At the outpatient clinic this morning, a 72-year-old man with anal incontinence was admitted. This old man has no special medical history. He only has a second history of "mixed hemorrhoid" surgery. Therefore, it is considered that the old man’s anal incontinence is related to mixed hemorrhoid surgery; also, I think When I was a visiting scholar in Cleveland, USA in 2007, and Dr. Wexner was working on the etiology of patients with anal incontinence, it was found that many people did not have a special medical history, and 80% of patients had mixed hemorrhoids or anal fissures when they were young. A history of surgery, so Dr. Wexner said that even minor anal operations like mixed hemorrhoids and anal fissures may cause anal incontinence.
In our clinical work, mixed hemorrhoids are a very common disease. In ancient China, there was a saying of “ten men and nine hemorrhoids”, indicating that patients with mixed hemorrhoids are very common, and in normal clinical practice, patients are also very familiar with mixed hemorrhoid surgery. At random, in the outpatient clinic, some patients often say "have to cut off the hemorrhoids." Many people do not have very serious symptoms of bleeding and prolapse. In fact, they don't need surgery at all. Some patients ask about hemorrhoid surgery in the outpatient clinic. Can it be "radically cured", in fact, there is no "radical" surgery for hemorrhoids. The purpose of hemorrhoid treatment is to relieve the symptoms of the patient, not to eliminate the hemorrhoids themselves. To understand this problem, we must understand the nature of hemorrhoids? What kind of hemorrhoids are indexed? What are the treatments for hemorrhoids?
1. What is the nature of hemorrhoids?
Hemorrhoids are pathologically enlarged anal cushions or dilated venous masses at the lower end of the rectum, which appear as hemispherical bulges and prolapses. The onset of hemorrhoids includes the theory of lower anal cushion and the theory of varicose veins. The former believes that hemorrhoids are normal human tissues at the lower end of the anal canal, which can feel and finely control the stool with the anus. It is equivalent to the liner at the tap interface and has the effect of preventing air leakage. When the hemorrhoid tissue proliferates, enlarges, or shifts due to various reasons, causing pathological changes in the anal cushion, it is called hemorrhoids; the theory of varicose veins believes that there are communication branches between the human inferior rectal venous plexus and the hemorrhoidal venous plexus. The branches are not expanded under normal circumstances. When the communicating branches between the submucosal subrectal venous plexus of the anal canal and the hemorrhoidal venous plexus are expanded and hypertrophy due to forced defecation, high abdominal pressure, sedentary, etc., a varicose mass is formed. Hemorrhoids; in general, whether it is a pathological anal pad or varicose veins, the hemorrhoids themselves are caused by some pathological changes in the tissues that normally play a physiological role in the human body. In this sense, excessive resection of the nucleus may lead to bowel control function The modern view is that external hemorrhoids are perianal skin tags and hyperplastic tissues, which are generally asymptomatic. Only when thrombosis and inflammation occur in them, pain and edema symptoms may occur; mixed hemorrhoids refer to both internal and external hemorrhoids, which is one This is the most common clinical condition.
Regardless of the theory, the essence of hemorrhoids is that hemorrhoids are normal tissues and structures of the human body. These normal tissues have undergone pathological changes, and symptoms such as bleeding and prolapse appear, which are called hemorrhoids. Usually internal hemorrhoids show symptoms of bleeding and prolapse; external hemorrhoids show symptoms of perianal skin tags and hyperplasia. If thrombosis or edema occurs in the external hemorrhoids, it is called thrombotic external hemorrhoids or inflammatory external hemorrhoids. Hemorrhoid attacks are often related to constipation, sitting for a long time, eating spicy food, pregnancy, or old age and infirmity.
2. How to grade hemorrhoids?
In China, hemorrhoids are divided into four degrees according to their symptoms such as bleeding and prolapse. One degree refers to bloody, dripping or jet-like bleeding during defecation, and bleeding can stop automatically after stool without prolapse of anal mass; second degree refers to blood in the stool , The mass prolapses out of the anus during defecation, and can be repaid by itself after defecation; third degree refers to defecation or standing for a long time, coughing, fatigue, and the mass in the anus prolapses during weight bearing, and needs to be repaid by hand; fourth degree refers to occasional blood in the stool, Intra-anal mass prolapsed and could not be repaid, strangulation, incarceration, severe pain. Generally speaking, first-degree hemorrhoids can only be treated conservatively. After conservative treatment of second-degree hemorrhoids is ineffective, injection therapy, band ligation or surgery can be used. Third-degree and fourth-degree hemorrhoids are generally treated with surgery, and conservative treatment often cannot relieve them. Symptoms, especially to relieve symptoms of prolapse.
3. What are the treatment methods for hemorrhoids
(1) General treatment
Adjust the diet, add more dietary fiber and crude fiber food, and develop good bowel habits. At the same time, take a warm water bath, proper exercise, do not sit for a long time, keep the anus clean, promote local blood circulation, and improve the symptoms and symptoms of early hemorrhoids. It is necessary to prevent the occurrence of hemorrhoids.
(2) Conservative treatment
Commonly used oral drugs for hemorrhoid patients include intravenous tonicity agents such as Maizhiling, Xiaotuozhi, Diosimia, etc., which have hemostatic and swelling effects, and reduce symptoms such as bleeding and edema. In addition, traditional Chinese medicines can be given orally according to Chinese medicine differentiation. .
Sitz bath is very important in the treatment of hemorrhoids. In the past, potassium permanganate was used to bathe. However, it is not easy for the patient to grasp the concentration, and the concentration is too high, which can cause skin burns. Now it is rarely used; some traditional Chinese medicine decoctions or important patent medicines are often used. , Can achieve relatively good results.
Suppositories and ointments used in the rectum are also very important in the treatment of hemorrhoids. They have anti-inflammatory and astringent effects. Commonly used are Taining suppository, Jiuhua hemorrhoid suppository, and Mayinglong hemorrhoid suppository. In conservative treatment, these methods are often used in conjunction to exert curative effects.
(3) Surgical treatment
When conservative treatment fails, surgery is considered. Currently, hemorrhoids are treated with surgery. The most basic operation for hemorrhoid surgery is external stripping and internal ligation (known as MM surgery abroad). This surgical method has been used for nearly a hundred years, the effect is the most positive, and the long-term effect is the best; but after external stripping and internal ligation The patient’s pain is more serious, especially when the patient has severe pain during the first bowel movement, and is prone to symptoms such as edema and bleeding. Therefore, some patients are unwilling to accept it. However, in recent years, with the improvement of surgical skills, rational use of some painkillers, external stripping The pain of internal ligation surgery is not so obvious. Most patients have mild to moderate postoperative pain. It is sufficient to use some painkillers or oral drugs locally.
In foreign countries, apron band ligation and hemorrhoid artery ligation are used as first-line treatments. The main reason is that these techniques can be completed without special anesthesia or only using local anesthesia. They are a kind of surgical procedure that can be completed in the "office", so they are widely used in clinical practice. use. The basic principle of apron ligation is to use a rubber ring to ligate the hemorrhoids or the mucosa on the hemorrhoids to make the hemorrhoids aseptically fall off and necrosis, achieve immediate hemostasis and deal with pathological anal cushions; hemorrhoid artery ligation is guided by ultrasound Doppler Ligation of hemorrhoid tissue supplying blood vessels can achieve immediate hemostasis, shrink hemorrhoids and achieve the purpose of treating hemorrhoids. In China, because the medical insurance payment method is different from abroad, these treatments often require hospitalization, and the long-term effect of this operation is also poor.
In the past ten years, the biggest advancement in the treatment of hemorrhoids is the prolapse of hemorrhoid mucosa (PPH surgery). The basic principle of this operation is to remove the 4 cm mucosa on the hemorrhoids and lift the lowered anal cushion to its original position. To achieve the purpose of treating hemorrhoids. The main purpose of PPH surgery is to solve the problem of pain after external stripping and internal ligation of hemorrhoids. Therefore, it has been widely sought after after being imported into China. However, some complications after PPH surgery such as persistent anal pain, urge to defecate, bleeding, etc. There are also many reports of symptoms, especially some serious surgical complications such as pelvic abscess, rectovaginal fistula, etc., so this technique must be used very carefully; long-term follow-up studies have proved that the recurrence rate after PPH surgery is significantly higher than that of external ablation Internal ligation, and the cost is relatively high. Therefore, PPH surgery must be used in particularly suitable patients.
Recently, the selective hemorrhoid mucosal resection (TST) developed in China has improved some of the shortcomings of excessive PPH surgical resection, significantly reduced surgical complications, and has relatively mild postoperative pain and other symptoms. It is widely used in China .
Correctly understand the "minimally invasive treatment" of hemorrhoids
In our outpatient clinics, I often encounter some patients asking if you can do minimally invasive treatment of hemorrhoids. A doctor who has been engaged in anorectal surgery for more than 20 years is often very at a loss. I don't know what the concept of minimally invasive hemorrhoids is! On the contrary, when we opened some Internet search engines, the publicity of minimally invasive treatment of hemorrhoids was overwhelming. In fact, the so-called minimally invasive treatment of hemorrhoids combined the current methods of hemorrhoid treatment such as PPH surgery, TST surgery, band ligation, hemorrhoid artery ligation, and even Putting some previously used laser procedures in a package is a bit of over-publicity; especially under the concept of "minimally invasive treatment", some risks that may be faced by hemorrhoid treatment are covered up, making patients regret after the operation. Treatment is a "double-edged sword". Any surgical method may have its shortcomings. Therefore, "two evils, whichever is the least" is the correct attitude. Minimally invasive surgery without risk makes it non-existent. .
Maintenance of hemorrhoids after surgery
No matter which type of hemorrhoid surgery, it is a symptom of hemorrhoids, and it is impossible to completely eradicate the hemorrhoids. Therefore, if the hemorrhoids are not maintained after surgery and the lifestyle is not changed, there is still the possibility of recurrence. After hemorrhoid surgery, you need to pay attention to the following issues: (1) Avoid drinking: Drinking can cause hemorrhoid vein congestion, dilation, and swelling of hemorrhoids; (2) Avoid spicy: If hemorrhoids sufferers add to irritating spicy food, such as pepper, garlic, ginger, etc. , Can promote congestion of hemorrhoids, thereby aggravating pain; (3) Avoid sedentary: sitting for a long time without exercise will hinder the blood circulation of the waist and buttocks, and aggravate the condition of hemorrhoids; (4) Avoid holding stool: stool in the intestine If it stays for a long time, too much water will be absorbed and it will become dry and hard, causing the patient to have difficulty in defecation, increased abdominal pressure, and bleeding from hemorrhoids.