2020年10月28日星期三

hemorrhoids and anal fissures,Clinical analysis of 1918 cases of mixed hemorrhoids treated by external stripping and internal ligation

    Abstract Objective: To observe the clinical effect of mixed hemorrhoids external stripping and internal ligation plus Xiaozhiling injection instead of partial hemorrhoidectomy (restrictive hemorrhoidectomy). Method: Retrospectively summarize the clinical data of 1918 cases of mixed hemorrhoids treated by this method. Results: The clinical cure rate was 100%, the average hemorrhoid shedding time was 9.5 days, and the wound healing time was 25 days. There was no obvious anal stenosis affecting defecation function in all cases. Conclusion: The operation is simple and effective. Xiaozhiling sclerosis injection is used to replace part of hemorrhoid area resection, plus correct and reasonable anal expansion before operation and necessary internal sphincterotomy for some patients after operation to reduce postoperative Complications such as bleeding, pain, anal edema and anal stenosis.

    Guan Jian's words Mixed hemorrhoids External peeling and internal ligation

    External stripping and internal ligation of mixed hemorrhoids is a classic procedure for the treatment of mixed hemorrhoids. The author makes a retrospective summary of the data of hospitalized patients since 1986 for 20 years.

    1. clinical information

    This group of 1918 patients (patients hospitalized from 1986 to 2005), 910 males, 1008 females, aged 17-82 years old, 35-65 years old accounted for 86.23%, the course of the disease was 5-60 years, and the clinical symptoms were such that blood and hemorrhoids were prolapsed. the Lord. Among them, there were 328 cases of circular mixed hemorrhoids, 98 cases of incarceration, 135 cases of anal fissures, 69 cases of nipple hypertrophy, 15 cases of polyps, and 32 cases of pregnant patients. The diagnosis met the standards established by the National Anorectal Academic Conference in 1975 [1].

    2. method

    Adopt mixed hemorrhoids external stripping and internal ligation, do not clean the enema before the operation, lying on the left side, disinfect conventional drapes, use 20ml of compound anesthesia (0.75% bupivacaine 5ml, 2% lidocaine 5ml, 0.9% chlorine Sodium 10ml) for perianal local anesthesia at 3 and 9 o'clock, slowly expand the anus to the four fingers, clamp the base of the internal hemorrhoids with a large curved vascular clamp, and use a No. 7 double-stranded wire to penetrate above the internal hemorrhoids first Tie a knot, use tissue forceps to lift the external hemorrhoid skin to make a V-shaped incision, separate the external hemorrhoid tissue along the base, purely free the skin, gather the wound inward under the dent line to make the wound surface above the dent line and then ligate the base Cut off the hemorrhoid stump 0.5cm from the ligation line, and put a Vaseline gauze on the wound. The ring-shaped mixed hemorrhoids are ligated in segments according to the natural depression of the hemorrhoid mucosa. The ligation points are staggered up and down to avoid being on the same level, and the mucosal skin bridge of each ligation area is more than 0.5cm. For hemorrhoids or smaller hemorrhoids that are not serious and cause no symptoms, Xiaozhiling injection should be properly administered. For circular mixed hemorrhoids, incarcerated internal hemorrhoids, and anal fissures, incisions are made at 5 o'clock in the skin of the external sphincter and the lower edge of the internal sphincter. Normal patients do not make incisions. After surgery, intravenous infusion of antibiotics and hemostatic agents throughout the body for about 3 days, appropriate oral laxatives, defecation after 24 hours, after the defecation with potassium permanganate solution for a bath, for postoperative edema with 50 grams of warm water bath, each Daily self-made Chinese medicine external agent Shengji Yuhong ointment gauze change dressing.

    3. result

    All cases were cured, the symptoms disappeared, and the hemorrhoids disappeared. The time for hemorrhoids to fall off was 7-14 days, with an average of 9.5 days, and the wound healing time was 18-28 days, with an average of 25 days. 8 cases of postoperative hemorrhage (blood volume above 400ml), 205 cases of postoperative pain requiring narcotic analgesics, 302 cases of obvious postoperative anal edema, 125 cases of re-surgical resection, 52 cases of postoperative urinary retention requiring catheterization In all cases, there was no obvious anal stenosis affecting defecation function.

    4. discuss

    At present, there are many surgical treatment methods for mixed hemorrhoids. The purpose of a variety of improved external stripping and internal ligation is to eliminate the hemorrhoid itself, and only have certain changes in the prevention of postoperative complications and the protection of anal function. The study of the theory of lowering the cushion is in-depth. PPH has solved the problem of partial circular mixed hemorrhoids, but the long-term effect remains to be seen. At present, it cannot replace the external stripping and internal ligation. Therefore, the external stripping and internal ligation of mixed hemorrhoids is still a classic The hemorrhoid surgery method is effective and simple, but its main complications are bleeding, edema, pain and slow wound healing.

    1. Intraoperative hemorrhoid resection range: theoretically, the mother hemorrhoid area is the most common place for hemorrhoids. However, from a clinical point of view, there are generally more hemorrhoids at 11 o'clock, some at 7-9 o'clock, and 5 and 2 o'clock are not uncommon. Therefore, it is not necessary to stick to the so-called female hemorrhoid area during surgery. Circular mixed hemorrhoids should be treated in sections according to the natural depression of the hemorrhoid mucosa. The ligated hemorrhoid pedicles should be staggered up and down, in a jagged shape, leaving enough skin and mucous membrane bridges, generally above 0.5-1.0cm, to prevent anal stenosis . It has also been reported that the large hemorrhoids are artificially divided into two small hemorrhoids, which is easy to ligate and has less bleeding, short shedding time, and light postoperative pain [2]. The treatment of external hemorrhoids should be purely separated to the tooth line. Pay attention to protecting the tooth line area. The wound surface under the tooth line should be folded inward in a fusiform shape. The vein clusters on both sides should be peeled off, and then the incision should be extended outward to facilitate drainage.In recent years, with the in-depth research on the theory of anal cushion shifting down, more and more attention has been paid to the role of anal cushion. The operation of hemorrhoids is not as clean as possible. The purpose of the operation is to relieve the symptoms, not to eliminate the hemorrhoids. During the operation, the hemorrhoids (anal pads) that are not serious and cause no symptoms should be preserved, instead of removing all the hemorrhoid tissues in the mother hemorrhoids. You can use hemorrhoids. Spirit hardening treatment instead. Therefore, some people put forward the "restrictive hemorrhoidectomy" that is in line with the view of modern minimally invasive medicine. While achieving the purpose of treatment, it should minimize surgical trauma and retain relatively normal tissue [3].

    2. Internal sphincter incision: At present, there are many reports of incision of part of the internal sphincter while mixed hemorrhoid surgery. It is believed that it is beneficial to relieve the persistent spasm of the internal sphincter to relieve postoperative pain, prevent anal stenosis and reduce postoperative anal edema[ 4]. The author believes that effective preoperative anal expansion can have the same effect for general mixed patients, and it is not suitable for internal sphincterotomy especially for elderly and weak patients. For patients with partial circular mixed hemorrhoids, incarcerated mixed hemorrhoids and anal fissures, the undercut of the external sphincter skin and part of the internal sphincter can be cut at the same time, and the location should be 5 o'clock behind the anus. After the preoperative local anesthesia, first insert one finger into the anus for digital examination, and then expand the anus with two fingers. The movements should be gentle and slow to 6 or 12 o'clock. After expanding the anus to the four fingers, continue for a while to avoid sudden violent anal expansion. Anal tear and extensive subcutaneous bleeding.

    5. Postoperative pain: Postoperative pain is a major problem of this operation. The incision pain is the most severe 24 hours after the operation. The degree of pain is related to the scope of surgical resection, anal edema, defecation difficulties, sphincter spasm, and patient tolerance. Receiving ability is related, clinically, the author compares mixed hemorrhoids after one or two hemorrhoids and circular mixed hemorrhoids; after circular mixed hemorrhoids, the internal sphincter is cut and not cut, and the postoperative pain of patients is obviously different. During the operation, ligation of the wound of external hemorrhoids should be avoided as much as possible. The wound must be stripped to the tooth line and then ligated. After the operation, massage the anus to bring the ligated hemorrhoids back to help reduce postoperative pain.

    references

    [1] Wang Jingjing et al. Criteria for diagnosis and efficacy of clinical syndromes of traditional Chinese medicine. Changsha: Hunan Science and Technology Press, 1993, 361-362.

    [2] Li Zhixun and others. Clinical observation of ligation of mixed hemorrhoids, stage Ⅱ and Ⅲ hemorrhoids and large hemorrhoids. Chinese Journal of Modern Surgery, 2006, 3 (2): 179.

    [3] Yang Xinqing. Progress in surgical treatment of hemorrhoids. Chinese Journal of Modern Surgery, 2003, 7 (3): 169.

    [4] Li Chunyu et al. Clinical observation of external stripping and internal ligation plus sphincterotomy in the treatment of circular mixed hemorrhoids. Colorectal and Anal Surgery, 2006, 12(3): 172.

    Email: dxm723@nbip.net

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