize \u2013 p\u0159\u00edprava laloku dle Schimanowsk\u00e9ho\" alt=\"Obr. 68 \u2013 Ko\u017en\u00ed incize \u2013 p\u0159\u00edprava laloku dle Schimanowsk\u00e9ho\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_427.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 68 \u2013 Ko\u017en\u00ed incize \u2013 p\u0159\u00edprava laloku dle Schimanowsk\u00e9ho<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_426.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 69 \u2013 Schimanowsk\u00e9ho lalok po vyt\u011bt\u00ed lo\u017eiska sinu\" alt=\"Obr. 69 \u2013 Schimanowsk\u00e9ho lalok po vyt\u011bt\u00ed lo\u017eiska sinu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_426.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 69 \u2013 Schimanowsk\u00e9ho lalok po vyt\u011bt\u00ed lo\u017eiska sinu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_429.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 70 \u2013 Schimanowsk\u00e9ho lalok p\u0159ichyst\u00e1n k proveden\u00ed p\u0159esunu\" alt=\"Obr. 70 \u2013 Schimanowsk\u00e9ho lalok p\u0159ichyst\u00e1n k proveden\u00ed p\u0159esunu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_429.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 70 \u2013 Schimanowsk\u00e9ho lalok p\u0159ichyst\u00e1n k proveden\u00ed p\u0159esunu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_428.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 71 \u2013 V\u00fdsledn\u00fd stav plastiky\" alt=\"Obr. 71 \u2013 V\u00fdsledn\u00fd stav plastiky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_428.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 71 \u2013 V\u00fdsledn\u00fd stav plastiky<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Operace pilonid\u00e1ln\u00edho sinu posuvn\u00fdm lalokem dle Schimanowsk\u00e9ho<\/h6>\n<p>Podstata v\u00fdkonu op\u011bt spo\u010d\u00edv\u00e1 v excizi sinu, tentokr\u00e1t ve tvaru obd\u00e9ln\u00edka a ve vytvo\u0159en\u00ed ko\u017en\u011b-podko\u017en\u00edho obd\u00e9ln\u00edkov\u00e9ho laloku, kter\u00fd je dopln\u011bn na later\u00e1ln\u00ed stran\u011b dv\u011bma uvol\u0148ovac\u00edmi trigon\u00e1ln\u00edmi excizemi, kter\u00e9 umo\u017en\u00ed jeho medi\u00e1ln\u00ed p\u0159esun a kryt\u00ed vznikl\u00e9ho defektu (obr. 68\u201371).<\/p>\n<h6>Dal\u0161\u00ed mo\u017enou modifikac\u00ed je \u0159e\u0161en\u00ed sinu plastikou V-Y (obr. 72\u201375)<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_431.png\"><img decoding=\"async\" title=\"Obr. 72 \u2013 N\u00e1kres V-Y plastiky u recidivuj\u00edc\u00edho sinu pilonid\u00e1ln\u00edho\" alt=\"Obr. 72 \u2013 N\u00e1kres V-Y plastiky u recidivuj\u00edc\u00edho sinu pilonid\u00e1ln\u00edho\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_431.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 72 \u2013 N\u00e1kres V-Y plastiky u recidivuj\u00edc\u00edho sinu pilonid\u00e1ln\u00edho<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_430.png\"><img decoding=\"async\" title=\"Obr. 73 \u2013 Excidovan\u00fd sinus s n\u00e1\u0159ezy\" alt=\"Obr. 73 \u2013 Excidovan\u00fd sinus s n\u00e1\u0159ezy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_430.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 73 \u2013 Excidovan\u00fd sinus s n\u00e1\u0159ezy<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_434.png\"><img decoding=\"async\" title=\"Obr. 74 \u2013 Sutura defektu po excizi sinu\" alt=\"Obr. 74 \u2013 Sutura defektu po excizi sinu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_434.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 74 \u2013 Sutura defektu po excizi sinu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_433.png\"><img decoding=\"async\" title=\"Obr. 75 \u2013 Plastika V-Y\" alt=\"Obr. 75 \u2013 Plastika V-Y\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_433.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 75 \u2013 Plastika V-Y<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>9.3 \u0158itn\u00ed trhliny<\/h4>\n<h6>Obecn\u011b<\/h6>\n<p style=\"text-align: justify;\">\u0158itn\u00ed trhlina pat\u0159\u00ed svou klinickou symptomatologi\u00ed v\u00fdrazn\u00fdch a intenzivn\u00edch bolest\u00ed k nejpozoruhodn\u011bj\u0161\u00edm proktologick\u00fdm onemocn\u011bn\u00edm. Jedn\u00e1 se p\u0159itom o pod\u00e9ln\u00fd, v\u0159edovit\u00fd defekt v oblasti vysoce citliv\u00e9ho anodermu. Bez c\u00edlen\u011b prov\u00e1d\u011bn\u00e9 l\u00e9\u010dby lze \u010dasem o\u010dek\u00e1vat chronick\u00fd pr\u016fb\u011bh nemoci. P\u0159esn\u00e1 \u010d\u00edsla ohledn\u011b \u010detnosti v\u00fdskytu \u0159itn\u00edch trhlin nejsou k dispozici. V proktologick\u00fdch ordinac\u00edch lze po\u010d\u00edtat, \u017ee budou tvo\u0159it 10\u201315 % v\u0161ech p\u0159\u00edpad\u016f.<\/p>\n<h6>Etiopatogeneze<\/h6>\n<p style=\"text-align: justify;\">Na vzniku \u0159itn\u00edch trhlin se pod\u00edl\u00ed v\u00edce faktor\u016f. Velk\u00fd v\u00fdznam maj\u00ed poruchy vyprazd\u0148ov\u00e1n\u00ed stolice. Ke vzniku \u0159itn\u00edch trhlin nevede pouze tuh\u00e1 stolice, ale tak\u00e9 ka\u0161ovit\u00e1 a pr\u016fjmov\u00e1 stolice, kter\u00e1 m\u016f\u017ee b\u00fdt konstipa\u010dn\u00edho p\u016fvodu, je d\u016fsledkem nadm\u011brn\u00e9ho u\u017e\u00edv\u00e1n\u00ed laxativ nebo se vyskytuje p\u0159i chronick\u00fdch z\u00e1n\u011btliv\u00fdch st\u0159evn\u00edch onemocn\u011bn\u00edch. Doch\u00e1z\u00ed k z\u00e1n\u011btliv\u00fdm proces\u016fm v oblasti an\u00e1ln\u00edch krypt. Krom\u011b toho nen\u00ed \u0159itn\u00ed kan\u00e1l dostate\u010dn\u011b rozp\u00edn\u00e1n, \u010d\u00edm\u017e trp\u00ed jeho elasticita. Sv\u016fj v\u00fdznamn\u00fd pod\u00edl maj\u00ed tak\u00e9 hemoroidy. Za t\u011bchto okolnost\u00ed doch\u00e1z\u00ed ji\u017e p\u0159i fyziologick\u00e9m nam\u00e1h\u00e1n\u00ed \u0159itn\u00edho kan\u00e1lu p\u0159i defekaci k natr\u017een\u00ed anodermu se \u0161patnou tendenc\u00ed k hojen\u00ed.<\/p>\n<ul>\n<li style=\"text-align: justify;\">K endogenn\u00edm faktor\u016fm, kter\u00e9 p\u0159isp\u00edvaj\u00ed ke vzniku trhliny, \u0159ad\u00edme rodinnou predispozi\u010dn\u00ed z\u00e1t\u011b\u017e, nadv\u00e1hu a tak\u00e9 sklon k tromb\u00f3ze.<\/li>\n<li style=\"text-align: justify;\">K exogenn\u00edm faktor\u016fm pat\u0159\u00ed nevhodn\u00e1 skladba stravy, nedostatek pohybu, nadm\u011brn\u00e9 u\u017e\u00edv\u00e1n\u00ed laxativ.<\/li>\n<li style=\"text-align: justify;\">Endogenn\u00ed faktory spole\u010dn\u011b s exogenn\u00edmi vedou ke zt\u00ed\u017een\u00e9mu pr\u016fb\u011bhu defekace, nedostate\u010dn\u00e9mu vypr\u00e1zdn\u011bn\u00ed krve z hemoroid\u00e1ln\u00edch pol\u0161t\u00e1\u0159\u016f b\u011bhem defekace, k ekt\u00e1zii hemoroid\u016f s rigiditou an\u00e1ln\u00edho kan\u00e1lu. <strong>V\u00fdsledn\u00fdm stavem je circulus vitiosus<\/strong>: mikrotrauma, z\u00e1n\u011bt, bolestiv\u00fd spasmus sv\u011bra\u010de\u2026 Tak vznik\u00e1 bludn\u00fd kruh, kter\u00fd vysv\u011btluje vysokou n\u00e1chylnost k chronick\u00e9mu pr\u016fb\u011bhu onemocn\u011bn\u00ed.<\/li>\n<\/ul>\n<h6>Klinick\u00fd obraz<\/h6>\n<p style=\"text-align: justify;\">Na rozd\u00edl od mnoha jin\u00fdch proktologick\u00fdch onemocn\u011bn\u00ed se u \u0159itn\u00ed trhliny vyskytuje typick\u00e1 symptomatologie. V pop\u0159ed\u00ed stoj\u00ed bolesti souvisej\u00edc\u00ed s vyprazd\u0148ov\u00e1n\u00edm stolice, kter\u00e9 nastupuj\u00ed p\u0159i defekaci (okam\u017eit\u00e1 bolest) a mohou p\u0159etrv\u00e1vat n\u011bkolik hodin. P\u0159i \u010dast\u00e9m vyprazd\u0148ov\u00e1n\u00ed stolice trp\u00ed posti\u017een\u00fd jedinec bolestmi v pr\u016fb\u011bhu cel\u00e9ho dne. Jinak bolesti v\u011bt\u0161inou odezn\u00ed ve\u010der a v pr\u016fb\u011bhu noci a n\u00e1sleduj\u00edc\u00ed den se op\u011bt dostav\u00ed p\u0159i vyprazd\u0148ov\u00e1n\u00ed stolice. Mnoho pacient\u016f se z d\u016fvodu siln\u00fdch bolest\u00ed uchyluje k pou\u017e\u00edv\u00e1n\u00ed proj\u00edmadel, aby m\u011bli stolici co nejm\u011bk\u010d\u00ed a p\u0159i defekaci m\u011bli men\u0161\u00ed bolesti. Pr\u00e1v\u011b tento krok je ale chybn\u00fd, proto\u017ee ka\u0161ovit\u00e1 nebo tekut\u00e1 stolice sn\u00e1ze ulp\u00edv\u00e1 v trhlin\u011b a poru\u0161uje okraje r\u00e1ny, \u010d\u00edm\u017e aktivuje setrval\u00fd z\u00e1n\u011btliv\u00fd proces. P\u0159i p\u0159echodu do chronick\u00e9ho stadia intenzita bolest\u00ed ustupuje. D\u00e1le je typick\u00e9 <b>k\u0159e\u010dovit\u00e9 sta\u017een\u00ed vnit\u0159n\u00edho sv\u011bra\u010de \u0159itn\u00edho <\/b>zp\u016fsoben\u00e9 bolestmi. Digit\u00e1ln\u00ed vy\u0161et\u0159en\u00ed je mnohdy st\u011b\u017e\u00ed mo\u017en\u00e9; stolice je \u0161irok\u00e1 pouze jako tu\u017eka. Krev se obvykle vyskytuje v pod\u00e9ln\u00fdch prou\u017ec\u00edch na sloupku stolice nebo p\u0159i \u010di\u0161t\u011bn\u00ed na toaletn\u00edm pap\u00edru. Trhlina m\u016f\u017ee nakonec neust\u00e1le vym\u011b\u0161ovat <b>sekret, <\/b>a t\u00edm zp\u016fsobovat an\u00e1ln\u00ed ekz\u00e9m.\u0158itn\u00ed trhliny se vyskytuj\u00ed v 80 % na zadn\u00ed komisu\u0159e, v 10\u201315 % na p\u0159edn\u00ed komisu\u0159e a z\u0159\u00eddka v postrann\u00edch oblastech. U morfologick\u00e9ho n\u00e1lezu m\u016f\u017eeme rozli\u0161it\u00a0akutn\u00ed a chronick\u00e9 \u0159itn\u00ed trhliny, p\u0159i\u010dem\u017e p\u0159echod mezi nimi je \u010dasto plynul\u00fd.<\/p>\n<h6>Akutn\u00ed \u0159itn\u00ed trhliny<\/h6>\n<p style=\"text-align: justify;\">Akutn\u00ed \u0159itn\u00ed trhliny se p\u0159i klinick\u00e9m vy\u0161et\u0159en\u00ed jev\u00ed jako ploch\u00e9, pod\u00e9ln\u00e9 defekty s d\u00e9lkou 0,5\u20131,0 cm v oblasti anodermu. Spodina r\u00e1ny je zpo\u010d\u00e1tku prokrv\u00e1cen\u00e1 a pozd\u011bji pokryt\u00e1 fibr\u00f3zn\u00edm n\u00e1letem. N\u00e1padn\u00e9 jsou v tomto stadiu v\u00fdrazn\u011b ohrani\u010den\u00e9 okraje. Mnohdy lze zjistit apik\u00e1ln\u011b v trhlin\u011b prohlouben\u00e9 krypty (obr. 76).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_436.png\"><img decoding=\"async\" title=\"Obr. 76 \u2013 Akutn\u00ed \u0159itn\u00ed trhlina\" alt=\"Obr. 76 \u2013 Akutn\u00ed \u0159itn\u00ed trhlina\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_436.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 76 \u2013 Akutn\u00ed \u0159itn\u00ed trhlina<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_437.png\"><img decoding=\"async\" title=\"Obr. 77 \u2013 Chronick\u00e1 \u0159itn\u00ed trhlina\" alt=\"Obr. 77 \u2013 Chronick\u00e1 \u0159itn\u00ed trhlina\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_437.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 77 \u2013 Chronick\u00e1 \u0159itn\u00ed trhlina<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Chronick\u00e9 \u0159itn\u00ed trhliny<\/h6>\n<p style=\"text-align: justify;\">Chronick\u00e9 \u0159itn\u00ed trhliny se od akutn\u00edch z\u0159eteln\u011b li\u0161\u00ed. Morfologick\u00fd n\u00e1lez p\u0159ipom\u00edn\u00e1 kal\u00f3zn\u00ed v\u0159ed, na jeho\u017e spodn\u00ed \u010d\u00e1sti lze pozorovat p\u0159\u00ed\u010dn\u011b prob\u00edhaj\u00edc\u00ed b\u011blav\u00e1 vl\u00e1kna vnit\u0159n\u00edho \u0159itn\u00edho sv\u011bra\u010de. Okraje chronick\u00fdch trhlin jsou hrub\u00e9 a vystoupl\u00e9. V\u011bt\u0161inou jsou poru\u0161en\u00e9. Typick\u00e9 pro chronick\u00e9 \u0159itn\u00ed trhliny jsou hypertrofick\u00e9\u00a0an\u00e1ln\u00ed papily dosahuj\u00edc\u00ed a\u017e velikosti t\u0159e\u0161n\u011b a an\u00e1ln\u00ed ko\u017en\u00ed \u0159asy, kter\u00e9 p\u0159i prohl\u00eddce jako tzv. p\u0159edsunut\u00e9 vr\u00e1sy \u010di str\u00e1\u017en\u00ed hrboly poukazuj\u00ed na um\u00edst\u011bn\u00ed trhliny (viz obr. 80). I tyto mohou nez\u0159\u00eddka dosahovat a\u017e velikosti l\u00edskov\u00e9ho o\u0159echu. Chronick\u00e9 \u0159itn\u00ed trhliny mohou v\u00e9st ke vzniku ne\u00fapln\u00e9 vnit\u0159n\u00ed p\u00ed\u0161t\u011ble vych\u00e1zej\u00edc\u00ed ze spodn\u00ed \u010d\u00e1sti trhliny, sm\u011b\u0159uj\u00edc\u00ed vzad. To vede k zes\u00edlen\u00e9mu vym\u011b\u0161ov\u00e1n\u00ed hnisav\u00e9ho sekretu. Mnohdy lze hovo\u0159it o chronick\u00fdch \u0159itn\u00edch trhlin\u00e1ch tak\u00e9 tehdy, nezhoj\u00ed-li se po \u0161esti t\u00fddnech (obr. 77).<\/p>\n<h6>Histologie<\/h6>\n<p style=\"text-align: justify;\">Pro \u0159itn\u00ed trhliny je na rozd\u00edl od jin\u00fdch defekt\u016f \u0159itn\u00edho kan\u00e1lu charakteristick\u00fd z\u00e1n\u011btliv\u00fd infiltr\u00e1t pod spodinou trhliny. Rozsah t\u011bchto z\u00e1n\u011btliv\u00fdch zm\u011bn se projevuje obzvl\u00e1\u0161t\u011b pod\u00e9l nejjemn\u011bj\u0161\u00edch nervov\u00fdch vl\u00e1ken. T\u00edm se vysv\u011btluje tak\u00e9 siln\u00e1 intenzita bolest\u00ed a hypertonus sv\u011bra\u010de.<\/p>\n<h6>Pr\u016fb\u011bh a progn\u00f3za<\/h6>\n<p style=\"text-align: justify;\">Nepoda\u0159\u00ed-li se co nejd\u0159\u00edve prolomit bludn\u00fd kruh vyskytuj\u00edc\u00ed se u \u0159itn\u00edch trhlin, je nutn\u00e9 po\u010d\u00edtat s p\u0159echodem do chronicity. P\u0159i n\u00ed se st\u00e1vaj\u00ed obt\u00ed\u017ee sice m\u00e9n\u011b dramatick\u00fdmi a p\u0159\u00edle\u017eitostn\u011b tak\u00e9 zcela vymiz\u00ed, ale onemocn\u011bn\u00ed nen\u00ed vyl\u00e9\u010deno. V\u017edy je za t\u011bchto okolnost\u00ed nutn\u00e9 po\u010d\u00edtat s akutn\u00ed exacerbac\u00ed a vznikem absceduj\u00edc\u00edch p\u00ed\u0161t\u011blov\u00fdch onemocn\u011bn\u00ed. Tyto pr\u016fb\u011bhy onemocn\u011bn\u00ed p\u0159edstavuj\u00ed riziko pro kontinenci.<\/p>\n<h6 style=\"text-align: justify;\">Diagnostika<\/h6>\n<p style=\"text-align: justify;\">Akutn\u00ed \u0159itn\u00ed trhliny lze v\u011bt\u0161inou velice snadno diagnostikovat na z\u00e1klad\u011b typick\u00fdch bolest\u00ed souvisej\u00edc\u00edch s vyprazd\u0148ov\u00e1n\u00edm stolice, k\u0159e\u010dovit\u011b sta\u017een\u00e9ho svalstva sv\u011bra\u010de, se stolic\u00ed \u010dasto o \u0161\u00ed\u0159ce pouh\u00e9 tu\u017eky a krv\u00ed na stolici nebo toaletn\u00edm pap\u00edru. Vy\u0161et\u0159en\u00ed \u2013 nejl\u00e9pe pomoc\u00ed an\u00e1ln\u00edho spekula \u2013 lze usnadnit aplikac\u00ed lok\u00e1ln\u00edho anestetika na trhlinu. Pomoc\u00ed r\u016fzn\u011b zak\u0159iven\u00fdch sond lze snadno zjistit kapsovit\u00e9 a p\u00ed\u0161t\u011blov\u00e9 \u00fatvary a posoudit nejv\u00edce prohlouben\u00e9 krypty. U chronick\u00fdch trhlin je vy\u0161et\u0159en\u00ed obecn\u011b m\u00e9n\u011b problematick\u00e9. Trhlinu lze rozpoznat \u010dasto ji\u017e p\u0159i rozev\u0159en\u00ed h\u00fd\u017ed\u00ed. Digit\u00e1ln\u00ed sondov\u00e1n\u00ed \u0159itn\u00edho kan\u00e1lu a vy\u0161et\u0159en\u00ed pomoc\u00ed \u00fazk\u00e9ho an\u00e1ln\u00edho spekula lze obecn\u011b prov\u00e9st bez znecitliv\u011bn\u00ed. M\u011b\u0159en\u00ed tlaku sv\u011bra\u010de nem\u00e1 u \u0159itn\u00edch trhlin \u017e\u00e1dn\u00fd obzvl\u00e1\u0161\u0165 velk\u00fd v\u00fdznam \u2013 ani p\u0159ed operativn\u00edmi z\u00e1sahy z pohledu forenzn\u00ed medic\u00edny, nebo\u0165 neposkytuj\u00ed v\u00fdpov\u011b\u010f o patofyziologick\u00fdch pom\u011brech sv\u011bra\u010dov\u00e9ho syst\u00e9mu. Pov\u0161echn\u011b trv\u00e1 algicitou indukovan\u00fd hypertonus.<\/p>\n<h6>Diferenci\u00e1ln\u00ed diagn\u00f3za<\/h6>\n<p style=\"text-align: justify;\">Defekty trhlinov\u00e9ho charakteru se objevuj\u00ed i u jin\u00fdch an\u00e1ln\u00edch onemocn\u011bn\u00ed. Morfologicky \u010dasto nab\u00edzej\u00ed podobn\u00fd obraz, ale v\u011bt\u0161inou jinou klinickou symptomatologii. \u201e\u0158itn\u00ed trhliny\u201c u Crohnovy choroby lze nal\u00e9zt ve v\u0161ech oblastech \u0159itn\u00edho kan\u00e1lu, z\u0159\u00eddka v\u0161ak vedou k bolestem a k\u0159e\u010d\u00edm sv\u011bra\u010de. Hovo\u0159\u00edme tak\u00e9 o atypick\u00fdch trhlin\u00e1ch. Obdobn\u011b se jev\u00ed l\u00e9ze trhlinov\u00e9ho charakteru u an\u00e1ln\u00ed syfilis. Trhlinov\u00e9 defekty karcinomu \u0159itn\u00edho kan\u00e1lu mohou za\u010d\u00ednat jako u typick\u00e9 trhliny s bolestmi souvisej\u00edc\u00edmi s vyprazd\u0148ov\u00e1n\u00edm stolice. U dr\u00e1\u017ediv\u00e9ho toxick\u00e9ho an\u00e1ln\u00edho ekz\u00e9mu jsou \u010dast\u00e9 bolestiv\u00e9 paprskovit\u011b rozlo\u017een\u00e9 rag\u00e1dy a od\u011brky.<\/p>\n<h6>L\u00e9\u010dba<\/h6>\n<h6>Konzervativn\u00ed l\u00e9\u010dba<\/h6>\n<p>Klinick\u00e1 symptomatika na stran\u011b jedn\u00e9 a nebezpe\u010d\u00ed p\u0159echodu do chronicity na stran\u011b druh\u00e9 u akutn\u00ed trhliny p\u0159\u00edmo vy\u017eaduj\u00ed d\u016fsledn\u00fd postup. 70\u201390 % v\u0161ech akutn\u00edch forem lze vyl\u00e9\u010dit konzervativn\u011b, p\u0159eru\u0161en\u00edm bludn\u00e9ho kruhu farmakologick\u00fdmi p\u0159\u00edpravky. Z\u00e1kladem je v\u017edy \u00faprava stolice prost\u0159ednictv\u00edm stravy bohat\u00e9 na balastn\u00ed l\u00e1tky a p\u0159\u00edjmu dostate\u010dn\u00e9ho mno\u017estv\u00ed tekutin (v\u00edce ne\u017e 3 litry denn\u011b).<\/p>\n<h6>An\u00e1ln\u00ed dilatace, mas\u00e1\u017e sfinkter\u016f, an\u00e1ln\u00ed tampony<\/h6>\n<p style=\"text-align: justify;\">Lok\u00e1ln\u00ed anestezie s infiltrac\u00ed spodiny trhliny umo\u017en\u00ed nejen p\u0159esn\u00e9 vy\u0161et\u0159en\u00ed, ale je tak\u00e9 rozhoduj\u00edc\u00edm terapeutick\u00fdm \u00favodem k samotn\u00e9mu o\u0161et\u0159en\u00ed trhliny: ka\u017edodenn\u00ed vlastn\u00ed dilatace sv\u011bra\u010de pomoc\u00ed n\u00e1stroje k rozta\u017een\u00ed an\u00e1ln\u00edho otvoru a anestetizuj\u00edc\u00edho kr\u00e9mu, dopln\u011bn\u00e9 o z\u00e1v\u011bre\u010dnou aplikaci obdobn\u011b p\u016fsob\u00edc\u00edho an\u00e1ln\u00edho tamponu. U m\u00e9n\u011b bolestiv\u00fdch \u0159itn\u00edch trhlin lze ka\u017edodenn\u00ed aplikaci an\u00e1ln\u00edho tamponu, p\u0159\u00edpadn\u011b dilataci sv\u011bra\u010de prov\u00e1d\u011bt bez infiltrace lok\u00e1ln\u00ed anestezi\u00ed (obr. 78\u201379).<\/p>\n<h6>Glyceroltrinitr\u00e1t (GTN)<\/h6>\n<p style=\"text-align: justify;\">GTN je p\u0159i lok\u00e1ln\u00ed aplikaci na vnit\u0159n\u00ed a vn\u011bj\u0161\u00ed sv\u011bra\u010d \u0159itn\u00ed v koncentraci 0,1\u20130,4 % metabolizov\u00e1n na oxid dusnat\u00fd (NO), co\u017e je l\u00e1tka s vlastn\u00edm terapeutick\u00fdm \u00fa\u010dinkem. Odstran\u00ed k\u0159e\u010de sv\u011bra\u010de, navod\u00ed jeho relaxaci, zlep\u0161\u00ed podko\u017en\u00ed prokrven\u00ed anodermu a zajist\u00ed p\u0159edpoklad pro zhojen\u00ed trhliny. P\u0159\u00edpravek by se m\u011bl vmas\u00edrovat 2\u20133\u00d7 denn\u011b nejen do oblasti trhliny, ale do oblasti cel\u00e9ho \u0159itn\u00edho otvoru. Od 1. 1. 2007 je k dispozici Rectogesic jako hotov\u00fd p\u0159\u00edpravek. Tento p\u0159\u00edpravek v\u0161ak nen\u00ed registrov\u00e1n \u010desk\u00fdm l\u00e9kopisem, dal\u0161\u00edm nep\u0159\u00edzniv\u00fdm ukazatelem je jeho vysok\u00e1 cena, v neposledn\u00ed \u0159ad\u011b se aplikace p\u0159\u00edpravku setk\u00e1v\u00e1 s pom\u011brn\u011b \u010dast\u00fdmi vedlej\u0161\u00edmi \u00fa\u010dinky (bolesti hlavy, nitr\u00e1tov\u00e1 vazodilatace).<\/p>\n<h6>Kalciov\u00ed antagonist\u00e9<\/h6>\n<p style=\"text-align: justify;\">L\u00e9\u010dba kalciov\u00fdmi antagonisty je dal\u0161\u00ed mo\u017enost\u00ed \u201echemick\u00e9 sfinkterotomie\u201c u chronick\u00fdch \u0159itn\u00edch trhlin. Hypertonus hladk\u00e9ho svalstva sv\u011bra\u010de u \u0159itn\u00edch trhlin je zalo\u017een na mechanismu, kter\u00fd je ovlivn\u011bn kalciem. Kalciov\u00ed antagonist\u00e9 jako Diltiazem sni\u017euj\u00ed tonus sv\u011bra\u010de, \u010d\u00edm\u017e zlep\u0161uj\u00ed prokrven\u00ed. T\u00edmto zp\u016fsobem se, stejn\u011b jako u GTN, zajist\u00ed podm\u00ednky pro zhojen\u00ed trhliny. L\u00e1tka zpracovan\u00e1 ve form\u011b masti se nan\u00e1\u0161\u00ed 2\u20133\u00d7 denn\u011b do oblasti an\u00e1ln\u00edho otvoru. Proto\u017ee tato indikace nen\u00ed v \u010cesk\u00e9 republice schv\u00e1lena, nen\u00ed hrazena zdravotn\u00ed poji\u0161\u0165ovnou.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_439.png\"><img decoding=\"async\" title=\"Obr. 78 \u2013 Dilatan\" alt=\"Obr. 78 \u2013 Dilatan\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_439.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 78 \u2013 Dilatan<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_440.png\"><img decoding=\"async\" title=\"Obr. 79 \u2013 An\u00e1ln\u00ed tampony\" alt=\"Obr. 79 \u2013 An\u00e1ln\u00ed tampony\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_440.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 79 \u2013 An\u00e1ln\u00ed tampony<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Botulotoxin typu A (BTX)<\/h6>\n<p style=\"text-align: justify;\">Tato l\u00e1tka je toxinem, kter\u00fd vytv\u00e1\u0159\u00ed bakterie Clostridium botulinum. P\u0159i intramuskul\u00e1rn\u00edm pod\u00e1n\u00ed je BTX v\u00e1z\u00e1n motorick\u00fdmi nervov\u00fdmi zakon\u010den\u00edmi a zp\u016fsobuje zhruba t\u0159\u00edm\u011bs\u00ed\u010dn\u00ed ochrnut\u00ed svalstva v d\u016fsledku potla\u010den\u00ed vylu\u010dov\u00e1n\u00ed acetylcholinu. V tomto \u010dasov\u00e9m \u00faseku jsou vytvo\u0159eny podm\u00ednky pro zhojen\u00ed trhliny. Ji\u017e dlouhou dobu je zn\u00e1m jeho efekt v kosmetice a plastick\u00e9 chirurgii, jeho u\u017eit\u00ed v neurologick\u00fdch indikac\u00edch a v proktologii je krat\u0161\u00ed. Aplikac\u00ed p\u0159esn\u011b dan\u00e9 d\u00e1vky botulotoxinu typu A do oblasti trhlinky vede k do\u010dasn\u00e9 relaxaci vnit\u0159n\u00edho sv\u011bra\u010de, a t\u00edm k uvoln\u011bn\u00ed velk\u00e9ho svalov\u00e9ho nap\u011bt\u00ed a ke zmen\u0161en\u00ed trhliny. K l\u00e9\u010db\u011b se pou\u017e\u00edv\u00e1 velmi tenk\u00e1 jehla a aplikace je prov\u00e1d\u011bna bez celkov\u00e9 \u010di lok\u00e1ln\u00ed anestezie. N\u00e1stup \u00fa\u010dinku prepar\u00e1tu je uv\u00e1d\u011bn v obdob\u00ed 2\u20133 dn\u016f po aplikaci, na\u0161e zku\u0161enosti ukazuj\u00ed, \u017ee n\u00e1stup m\u016f\u017ee b\u00fdt i 4. den po aplikaci. D\u00e9lka p\u016fsoben\u00ed BTX je 4\u20136 t\u00fddn\u016f a b\u011bhem t\u00e9to doby m\u00e1me mo\u017enost (pomoc\u00ed mast\u00ed, pou\u017e\u00edv\u00e1n\u00edm \u010d\u00edpk\u016f a lok\u00e1ln\u00edch medikament\u016f) nastartovat hojen\u00ed fisury, nebo ji dokonce zcela zahojit. Jako t\u00e9m\u011b\u0159 ve\u0161ker\u00e9 d\u011bn\u00ed v medic\u00edn\u011b je i rychlost hojen\u00ed fisury zcela individu\u00e1ln\u00ed, d\u00e1 se v\u0161ak konstatovat, \u017ee \u010d\u00edm d\u00e9le a dramati\u010dt\u011bji trhlina v kone\u010dn\u00edku \u201eobt\u011b\u017eovala\u201c, t\u00edm je i l\u00e9\u010den\u00ed zdlouhav\u011bj\u0161\u00ed. V t\u011b\u017e\u0161\u00edch p\u0159\u00edpadech je indikace i k opakovan\u00e9 aplikaci uveden\u00e9ho prepar\u00e1tu BTX. Tento zp\u016fsob l\u00e9\u010dby je mo\u017en\u00fd opakovat. Rizika stoj\u00edc\u00ed za zm\u00ednku p\u0159i t\u00e9to l\u00e9\u010db\u011b neexistuj\u00ed. Nanejv\u00fd\u0161e je pot\u0159eba po\u010d\u00edtat ve 2\u20133 % p\u0159\u00edpad\u016f s p\u0159echodn\u00fdm omezen\u00edm kontinence. Nev\u00fdhodou jsou vysok\u00e9 n\u00e1klady. L\u00e9\u010dba kalciov\u00fdmi antagonisty, GTN a BTX p\u0159edstavuje zp\u016fsob chemick\u00e9 sfinkterotomie.<\/p>\n<h6>Terapie infra\u010dervenou koagulac\u00ed<\/h6>\n<p>Princip t\u00e9to terapie spo\u010d\u00edv\u00e1 v termick\u00e9m po\u0161kozen\u00ed fisurace (akutn\u00ed nebo chronick\u00e9) s vytvo\u0159en\u00edm nekr\u00f3zy (je nebolestiv\u00e1, nebo\u0165 do\u0161lo k destrukci senzitivn\u00edch nervov\u00fdch zakon\u010den\u00ed vytvo\u0159en\u00edm pop\u00e1leniny III. stupn\u011b) a jej\u00edm n\u00e1sledn\u00fdm odhojen\u00edm s epitelizac\u00ed z okraj\u016f defektu. V\u00fdkon je prov\u00e1d\u011bn v lok\u00e1ln\u00ed\u00a0anestezii, kter\u00e1 n\u00e1m ihned po za\u010d\u00e1tku sv\u00e9ho p\u016fsoben\u00ed umo\u017en\u00ed proveden\u00ed \u0161etrn\u00e9 divulze se zaveden\u00edm anoskopu o dostate\u010dn\u00e9m pr\u016fm\u011bru (obr. 80\u201384).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_442.png\"><img decoding=\"async\" title=\"Obr. 80 \u2013 Str\u00e1\u017en\u00fd hrbolek chronick\u00e9 fisurace\" alt=\"Obr. 80 \u2013 Str\u00e1\u017en\u00fd hrbolek chronick\u00e9 fisurace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_442.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 80 \u2013 Str\u00e1\u017en\u00fd hrbolek chronick\u00e9 fisurace<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_443.png\"><img decoding=\"async\" title=\"Obr. 81 \u2013 Aplikace lok\u00e1ln\u00ed aneste\" alt=\"Obr. 81 \u2013 Aplikace lok\u00e1ln\u00ed aneste\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_443.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 81 \u2013 Aplikace lok\u00e1ln\u00ed aneste<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_445.png\"><img decoding=\"async\" title=\"Obr. 82 \u2013 Snesen\u00ed str\u00e1\u017en\u00e9ho hrbolku\" alt=\"Obr. 82 \u2013 Snesen\u00ed str\u00e1\u017en\u00e9ho hrbolku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_445.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 82 \u2013 Snesen\u00ed str\u00e1\u017en\u00e9ho hrbolku<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_444.png\"><img decoding=\"async\" title=\"Obr. 83 \u2013 \u0160etrn\u00e1 dilatace anoskopem s oz\u0159ejm\u011bn\u00edm fisurace\" alt=\"Obr. 83 \u2013 \u0160etrn\u00e1 dilatace anoskopem s oz\u0159ejm\u011bn\u00edm fisurace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_444.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 83 \u2013 \u0160etrn\u00e1 dilatace anoskopem s oz\u0159ejm\u011bn\u00edm fisurace<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_447.png\"><img decoding=\"async\" title=\"Obr. 84 \u2013 Termokoagulace Infra rot\" alt=\"Obr. 84 \u2013 Termokoagulace Infra rot\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_447.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 84 \u2013 Termokoagulace Infra rot<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Chirurgick\u00e1 l\u00e9\u010dba<\/h6>\n<p style=\"text-align: justify;\">Operaci trhliny indikujeme tehdy, kdy\u017e metody konzervativn\u00ed l\u00e9\u010dby nevedly ke zhojen\u00ed nebo kdy\u017e na z\u00e1klad\u011b sekund\u00e1rn\u00edch zm\u011bn, jak\u00fdmi jsou hypertrofick\u00e9 an\u00e1ln\u00ed papily s prohlouben\u00fdmi kryptami, naru\u0161en\u00e9 p\u0159edsunut\u00e9 vr\u00e1sy nebo p\u00ed\u0161t\u011bl na spodin\u011b trhliny, nelze zhojen\u00ed o\u010dek\u00e1vat. P\u0159i chirurgick\u00e9m \u0159e\u0161en\u00ed \u0159itn\u00edch trhlin jsou k dispozici t\u0159i postupy: later\u00e1ln\u00ed sfinkterotomie podle Notarase nebo Parkse, medi\u00e1nn\u00ed nebo posteriorn\u00ed sfinkterotomie podle Eisenhammera a fisurektomie podle Gabriela s opatrn\u00fdm manu\u00e1ln\u00edm rozp\u00edn\u00e1n\u00edm. V\u0161echny t\u0159i postupy lze prov\u00e1d\u011bt ambulantn\u011b, v lok\u00e1ln\u00ed anestezii.<\/p>\n<p style=\"text-align: justify;\">P\u0159i <b>later\u00e1ln\u00ed sfinkterotomii <\/b>je kaud\u00e1ln\u00ed okraj vnit\u0159n\u00edho sv\u011bra\u010de \u0159itn\u00edho incidov\u00e1n a prost\u0159ednictv\u00edm sn\u00ed\u017een\u00ed tonusu se tak vytv\u00e1\u0159\u00ed podm\u00ednka ke zhojen\u00ed trhliny. Z\u00e1krok lze prov\u00e1d\u011bt jako otev\u0159en\u00fd (podle Parkse) nebo zav\u0159en\u00fd (podle Notarase). Samotn\u00e1 trhlina i se sekund\u00e1rn\u00edmi zm\u011bnami a p\u0159\u00edpadn\u00fdmi prohlouben\u00fdmi kryptami by m\u011bla b\u00fdt sou\u010dasn\u011b vy\u0159\u00edznuta, p\u0159itom by m\u011bl b\u00fdt zanech\u00e1n dostate\u010dn\u00fd dren\u00e1\u017en\u00ed troj\u00faheln\u00edk. P\u016fvodn\u00ed technika jej nezahrnovala.<\/p>\n<p style=\"text-align: justify;\">P\u0159i <b>operaci trhliny podle Eisenhammera <\/b>se p\u0159i vy\u0159\u00edznut\u00ed trhliny a jej\u00edch sekund\u00e1rn\u00edch zm\u011bn prov\u00e1d\u00ed hlubok\u00e1 sfinkterotomie v oblasti trhliny. Nev\u00fdhodou je zde mo\u017enost vzniku tzv. defektu kl\u00ed\u010dov\u00e9 d\u00edrky, kter\u00fd pot\u00e9 m\u016f\u017ee negativn\u011b ovliv\u0148ovat jemnou kontinenci. Gabriel z tohoto hlediska upustil od hlubok\u00e9 sfinkterotomie a odstra\u0148uje pouze trhlinu a chronick\u00e9 zm\u011bny jako p\u0159edsunut\u00e9 vr\u00e1sy, hypertrofick\u00e9 an\u00e1ln\u00ed papily, prohlouben\u00e9 krypty a okraje jizvy. To vedlo ke stejn\u011b dobr\u00fdm v\u00fdsledk\u016fm s men\u0161\u00edmi vedlej\u0161\u00edmi \u00fa\u010dinky. Ve spojen\u00ed s n\u011bkolikaminutovou manu\u00e1ln\u00ed divulz\u00ed sv\u011bra\u010de za vhodn\u00e9ho znecitliv\u011bn\u00ed je proto tato operace uplat\u0148ov\u00e1na u v\u011bt\u0161iny p\u0159\u00edpad\u016f. P\u0159i p\u0159ekotn\u00e9m rozp\u00edn\u00e1n\u00ed \u0159itn\u00edho kan\u00e1lu m\u016f\u017ee doj\u00edt k ruptu\u0159e \u010d\u00e1st\u00ed svalstva sv\u011bra\u010de. S analgetiky by se po operaci nem\u011blo \u0161et\u0159it. Vla\u017en\u00e9 sedac\u00ed koupele maj\u00ed p\u0159\u00edzniv\u00fd vliv na bolesti a slou\u017e\u00ed k d\u016fkladn\u00e9mu o\u010di\u0161t\u011bn\u00ed r\u00e1ny po vypr\u00e1zdn\u011bn\u00ed stolice. Nakonec se doporu\u010duje h\u00fd\u017ed\u011b a r\u00e1nu opatrn\u011b osu\u0161it lehk\u00fdmi doteky a nosit mezi p\u016flkami h\u00fd\u017ed\u00ed mal\u00e9 vlo\u017eky z g\u00e1zy. Takto se p\u0159edch\u00e1z\u00ed an\u00e1ln\u00edmu ekz\u00e9mu zap\u0159\u00ed\u010din\u011bn\u00e9mu sekretem z r\u00e1ny. Stolice by nem\u011bla b\u00fdt p\u0159\u00edli\u0161 m\u011bkk\u00e1, jinak se zhojen\u00ed r\u00e1ny prodlou\u017e\u00ed. Nav\u00edc by se m\u011blo asi od osm\u00e9ho dne po operaci za\u010d\u00edt s vlastn\u00edm o\u0161et\u0159en\u00edm (1\u20132\u00d7 denn\u011b) pomoc\u00ed n\u00e1stroje k dilataci an\u00e1ln\u00edho otvoru, kter\u00e9 bude p\u016fsobit p\u0159\u00edzniv\u011b na zhojen\u00ed r\u00e1ny.<\/p>\n<h6>V\u00fdsledky konzervativn\u00ed l\u00e9\u010dby<\/h6>\n<p style=\"text-align: justify;\">Prodlou\u017een\u00e9 rozp\u00edn\u00e1n\u00ed sv\u011bra\u010de pomoc\u00ed n\u00e1stroje k rozta\u017een\u00ed an\u00e1ln\u00edho otvoru a lubrika\u010dn\u00edho gelu vede u akutn\u00edch \u0159itn\u00edch trhlin ke zhojen\u00ed v 90 % , p\u0159i\u010dem\u017e v\u0161ak v 50 % lze po\u010d\u00edtat se spont\u00e1nn\u00edm vyl\u00e9\u010den\u00edm. P\u0159i l\u00e9\u010db\u011b glyceroltrinitr\u00e1tem jde o podobn\u00fd pr\u016fb\u011bh. Lze takto \u00fasp\u011b\u0161n\u011b l\u00e9\u010dit nejen akutn\u00ed, ale tak\u00e9 chronick\u00e9 \u0159itn\u00ed trhliny. Takto dos\u00e1hli Palazzo u chronick\u00fdch \u0159itn\u00edch trhlin p\u0159i pou\u017eit\u00ed 0,5% GTN masti zhojen\u00ed v 73 % a Hasegawa dos\u00e1hl s 0,2% GTN masti zhojen\u00ed v 50 % chronick\u00fdch \u0159itn\u00edch trhlin. Lund zjistil u 80 pacient\u016f, kte\u0159\u00ed byli o\u0161et\u0159ov\u00e1ni bu\u010f 0,2% GTN nebo placebem, \u017ee u GTN se trhlina zhojila v 80 % a u placeba pouze v 8 %. Obdobn\u00e9 v\u00fdsledky jsou p\u0159i srovn\u00e1n\u00ed GTN a Lidocaingelu. U GTN do\u0161lo u akutn\u00edch a chronick\u00fdch \u0159itn\u00edch trhlin ke zhojen\u00ed v 64 %, zat\u00edmco u Lidocaingelu toho nebylo mo\u017eno dos\u00e1hnout. Tyto pozitivn\u00ed l\u00e9\u010debn\u00e9 \u00fa\u010dinky GTN odpov\u00eddaj\u00ed prokazateln\u00e9mu sn\u00ed\u017een\u00ed tonu sv\u011bra\u010de a zlep\u0161en\u00e9mu prokrven\u00ed. Jev\u00ed se, \u017ee koncentrace GTN m\u00e1 u v\u00fdsledk\u016f l\u00e9\u010dby d\u00edl\u010d\u00ed v\u00fdznam. V ka\u017ed\u00e9m p\u0159\u00edpad\u011b zjistil Monokian u koncentrac\u00ed mezi 0,2\u20131,0% GTN v\u00fdznamn\u00fd nem\u011bnn\u00fd pod\u00edl zhojen\u00ed, kter\u00fd \u010dinil u akutn\u00edch \u0159itn\u00edch trhlin 69 % a u chronick\u00fdch \u0159itn\u00edch trhlin 59 %. Rozd\u00edln\u00e9 koncentrace jsou dle jeho \u00fadaj\u016f odpov\u011bdn\u00e9 za vedlej\u0161\u00ed \u00fa\u010dinky (&gt; 0,2 % v\u00fdznamn\u00fd n\u00e1r\u016fst bolest\u00ed hlavy, synkop\u00e1ln\u00ed stavy). V\u011bt\u0161ina studi\u00ed se vztahuje k chronick\u00fdm \u0159itn\u00edm trhlin\u00e1m, ani\u017e by v\u0161ak pro n\u011b existovala p\u0159esn\u00e1 definice. Mnohdy se hovo\u0159\u00ed o nekomplikovan\u00fdch trhlin\u00e1ch. P\u0159esn\u00fd popis morfologick\u00e9ho n\u00e1lezu nebo trv\u00e1n\u00ed onemocn\u011bn\u00ed nen\u00ed k dispozici. P\u0159i t\u00e9to nep\u0159esn\u00e9 definici chronick\u00fdch \u0159itn\u00edch trhlin nep\u0159ekvapuj\u00ed studie s opa\u010dn\u00fdmi v\u00fdsledky. Tak nebyly zji\u0161t\u011bny, jak uv\u00e1d\u011bj\u00ed Altomare et al., v multicentrick\u00e9 randomizovan\u00e9 dvojit\u00e9 slep\u00e9 studii s kontroln\u00ed skupinou s placebem u 120 pacient\u016f s chronick\u00fdmi \u0159itn\u00edmi trhlinami \u017e\u00e1dn\u00e9\u00a0rozd\u00edly u v\u00fdsledk\u016f l\u00e9\u010dby mezi 0,2% GTN a placebem. Pravd\u011bpodobn\u011b to lze vzt\u00e1hnout k nejednozna\u010dn\u011b popsan\u00fdm sekund\u00e1rn\u00edm zm\u011bn\u00e1m u chronick\u00fdch \u0159itn\u00edch trhlin, jak\u00fdmi jsou hypertrofick\u00e9 an\u00e1ln\u00ed papily nebo p\u0159edsunut\u00e9 vr\u00e1sy. Tyto domn\u011bnky potvrzuj\u00ed i v\u00fdsledky Br\u00fchla et al. V t\u00e9to studii byly rozd\u011bleny \u0159itn\u00ed trhliny na trhliny s hypertrofick\u00fdmi an\u00e1ln\u00edmi papilami nebo p\u0159edsunut\u00fdmi vr\u00e1sami a trhliny bez t\u011bchto zm\u011bn. P\u0159i l\u00e9\u010db\u011b 0,3% GTN nedo\u0161lo v prvn\u00ed skupin\u011b ke zhojen\u00ed, zat\u00edmco u druh\u00e9 skupiny jej bylo dosa\u017eeno v 80 %. Zd\u00e1 se, \u017ee l\u00e9\u010dba kalciov\u00fdmi antagonisty je pacienty l\u00e9pe sn\u00e1\u0161ena, nebo\u0165 se u n\u00ed nevyskytuj\u00ed nitr\u00e1tov\u00e9 bolesti hlavy jako u GTN. Studie, kter\u00e9 provedli Griffin aj., Billecki, Bader aj., prok\u00e1zaly na skupin\u011b 32 pacient\u016f, z nich\u017e 50 % bylo p\u0159edt\u00edm ne\u00fasp\u011b\u0161n\u011b l\u00e9\u010deno pomoc\u00ed GTN, \u017ee u 30 pacient\u016f se trhliny zhojily. Dv\u011b z t\u011bchto nezhojen\u00fdch trhlin musely b\u00fdt o\u0161et\u0159eny chirurgicky. Vedlej\u0161\u00ed \u00fa\u010dinky se u t\u00e9to l\u00e9\u010dby nevyskytly; recidivy nebyly v pr\u016fb\u011bhu 6 m\u011bs\u00edc\u016f n\u00e1sledn\u00e9ho sledov\u00e1n\u00ed zaznamen\u00e1ny. Pou\u017eit\u00ed botulotoxinu k l\u00e9\u010db\u011b \u0159itn\u00edch trhlin vykazuje dobr\u00e9 v\u00fdsledky. U nekomplikovan\u00fdch trhlin lze u 70\u201380 % po zhruba \u010dtvrtroce po\u010d\u00edtat s \u00fapln\u00fdm zhojen\u00edm. To potvrzuje studie Josta, kter\u00fd pomoc\u00ed BTX u 100 pacient\u016f s \u0159itn\u00edmi trhlinami dos\u00e1hl vymizen\u00ed bolesti po 8 dnech v 70 % a \u00fapln\u00e9ho vyl\u00e9\u010den\u00ed po 6 m\u011bs\u00edc\u00edch v 79 %. 21% muselo b\u00fdt o\u0161et\u0159eno operativn\u011b. Ve dvojit\u00e9 slep\u00e9 studii s kontroln\u00ed skupinou s placebem uv\u00e1d\u00ed Maria u chronick\u00fdch \u0159itn\u00edch trhlin zhojen\u00ed ve zhruba 73 %. Vzhledem k mno\u017estv\u00ed je u vy\u0161\u0161\u00edch d\u00e1vek (25 jednotek nam\u00edsto 15 jednotek) mo\u017eno o\u010dek\u00e1vat celkov\u011b \u00fa\u010dinn\u011bj\u0161\u00ed dlouhodob\u00e9 p\u016fsoben\u00ed. D\u016fle\u017eit\u00e9 je tak\u00e9 m\u00edsto vpichu injekce. Aplikace nalevo a napravo vedle p\u0159edn\u00ed komisury vede u posteriorn\u00edch \u0159itn\u00edch trhlin k lep\u0161\u00edmu zhojen\u00ed a del\u0161\u00edmu ochrnut\u00ed sval\u016f ne\u017e u injekce v oblasti zadn\u00ed komisury. U \u0159itn\u00edch trhlin rezistentn\u00edch v\u016f\u010di l\u00e9\u010db\u011b, kter\u00e9 nebyly zhojeny pomoc\u00ed aplikace BTX, prok\u00e1zali Lysy et al., \u017ee dopl\u0148kov\u00e1 l\u00e9\u010dba pomoc\u00ed GTN v\u00fdrazn\u011b zv\u00fd\u0161ila pod\u00edl zhojen\u00ed. Srovn\u00e1vac\u00ed \u0161et\u0159en\u00ed u chronick\u00fdch \u0159itn\u00edch trhlin s GTN a BTX vedla u skupin 25 pacient\u016f ke zhojen\u00ed trhlin u BTX v 96 % a u GTN v 60 %. P\u0159i cross-over studii vyk\u00e1zaly v\u0161echny dosud nevyl\u00e9\u010den\u00e9 trhliny zhojen\u00ed (9 u GTN a 1 u BT). Ov\u0161em Nelson na z\u00e1klad\u011b metaanal\u00fdzy dok\u00e1zal, \u017ee u GTN a BTX i jin\u00fdch l\u00e1tek, jak\u00fdmi jsou kalciov\u00ed antagonist\u00e9, hydrokortizon, Lidocain a strava bohat\u00e1 na balastn\u00ed l\u00e1tky, lze oproti placebu o\u010dek\u00e1vat pouze nepatrn\u00e9 v\u00fdhody. Je nutn\u00e9 vych\u00e1zet z toho, \u017ee trhliny s v\u00fdrazn\u00fdmi sekund\u00e1rn\u00edmi zm\u011bnami (hypertrofick\u00e9 an\u00e1ln\u00ed papily, p\u0159edsunut\u00e9 vr\u00e1sy, po\u0161kozen\u00e9 zjizven\u00e9 okraje, voln\u011b le\u017e\u00edc\u00ed a sklerotizovan\u00e1 vnit\u0159n\u00ed \u010d\u00e1st) v\u011bt\u0161inou nebylo mo\u017eno vyhojit pomoc\u00ed konzervativn\u00ed terapie.<\/p>\n<h6>Chirurgick\u00e1 nebo konzervativn\u00ed l\u00e9\u010dba<\/h6>\n<p style=\"text-align: justify;\">Chirurgick\u00e9 o\u0161et\u0159en\u00ed chronick\u00fdch \u0159itn\u00edch trhlin vede k lep\u0161\u00edm v\u00fdsledk\u016fm, ne\u017e kter\u00fdch lze dos\u00e1hnout konzervativn\u00edm zp\u016fsobem pomoc\u00ed GTN nebo BTX. Agor et al. prok\u00e1zali ve sledovan\u00e9m obdob\u00ed mezi \u010dty\u0159mi a\u017e dvaceti lety u 2108 pacient\u016f, \u017ee later\u00e1ln\u00ed sfinkterotomie vedla k lep\u0161\u00edm dlouhodob\u00fdm v\u00fdsledk\u016fm ne\u017e GTN nebo BTX.V N\u011bmecku se k l\u00e9\u010db\u011b chronick\u00fdch \u0159itn\u00edch trhlin doporu\u010duje manu\u00e1ln\u00ed rozp\u00edn\u00e1n\u00ed sv\u011bra\u010de s fisurektomi\u00ed\u2013 v neposledn\u00ed \u0159ad\u011b na z\u00e1klad\u011b \u0161et\u0159en\u00ed Hasse. V angloamerick\u00fdch zem\u00edch se prov\u00e1d\u00ed otev\u0159en\u00e1 i uzav\u0159en\u00e1 later\u00e1ln\u00ed sfinkterotomie s posteriorn\u00edm postupem. Na na\u0161em pracovi\u0161ti preferujeme proveden\u00ed modifikovan\u00e9 later\u00e1ln\u00ed sfinkteromyotomie dle Parkse.<\/p>\n<h6>Later\u00e1ln\u00ed sfinkteromyotomie dle Parkse<\/h6>\n<p style=\"text-align: justify;\">Operaci prov\u00e1d\u00edme v kr\u00e1tkodob\u00e9 celkov\u00e9 anestezii, v gynekologick\u00e9 poloze. V\u00fdkon za\u010d\u00edn\u00e1me proveden\u00edm \u0161etrn\u00e9 divulze anu dle R\u00e9camiera ve sm\u011bru latero-later\u00e1ln\u00edm a ventro-dorz\u00e1ln\u00edm v cel\u00e9m obvodu anu. Na \u010d. 3 prov\u00e1d\u00edme drobnou ko\u017en\u00ed incizi v d\u00e9lce 3 mm. Zde prov\u00e1d\u00edme infiltraci perirekt\u00e1ln\u00ed tk\u00e1n\u011b, vnit\u0159n\u00edho sfinkteru a submuk\u00f3zy 20 ml roztoku 1 % Mesocainu s adrenalinem 1\/200 000. Pak zav\u00e1d\u00edme tangenci\u00e1ln\u011b zav\u0159en\u00e9 bran\u017ee prepara\u010dn\u00edch Metzenbaumov\u00fdch n\u016f\u017eek, kter\u00fdmi obkru\u017eujeme zevn\u011b musculus sfinkter ani externus sm\u011brem do intersfinkterick\u00e9ho sulku. Tento oz\u0159ejmujeme ukazov\u00e1kem lev\u00e9 ruky zaveden\u00fdm do an\u00e1ln\u00edho kan\u00e1lu. Pak prov\u00e1d\u00edme obrat n\u016f\u017eek o 90 stup\u0148\u016f. Rozev\u0159enou bran\u017ei zav\u00e1d\u00edme pod kontrolou pohmatem submuk\u00f3zn\u011b a prov\u00e1d\u00edme prost\u0159i\u017een\u00ed masy musculus sphincter ani internus v d\u00e9lce cca25 mm. Pohmatem zji\u0161\u0165ujeme miskovit\u00fd defekt na \u010d. 3. D\u00e1v\u00e1me bedliv\u00fd pozor, abychom neperforovali st\u011bnu rekta. Po vyta\u017een\u00ed n\u016f\u017eek nesuturujeme vstupn\u00ed incizi. O\u0161et\u0159ujeme ji toaletou a kryt\u00edm. Dle velikosti a charakteru fisurace lze prov\u00e9st n\u00e1sledn\u011b jej\u00ed trigon\u00e1ln\u00ed excizi, kterou m\u016f\u017eeme kr\u00fdt eventu\u00e1ln\u011b Y-V plastikou (obr. 85\u201392).<\/p>\n<h6>L\u00e9\u010debn\u00e1 doporu\u010den\u00ed<\/h6>\n<p style=\"text-align: justify;\">EBM d\u016fkazn\u00ed algoritmus (evropsk\u00fd konsenzus) k l\u00e9\u010db\u011b \u0159itn\u00edch trhlin doporu\u010duje bez ohledu na morfologick\u00e9 a \u010dasov\u00e9 faktory n\u00e1sleduj\u00edc\u00ed postup: prim\u00e1rn\u00ed l\u00e9\u010dba by m\u011bla b\u00fdt prov\u00e1d\u011bna pomoc\u00ed nitr\u00e1t\u016f nebo kalciov\u00fdch antagonist\u016f, p\u0159i\u010dem\u017e se doporu\u010duje pod\u00e1v\u00e1n\u00ed balastn\u00edch nebo bobtnav\u00fdch l\u00e1tek (zbytkov\u00e1 strava). Nav\u00edc lze pacient\u016fm p\u0159edepsat analgetika. Kontroln\u00ed vy\u0161et\u0159en\u00ed by m\u011blo prob\u011bhnout po 6\u20138 t\u00fddnech. U zhojen\u00fdch trhlin se doporu\u010duje i nad\u00e1le dodr\u017eovat dietu\u00a0bohatou na balastn\u00ed l\u00e1tky. Nezhojen\u00e9 trhliny se z\u0159eteln\u00fdm \u00fastupem obt\u00ed\u017e\u00ed lze v pr\u016fb\u011bhu dal\u0161\u00edch 6\u20138 t\u00fddn\u016f l\u00e9\u010dit nitrop\u0159\u00edpravky nebo kalciov\u00fdmi antagonisty. Nedojde-li ani pot\u00e9 ke zhojen\u00ed, doporu\u010duje se jako dal\u0161\u00ed l\u00e9\u010dba operace (fisurektomie p\u0159\u00edp. sfinkterotomie). V p\u0159\u00edpad\u011b nezhojen\u00ed trhlin po fisurektomii (1\u20135 %) by m\u011bla b\u00fdt provedena sfinkterotomie.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_450.png\"><img decoding=\"async\" title=\"Obr. 85 \u2013 Divulze anu dle R\u00e9camiera \u2013 latero-later\u00e1ln\u00ed\" alt=\"Obr. 85 \u2013 Divulze anu dle R\u00e9camiera \u2013 latero-later\u00e1ln\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_450.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 85 \u2013 Divulze anu dle R\u00e9camiera \u2013 latero-later\u00e1ln\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_453.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 86 \u2013 Divulze anu dle R\u00e9camiera ventro-dorz\u00e1ln\u00ed\" alt=\"Obr. 86 \u2013 Divulze anu dle R\u00e9camiera ventro-dorz\u00e1ln\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_453.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 86 \u2013 Divulze anu dle R\u00e9camiera ventro-dorz\u00e1ln\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_451.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 87 \u2013 Aplikace roztoku lok\u00e1ln\u00edho anestetika s adrenalinem\" alt=\"Obr. 87 \u2013 Aplikace roztoku lok\u00e1ln\u00edho anestetika s adrenalinem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_451.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 87 \u2013 Aplikace roztoku lok\u00e1ln\u00edho anestetika s adrenalinem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_454.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 88a \u2013 Bodov\u00e1 incize na \u010d. 3\" alt=\"Obr. 88a \u2013 Bodov\u00e1 incize na \u010d. 3\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_454.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 88a \u2013 Bodov\u00e1 incize na \u010d. 3<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_452.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 88b \u2013 Metzenbaumovy n\u016f\u017eky obkru\u017euj\u00ed musculus sphincter ani externus\" alt=\"Obr. 88b \u2013 Metzenbaumovy n\u016f\u017eky obkru\u017euj\u00ed musculus sphincter ani externus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_452.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 88b \u2013 Metzenbaumovy n\u016f\u017eky obkru\u017euj\u00ed musculus sphincter ani externus<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_455.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 89 \u2013 Po oto\u010den\u00ed o 90 stup\u0148\u016f prost\u0159\u00edh\u00e1v\u00e1me musculus sphincter ani internus v d\u00e9lce 25 mm\" alt=\"Obr. 89 \u2013 Po oto\u010den\u00ed o 90 stup\u0148\u016f prost\u0159\u00edh\u00e1v\u00e1me musculus sphincter ani internus v d\u00e9lce 25 mm\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_455.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 89 \u2013 Po oto\u010den\u00ed o 90 stup\u0148\u016f prost\u0159\u00edh\u00e1v\u00e1me musculus sphincter ani internus v d\u00e9lce 25 mm<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_457.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 90 \u2013 Vlastn\u00ed fisura\" alt=\"Obr. 90 \u2013 Vlastn\u00ed fisura\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_457.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 90 \u2013 Vlastn\u00ed fisura<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_458.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 91 \u2013 Trigon\u00e1ln\u00ed excize k t\u011blesu musculus sphincter ani externus\" alt=\"Obr. 91 \u2013 Trigon\u00e1ln\u00ed excize k t\u011blesu musculus sphincter ani externus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_458.png\" width=\"200\" height=\"152\" \/><\/a><p class=\"wp-caption-text\">Obr. 91 \u2013 Trigon\u00e1ln\u00ed excize k t\u011blesu musculus sphincter ani externus<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_459.png\"><img decoding=\"async\" title=\"Obr. 92 \u2013 Y-V plastika\" alt=\"Obr. 92 \u2013 Y-V plastika\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_459.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 92 \u2013 Y-V plastika<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>9.4 Hemoroidy<\/h4>\n<h6>V\u0161eobecn\u011b<\/h6>\n<p style=\"text-align: justify;\">Nad linea dentata, pod sliznic\u00ed rekta, se rozv\u011btvuj\u00ed termin\u00e1ln\u00ed v\u011btve arteria rectalis superior \u2013 hemoroid\u00e1ln\u00ed arterie \u2013 k c\u00e9vn\u00edmu konglomer\u00e1tu corpus cavernosum recti (hemoroid\u00e1ln\u00edmu pol\u0161t\u00e1\u0159i). P\u0159i hyperplazii t\u00e9to fyziologick\u00e9 c\u00e9vn\u00ed struktury se hovo\u0159\u00ed o hemoroidech I. a\u017e IV. stupn\u011b a z toho vypl\u00fdvaj\u00edc\u00edch obt\u00ed\u017e\u00edch \u2013 o hemoroid\u00e1ln\u00ed nemoci. V\u00edce ne\u017e 100 let byly na z\u00e1klad\u011b Virchow-Schenovy interpretace hemoroidy vn\u00edm\u00e1ny jako an\u00e1ln\u00ed varixy, a\u010dkoli byly ji\u017e tehdy o t\u00e9to p\u0159edstav\u011b pochybnosti. A\u017e Stelzner et al. prok\u00e1zali, \u017ee se u corpus cavernosum recti nejedn\u00e1 o \u017e\u00edly, n\u00fdbr\u017e o arterio-ven\u00f3zn\u00ed houbovit\u00e9 t\u011bleso s lokalizac\u00ed na predilek\u010dn\u00edch m\u00edstech na 3, 7 a 11 hodinov\u00e9ho cifern\u00edku v litotomick\u00e9 poloze. Corpus cavernosum m\u00e1 d\u016fle\u017eitou funkci pro zachov\u00e1n\u00ed jemn\u00e9 kontinence.<\/p>\n<h6>Fyziologie<\/h6>\n<p style=\"text-align: justify;\">Corpus cavernosum recti m\u00e1 b\u011bhem kontine\u010dn\u00ed f\u00e1ze pru\u017enou elastickou konzistenci, nebo\u0165 \u017eiln\u00ed, transfinkterick\u00fd odtok krve je v n\u00e1vaznosti na kontrakci musculus sphincter ani internus oblen\u011bn. T\u00edmto jsou c\u00e9vn\u00ed pol\u0161t\u00e1\u0159ky k sob\u011b intimn\u011b p\u0159ilo\u017eeny a br\u00e1n\u00ed necht\u011bn\u00e9mu odchodu v\u011btr\u016f a \u0159id\u0161\u00ed stolice. P\u0159i defekaci umo\u017e\u0148uje relaxace vnit\u0159n\u00edho sv\u011bra\u010de neru\u0161en\u00fd odtok krve z hemoroid\u00e1ln\u00edch pol\u0161t\u00e1\u0159\u016f; tyto se vypr\u00e1zdn\u00ed a stolice m\u016f\u017ee bezprobl\u00e9mov\u011b odej\u00edt bez traumatizace an\u00e1ln\u00edho kan\u00e1lu. P\u0159edpoklad pro tento fyziologick\u00fd postup je dob\u0159e tvarovan\u00e1 stolice s dostate\u010dn\u00fdm dilata\u010dn\u00edm efektem na vnit\u0159n\u00ed sv\u011bra\u010d.<\/p>\n<h6>Etiopatogeneze<\/h6>\n<p style=\"text-align: justify;\">V\u00fdskyt hemoroid\u00e1ln\u00edch pot\u00ed\u017e\u00ed a s nimi spojen\u00e9 morfologick\u00e9 zm\u011bny jsou zp\u016fsobeny jak geneticky, tak v d\u016fsledku naru\u0161en\u00e9 defekace p\u0159i potrav\u011b chud\u00e9 na balastn\u00ed l\u00e1tky. V mnoha rodin\u00e1ch jsou \u010dast\u00e9 hemoroid\u00e1ln\u00ed pot\u00ed\u017ee a vy\u0161et\u0159en\u00ed jednotliv\u00fdch rodinn\u00fdch p\u0159\u00edslu\u0161n\u00edk\u016f ukazuje \u010dasto identick\u00e9 morfologick\u00e9 n\u00e1lezy. M\u00e9n\u011b jsou posti\u017eeny osoby s tu\u017e\u0161\u00ed stolic\u00ed, p\u0159i kter\u00e9 mus\u00ed tla\u010dit, ne\u017e osoby s ka\u0161ovitou a\u017e pr\u016fjmovou konzistenc\u00ed stolice. V ka\u017ed\u00e9m p\u0159\u00edpad\u011b je procentu\u00e1ln\u00ed v\u00fdskyt hemoroid\u00e1ln\u00edch onemocn\u011bn\u00ed p\u0159i chronick\u00e9 z\u00e1cp\u011b men\u0161\u00ed (10\u201316 %) ne\u017e p\u0159i pr\u016fjmech (&gt; 20 %). Stolice takov\u00e9 konzistence je nefyziologick\u00e1 z\u00e1t\u011b\u017e pro hemoroid\u00e1ln\u00ed pol\u0161t\u00e1\u0159e: nedojde k dosta\u010duj\u00edc\u00edmu rozta\u017een\u00ed a relaxaci an\u00e1ln\u00edho kan\u00e1lu, tak\u017ee je\u0161t\u011b pru\u017en\u00e9 pln\u00e9 hemoroid\u00e1ln\u00ed pol\u0161t\u00e1\u0159e jsou p\u0159i pr\u016fchodu stolice vystaveny zes\u00edlen\u00e9mu traumatu. Zda m\u00e1 kvalita stolice v d\u016fsledku p\u0159\u00edjmu ost\u0159e ko\u0159en\u011bn\u00fdch j\u00eddel nebo alkoholu vliv na symptomatiku hemoroid\u00e1ln\u00edch obt\u00ed\u017e\u00ed, je ot\u00e1zkou. V ka\u017ed\u00e9m p\u0159\u00edpad\u011b se v ohledu na hemoroid\u00e1ln\u00ed symptomatologii neprok\u00e1zal rozd\u00edl mezi t\u00fddenn\u00edm pod\u00e1v\u00e1n\u00edm ost\u0159e ko\u0159en\u011bn\u00e9ho j\u00eddla s kayensk\u00fdm pep\u0159em a pod\u00e1v\u00e1n\u00edm placeba.<\/p>\n<p style=\"text-align: justify;\">Dle Stelznerovy teorie je na anorekt\u00e1ln\u00ed vaskul\u00e1rn\u00ed plexus \u2013 AVP (corpus cavernosum recti) nahl\u00ed\u017eeno jako na plexus, tvo\u0159en\u00fd funk\u010dn\u00edmi kavernami \u2013 arte\u00a0riemi a \u017e\u00edlami, jejich\u017e st\u011bna je bohat\u011b vystav\u011bna svalovinou a mezi kter\u00fdmi je bohat\u00e1 s\u00ed\u0165 arterio-ven\u00f3zn\u00edch zkrat\u016f (shunt\u016f). V m\u00edst\u011b AV shunt\u016f svalov\u00fd mechanismus podobn\u00fd sfinkteru reguluje n\u00e1pl\u0148 a v\u00fdtok krve z kaveren AVP. P\u0159i hemoroid\u00e1ln\u00ed chorob\u011b je tento mechanismus v\u00fdrazn\u011b zm\u011bn\u011bn. Doch\u00e1z\u00ed k redukci svalov\u00fdch vl\u00e1ken ve st\u011bn\u00e1ch kaveren a k redukci elastick\u00fdch vl\u00e1ken v submuk\u00f3ze (obr. 93\u201395).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_461.png\"><img decoding=\"async\" title=\"Obr. 93 \u2013 Odlitek c\u00e9v hemoroid\u00e1ln\u00edho plexu\" alt=\"Obr. 93 \u2013 Odlitek c\u00e9v hemoroid\u00e1ln\u00edho plexu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_461.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 93 \u2013 Odlitek c\u00e9v hemoroid\u00e1ln\u00edho plexu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_463.png\"><img decoding=\"async\" title=\"Obr. 95 \u2013 Corpus cavernosum recti \u2013 AV shunt\" alt=\"Obr. 95 \u2013 Corpus cavernosum recti \u2013 AV shunt\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_463.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 95 \u2013 Corpus cavernosum recti \u2013 AV shunt<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_462.png\"><img decoding=\"async\" title=\"Obr. 94 \u2013 Kavern\u00f3zn\u00ed plexus \u2013 mikrofoto\" alt=\"Obr. 94 \u2013 Kavern\u00f3zn\u00ed plexus \u2013 mikrofoto\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_462.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 94 \u2013 Kavern\u00f3zn\u00ed plexus \u2013 mikrofoto<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Hodnocen\u00ed p\u0159\u00ed\u010din onemocn\u011bn\u00ed dle Aignera<\/h6>\n<table style=\"width: 100%;\">\n<tbody>\n<tr>\n<td width=\"50%\">N\u00edzk\u00fd pod\u00edl vl\u00e1kniny ve strav\u011b<\/td>\n<td>Sporn\u00e9<\/td>\n<\/tr>\n<tr>\n<td>Obstipace nebo pr\u016fjmy<\/td>\n<td>Sporn\u00e9<\/td>\n<\/tr>\n<tr>\n<td>ODS<\/td>\n<td>Diskutov\u00e1no<\/td>\n<\/tr>\n<tr>\n<td>Zv\u00fd\u0161en\u00fd tonus sfinkter\u016f<\/td>\n<td>Sporn\u00e9<\/td>\n<\/tr>\n<tr>\n<td>Genetick\u00e1 dispozice<\/td>\n<td>Diskutov\u00e1no<\/td>\n<\/tr>\n<tr>\n<td>Vaskul\u00e1rn\u00ed poruchy<\/td>\n<td>Diskutov\u00e1no<\/td>\n<\/tr>\n<tr>\n<td>Poruchy provazc\u016f m\u00ed\u0161n\u00edch<\/td>\n<td>Diskutov\u00e1no<\/td>\n<\/tr>\n<tr>\n<td>V\u011bk<\/td>\n<td>Diskutov\u00e1no<\/td>\n<\/tr>\n<tr>\n<td>T\u011bhotenstv\u00ed<\/td>\n<td>Potvrzeno dle EBM (Evidence Based Medicine)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Klinick\u00fd obraz<\/h6>\n<p style=\"text-align: justify;\">Pot\u00ed\u017ee vztahuj\u00edc\u00ed se k hemoroid\u016fm jsou netypick\u00e9 a tak\u00e9 existuj\u00ed u mnoha jin\u00fdch proktologick\u00fdch onemocn\u011bn\u00ed. Nejsou z\u00e1visl\u00e9 na morfologick\u00e9m rozsahu hemoroid\u016f. Nej\u010dast\u011bj\u0161\u00ed je krv\u00e1cen\u00ed. Nepoch\u00e1z\u00ed p\u0159\u00edmo z hemoroid\u016f, ale z trombozovan\u00fdch c\u00e9v ve sliznici. Krv\u00e1cen\u00ed b\u00fdv\u00e1 nejen p\u0159i stolici, p\u0159\u00edpadn\u011b p\u0159i prolabovan\u00fdch hemoroidech, ale tak\u00e9 i po stolici. Sv\u011btle \u010derven\u00e1 krev m\u016f\u017ee \u010dasto kapat nebo st\u0159\u00edkat a pot\u0159\u00edsnit toaletn\u00ed m\u00edsu. Krv\u00e1cen\u00ed m\u00e1 t\u00e9m\u011b\u0159 v\u017edy sv\u011btle \u010dervenou barvu. M\u016f\u017ee se vyskytovat denn\u011b u ka\u017ed\u00e9 stolice a pak se bez jak\u00e9koliv terapie m\u016f\u017ee na t\u00fddny i m\u011bs\u00edce zastavit. Hemoroid\u00e1ln\u00ed krv\u00e1cen\u00ed m\u016f\u017ee v\u00e9st k v\u00fdrazn\u00fdm an\u00e9mi\u00edm. U hemoroid\u016f je \u010dasto naru\u0161ena jemn\u00e1 kontinence. Spodn\u00ed pr\u00e1dlo b\u00fdv\u00e1 vlhk\u00e9 a zne\u010di\u0161t\u011bn\u00e9 od stolice. Z toho iritativn\u011b vznikl\u00e9 typick\u00e9 an\u00e1ln\u00ed ekz\u00e9my se sv\u011bd\u011bn\u00edm jsou po krv\u00e1civosti nejroz\u0161\u00ed\u0159en\u011bj\u0161\u00ed hemoroid\u00e1ln\u00edm p\u0159\u00edznakem. Bolesti nejsou pro hemoroidy typick\u00e9. Nez\u00e1visle na stolici si v\u0161ak pacienti st\u011b\u017euj\u00ed na tup\u00fd tlak nebo na pocit ciz\u00edho t\u011blesa v kone\u010dn\u00edku. \u010casto jsou ud\u00e1v\u00e1ny p\u00e1liv\u00e9 bolesti p\u0159i synchronn\u011b existuj\u00edc\u00edch rag\u00e1d\u00e1ch nebo fisur\u00e1ch anodermu (hemoroidy II.\u00b0 a\u017e v 70 %). Siln\u00e9 bolesti jsou ale v p\u0159\u00edpad\u011b hemoroid\u00e1ln\u00ed tromb\u00f3zy a p\u0159i v\u00fdrazn\u00e9m otoku uzl\u016f. Takov\u00fd klinick\u00fd obraz je pak charakterizov\u00e1n velmi nam\u00e1havou stolic\u00ed s dlouhodob\u011b p\u0159etrv\u00e1vaj\u00edc\u00edmi pot\u00ed\u017eemi.<\/p>\n<h6>N\u00e1lez<\/h6>\n<p>Dle morfologick\u00fdch a klinick\u00fdch zm\u011bn se rozli\u0161uj\u00ed<img decoding=\"async\" alt=\"\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_465.png\" \/>4 stupn\u011b hemoroid\u016f (obr. 96\u201399):<\/p>\n<table style=\"width: 100%;\">\n<tbody>\n<tr>\n<td width=\"70\">I \u00b0<\/td>\n<td>jen proktoskopicky viditeln\u00e9 pol\u0161t\u00e1\u0159ky<\/td>\n<\/tr>\n<tr>\n<td>II \u00b0<\/td>\n<td>prolaps u defekace \u2013 retrahuje se spont\u00e1nn\u011b<\/td>\n<\/tr>\n<tr>\n<td>III \u00b0<\/td>\n<td>prolaps u defekace \u2013 manu\u00e1ln\u011b reponibiln\u00ed<\/td>\n<\/tr>\n<tr>\n<td>IV \u00b0<\/td>\n<td>prolaps perian\u00e1ln\u011b fixovan\u00fd a fibr\u00f3zn\u00ed \u2013nereponibiln\u00ed<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\">Hemoroidy I.\u00b0 v proktoskopu se jev\u00ed jako pru\u017en\u00e1 elastick\u00e1, sliznic\u00ed pokryt\u00e1 klenut\u00ed, kter\u00e1 se p\u0159i tlaku na stolici \u010di zaka\u0161l\u00e1n\u00ed je\u0161t\u011b v\u00edce zv\u00fdrazn\u00ed.<\/li>\n<li style=\"text-align: justify;\">Hemoroidy II.\u00b0 prolabuj\u00ed u defekace a pak se zase spont\u00e1nn\u011b zat\u00e1hnou zp\u011bt. Mohou se vyskytnout jednotliv\u011b nebo jako kruhov\u00fd prolaps. Prolabovan\u00e9 hemoroidy se nedaj\u00ed zam\u011bnit s charakteristick\u00fdm perian\u00e1ln\u00edm, p\u0159\u00edpadn\u011b subanoderm\u00e1ln\u00edm\u00a0\u017eiln\u00edm pol\u0161t\u00e1\u0159em. Tyto mohou imponovat p\u0159i tlaku na stolici jako prolaps, jsou v\u0161ak \u2013 na rozd\u00edl od hemoroid\u016f \u2013 pokryty dla\u017edicovit\u00fdm rohov\u011bj\u00edc\u00edm epitelem.<\/li>\n<\/ul>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_467.png\"><img decoding=\"async\" title=\"Obr. 96 \u2013 Hemoroidy I. stupn\u011b\" alt=\"Obr. 96 \u2013 Hemoroidy I. stupn\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_467.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 96 \u2013 Hemoroidy I. stupn\u011b<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_468.png\"><img decoding=\"async\" title=\"Obr. 97 \u2013 Hemoroidy II. stupn\u011b\" alt=\"Obr. 97 \u2013 Hemoroidy II. stupn\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_468.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 97 \u2013 Hemoroidy II. stupn\u011b<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_469.png\"><img decoding=\"async\" title=\"Obr. 98 \u2013 Hemoroidy III. stupn\u011b\" alt=\"Obr. 98 \u2013 Hemoroidy III. stupn\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_469.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 98 \u2013 Hemoroidy III. stupn\u011b<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\">Hemoroidy III.\u00b0 prolabuj\u00ed po defekaci nebo t\u011blesn\u00e9 n\u00e1maze. Nezat\u00e1hnou se spont\u00e1nn\u011b zp\u011bt, ale mus\u00ed b\u00fdt manu\u00e1ln\u011b reponov\u00e1ny. To m\u016f\u017ee b\u00fdt spojeno s n\u00e1sledn\u00fdm tlakem nebo pocitem ciz\u00edho t\u011bl\u00edska v kone\u010dn\u00edku. Stejn\u011b jako hemoroidy II.\u00b0 nemus\u00ed p\u016fsobit p\u0159i dal\u0161\u00ed defekaci \u017e\u00e1dn\u00e9 pot\u00ed\u017ee. \u010casto prolabuj\u00ed nejen masivn\u011b zv\u011bt\u0161en\u00e9 hemoroid\u00e1ln\u00ed pol\u0161t\u00e1\u0159e, ale tak\u00e9 z\u00e1rove\u0148 linea dentata s rozvoln\u011bn\u00fdm anodermem \u2013 zn\u00e1mka naru\u0161en\u00e9 struktury an\u00e1ln\u00edho kan\u00e1lu.<\/li>\n<li style=\"text-align: justify;\">\u00a0Hemoroidy IV.\u00b0 jsou zv\u011bt\u0161en\u00e9, prolabovan\u00e9 hemoroid\u00e1ln\u00ed komplexy, spolu s vyh\u0159ez\u00e1vaj\u00edc\u00edm anodermem dist\u00e1ln\u00edho an\u00e1ln\u00edho kan\u00e1lu. Tyto struktury jsou \u010d\u00e1ste\u010dn\u011b fibrotizovan\u00e9, zvenku fixovan\u00e9. Nedaj\u00ed se ji\u017e reponovat.<br \/>\nHemoroidy IV.\u00b0 nemus\u00ed zp\u016fsobovat \u017e\u00e1dn\u00e9 pot\u00ed\u017ee typu bolest\u00ed nebo krv\u00e1cen\u00ed. Zp\u016fsobuj\u00ed ale poruchu jemn\u00e9 kontinence.<\/li>\n<\/ul>\n<p>Dnes se pomalu za\u010d\u00edn\u00e1me p\u0159ikl\u00e1n\u011bt k podstatn\u011b jednodu\u0161\u0161\u00edmu d\u011blen\u00ed.<\/p>\n<ul>\n<li>Uzly I a II ozna\u010dujeme jako low grade LGH.<\/li>\n<li>Uzly III a IV ozna\u010dujeme jako high grade HGH.<\/li>\n<\/ul>\n<h6>Pr\u016fb\u011bh a progn\u00f3za<\/h6>\n<p style=\"text-align: justify;\">Hemoroidy jsou progreduj\u00edc\u00ed onemocn\u011bn\u00ed; bez efektivn\u00ed terapie nar\u016fst\u00e1 jejich velikost i obt\u00ed\u017ee jimi zp\u016fsobovan\u00e9. Z\u00e1le\u017e\u00ed na dispozic\u00edch a jin\u00fdch faktorech (nap\u0159. z\u00e1cp\u011b, tla\u010den\u00ed u defekace, nadv\u00e1ze), jak rychle povedou hemoroidy I.\u00b0 k hemoroid\u016fm II., III. a IV. stupn\u011b. Stadia mohou n\u00e1sledovat po sob\u011b, ale mohou se tak\u00e9 vyskytnout nez\u00e1visle na sob\u011b. L\u00e9\u010dbou hemoroid\u016f se d\u00e1 takov\u00e9mu pr\u016fb\u011bhu spolehliv\u011b p\u0159edej\u00edt (regulac\u00ed stolice, sklerotizac\u00ed, band\u00e1\u017e\u00ed elastick\u00fdm liga\u010dn\u00edm krou\u017ekem, hemoroid\u00e1ln\u00ed arteri\u00e1ln\u00ed ligac\u00ed \u010di hemoroid\u00e1ln\u00ed laserovou okluz\u00ed).<\/p>\n<h6>Diagnostika<\/h6>\n<p style=\"text-align: justify;\">Neprolabovan\u00e9 hemoroidy (hemoroidy I.\u00b0)se daj\u00ed nejl\u00e9pe rozeznat anoskopicky. Nejvhodn\u011bj\u0161\u00edmi se jev\u00ed proktoskopy firmy Sapimed. Prolabovan\u00e9 hemoroidy se daj\u00ed nejz\u0159eteln\u011bji zjistit po defekaci (je-li t\u0159eba, po provokaci klyzmatem), p\u0159i\u010dem\u017e hemoroidy II.\u00b0 se p\u0159i n\u00e1sledn\u00e9 prohl\u00eddce ji\u017e \u010dasto reponuj\u00ed. Pak by m\u011bl b\u00fdt pacient vy\u0161et\u0159en v pod\u0159epu a p\u0159i tlaku na stolici. Zvenku fixovan\u00e9 a d\u00e1le nereponovateln\u00e9 hemoroidy (hemoroidy IV.\u00b0) se daj\u00ed dob\u0159e posoudit inspekc\u00ed.<\/p>\n<h6>Histologie<\/h6>\n<p style=\"text-align: justify;\">Histologicky se jedn\u00e1 u hemoroid\u016f o submuk\u00f3zn\u00ed, \u010dasto tenkost\u011bnn\u00e9 a s\u00ed\u0165ovit\u011b navz\u00e1jem propojen\u00e9 krevn\u00ed prostory, kter\u00e9 ve sv\u00e9 celistvosti tvo\u0159\u00ed tzv. plexus\u00a0submucosus anorectalis. \u010c\u00e1st t\u011bchto c\u00e9v je pojivov\u00fdmi tk\u00e1n\u011bmi ohrani\u010dena na zp\u016fsob kavern\u00f3zn\u00edho t\u011blesa v mal\u00e9 a v\u011bt\u0161\u00ed c\u00e9vn\u00ed konvoluty. Mezi nimi le\u017e\u00ed siln\u011b dilatovan\u00e9 \u017e\u00edly. Tak\u00e9 arterie vedou do c\u00e9vn\u00edch konglomer\u00e1t\u016f a jev\u00ed se po \u00fasec\u00edch jako arterioven\u00f3zn\u00ed anastom\u00f3zy. Tento komplex vybudovan\u00fdch c\u00e9vn\u00edch s\u00edt\u00ed p\u0159ipom\u00edn\u00e1 sv\u00fdm charakterem a funkc\u00ed houbovit\u00e9 t\u011bleso (corpus cavernosum recti) (obr. 100).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_471.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 99 \u2013 Stanoven\u00ed stupn\u011b hemoroid\u00e1ln\u00edho onemocn\u011bn\u00ed \u2013 \u00d6rhlami, Gerjiy\" alt=\"Obr. 99 \u2013 Stanoven\u00ed stupn\u011b hemoroid\u00e1ln\u00edho onemocn\u011bn\u00ed \u2013 \u00d6rhlami, Gerjiy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_471.png\" width=\"200\" height=\"161\" \/><\/a><p class=\"wp-caption-text\">Obr. 99 \u2013 Stanoven\u00ed stupn\u011b<br \/>hemoroid\u00e1ln\u00edho onemocn\u011bn\u00ed \u2013 \u00d6rhlami, Gerjiy<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_473.png\"><img decoding=\"async\" title=\"Obr. 100 \u2013 Corpus cavernosum recti\" alt=\"Obr. 100 \u2013 Corpus cavernosum recti\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_473.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 100 \u2013 Corpus cavernosum recti<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Terapie<\/h6>\n<p style=\"text-align: justify;\">C\u00edlem terapie je pokud mo\u017eno trval\u00e9 odstran\u011bn\u00ed pot\u00ed\u017e\u00ed a symptom\u016f s co nejlep\u0161\u00edm obnoven\u00edm p\u016fvodn\u00edch fyziologick\u00fdch a anatomick\u00fdch pom\u011br\u016f. K tomuto v\u00fdsledku vedou 4 cesty:<\/p>\n<ol>\n<li>z\u00e1kladn\u00ed terapie,<\/li>\n<li>l\u00e9\u010den\u00ed p\u0159\u00edznak\u016f,<\/li>\n<li>redukce hyperplastick\u00fdch c\u00e9vn\u00edch konvolut\u016f,<\/li>\n<li>profylaxe recidivy.<\/li>\n<\/ol>\n<h6>Z\u00e1kladn\u00ed terapie<\/h6>\n<p style=\"text-align: justify;\">Z\u00e1kladn\u00ed peror\u00e1ln\u00ed medikac\u00ed jsou v dne\u0161n\u00ed dob\u011b flavonoidy v kombinaci s aescinem. Samotn\u00e1 venotonika v terapii postr\u00e1daj\u00ed v\u011brohodnost, nebo\u0165 hyperplastick\u00e9 hemoroid\u00e1ln\u00ed pol\u0161t\u00e1\u0159e nejsou k\u0159e\u010dov\u00e9 \u017e\u00edly (varixy). D\u00e1le je d\u016fle\u017eit\u00e1 eliminace exogenn\u00edch \u0161kodlivin, nebo\u0165 genetick\u00e9 komponenty se prozat\u00edm nedaj\u00ed odstranit. Pro posti\u017een\u00e9ho plat\u00ed konzumovat vl\u00e1kninnou bohatou stravu, dostate\u010dn\u00e9 mno\u017estv\u00ed tekutin a dodr\u017eovat z\u00e1sady spr\u00e1vn\u00e9 defekace. Stolice by m\u011bla b\u00fdt formovan\u00e1. Toaletu by m\u011bl pacient vyhledat p\u0159i typick\u00fdch nutk\u00e1n\u00edch. P\u0159edev\u0161\u00edm by se m\u011bl vyvarovat tla\u010den\u00ed. Strava bohat\u00e1 na balastn\u00ed l\u00e1tky m\u016f\u017ee p\u0159\u00edzniv\u011b ovlivnit hemoroid\u00e1ln\u00ed nemoc p\u0159edev\u0161\u00edm u pacient\u016f trp\u00edc\u00edch z\u00e1cpou.<\/p>\n<h6>L\u00e9\u010den\u00ed p\u0159\u00edznak\u016f<\/h6>\n<p style=\"text-align: justify;\">Nez\u00e1visle na stupni hemoroid\u00e1ln\u00edch obt\u00ed\u017e\u00ed plat\u00ed \u2013 p\u0159\u00edznaky pokud mo\u017eno co nejrychleji a \u00fa\u010dinn\u011b lok\u00e1ln\u011b terapeuticky odstranit, p\u0159\u00edpadn\u011b zm\u00edrnit.<\/p>\n<p style=\"text-align: justify;\">Prvn\u00edm a z\u00e1kladn\u00edm krokem konzervativn\u00ed terapie perian\u00e1ln\u00edch hemoroid\u00e1ln\u00edch pot\u00ed\u017e\u00ed je vhodn\u00e1 an\u00e1ln\u00ed hygiena teplou vodou bez m\u00fddla nebo sprchovac\u00edho gelu. Nem\u011bly by se pou\u017e\u00edvat ani navlh\u010den\u00e9 toaletn\u00ed ubrousky (alergenn\u00ed a ekz\u00e9m tvo\u0159\u00edc\u00ed potenci\u00e1l d\u00edky chemick\u00fd p\u0159\u00edsad\u00e1m).P\u0159i lok\u00e1ln\u00ed, tzn. \u010dist\u011b symptomatick\u00e9 hemoroid\u00e1ln\u00ed l\u00e9\u010db\u011b mus\u00ed b\u00fdt pamatov\u00e1no, \u017ee<\/p>\n<ul>\n<li>symptomatologie m\u016f\u017ee spont\u00e1nn\u011b v\u00fdrazn\u011b kol\u00edsat, hemoroidy nejsou o\u0161et\u0159ov\u00e1ny p\u0159\u00edmo,<\/li>\n<li>\u010dasto je dosa\u017eeno jen kr\u00e1tkodob\u00e9ho zlep\u0161en\u00ed a<\/li>\n<li>pokra\u010dov\u00e1n\u00ed nemoci nen\u00ed ovlivn\u011bno.<\/li>\n<\/ul>\n<p>K dispozici jsou jen dva komplexy p\u0159\u00edznak\u016f ur\u010den\u00fdch k lok\u00e1ln\u00ed terapii:<\/p>\n<ul>\n<li style=\"text-align: justify;\">dr\u00e1\u017ed\u011bn\u00ed perian\u00e1ln\u00ed k\u016f\u017ee: sv\u011bd\u011bn\u00ed, p\u00e1len\u00ed, bolest\u00a0(iritativn\u011b-toxick\u00fd an\u00e1ln\u00ed ekz\u00e9m),<\/li>\n<li style=\"text-align: justify;\">pot\u00ed\u017ee v dist\u00e1ln\u00edm, tedy v senzitivn\u00edm an\u00e1ln\u00edm kan\u00e1lu (bolesti a dr\u00e1\u017ed\u011bn\u00ed anodermu), \u010dasto se zv\u00fd\u0161en\u00fdm tonem sfinkter\u016f.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Dr\u00e1\u017ed\u011bn\u00e1 perian\u00e1ln\u00ed k\u016f\u017ee na z\u00e1klad\u011b nedostate\u010dn\u00e9ho sv\u00edr\u00e1n\u00ed kone\u010dn\u00edku se d\u00e1 jednodu\u0161e ochr\u00e1nit zinkovou pastou. P\u0159i siln\u011bj\u0161\u00edch ekzemat\u00f3zn\u00edch zm\u011bn\u00e1ch jsou indikov\u00e1na speci\u00e1ln\u00ed dermatika. Principem terapie hemoroid\u00e1ln\u00ed nemoci je odstran\u011bn\u00ed nebo zm\u00edrn\u011bn\u00ed symptom\u016f hemoroid\u00e1ln\u00ed nemoci, jako jsou bolest, krv\u00e1cen\u00ed, sv\u011bd\u011bn\u00ed, p\u00e1len\u00ed. \u017d\u00e1dn\u00e1 terapie nem\u016f\u017ee b\u00fdt zah\u00e1jena bez klinick\u00e9ho vy\u0161et\u0159en\u00ed. Postupuje se od konzervativn\u00ed terapie, kter\u00e1 je indikovan\u00e1 pro v\u0161echna stadia hemoroid\u00e1ln\u00ed nemoci, p\u0159es miniinvazivn\u00ed ambulantn\u00ed postupy a\u017e k operaci. D\u016fle\u017eitou sou\u010d\u00e1st\u00ed terapie je \u00faprava \u017eivotospr\u00e1vy a p\u00e9\u010de o pravidelnou defekaci. P\u0159i obstipa\u010dn\u00edch probl\u00e9mech je d\u016fle\u017eit\u00e9 vy\u0161et\u0159it p\u0159\u00ed\u010dinu obstipace a vylou\u010dit pop\u0159\u00edpad\u011b obstruk\u010dn\u00ed defeka\u010dn\u00ed syndrom, kter\u00fd m\u016f\u017ee b\u00fdt zp\u016fsoben zevn\u00edm \u00fatlakem p\u0159i sigmoideok\u00e9le, enterok\u00e9le, prolapsem gynekologick\u00fdch org\u00e1n\u016f nebo m\u016f\u017ee b\u00fdt zp\u016fsoben rektok\u00e9lou \u010di intususcepc\u00ed rekta. Tyto n\u00e1lezy jsou zpravidla doprov\u00e1zeny nutnost\u00ed usilovn\u00e9 defekace, kter\u00e1 m\u016f\u017ee b\u00fdt jednou z p\u0159\u00ed\u010din vzniku hemoroid\u00e1ln\u00edch uzl\u016f. Nejv\u011bt\u0161\u00edho efektu konzervativn\u00ed terapie lze dos\u00e1hnout v po\u010d\u00e1te\u010dn\u00edch stadi\u00edch hemoroid\u00e1ln\u00ed nemoci. V pokro\u010dilej\u0161\u00edch stadi\u00edch je konzervativn\u00ed terapie dopl\u0148kov\u00e1 a zm\u00edr\u0148uje symptomy hemoroid\u00e1ln\u00ed nemoci.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Prost\u0159edky pro \u00fapravu konzistence stolice<\/strong> \u2013 d\u016fle\u017eitou sou\u010d\u00e1st\u00ed konzervativn\u00ed terapie je p\u00e9\u010de o pravidlenou stolici, proto je d\u016fle\u017eit\u00fd dostate\u010dn\u00fd p\u0159\u00edsun stravy bohat\u00e9 na vl\u00e1kninu. Vhodn\u00fdm zm\u011bk\u010dovadlem stolice je laktul\u00f3za. Vhodn\u00e1 jsou i probiotika p\u0159i pr\u016fjmov\u00fdch onemocn\u011bn\u00edch. Samotn\u00e9 u\u017eit\u00ed laxativ je v l\u00e9\u010db\u011b hemoroid\u016f nanejv\u00fd\u0161e sporn\u00e9. \u0158\u00eddk\u00e1 stolice nevytv\u00e1\u0159\u00ed sv\u00fdm tlakem na senzitivn\u00ed z\u00f3nu v abor\u00e1ln\u00ed \u010d\u00e1sti rekta dostate\u010dn\u00fd impulz k relaxaci anu, a t\u00edm tak\u00e9 povel k vypr\u00e1zdn\u011bn\u00ed arterioven\u00f3zn\u00edho anorekt\u00e1ln\u00edho plexu.<\/li>\n<li style=\"text-align: justify;\"><strong>Lok\u00e1ln\u00ed masti a \u010d\u00edpky<\/strong> \u2013 prepar\u00e1ty zm\u00edr\u0148uj\u00ed symptomy hemoroid\u00e1ln\u00ed nemoci, jako jsou p\u00e1len\u00ed, sv\u011bd\u011bn\u00ed, krv\u00e1cen\u00ed a bolesti. P\u0159\u00edpravky se v\u011bt\u0161inou p\u0159\u00edli\u0161 neli\u0161\u00ed ve slo\u017een\u00ed a obsahuj\u00ed protiz\u00e1n\u011btlivou slo\u017eku, lok\u00e1ln\u00ed anestetikum, adstringent, vazokonstriktor a epitelizans v r\u016fzn\u00fdch kombinac\u00edch. V zahrani\u010d\u00ed jsou \u010dastou slo\u017ekou antihemoroid\u00e1ln\u00edch \u010d\u00edpk\u016f a mast\u00ed i kortikosteroidy. V \u010cR nen\u00ed v sou\u010dasnosti na trhu \u017e\u00e1dn\u00fd p\u0159\u00edpravek obsahuj\u00edc\u00ed kortikosteroid. P\u0159i konzervativn\u00e9 l\u00e9\u010db\u011b d\u00e1v\u00e1me v\u017edy p\u0159ednost mastem p\u0159ed \u010d\u00edpky.<\/li>\n<li style=\"text-align: justify;\"><strong>Protektanty<\/strong> \u2013 jedn\u00e1 se v\u011bt\u0161inou o kakaov\u00e9 m\u00e1slo obsa\u017een\u00e9 ve vehikulu, glycerin, kaolin, lanolin, miner\u00e1ln\u00ed oleje, oxidy zinku, vitaminy A a D, extrakty ze \u017eralo\u010d\u00edch chrupavek atd. Pat\u0159\u00ed sem prepar\u00e1ty Preparation H a p\u0159\u00edrodn\u00ed p\u0159\u00edpravky jako Hemodin, Hemostop. Protektanty br\u00e1n\u00ed iritaci perian\u00e1ln\u00ed oblasti tvorbou fyzik\u00e1ln\u00ed bari\u00e9ry na k\u016f\u017ei, a br\u00e1n\u00ed tak kontaktu k\u016f\u017ee se stolic\u00ed nebo secernuj\u00edc\u00ed hemoroid\u00e1ln\u00ed sliznic\u00ed. Tato bari\u00e9ra tak br\u00e1n\u00ed nebo zm\u00edr\u0148uje sv\u011bd\u011bn\u00ed, p\u00e1len\u00ed a bolesti v okol\u00ed kone\u010dn\u00edku.<\/li>\n<li style=\"text-align: justify;\"><strong>Vazokonstrik\u010dn\u00ed l\u00e1tky<\/strong> \u2013 fenylefrine, efedrine sulf\u00e1t, epinefrin (Preparation H). Zm\u00edr\u0148uj\u00ed bolest a sv\u011bd\u011bn\u00ed m\u00edrn\u00fdm anestetick\u00fdm \u00fa\u010dinkem.<\/li>\n<li style=\"text-align: justify;\"><strong>Adstringenty<\/strong> \u2013 zlep\u0161uj\u00ed koagulaci a zklid\u0148uj\u00ed podr\u00e1\u017ed\u011bnou poko\u017eku perian\u00e1ln\u00ed oblasti, Spofax, Doxiproct, dubov\u00e1 k\u016fra, Hemostop.<\/li>\n<li style=\"text-align: justify;\"><b>Lok\u00e1ln\u00ed anestestik<\/b>a <i>\u2013 <\/i>cinchocain, lidokain.Jak bylo v\u00fd\u0161e uvedeno, v\u0161echny prepar\u00e1ty jsoukombinac\u00ed r\u016fzn\u00fdch skupin. Kombinuj\u00ed v\u0161echny,nebo jen n\u011bkter\u00e9 slo\u017eky. Snad v\u00edce protiz\u00e1n\u011btliv\u011b p\u016fsob\u00ed sv\u00fdm slo\u017een\u00edm prepar\u00e1ty Faktu, Mastu,\u00a0Proctoglyvenol. M\u00edrn\u011b vazokonstrik\u010dn\u011b a v\u00edce hemostypticky pak Spofax, Doxiproct, Proctoglyvenol. V\u00edc antiedemat\u00f3zn\u011b Preparation H, Dobexil H,Hemostop, Hemodin, Hemoval, Cyclo3Fort.<\/li>\n<li style=\"text-align: justify;\"><strong>Venotonika<\/strong> \u2013 hlavn\u00edm p\u0159edstavitelem je flavonoid diosmin, v\u011bt\u0161inou v mikronizovan\u00e9 form\u011b.V \u010cR maj\u00ed identick\u00fd obsah diosminu prepar\u00e1tyHemostop, Mobiven, Detralex, Vitavenon. Ve slo\u017een\u00ed p\u0159\u00eddavn\u00fdch slo\u017eek jsou jen minim\u00e1ln\u00ed rozd\u00edly. Nejlep\u0161\u00edho l\u00e9\u010debn\u00e9ho efektu venotonik je dosa\u017eeno p\u0159i terapii akutn\u00ed hemoroid\u00e1ln\u00ed ataky p\u0159iakutn\u00ed tromb\u00f3ze. Efekt del\u0161\u00edho nebo chronick\u00e9hou\u017e\u00edv\u00e1n\u00ed diosminu v indikaci hemoroid\u00e1ln\u00ed nemocije sporn\u00fd.<\/li>\n<\/ul>\n<h6>Redukce hyperplastick\u00fdch uzl\u016f<\/h6>\n<p style=\"text-align: justify;\">Redukce patologicky zv\u011bt\u0161en\u00fdch (hyperplastick\u00fdch) c\u00e9vn\u00edch konvolut\u016f, tedy obnova p\u016fvodn\u00edho stavu corpus cavernosum recti, je v n\u00e1vaznosti na p\u0159\u00edznaky vid\u011bna jako \u201ekauz\u00e1ln\u00ed terapie\u201c. Na rozd\u00edl od l\u00e9\u010den\u00ed p\u0159\u00edznak\u016f by m\u011bla b\u00fdt patologicky hyperplastick\u00e1 hemoroid\u00e1ln\u00ed tk\u00e1\u0148 redukov\u00e1na na fyziologickou velikost, a t\u00edm obnovena norm\u00e1ln\u00ed anatomie an\u00e1ln\u00edho kan\u00e1lu. Terapeutick\u00e9 v\u00fdkony se \u0159\u00edd\u00ed stupn\u011bm zm\u011bn. Invazivn\u00ed, nap\u0159. operativn\u00ed z\u00e1kroky (hemoroidopexa pomoc\u00ed infrarot \u010di argonov\u00e9 koagulace, podv\u00e1z\u00e1n\u00ed gumov\u00fdm krou\u017ekem dle Barrona, hemoroid\u00e1ln\u00ed arteri\u00e1ln\u00ed ligace HAL, hemoroid\u00e1ln\u00ed laserov\u00e1 arteri\u00e1ln\u00ed okluze HALOHelp, hemoroidektomie), event. plastick\u00e9 rekonstrukce an\u00e1ln\u00edho kan\u00e1lu, jsou indikov\u00e1ny u zm\u011bn vy\u0161\u0161\u00edch stup\u0148\u016f.<\/p>\n<h6>Profylaxe recidivy<\/h6>\n<p style=\"text-align: justify;\">P\u0159i v\u0161ech mo\u017enostech terapie mus\u00ed b\u00fdt tak\u00e9 po\u010d\u00edt\u00e1no s recidivami. V profylaxi recidivy n\u00e1m z\u016fst\u00e1v\u00e1 jen vylou\u010den\u00ed exogenn\u00edch \u0161kodlivin, nebo\u0165 genetickou predispozici moment\u00e1ln\u011b nelze ovlivnit. Nej\u00fa\u010dinn\u011bj\u0161\u00ed prevenc\u00ed je ji\u017e v\u00fd\u0161e popsan\u00e1 z\u00e1kladn\u00ed terapie: strava bohat\u00e1 na vl\u00e1kninu, dostate\u010dn\u00e9 mno\u017estv\u00ed tekutin a spr\u00e1vn\u00fd pr\u016fb\u011bh defekace. Kontroly kone\u010dn\u00edku a tlust\u00e9ho st\u0159eva specialistou \u2013 pokud mo\u017eno v pravideln\u00fdch intervalech \u2013 umo\u017en\u00ed recidivu rozpoznat v\u010das a tak\u00e9 efektivn\u011b a bezprobl\u00e9mov\u011b l\u00e9\u010dit.<\/p>\n<h6>Terapie<\/h6>\n<h6>L\u00e9\u010dba sklerotizac\u00ed<\/h6>\n<p style=\"text-align: justify;\">Sklerotizace hemoroid\u016f m\u016f\u017ee b\u00fdt provedena dle Blonda nebo Blancharda, p\u0159\u00edp. Bensaudeho. Metody jsou v anglosask\u00e9 literatu\u0159e pova\u017eov\u00e1ny za terapi prvn\u00ed volby u hemoroid\u016f I.\u00b0. V na\u0161ich podm\u00ednk\u00e1ch doporu\u010dujeme l\u00e9\u010dbu flavonoidy a slizni\u010dn\u00ed fixaci technikou Infrarot. Nen\u00ed ale od v\u011bci se o technice zm\u00ednit.U <b>Blondovy metody <\/b>je sklerotiza\u010dn\u00ed roztok (nap\u0159. Polidocanol, Thesit, Chinin, Calcium-zinek-chlorid) anoskopem cirkul\u00e1rn\u011b injektov\u00e1n nad linea dentata submuk\u00f3zn\u011b do hemoroid\u00e1ln\u00ed tk\u00e1n\u011b. K tomu sta\u010d\u00ed 1,0\u20133,0 ml sklerotiza\u010dn\u00edho roztoku, kter\u00fd je aplikov\u00e1n opakovan\u011b, s odstupem 8\u201314 dn\u00ed. Blondovou sklerotizac\u00ed by se m\u011blo zabr\u00e1nit vytvo\u0159en\u00ed vnit\u0159n\u00edho prolapsu hemoroid\u016f do an\u00e1ln\u00edho kan\u00e1lu p\u0159i defekaci a m\u011blo by se p\u0159edej\u00edt traumatizaci p\u0159i pr\u016fchodu stolice.U sklerotiza\u010dn\u00ed techniky dle <b>Blancharda <\/b>se aplikuje v\u017edy 1\u20133 ml roztoku fenolu a mandlov\u00e9ho oleje nebo roztok fenolu a oleje z bursk\u00fdch o\u0159ech\u016f v oblasti p\u0159\u00edvodn\u00ed hemoroid\u00e1ln\u00ed arterie p\u0159i 3, 7 a 11 hod. v\u00a0litotomick\u00e9 poloze. <b>Bensaude <\/b>pou\u017e\u00edv\u00e1 0,5\u20131,0 ml Natetradecylsulf\u00e1tu p\u0159i stejn\u00e9 technice. Tak\u00e9 zde jsou nutn\u00e1 zpravidla 2\u20133 o\u0161et\u0159en\u00ed s odstupem 1\u20132 t\u00fddn\u016f. P\u016fvodn\u00ed p\u0159edstava, \u017ee se sklerotizac\u00ed dos\u00e1hne omezen\u00ed p\u0159\u00edtoku krve k hemoroid\u00e1ln\u00edm pol\u0161t\u00e1\u0159\u016fm, byla histologick\u00fdmi vy\u0161et\u0159en\u00edmi vyvr\u00e1cena. Terapeutick\u00fd efekt souvis\u00ed s fixac\u00ed hemoroid\u00e1ln\u00edch pol\u0161t\u00e1\u0159\u016f nad linea dentata. Oba postupy nejsou bez komplikac\u00ed. T\u00fdk\u00e1 se to krv\u00e1cen\u00ed, kter\u00e9 m\u016f\u017ee velmi z\u0159\u00eddka nab\u00fdt nebezpe\u010dn\u00fdch rozm\u011br\u016f. P\u0159\u00edle\u017eitostn\u011b se mohou tak\u00e9 vyskytovat bolestiv\u00e9 tlaky nebo pocit ciz\u00edho t\u011blesa. P\u0159i pou\u017e\u00edv\u00e1n\u00ed sklerotiza\u010dn\u00edho roztoku obsahuj\u00edc\u00edho chinin se mus\u00ed po\u010d\u00edtat ve 3\u20134 % s alergick\u00fdmi reakcemi. V ojedin\u011bl\u00fdch p\u0159\u00edpadech mohou nastat nekr\u00f3zy rekta a septick\u00e9 komp\u013aikace s n\u00e1sledkem smrti. P\u0159i srovn\u00e1vac\u00edm vy\u0161et\u0159en\u00ed obou metod vykazuje lep\u0161\u00ed efekt Blond\u016fv postup. Hemoroid\u00e1ln\u00ed pot\u00ed\u017ee (krv\u00e1cen\u00ed) odezn\u00ed p\u0159i Blondov\u011b postupu po dvou o\u0161et\u0159en\u00edch ji\u017e v 70\u201380 %. S recidivou se po\u010d\u00edt\u00e1 u 70 % po t\u0159ech letech. Relativn\u00edmi kontraindikacemi jsou ulcer\u00f3zn\u00ed kolitida, an\u00e1ln\u00ed forma Crohnovy choroby a imunosuprese (obr. 101\u2013102).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_476.png\"><img decoding=\"async\" title=\"Obr. 101 \u2013 Dopplerometrick\u00e1 navigace termin\u00e1ln\u00ed hemoroid\u00e1ln\u00ed arterie\" alt=\"Obr. 101 \u2013 Dopplerometrick\u00e1 navigace termin\u00e1ln\u00ed hemoroid\u00e1ln\u00ed arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_476.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 101 \u2013 Dopplerometrick\u00e1 navigace termin\u00e1ln\u00ed hemoroid\u00e1ln\u00ed arterie<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_477.png\"><img decoding=\"async\" title=\"Obr. 102 \u2013 Aplikace sklerotiza\u010dn\u00edho roztoku\" alt=\"Obr. 102 \u2013 Aplikace sklerotiza\u010dn\u00edho roztoku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_477.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 102 \u2013 Aplikace sklerotiza\u010dn\u00edho roztoku<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Podv\u00e1z\u00e1n\u00ed gumov\u00fdm krou\u017ekem dle Barrona \u2013\u00a0rubber band ligation<\/h6>\n<p style=\"text-align: justify;\">Hemoroidy druh\u00e9ho stupn\u011b se daj\u00ed elegantn\u011b a \u00fasp\u011b\u0161n\u011b odstranit mal\u00fdm gumov\u00fdm krou\u017ekem. K tomu vytvo\u0159il Blaisdell v roce 1954 postup, kter\u00fd byl Barronem modifikov\u00e1n a dodnes plat\u00ed jako terapie prvn\u00ed volby k l\u00e9\u010den\u00ed hemoroid\u016f II.\u00b0. Jestli\u017ee jsou hemoroidy III.\u00b0 segment\u00e1rn\u00ed, dob\u0159e reponibiln\u00ed a bez doprov\u00e1zej\u00edc\u00edch an\u00e1ln\u00edch prolaps\u016f, m\u016f\u017ee b\u00fdt tato metoda stejn\u011b tak pou\u017eita s dobr\u00fdm efektem. Za pomoci speci\u00e1ln\u00edho aplik\u00e1toru se hemoroid\u00e1ln\u00ed uzly podv\u00e1\u017eou. B\u011bhem kr\u00e1tk\u00e9 doby to vede k nekr\u00f3ze a v n\u00e1sleduj\u00edc\u00edch dnech k odpadnut\u00ed mrtv\u00e9 tk\u00e1n\u011b. Gumov\u00e9 krou\u017eky nesm\u00ed b\u00fdt za \u017e\u00e1dn\u00fdch okolnost\u00ed um\u00edst\u011bny pod linea dentata, n\u00fdbr\u017e jen v necitliv\u00fdch oblastech nad touto lini\u00ed. Jinak mus\u00edme po\u010d\u00edtat po n\u011bkolik dn\u00ed se siln\u00fdmi bolestmi. Ostatn\u011b bolesti se mnohdy objev\u00ed i po spr\u00e1vn\u00e9 aplikaci nad linea dentata, jsou velice individu\u00e1ln\u00ed. N\u011bkte\u0159\u00ed auto\u0159i doporu\u010duj\u00ed gumov\u00e9 krou\u017eky neum\u00edstit p\u0159\u00edmo na hemoroid\u00e1ln\u00ed pol\u0161t\u00e1\u0159e, ale t\u011bsn\u011b nad n\u011b, a t\u00edmto sliznici \u201enabrat\u201c. Toto p\u016fsob\u00ed proti prolabov\u00e1n\u00ed hemoroid\u00e1ln\u00edch uzl\u016f, ani\u017e by se musely z\u00e1rove\u0148 poru\u0161it. Aby se zabr\u00e1nilo sklouznut\u00ed gumov\u00e9ho krou\u017eku z mal\u00e9ho uzlu, m\u016f\u017ee se sklerotiza\u010dn\u00ed prost\u0159edek injektovat p\u0159\u00edmo do uzlu. Z ekonomick\u00fdch d\u016fvod\u016f m\u00e1 smysl o\u0161et\u0159it v\u0161echny prolabovan\u00e9 uzly sou\u010dasn\u011b, tzn. p\u0159i jednom sezen\u00ed. Na z\u00e1klad\u011b mo\u017en\u00fdch rizik by se v\u0161ak p\u0159itom m\u011blo db\u00e1t opatrnosti. S po\u010dtem podv\u00e1zan\u00fdch uzl\u016f stoup\u00e1 zjevn\u011b riziko komplikac\u00ed. Po prvn\u00edm o\u0161et\u0159en\u00ed by se m\u011blo s dal\u0161\u00ed kontrolou po\u010dkat 4\u20136 t\u00fddn\u016f. Teprve potom je mo\u017en\u00e9 dostate\u010dn\u011b posoudit terapeutick\u00fd efekt a morfologick\u00e9 zm\u011bny, a t\u00edm zv\u00e1\u017eit a prov\u00e9st eventu\u00e1ln\u00ed c\u00edlen\u00e9 um\u00edst\u011bn\u00ed dal\u0161\u00edho gumov\u00e9ho krou\u017eku. Vedle bolest\u00ed (14 %) se mus\u00ed v ojedin\u011bl\u00fdch p\u0159\u00edpadech po\u010d\u00edtat se siln\u00fdm krv\u00e1cen\u00edm, kter\u00e9 m\u016f\u017ee b\u00fdt dokonce hemodynamicky v\u00fdznamn\u00e9. To se m\u016f\u017ee vyskytnout cca 1 t\u00fdden po o\u0161et\u0159en\u00ed. Referov\u00e1no bylo tak\u00e9 o poruch\u00e1ch mikce, teplot\u011b, abscesech, tromb\u00f3ze a tvorb\u011b fistul. Jako z\u00e1va\u017en\u00e1 komplikace s n\u00e1sledkem smrti je pops\u00e1na pozdn\u00ed alergick\u00e1 reakce na gumov\u00e1 aditiva. U gumov\u00fdch krou\u017ek\u016f z p\u0159\u00edrodn\u00edho kau\u010duku bez chemick\u00fdch p\u0159\u00edsad nebo u termoplastick\u00fdch izomer\u016f tato komplikace pops\u00e1na nebyla. Doposud byla u ur\u010dit\u00e9 skupiny pacient\u016f (transplantovan\u00ed, imunosuprimovan\u00ed, po implantac\u00edch c\u00e9vn\u00edch stent\u016f a n\u00e1hrad, stejn\u011b tak po kardi\u00e1ln\u00edch implant\u00e1tech) u ligatury dle Barrona, stejn\u011b jako u sklerotizace doporu\u010dov\u00e1na antibiotick\u00e1 endokarditick\u00e1 profylaxe. Po aktu\u00e1ln\u00edch doporu\u010den\u00edch kardiologick\u00e9 spole\u010dnosti z roku 2007 nen\u00ed l\u00e9ka\u0159sk\u00fd benefit dolo\u017een a od aplikace ATB profylaxe bylo upu\u0161t\u011bno. L\u00e9\u010debn\u00e9 \u00fasp\u011bchy ligatury gumov\u00fdm krou\u017ekem jsou u hemoroid\u016f II.\u00b0 po dlouhodob\u00e9m sledov\u00e1n\u00ed 3\u20135 let mezi\u00a070\u201380%. V porovn\u00e1n\u00ed s o\u0161et\u0159en\u00edm sklerotizac\u00ed a koagulac\u00ed infra\u010derven\u00fdm z\u00e1\u0159en\u00edm jsou uv\u00e1d\u011bny p\u0159ev\u00e1\u017en\u011b lep\u0161\u00ed v\u00fdsledky. Stupe\u0148 recidivy je v porovn\u00e1n\u00ed se sklerotizac\u00ed signifikantn\u011b ni\u017e\u0161\u00ed \u2013 25 % po 4 letech.<\/p>\n<h6>Terapeutick\u00e9 v\u00fdsledky<\/h6>\n<p style=\"text-align: justify;\">Metaanal\u00fdza, kter\u00e1 se vztahuje k 18 randomizovan\u00fdm studi\u00edm, do\u0161la p\u0159i porovn\u00e1v\u00e1n\u00ed jednotliv\u00fdch terapeutick\u00fdch postup\u016f k n\u00e1sleduj\u00edc\u00edm v\u00fdsledk\u016fm: operativn\u00ed o\u0161et\u0159en\u00ed hemoroid\u016f je zjevn\u011b efektivn\u011bj\u0161\u00ed ne\u017e manu\u00e1ln\u00ed divulze kone\u010dn\u00edku, pot\u0159ebuje m\u00e9n\u011b \u010dasto dal\u0161\u00ed l\u00e9\u010den\u00ed, neukazuje \u017e\u00e1dn\u00fd rozd\u00edl v n\u00e1vaznosti na komplikace, ale zp\u016fsobuje v\u00edce bolesti. Tak\u00e9 ve srovn\u00e1n\u00ed s ligaturou gumov\u00fdm krou\u017ekem se p\u0159i opera\u010dn\u00edm postupu o\u010dek\u00e1vaj\u00ed lep\u0161\u00ed v\u00fdsledky, i kdy\u017e jsou komplikace v\u011bt\u0161\u00ed, speci\u00e1ln\u011b s ohledem na bolesti. Ligatura gumov\u00fdm krou\u017ekem je oproti tomu \u00fasp\u011b\u0161n\u011bj\u0161\u00ed ne\u017e sklerotizace u hemoroid\u00e1ln\u00edch onemocn\u011bn\u00ed I.\u2013III. stupn\u011b. Komplikace p\u0159i sklerotizaci nebo ligatu\u0159e gumov\u00fdm krou\u017ekem b\u00fdvaj\u00ed stejn\u011b \u010dast\u00e9. Nutnostd\u00e1le pokra\u010duj\u00edc\u00ed terapie p\u0159i o\u0161et\u0159en\u00ed sklerotizac\u00ed a p\u0159i koagulaci infra\u010derven\u00fdmi paprsky je ud\u00e1v\u00e1na \u010dast\u011bji ne\u017e u ligatury gumov\u00fdm krou\u017ekem. Bolesti b\u00fdvaj\u00ed u sklerotizace a koagulace infra\u010derven\u00fdmi paprsky jen z\u0159\u00eddka proti ligatu\u0159e gumov\u00fdm krou\u017ekem. Na z\u00e1klad\u011b\u00a0t\u00e9to anal\u00fdzy je v USA ligatura gumov\u00fdm krou\u017ekem doporu\u010dov\u00e1na jako po\u010d\u00e1te\u010dn\u00ed terapie u hemoroid\u016f I. a\u017e III. stupn\u011b, i kdy\u017e operace vede k lep\u0161\u00edm v\u00fdsledk\u016fm. Vzhledem k tomu, \u017ee operativn\u00ed o\u0161et\u0159en\u00ed je zat\u00ed\u017eeno v\u011bt\u0161\u00edmi komplikacemi, m\u011blo by se k n\u011bmu p\u0159istoupit, kdy\u017e ligatura gumov\u00fdm krou\u017ekem nen\u00ed \u00fasp\u011b\u0161n\u00e1. U n\u00e1s b\u00fdvaj\u00ed hemoroidy III. stupn\u011b o\u0161et\u0159ov\u00e1ny ponejv\u00edce chirurgicky (obr. 105\u2013109).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_479.png\"><img decoding=\"async\" title=\"Obr. 105 \u2013 Nasazen\u00ed elastick\u00e9ho krou\u017eku na podtlakov\u00fd lig\u00e1tor\" alt=\"Obr. 105 \u2013 Nasazen\u00ed elastick\u00e9ho krou\u017eku na podtlakov\u00fd lig\u00e1tor\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_479.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 105 \u2013 Nasazen\u00ed elastick\u00e9ho krou\u017eku na podtlakov\u00fd lig\u00e1tor<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_480.png\"><img decoding=\"async\" title=\"Obr. 106 \u2013 Nasazen\u00fd krou\u017eek\" alt=\"Obr. 106 \u2013 Nasazen\u00fd krou\u017eek\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_480.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 106 \u2013 Nasazen\u00fd krou\u017eek<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_481.png\"><img decoding=\"async\" title=\"Obr. 107 \u2013 Nalo\u017een\u00ed Barronovy ligatury podtlakov\u00fdm aplik\u00e1torem\" alt=\"Obr. 107 \u2013 Nalo\u017een\u00ed Barronovy ligatury podtlakov\u00fdm aplik\u00e1torem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_481.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 107 \u2013 Nalo\u017een\u00ed Barronovy ligatury podtlakov\u00fdm aplik\u00e1torem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_483.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 108 \u2013 Aplikace Barronovy ligatury \u2013 pohled do anu\" alt=\"Obr. 108 \u2013 Aplikace Barronovy ligatury \u2013 pohled do anu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_483.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 108 \u2013 Aplikace Barronovy ligatury \u2013 pohled do anu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_482.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 109 \u2013 Nalo\u017een\u00e9 ligatury 1-5-9 v genupektor\u00e1ln\u00ed poloze\" alt=\"Obr. 109 \u2013 Nalo\u017een\u00e9 ligatury 1-5-9 v genupektor\u00e1ln\u00ed poloze\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_482.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 109 \u2013 Nalo\u017een\u00e9 ligatury 1-5-9 v genupektor\u00e1ln\u00ed poloze<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Koagulace infra\u010derven\u00fdmi paprsky \u2013 infrarot<\/h6>\n<p style=\"text-align: justify;\">Koagulace infra\u010derven\u00fdmi paprsky p\u0159edstavuje velice jednoduch\u00fd a efektivn\u00ed terapeutick\u00fd postup, kter\u00fd se velmi dob\u0159e osv\u011bd\u010dil u l\u00e9\u010den\u00ed krv\u00e1cej\u00edc\u00edch hemoroid\u016f I. stupn\u011b. Pou\u017e\u00edv\u00e1 se p\u0159itom infra\u010derven\u00fd koagul\u00e1tor podobn\u00fd pistoli, kter\u00fdm jsou o\u0161et\u0159ov\u00e1ny hemoroidy otev\u0159en\u00fdm proktoskopem. Terapeutick\u00fd efekt m\u00e1 na infra\u010derven\u00e9 z\u00e1\u0159en\u00ed, kter\u00e9 vede svou teplotou 100 \u00b0C k nekr\u00f3ze tk\u00e1n\u011b. Koagula\u010dn\u00ed body mus\u00ed b\u00fdt um\u00edst\u011bny nad linea dentata. Tato metoda o\u0161et\u0159en\u00ed je bezbolestn\u00e1 a vede zhruba po 2 sezen\u00edch asi k 75%\u00a0\u00fasp\u011b\u0161nosti. U v\u00fdlu\u010dn\u011b krv\u00e1cej\u00edc\u00edch hemoroid\u016f I. stupn\u011b jsou pops\u00e1ny stejn\u011b dobr\u00e9 v\u00fdsledky l\u00e9\u010dby jako u ligatury gumov\u00fdm krou\u017ekem. Na jedno sezen\u00ed nesm\u00ed b\u00fdt aplikov\u00e1ny v\u00edce ne\u017e 4 koagulace. Vedlej\u0161\u00ed \u00fa\u010dinky by b\u00fdt nem\u011bly, p\u0159i\u010dem\u017e krv\u00e1cen\u00ed v prvn\u00edch dnech po o\u0161et\u0159en\u00ed nen\u00ed nic neobvykl\u00e9ho a pacient mus\u00ed b\u00fdt o n\u011bm po v\u00fdkonu v\u017edy \u0159\u00e1dn\u011b pou\u010den (obr. 110\u2013112).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_485.png\"><img decoding=\"async\" title=\"Obr. 110 \u2013 Koagul\u00e1tor infrarot\" alt=\"Obr. 110 \u2013 Koagul\u00e1tor infrarot\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_485.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 110 \u2013 Koagul\u00e1tor infrarot<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_486.png\"><img decoding=\"async\" title=\"Obr. 111 \u2013 Koagul\u00e1tor v anoskopu\" alt=\"Obr. 111 \u2013 Koagul\u00e1tor v anoskopu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_486.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 111 \u2013 Koagul\u00e1tor v anoskopu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_487.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 112 \u2013 Infra\u010derven\u00e1 koagulace hemoroid\u00e1ln\u00edho uzlu\" alt=\"Obr. 112 \u2013 Infra\u010derven\u00e1 koagulace hemoroid\u00e1ln\u00edho uzlu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_487.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 112 \u2013 Infra\u010derven\u00e1 koagulace hemoroid\u00e1ln\u00edho uzlu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Hemoroid\u00e1ln\u00ed arteri\u00e1ln\u00ed ligace (HAL)<\/h6>\n<p style=\"text-align: justify;\">Mo\u017enost \u00fasp\u011b\u0161n\u011b zmen\u0161it hemoroidy II. a III. stupn\u011b dopplerometricky navigovanou ligaturou je p\u016fvodn\u011b pops\u00e1na Morinaganou a modifikov\u00e1na Meintjesem. Princip spo\u010d\u00edv\u00e1 v tom, \u017ee pomoc\u00ed speci\u00e1ln\u00edho proktoskopu, ve kter\u00e9m je zabudovan\u00e1 dopplerovsk\u00e1 sonda, se p\u0159\u00edvodn\u00e9 hemoroid\u00e1ln\u00ed arterie lokalizuj\u00ed a podv\u00e1\u017eou. To vede ke zmen\u0161en\u00ed arteri\u00e1ln\u00edho pln\u011bn\u00ed a n\u00e1sledn\u00e9mu smr\u0161t\u011bn\u00ed hemoroid\u00e1ln\u00edch uzl\u016f. T\u00edmto by nem\u011bl zmizet pouze hemoroid\u00e1ln\u00ed prolaps, n\u00fdbr\u017e tak\u00e9 s n\u00edm spojen\u00e9 obt\u00ed\u017ee. Auto\u0159i metody u 1415 o\u0161et\u0159en\u00fdch pacient\u016f popisuj\u00ed \u00fasp\u011b\u0161nost 93 %. P\u0159edpokladem je podv\u00e1zat nejen hlavn\u00ed arterie v lokalizaci 3, 7 a 11 cifern\u00edku hodin, ale tak\u00e9 v t\u00e9to studii dodate\u010dn\u011b popsan\u00e9 c\u00e9vy p\u0159i 1, 5 a 9 cifern\u00edku hodin. V\u00e1\u017en\u00e9 komplikace, jako krv\u00e1cen\u00ed, lok\u00e1ln\u00ed infekce, an\u00e1ln\u00ed fisury a perian\u00e1ln\u00ed tromb\u00f3zy, se objevuj\u00ed jen velice z\u0159\u00eddka. Mezit\u00edm jsou k dispozici tak\u00e9 jin\u00e9 studie o t\u00e9to l\u00e9\u010debn\u00e9 metod\u011b. \u00dasp\u011b\u0161nost je popisov\u00e1na mezi 50 a 70 %. Terapeutick\u00fd efekt se zd\u00e1 b\u00fdt ale v d\u016fsledku podv\u00e1z\u00e1n\u00ed hemoroid\u00e1ln\u00edch arteri\u00ed men\u0161\u00ed ne\u017e u o\u0161et\u0159en\u00ed hemoroid\u016f ligaturou gumov\u00fdm krou\u017ekem. Indikace a \u00fa\u010dinnost nejsou po v\u00edce ne\u017e desetilet\u00e9m pou\u017e\u00edv\u00e1n\u00ed jednozna\u010dn\u011b definovan\u00e9 (obr. 113\u2013115).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_489.png\"><img decoding=\"async\" title=\"Obr. 113 \u2013 HAL \u2013 detekce hemoroid\u00e1ln\u00ed arterie\" alt=\"Obr. 113 \u2013 HAL \u2013 detekce hemoroid\u00e1ln\u00ed arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_489.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 113 \u2013 HAL \u2013 detekce hemoroid\u00e1ln\u00ed arterie<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_490.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 114 \u2013 Opich hemoroid\u00e1ln\u00ed arterie \u2013 pohled z anoskopu\" alt=\"Obr. 114 \u2013 Opich hemoroid\u00e1ln\u00ed arterie \u2013 pohled z anoskopu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_490.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 114 \u2013 Opich hemoroid\u00e1ln\u00ed arterie \u2013 pohled z anoskopu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_492.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 115 \u2013 Opich hemoroid\u00e1ln\u00ed arterie \u2013 anatomick\u00fd \u0159ez\" alt=\"Obr. 115 \u2013 Opich hemoroid\u00e1ln\u00ed arterie \u2013 anatomick\u00fd \u0159ez\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_492.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 115 \u2013 Opich hemoroid\u00e1ln\u00ed arterie \u2013 anatomick\u00fd \u0159ez<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Rekto-anal-repair (RAR)<\/h6>\n<p style=\"text-align: justify;\">Tento postup p\u0159edstavuje dal\u0161\u00ed rozvoj metody HAL, p\u0159i kter\u00e9 nejsou podv\u00e1z\u00e1ny jen hemoroid\u00e1ln\u00ed arterie, ale hemoroid\u00e1ln\u00ed uzly jsou pokra\u010duj\u00edc\u00edm stehem spir\u00e1lov\u011b \u0159aseny a n\u00e1sledn\u011b je provedena jejich taxe do an\u00e1ln\u00edho kan\u00e1lu. Origin\u00e1ln\u00ed metoda u\u017e\u00edv\u00e1 speci\u00e1ln\u00ed Doppler-proktoskop, podobn\u00fd HAL-proktoskopu, se kter\u00fdm se tento z\u00e1sah m\u016f\u017ee prov\u00e1d\u011bt ve v\u00edce sektorech. Pokra\u010duj\u00edc\u00ed steh mus\u00ed b\u00fdt ukon\u010den striktn\u011b v denervovav\u00e9 z\u00f3n\u011b nad linea dentata. P\u0159esto je tato metoda spojena s vy\u0161\u0161\u00ed bolestivost\u00ed, krv\u00e1cen\u00edm a poruchami mo\u010den\u00ed v poopera\u010dn\u00edm pr\u016fb\u011bhu. Doposud nejsou k dispozici \u017e\u00e1dn\u00e9 konkr\u00e9tn\u00ed v\u00fdsledky studi\u00ed, kter\u00e9 zd\u016fvod\u0148uj\u00ed up\u0159ednostn\u011bn\u00ed tohoto o\u0161et\u0159en\u00ed p\u0159ed jin\u00fdmi etablovan\u00fdmi postupy (obr. 116\u2013119).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_491.png\"><img decoding=\"async\" title=\"Obr. 116 \u2013 Opich p\u0159\u00edvodn\u00e9 hemoroid\u00e1ln\u00ed arterie\" alt=\"Obr. 116 \u2013 Opich p\u0159\u00edvodn\u00e9 hemoroid\u00e1ln\u00ed arterie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_491.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 116 \u2013 Opich p\u0159\u00edvodn\u00e9 hemoroid\u00e1ln\u00ed arterie<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_493.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 117 \u2013 Nalo\u017een\u00ed pokra\u010duj\u00edc\u00edho stehu submuk\u00f3zn\u011b\" alt=\"Obr. 117 \u2013 Nalo\u017een\u00ed pokra\u010duj\u00edc\u00edho stehu submuk\u00f3zn\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_493.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 117 \u2013 Nalo\u017een\u00ed pokra\u010duj\u00edc\u00edho stehu submuk\u00f3zn\u011b<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_495.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 118 \u2013 Nalo\u017een\u00fd steh\" alt=\"Obr. 118 \u2013 Nalo\u017een\u00fd steh\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_495.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 118 \u2013 Nalo\u017een\u00fd steh<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_496.png\"><img decoding=\"async\" title=\"Obr. 119 \u2013 Rhafie sliznice a taxe uzlu\" alt=\"Obr. 119 \u2013 Rhafie sliznice a taxe uzlu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_496.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 119 \u2013 Rhafie sliznice a taxe uzlu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Elektrofrekven\u010dn\u00ed termoterapie<\/p>\n<p>Principem t\u00e9to metody je lok\u00e1ln\u00ed termick\u00e9 po\u0161kozen\u00ed patologick\u00e9 tk\u00e1n\u011b, k n\u00ed\u017e doch\u00e1z\u00ed mezi dv\u011bma bipol\u00e1rn\u00edmi elektrodami. V\u00fdsledkem je naru\u0161en\u00ed endotelov\u00e9 v\u00fdstelky \u017eiln\u00ed st\u011bny s n\u00e1sledn\u00fdm naru\u0161en\u00edm \u017eiln\u00edho toku. Vyu\u017e\u00edv\u00e1 se teplot kolem 60\u201380 \u00b0C, co\u017e je v\u00fdrazn\u011b ni\u017e\u0161\u00ed hodnota ne\u017e 600\u2013700 \u00b0C p\u0159i vyu\u017eit\u00ed laseru (obr. 120\u2013121).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_497.png\"><img decoding=\"async\" title=\"Obr. 120 \u2013 Hemoron\" alt=\"Obr. 120 \u2013 Hemoron\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_497.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 120 \u2013 Hemoron<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_498.png\"><img decoding=\"async\" title=\"Obr. 121 \u2013 O\u0161et\u0159en\u00ed uzlu hemoronem\" alt=\"Obr. 121 \u2013 O\u0161et\u0159en\u00ed uzlu hemoronem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_498.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 121 \u2013 O\u0161et\u0159en\u00ed uzlu hemoronem<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Hemoroid\u00e1ln\u00ed arteri\u00e1ln\u00ed laserov\u00e1 okluze HALO<\/h6>\n<p style=\"text-align: justify;\">Moriganovu techniku HAL modifikoval v roce 2005 Salfi vyu\u017eit\u00edm diodov\u00e9ho pulzn\u00edho laseru jako n\u00e1hrady vst\u0159ebateln\u00fdch ligatur. Tato zcela bezbolestn\u00e1 ambulantn\u00ed technika je ur\u010dena k l\u00e9\u010db\u011b hemoroid\u016f I. a II.stupn\u011b. Pro terapii uzl\u016f III. stupn\u011b je navr\u017een postup\u00a0s u\u017eit\u00edm speci\u00e1ln\u011b upraven\u00e9ho k\u00f3nick\u00e9ho laserov\u00e9ho vl\u00e1kna, kter\u00e9 je zav\u00e1d\u011bno axi\u00e1ln\u011b-perian\u00e1ln\u011b do oblasti hemoroid\u00e1ln\u00edho plexu z drobn\u00e9 ko\u017en\u00ed incize. Technika sleduje nejen uz\u00e1v\u011br termin\u00e1ln\u00ed v\u011btv\u011b p\u0159\u00edvodn\u00e9 hemoroid\u00e1ln\u00ed arterie, ale t\u00e9\u017e vytvo\u0159en\u00ed aseptick\u00e9 tepeln\u00e9 nekr\u00f3zy, kter\u00e1 po sv\u00e9m zhojen\u00ed m\u00e1 za n\u00e1sledek fixaci parci\u00e1ln\u00edho an\u00e1ln\u00edho prolapsu a jeho retrakci. Technika v\u0161ak mus\u00ed b\u00fdt provedena v lok\u00e1ln\u00ed anestezii \u010di kr\u00e1tkodob\u00e9 celkov\u00e9 anestezii, nebo\u0165 se ji\u017e nejedn\u00e1 o v\u00fdkon v senzitivn\u011b neinervovan\u00e9 \u010d\u00e1sti rekta. Technika HALO Help je jako zcela bezbolestn\u00e1 vypracov\u00e1na pouze pro I. a II. stupe\u0148 onemocn\u011bn\u00ed. Pro III. stupe\u0148 je modifikov\u00e1na jako v\u00fdkon p\u0159i u\u017eit\u00ed anestezie. U\u017eit\u00edm HALO pro III. stupe\u0148 m\u016f\u017eeme v\u0161ak doc\u00edlit downstagingu onemocn\u011bn\u00ed na I. a\u017e II. stupe\u0148 a aplikac\u00ed Barronovy ligatury pak vyu\u017eijeme v\u0161ech jej\u00edch v\u00fdhod k redukci zbyl\u00e9ho muk\u00f3zn\u00edho an\u00e1ln\u00edho prolapsu (obr. 122\u2013128).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_501.png\"><img decoding=\"async\" title=\"Obr. 122 \u2013 Princip dopplerometrick\u00e9 navigace HALO\" alt=\"Obr. 122 \u2013 Princip dopplerometrick\u00e9 navigace HALO\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_501.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 122 \u2013 Princip dopplerometrick\u00e9 navigace HALO<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_500.png\"><img decoding=\"async\" title=\" Obr. 123 \u2013 Laserov\u00e1 okluze HALO\" alt=\" Obr. 123 \u2013 Laserov\u00e1 okluze HALO\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_500.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 123 \u2013 Laserov\u00e1 okluze HALO<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_503.png\"><img decoding=\"async\" title=\"Obr. 124 \u2013 Kontroln\u00ed \u2013 nulov\u00e1 dopplerometrick\u00e1 detekce\" alt=\"Obr. 124 \u2013 Kontroln\u00ed \u2013 nulov\u00e1 dopplerometrick\u00e1 detekce\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_503.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 124 \u2013 Kontroln\u00ed \u2013 nulov\u00e1 dopplerometrick\u00e1 detekce<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_502.png\"><img decoding=\"async\" title=\"Obr. 125 \u2013 Diodov\u00fd laser\" alt=\"Obr. 125 \u2013 Diodov\u00fd laser\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_502.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 125 \u2013 Diodov\u00fd laser<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_505.png\"><img decoding=\"async\" title=\"Obr. 126 \u2013 Dopplerometrick\u00e1 sonda a laserov\u00e9 vl\u00e1kno\" alt=\"Obr. 126 \u2013 Dopplerometrick\u00e1 sonda a laserov\u00e9 vl\u00e1kno\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_505.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 126 \u2013 Dopplerometrick\u00e1 sonda a laserov\u00e9 vl\u00e1kno<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_504.png\"><img decoding=\"async\" title=\"Obr. 127 \u2013 Detekce arteria hemoroidalis dopplerometrickou sondou\" alt=\"Obr. 127 \u2013 Detekce arteria hemoroidalis dopplerometrickou sondou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_504.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 127 \u2013 Detekce arteria hemoroidalis dopplerometrickou sondou<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_507.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 128 \u2013 O\u0161et\u0159en\u00ed diodov\u00fdm laserem\" alt=\"Obr. 128 \u2013 O\u0161et\u0159en\u00ed diodov\u00fdm laserem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_507.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 128 \u2013 O\u0161et\u0159en\u00ed diodov\u00fdm laserem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Operace<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_508.png\"><img decoding=\"async\" title=\"Obr. 129 \u2013 Sekund\u00e1rn\u00ed marisky p\u0159i hemoroid\u00e1ln\u00edm onemocn\u011bn\u00ed\" alt=\"Obr. 129 \u2013 Sekund\u00e1rn\u00ed marisky p\u0159i hemoroid\u00e1ln\u00edm onemocn\u011bn\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_508.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 129 \u2013 Sekund\u00e1rn\u00ed marisky p\u0159i hemoroid\u00e1ln\u00edm onemocn\u011bn\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_509.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 130 \u2013 Uz\u00e1v\u011br v\u011btve arteria hemoroidalis harmonick\u00fdm skalpelem\" alt=\"Obr. 130 \u2013 Uz\u00e1v\u011br v\u011btve arteria hemoroidalis harmonick\u00fdm skalpelem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_509.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 130 \u2013 Uz\u00e1v\u011br v\u011btve arteria hemoroidalis harmonick\u00fdm skalpelem<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_510.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 131 \u2013 Tent\u00fd\u017e v\u00fdkon na \u010d. 7\" alt=\"Obr. 131 \u2013 Tent\u00fd\u017e v\u00fdkon na \u010d. 7\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_510.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 131 \u2013 Tent\u00fd\u017e v\u00fdkon na \u010d. 7<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_511.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 132 \u2013 Tent\u00fd\u017e na \u010d. 11\" alt=\"Obr. 132 \u2013 Tent\u00fd\u017e na \u010d. 11\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_511.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 132 \u2013 Tent\u00fd\u017e na \u010d. 11<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_513.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 133 \u2013 Excize uzlu dle Fergussona\" alt=\"Obr. 133 \u2013 Excize uzlu dle Fergussona\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_513.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 133 \u2013 Excize uzlu dle Fergussona<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_514.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 134 \u2013 Sutura muk\u00f3zy a anodermu\" alt=\"Obr. 134 \u2013 Sutura muk\u00f3zy a anodermu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_514.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 134 \u2013 Sutura muk\u00f3zy a anodermu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_515.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: justify;\" title=\"Obr. 135 \u2013 Stav po operaci se zaveden\u00fdm spongostanov\u00fdm vle\u010dkem\" alt=\"Obr. 135 \u2013 Stav po operaci se zaveden\u00fdm spongostanov\u00fdm vle\u010dkem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_515.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 135 \u2013 Stav po operaci se zaveden\u00fdm spongostanov\u00fdm vle\u010dkem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_516.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 136 \u2013 Princip nalo\u017een\u00ed Barronovy ligatury\" alt=\"Obr. 136 \u2013 Princip nalo\u017een\u00ed Barronovy ligatury\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_516.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 136 \u2013 Princip nalo\u017een\u00ed Barronovy ligatury<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Hemoroidy III. stupn\u011b, kter\u00e9 p\u0159i defekaci prolabuj\u00ed, se neretrahuj\u00ed spont\u00e1nn\u011b, a proto mus\u00ed b\u00fdt reponov\u00e1ny manu\u00e1ln\u011b, jen ve v\u00fdjime\u010dn\u00fdch p\u0159\u00edpadech jsou je\u0161t\u011b o\u0161et\u0159ov\u00e1ny konzervativn\u011b \u010di semiinvazivn\u011b s uspokojiv\u00fdm v\u00fdsledkem. Indikace k operaci mus\u00ed b\u00fdt stanovena individu\u00e1ln\u011b a velmi pe\u010dliv\u011b.Jsou k dispozici n\u00e1sleduj\u00edc\u00ed metody:<\/p>\n<ul>\n<li>otev\u0159en\u00e1 hemoroidektomie podle Milligan-Morgana,<\/li>\n<li>zav\u0159en\u00e1 hemoroidektomie podle Fergusona,<\/li>\n<li>submuk\u00f3zn\u00ed hemoroidektomie dle Parkse,<\/li>\n<li>rekonstruk\u010dn\u00ed hemoroidektomie dle Fanslera-Arnolda:\n<ul>\n<li>anoderm\u00e1ln\u00ed hemoroidektomie dle Whiteheada\u00a0nebo Toupeta.<\/li>\n<li>supraanoderm\u00e1ln\u00ed hemoroidopexe PPH staplerem dle Longa.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Obzvl\u00e1\u0161t\u011b p\u0159i segmentovan\u00fdch hemoroid\u00e1ln\u00edch uzlech se doporu\u010duj\u00ed postupy\u00a0dle\u00a0Milligan-Morganaa Fergusona, pokud u\u017e nen\u00ed indikov\u00e1na ligatura gumov\u00fdm krou\u017ekem. Zv\u011bt\u0161en\u00e9 hemoroid\u00e1ln\u00ed uzly jsou segment\u00e1rn\u011b resekov\u00e1ny s ponech\u00e1n\u00edm dostate\u010dn\u011b \u0161irok\u00fdch m\u016fstk\u016f anodermu, aby se zabr\u00e1nilo striktu\u0159e,eventu\u00e1ln\u011b poru\u0161e kontinence. Metoda dle <b>Milligan\u00ad<\/b><\/p>\n<p style=\"text-align: justify;\">\u00adMorgana je zalo\u017eena na \u0161irok\u00e9 excizi uzl\u016f, ponech\u00e1v\u00e1\u00a0vznikl\u00e9 defekty v anodermu otev\u0159en\u00e9 k sekund\u00e1rn\u00edmu\u00a0hojen\u00ed. Princip operace stav\u00ed ji\u017e na n\u00e1vrz\u00edch Milese z roku 1919. Kavern\u00f3zn\u00ed uzly jsou resekov\u00e1ny v typick\u00fdch lokalizac\u00edch, v\u010detn\u011b sliznice, a je proveden vysok\u00fd podvaz hemoroid\u00e1ln\u00ed arterie. Suturu sliznice a anodermu auto\u0159i neprov\u00e1d\u011bli (obr. 129\u2013132).<\/p>\n<p style=\"text-align: justify;\">U techniky dle <b>Fergusona <\/b>je uchov\u00e1no v\u00edce anodermu, aby se r\u00e1na mohla pohodln\u011b uzav\u0159\u00edt stehem. Resekce uzl\u016f je shodn\u00e1 s technikou Milligana a Morgana s t\u00edm rozd\u00edlem, \u017ee Fergusson pokra\u010dovac\u00edm stehem uzav\u00edr\u00e1 defekt ve sliznici i anodermu. Nev\u00fdhodou t\u00e9to metody je vy\u0161\u0161\u00ed riziko perian\u00e1ln\u00ed infekce a n\u00e1sledn\u00e9 dehiscence sutury. V\u011bt\u0161ina autor\u016f dnes vol\u00ed jak\u00fdsi kompromis a uzav\u00edr\u00e1 jen slizni\u010dn\u00ed porci s ponech\u00e1n\u00edm \u201edren\u00e1\u017en\u00edch otvor\u016f\u201c v anodermu (obr. 133\u2013135).<\/p>\n<h6>Operace dle Parkse<\/h6>\n<p style=\"text-align: justify;\">Operace dle Parkse spo\u010d\u00edv\u00e1 v submuk\u00f3zn\u00ed resekci uzl\u016f s n\u00edzk\u00fdm podvazem hemoroid\u00e1ln\u00ed arterie s n\u00e1slednou suturou sliznice. V dne\u0161n\u00ed dob\u011b je tento v\u00fdkon opu\u0161t\u011bn, pln\u011b jej nahrazuje proveden\u00ed tzv. rubber band ligation \u2013 Barronovy ligatury (obr. 136).<\/p>\n<p style=\"text-align: justify;\">Operace dle <b>Whiteheada <\/b>je indikov\u00e1na p\u0159i objemn\u00e9m n\u00e1lezu uzl\u016f IV. stupn\u011b s fixovan\u00fdm an\u00e1ln\u00edm prolapsem. Spo\u010d\u00edv\u00e1 v cirkumcizi anoderm\u00e1ln\u00edho p\u0159echodu, vypreparov\u00e1n\u00ed termin\u00e1ln\u00edch v\u011btv\u00ed arteria haemorrhoidalis v predilek\u010dn\u00edch m\u00edstech a n\u00e1sledn\u00e9 resekci. V\u00fdkon je ukon\u010den cirkul\u00e1rn\u00ed suturou mukokut\u00e1nn\u00edmi stehy \u010di za u\u017eit\u00ed stapleru. V\u00fdkon byl zat\u00ed\u017een vysok\u00fdm v\u00fdskytem z\u00e1va\u017en\u00fdch komplikac\u00ed (striktura anu, protruze an\u00e1ln\u00ed muk\u00f3zy s n\u00e1sledn\u00fdm syndromem vlhk\u00e9 \u201ekomor y\u201c (\u0159iti), sn\u00ed\u017een\u00edm senzitivity an\u00e1ln\u00ed s inkontinenc\u00ed I.\u2013II. stupn\u011b). Whiteheadova operace je u n\u00e1s dnes indikov\u00e1na jen v\u00fdjim\u011b\u010dn\u011b.\u00a0Renesanci Whiteheadova operace pro\u017e\u00edv\u00e1 v Americe (obr. 137\u2013140).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_518.png\"><img decoding=\"async\" title=\"Obr. 137 \u2013 Cirkumcize dle Whiteheada\" alt=\"Obr. 137 \u2013 Cirkumcize dle Whiteheada\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_518.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 137 \u2013 Cirkumcize dle Whiteheada<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_519.png\"><img decoding=\"async\" title=\"Obr. 138 \u2013 Kompletn\u00ed cirkumcize\" alt=\"Obr. 138 \u2013 Kompletn\u00ed cirkumcize\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_519.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 138 \u2013 Kompletn\u00ed cirkumcize<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_521.png\"><img decoding=\"async\" title=\"Obr. 139 \u2013 Mukokut\u00e1nn\u00ed sutura pokra\u010duj\u00edc\u00edm stehem\" alt=\"Obr. 139 \u2013 Mukokut\u00e1nn\u00ed sutura pokra\u010duj\u00edc\u00edm stehem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_521.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 139 \u2013 Mukokut\u00e1nn\u00ed sutura pokra\u010duj\u00edc\u00edm stehem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_520.png\"><img decoding=\"async\" title=\"Obr. 140 \u2013 Proveden\u00e1 cikul\u00e1rn\u00ed sutura\" alt=\"Obr. 140 \u2013 Proveden\u00e1 cikul\u00e1rn\u00ed sutura\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_520.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 140 \u2013 Proveden\u00e1 cikul\u00e1rn\u00ed sutura<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Modifikac\u00ed Whiteheadovy operace je operace dle <b>Toupeta. <\/b>V kvadrantech 3 a 9 je postupov\u00e1no jako p\u0159i Whiteheadobv\u011b cirkumcizi, v kvadrantech 12 a 6 jako p\u0159i operaci dle Milligana-Morgana. U \u010d\u00edsla 6 nav\u00edc prov\u00e1d\u011bl autor vnit\u0159n\u00ed sfinkterotomii.V \u010desk\u00fdch zem\u00edch jen v\u00fdjime\u010dn\u011b prov\u00e1d\u011bnou opera\u010dn\u00ed technikou je operace dle <b>Fanslera\u00adArnolda. <\/b>Je indikov\u00e1na u objemn\u00fdch uzl\u016f s prolapsem a spo\u010d\u00edv\u00e1 v subanoderm\u00e1ln\u00ed a submuk\u00f3zn\u00ed preparaci zevn\u00edho plexu s n\u00e1sledn\u00fdm odstran\u011bn\u00edm vnit\u0159n\u00ed porce spole\u010dn\u011b s muk\u00f3zou rekta. Vznikl\u00fd defekt v muk\u00f3ze je pak vykryt plastikou z \u201ep\u0159ebyte\u010dn\u00e9ho\u201c anodermu. Operace je n\u00e1ro\u010dn\u00e1 technicky i \u010dasov\u011b a oproti ostatn\u00edm v\u00fdkon\u016fm nep\u0159in\u00e1\u0161\u00ed signifikantn\u011b lep\u0161\u00ed v\u00fdsledky (obr. 141\u2013145).Pov\u0161echn\u011b m\u016f\u017eeme klasick\u00e9 opera\u010dn\u00ed postupy hodnotit jako techniky s opera\u010dn\u00edm \u010dasem okolo 10\u201360 minut, doba pobytu v nemocnici je 1\u20133 dny, pracovn\u00ed neschopnost asi 1\u20132 t\u00fddny, m\u00edra komplikac\u00ed je m\u00e9n\u011b\u00a0ne\u017e 10 %. Frekvence recidivy je ud\u00e1v\u00e1na v literatu\u0159e posledn\u00edch 20 let mezi 3 a 26 %, dle definice pojmu\u201erecidiva\u201c a d\u00e9lky n\u00e1sledn\u00e9ho sledov\u00e1n\u00ed. Kdy\u017e jsou zv\u011bt\u0161eny jen jeden nebo dva segmenty hemoroid\u00e1ln\u00edch pol\u0161t\u00e1\u0159\u016f, je resekce t\u011bchto \u010d\u00e1st\u00ed dosta\u010duj\u00edc\u00ed. Profylaktick\u00e1 operace nehypertrofovan\u00fdch hemoroid\u016f nen\u00ed smyslupln\u00e1. Opera\u010dn\u00ed v\u00fdkony laserem \u2013 m\u00edsto skalpelem \u2013 se orientuj\u00ed na v\u00fd\u0161e zm\u00edn\u011bn\u00e9 techniky, ale neukazuj\u00ed \u017e\u00e1dn\u00e9 efektivn\u00ed p\u0159ednosti, proto jsou pou\u017e\u00edv\u00e1ny jen velmi m\u00e1lo.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_524.png\"><img decoding=\"async\" title=\"Obr. 141 \u2013 Hemoroidy III. stupn\u011b\" alt=\"Obr. 141 \u2013 Hemoroidy III. stupn\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_524.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 141 \u2013 Hemoroidy III. stupn\u011b<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_523.png\"><img decoding=\"async\" title=\"Obr. 142 \u2013 Preparace uzlu dle Fanslera-Arnolda\" alt=\"Obr. 142 \u2013 Preparace uzlu dle Fanslera-Arnolda\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_523.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 142 \u2013 Preparace uzlu dle Fanslera-Arnolda<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_526.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 12.727272033691406px; line-height: 18.984848022460938px; text-align: start;\" title=\"Obr. 143 \u2013 Plastika vchl\u00edpen\u00edm laloku anodermu\" alt=\"Obr. 143 \u2013 Plastika vchl\u00edpen\u00edm laloku anodermu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_526.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 143 \u2013 Plastika vchl\u00edpen\u00edm laloku anodermu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_525.png\"><img decoding=\"async\" title=\"Obr. 144 \u2013 Tot\u00e9\u017e na \u010d. 7\" alt=\"Obr. 144 \u2013 Tot\u00e9\u017e na \u010d. 7\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_525.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 144 \u2013 Tot\u00e9\u017e na \u010d. 7<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_527.png\"><img decoding=\"async\" title=\"Obr. 145 \u2013 Po operaci s vlo\u017een\u00fdm spongostanov\u00fdm v\u00e1le\u010dkem\" alt=\"Obr. 145 \u2013 Po operaci s vlo\u017een\u00fdm spongostanov\u00fdm v\u00e1le\u010dkem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_527.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 145 \u2013 Po operaci s vlo\u017een\u00fdm spongostanov\u00fdm v\u00e1le\u010dkem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Longova metoda<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_529.png\"><img decoding=\"async\" title=\"Obr. 146 \u2013 Anoskop PPH Longo se zav\u00e1d\u011bc\u00ed man\u017eetou\" alt=\"Obr. 146 \u2013 Anoskop PPH Longo se zav\u00e1d\u011bc\u00ed man\u017eetou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_529.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 146 \u2013 Anoskop PPH Longo se zav\u00e1d\u011bc\u00ed man\u017eetou<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_530.png\"><img decoding=\"async\" title=\"Obr. 147 \u2013 Nalo\u017een\u00ed submuk\u00f3zn\u00edho cirkul\u00e1rn\u00edho stehu\" alt=\"Obr. 147 \u2013 Nalo\u017een\u00ed submuk\u00f3zn\u00edho cirkul\u00e1rn\u00edho stehu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_530.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 147 \u2013 Nalo\u017een\u00ed submuk\u00f3zn\u00edho cirkul\u00e1rn\u00edho stehu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_531.png\"><img decoding=\"async\" title=\"Obr. 148 \u2013 Uta\u017een\u00ed cirkul\u00e1rn\u00edho stehu kolem kovadlinky stapleru PPH Longo\" alt=\"Obr. 148 \u2013 Uta\u017een\u00ed cirkul\u00e1rn\u00edho stehu kolem kovadlinky stapleru PPH Longo\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_531.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 148 \u2013 Uta\u017een\u00ed cirkul\u00e1rn\u00edho stehu kolem kovadlinky stapleru PPH Longo<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_532.png\"><img decoding=\"async\" title=\"Obr. 149 \u2013 Prota\u017een\u00ed vl\u00e1kna otvory v hlavici stapleru a dota\u017een\u00ed\" alt=\"Obr. 149 \u2013 Prota\u017een\u00ed vl\u00e1kna otvory v hlavici stapleru a dota\u017een\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_532.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 149 \u2013 Prota\u017een\u00ed vl\u00e1kna otvory v hlavici stapleru a dota\u017een\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_533.png\"><img decoding=\"async\" title=\"Obr. 150 \u2013 V\u00fdsledn\u00fd efekt po resekci a sou\u010dasn\u00e9 sutu\u0159e titanov\u00fdmi svorkami\" alt=\"Obr. 150 \u2013 V\u00fdsledn\u00fd efekt po resekci a sou\u010dasn\u00e9 sutu\u0159e titanov\u00fdmi svorkami\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_533.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 150 \u2013 V\u00fdsledn\u00fd efekt po resekci a sou\u010dasn\u00e9 sutu\u0159e titanov\u00fdmi<br \/>svorkami<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_534.png\"><img decoding=\"async\" title=\"Obr. 151 \u2013 V\u00fdsledn\u00fd efekt na \u0159ezu\" alt=\"Obr. 151 \u2013 V\u00fdsledn\u00fd efekt na \u0159ezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_534.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 151 \u2013 V\u00fdsledn\u00fd efekt na \u0159ezu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Od roku 2001 m\u00e1 v \u010cesk\u00e9 republice zna\u010dn\u011b vzr\u016fstaj\u00edc\u00ed tendenci operace cirkul\u00e1rn\u00edm staplerem\u00a0<b>PPH Lon\u00adgo.\u00a0<\/b>Vyu\u017e\u00edv\u00e1 ji\u017e p\u0159es 20 let v kolonoa proktochirurgii u\u017e\u00edvan\u00fdch stapler\u016f, kter\u00e9 jsou modifikov\u00e1ny. Prolabovan\u00e9 hemoroidy jsou reponovan\u00e9, p\u0159ebytek muk\u00f3zn\u00ed tk\u00e1n\u011b, eventu\u00e1ln\u011b proxim\u00e1ln\u00edmi pod\u00edly hemoroid\u00e1ln\u00edho plexu jsou cirkul\u00e1rn\u011b resekovan\u00e9. T\u00edmto je dosa\u017eena taxe a fixace p\u0159edev\u0161\u00edm prolabovan\u00e9ho anodermu a\u00a0hemoroid\u00e1ln\u00edch plex\u016f ve fyziologick\u00e9 intraan\u00e1ln\u00ed pozici. V dal\u0161\u00edm pr\u016fb\u011bhu tak doch\u00e1z\u00ed sekund\u00e1rn\u011b k redukci tk\u00e1n\u011b na norm\u00e1ln\u00ed velikost plexu. P\u0159ednost\u00ed je p\u0159edev\u0161\u00edm mal\u00e1 poopera\u010dn\u00ed bolestivost. Dlest\u00e1vaj\u00edc\u00edch zku\u0161enost\u00ed je tato metoda \u010dasto indikov\u00e1na u cirkul\u00e1rn\u00edch uzl\u016f III. stupn\u011b. Je popisov\u00e1n men\u0161\u00ed po\u010det komplikac\u00ed ne\u017e u konven\u010dn\u00ed hemoroidektomie, doba pobytu v nemocnici a pracovn\u00ed neschopnost\u00a0jsou krat\u0161\u00ed. V Anglii a It\u00e1lii je metoda \u2013 v z\u00e1vislosti na jin\u00e9 struktu\u0159e zdravotn\u00edho syst\u00e9mu \u2013 prov\u00e1d\u011bna p\u0159ev\u00e1\u017en\u011b ambulantn\u011b. V sou\u010dasnosti je publikov\u00e1no v\u00edce ne\u017e 30 studi\u00ed, kter\u00e9 p\u0159edkl\u00e1daj\u00ed pozitivn\u00ed v\u00fdsledky. Skoro ve v\u0161ech je referov\u00e1no o signifikantn\u011b men\u0161\u00edch poopera\u010dn\u00edch bolestech a ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f je pops\u00e1n v\u011bt\u0161\u00ed komfort, stejn\u011b tak je rychleji dosa\u017eeno pracovn\u00ed schopnosti pacienta. V jedn\u00e9 studii je tak\u00e9 informov\u00e1no o pozitivn\u00edch v\u00fdsledc\u00edch p\u0159i akutn\u00edm hemoroid\u00e1ln\u00edm prolapsu (obr. 146\u2013151).P\u0159i dlouhodob\u00e9m hodnocen\u00ed recidivy prolapsu, obt\u00ed\u017e\u00ed a reoperac\u00ed se jev\u00ed lep\u0161\u00ed v\u00fdsledky u konven\u010dn\u00edch opera\u010dn\u00edch technik. P\u0159i interpretaci t\u011bchto dat prov\u00e1d\u011bn\u00fdch v letech 2000\u20132004 je t\u0159eba zohlednit, \u017ee zde byli zahrnuti pravd\u011bpodobn\u011b pacienti s hemoroidy IV. stupn\u011b, p\u0159\u00edpadn\u011b s fixovan\u00fdm an\u00e1ln\u00edm prolapsem. Teprve ve studi\u00edch po roce 2005 byly pro hemoroidy IV. stupn\u011b uv\u00e1d\u011bny signifikantn\u011b hor\u0161\u00ed v\u00fdsledky a indika\u010dn\u00ed hranice se v posledn\u00edch letech ve srovn\u00e1n\u00ed s d\u0159\u00edv\u011bj\u0161\u00edmi studiemi zm\u011bnila. Pokud se ned\u00e1 hemoroid\u00e1ln\u00ed prolaps ji\u017e reponovat, hovo\u0159\u00edme o hemoroidech IV. stupn\u011b. V p\u0159\u00edpad\u011b akutn\u00ed tromb\u00f3zy je d\u00e1v\u00e1na p\u0159ednost konzervativn\u00ed l\u00e9\u010db\u011b antiflogistiky, analgetiky a lok\u00e1ln\u00edmi prost\u0159edky. Zku\u0161en\u00fdm l\u00e9ka\u0159em m\u016f\u017ee b\u00fdt provedena okam\u017eit\u00e1 operace, ale mus\u00ed b\u00fdt br\u00e1n z\u0159etel p\u0159edev\u0161\u00edm na nebezpe\u010d\u00ed postopera\u010dn\u00ed striktury zp\u016fsoben\u00e9 nadm\u011brn\u00fdm rozsahem resekce v edemat\u00f3zn\u00edm stadiu. U chronick\u00fdch, fibr\u00f3zn\u00edch, fixovan\u00fdch n\u00e1lez\u016f, \u010dasto doprov\u00e1zen\u00fdch cirkul\u00e1rn\u00edm prolapsem anodermu, maj\u00ed tak\u00e9 smysl plastick\u00e9 rekonstruk\u010dn\u00ed postupy (Fansler-Arnold). Tento postup je opera\u010dn\u011b technick\u00fd delik\u00e1tn\u00ed a tak\u00e9 \u010dasov\u011b n\u00e1ro\u010dn\u00fd (doba operace 30\u201360 minut). Doc\u00edl\u00ed vedle resekce hemoroid\u00e1ln\u00edch uzl\u016f d\u00edky plastick\u00e9mu posuvn\u00e9mu laloku vytvo\u0159en\u00e9mu z prolabovan\u00e9ho anodermu cirkul\u00e1rn\u00ed, p\u0159\u00edpadn\u011b semicirkularn\u00ed rekonstrukci an\u00e1ln\u00edho kan\u00e1lu. Metoda je v\u0161ak zat\u00ed\u017eena vy\u0161\u0161\u00edm v\u00fdskytem poopera\u010dn\u00edch komplikac\u00ed hojen\u00ed. I po klasick\u00fdch operac\u00edch jsou pops\u00e1ny recidivy, ale p\u0159i pravideln\u00fdch kontrol\u00e1ch b\u00fdvaj\u00ed zachyceny v\u010das a daj\u00ed se \u0159e\u0161it semiinvazivn\u00edmi technikami. Po\u010det reoperac\u00ed je ni\u017e\u0161\u00ed ne\u017e 5 %. Trval\u00e9 poruchy kontinence se vyskytuj\u00ed jen u asi 5 % pacient\u016f, p\u0159i\u010dem\u017e permanentn\u00ed inkontinence b\u00fdv\u00e1 u tuh\u00e9 stolice v naprosto ojedin\u011bl\u00fdch p\u0159\u00edpadech. Metaanalytick\u00e1 srovn\u00e1n\u00ed opera\u010dn\u00edch metod s konzervativn\u00edmi postupy mluv\u00ed ve prosp\u011bch operac\u00ed s m\u00edrou \u00fasp\u011b\u0161nosti 96 % versus 77 %. V neprosp\u011bch operac\u00ed sv\u011bd\u010d\u00ed zv\u00fd\u0161en\u00e1 m\u00edra komplikac\u00ed 18 % versus6 % a v\u011bt\u0161\u00ed bolest 83 % versus 10 %. D\u0159\u00edve b\u011b\u017en\u00e1 divulze a sfinkterotomie se dnes v terapii hemoroid\u016f u\u017e\u00edvaj\u00ed jen ojedin\u011ble. Operace prov\u00e1d\u011bn\u00e9 laserovou technikou (jako n\u00e1hrada skalpelu) nep\u0159inesly \u017e\u00e1dn\u00e9 v\u00fdhody v porovn\u00e1n\u00ed s konven\u010dn\u00ed technikou n\u016f\u017ekami, skalpelem nebo elektrokoagulac\u00ed. Terapie hemoroid\u00e1ln\u00edho onemocn\u011bn\u00ed s adekv\u00e1tn\u011b indikovanou konzervativn\u00ed terapi\u00ed a s u\u017eit\u00edm semiinvazivn\u00edch chirurgick\u00fdch technik d\u00e1v\u00e1 vysok\u00e9 \u0161ance na vyl\u00e9\u010den\u00ed s n\u00edzk\u00fdm rizikem komplikac\u00ed a recidiv.<\/p>\n<h4>9.5 Pou\u017eit\u00e1 a doporu\u010den\u00ed studijn\u00ed literatura<\/h4>\n<ol>\n<li style=\"text-align: justify;\">Abu Galala KH, Salam IMA, Abu Samaan KR et\u00a0al. Treatment of pilonidal sinus by primary closure\u00a0with a transported rhomboid flap compared\u00a0with deep suturing: a prospective randomised\u00a0clinic trial. Eur Surg. 1999;165:468\u2013472.<\/li>\n<li style=\"text-align: justify;\">Akca T, Colak T, Ustunsoy B, et al. Randomized\u00a0clinical trial comparing primary closure with the\u00a0Limberg flap in the treatment of primary sacrococcygeal\u00a0pilonidal disease. Br J Surg. 2005;\u00a092:1081\u20131084.<\/li>\n<li style=\"text-align: justify;\">Altomare D, Rinaldi M, Milito G, et al. Glyceryl\u00a0trinitrate for chronic anal fissure \u2013 healing or\u00a0headache? Results of a multicenter, randomized,\u00a0Plazebo-controled, doubleblind trial. Dis Colon\u00a0Rectum. 2000;43:174\u2013179.<\/li>\n<li style=\"text-align: justify;\">Antebi E, Schwartz P, Gilon E. Sclerotherapy for\u00a0the treatment of fissure in ano. Surg Gynecol Obstet.\u00a01985;160:204\u2013206.<\/li>\n<li style=\"text-align: justify;\">Argor S, Levandovsky O. Open lateral sphincterotomy\u00a0is still the best treatment for chronic anal\u00a0fissure. Am J Surg. 2000;179:201\u2013202.<\/li>\n<li style=\"text-align: justify;\">Athanasiadis S, K\u00f6hler A, Nafe M. Treatment\u00a0of high anal fistulas by primary occlusion of the\u00a0internal ostium, drainage of the intersphincteric\u00a0space and mucosal advancement flap. Int J Colorect\u00a0Dis. 1994;9:323\u2013330.<\/li>\n<li style=\"text-align: justify;\">Bacher H, Mischinger H, Werkgarten G, et al. Local\u00a0nitroglycerin for treatment of anal fissure: an\u00a0alternative to lateral sphincterotomy? Dis Colon\u00a0Rectum. 1997;40:840\u2013845.<\/li>\n<li style=\"text-align: justify;\">Bader F, Bruch HP. Topisches Diltiazem zur Behandung\u00a0der chronischen Analfissur. Coloproctology.\u00a02006;28:309\u2013313.<\/li>\n<li style=\"text-align: justify;\">Ballas K, Psarras K, Rafailidis S, et al. Interdigital\u00a0pilonidal sinus in a hair dresser. J Hand Surg.\u00a02006;31:290\u2013291.<\/li>\n<li style=\"text-align: justify;\">Barwell L, Watkins R, Lloyd-Davies E, et al. Lifethreatening\u00a0retroperitoneal sepsis after hemorrhoid\u00a0injection sclerotherapy: report of a case.\u00a0Dis Colon Rectum. 1999;42:421\u2013423.<\/li>\n<li style=\"text-align: justify;\">Bascom F. Pilonidal disease: long-term results\u00a0of follicle removal. Dis Colon Rectum. 1983;12:\u00a0800\u2013807.<\/li>\n<li style=\"text-align: justify;\">Bat L, Melzer E, Koler M, et al. Complications of\u00a0rubberband ligation of symptomatic internal hemorrhoids.\u00a0Dis Colon Rectum. 1993;36:287\u2013290.<\/li>\n<li style=\"text-align: justify;\">Bensaude A, Neiger A, Nicholls R, et al. Vier Antworten\u00a0auf neun Fragen \u016fber die Sklerotherapie\u00a0von H\u00e1morrhoiden mit Chininderivaten und\u00a0Phenolmandelol. Coloproctology. 1981;3:182\u2013183.<\/li>\n<li style=\"text-align: justify;\">Blanchard C. Text-book of ambulant proctology.\u00a0Youngstown, Ohio: Medical Success Press; 1928.<\/li>\n<li style=\"text-align: justify;\">Blond K, Hoff H. Das Hamorrhoidalleiden. Leipzig,\u00a0Wien: Deutike; 1936.<\/li>\n<li style=\"text-align: justify;\">Broader JH, Gunn IF, Alexander-Williams F. Evalution\u00a0of a bulk-forming evacuant in the managment\u00a0of hemorrhoids. Br J Surg. 1974;61:142\u2013144.<\/li>\n<li style=\"text-align: justify;\">Brook L. Anaerobic meningitis in an infant associated\u00a0with pilonidal cryst abscess. Clin Neurol\u00a0Neurosurg. 1985;87:131\u2013132.<\/li>\n<li style=\"text-align: justify;\">Brown SR, Balan K, Ho E, et al. 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Tato \u010d\u00e1st za\u017e\u00edvac\u00edho traktu, ozna\u010dovan\u00e1 tak\u00e9 jako anorekt\u00e1ln\u00ed oblast, se skl\u00e1d\u00e1 z \u010d\u00e1sti p\u00e1nevn\u00ed a an\u00e1ln\u00ed. Toto rozli\u0161ov\u00e1n\u00ed \u010dasto neb\u00fdv\u00e1 u\u017e\u00edv\u00e1no zcela p\u0159esn\u011b. V klinick\u00e9 praxi by pojem kone\u010dn\u00edk m\u011bl b\u00fdt u\u017e\u00edv\u00e1n jen pro p\u00e1nevn\u00ed \u010d\u00e1st. V\u00fdvojov\u011b je an\u00e1ln\u00ed [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2447,"menu_order":9,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2747","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2747","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2747"}],"version-history":[{"count":24,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2747\/revisions"}],"predecessor-version":[{"id":3175,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2747\/revisions\/3175"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2447"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2747"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}