·Academic controversy· Since Longo, Italy, first reported the application of stapler promucosal hemorrhoids (PPH) at the 1998 Rome International Anorectal Conference , it has also been used all over the world, and controversy has continued to arise. After the first application of Yao Liqing in China in 2000, many hospitals continued to report on the application. Statistics show that each family pays more attention to the application of PPH and the prevention and treatment of complications. The treatment concept still stays at the "restoration of the normal anatomy of the anal mucosa" advocated by Longo for the first time, which "blocks the blood supply of the hemorrhoids, causing the hemorrhoids to gradually shrink. "on. Some scholars have also put forward the view that the effect of PPH is not ideal and the mechanism is not clear . The author will discuss the mechanism of PPH to discuss with colleagues who are keen on PPH, and re-examine and judge the application value and indications of PPH.
1. PPH does not really have a therapeutic effect on the pathology of hemorrhoids
1. After PPH circumcision, there is no therapeutic effect on the loose and broken Treitz muscle: the part of PPH circumcision has no anatomical relationship with Treitzs . Although part of Treitzs muscle descends with the longitudinal rectal muscle, the circumcision does not reach the muscle layer. . Some experts found that 140 cases of mucosal disease after PPH circumcision were found: only 3 cases contained smooth muscle fibers . Therefore, after circumcision, there is no change in the pathological fibrous tissue that is loose, disordered, twisted, broken, less elastic, more collagen, and partially inactivated in the hemorrhoid tissue .
2. PPH cannot correct the pathological state of hyperplasia and hypertrophy of the anal cushion tissue: long-term stage IV hemorrhoids are already irreversible pathological tissues [3-5], Longo's treatment philosophy and the early treatment of PPH just move this pathological tissue In the anal canal, the structure and integrity of the damaged sinus vein wall in the hemorrhoid tissue cannot be changed, and the anal cushion fixing and supporting structure including Treitz muscle and connective tissue cannot be changed.
3. The effect of suspension and fixation after PPH circumcision has been questioned again: According to clinical findings, prolapsed hemorrhoids and rectal mucosal prolapse often coexist. Proctoscopy reveals that the mucosal prolapse is at the lower end of the rectum. The downward movement of the mucosa often starts from the upper end of the rectum or even as high as the sigmoid colon, and the vertical height of the downward movement is more than 10cm, and the short-term intestinal mucosal effect of PPH is only below 6cm even with double purse-string sutures[6-7 ], so the long-term effect of suspension and solid prolapse for prolapsed hemorrhoids combined with intestinal mucosal prolapse is not accurate . After summarizing a large number of cases of PPH, Yao Liqing et al. pointed out that one operation may not be able to completely cure internal hemorrhoids with rectal mucosal prolapse; Yang Xiangdong et al. believed that PPH has limitations. For patients with huge hemorrhoids, although some tissues have been removed, it has not been resolved. If the liner continues to move down, it can still recur .
PPH circumcision "restoring the anatomy of the anal canal mucosa" is only temporarily mechanically pulled to restore the general anatomy of the position, and does not essentially restore the physiological anatomy and function of the anal cushion tissue.
2. After PPH circumcision, there is no substantial reduction in blood supply to the anal cushion
1. After PPH circumcision, there is no anatomical basis to block the blood supply of the partial hemorrhoidal artery : In 1975, Thomson performed 50 autopsy during the process of establishing the basic theory of the anal cushion, which confirmed that the superior rectal artery (superhemorrhoidal artery) is not It walks under the rectal mucosa from top to bottom, but walks outside the muscularis of the rectum with branches without a fixed pattern. After passing through the muscularis, it only distributes in the middle and lower parts of the rectum, generally not reaching the hemorrhoid area. This proves that the branch pattern of suprahemorrhoidal artery has nothing to do with the location of the mother hemorrhoid. Therefore, PPH circumcision can block the superior hemorrhoidal artery.
2. The main blood supply of the anal cushion is not reduced due to PPH circumcision: Professor Zhang Dongming observed 76 autopsy cases in 1986  and found that only 5 cases of suprahemorrhoidal artery appeared in the prone site of female hemorrhoids, accounting for only 6.6% , Which not only confirmed the same conclusion as Thomson:'Miles used the branch pattern of the superior rectal artery to explain the prone location of maternal hemorrhoids, lacking anatomical support. It also explains: The arteries of the anal cushion mainly come from the inferior rectal artery (middle hemorrhoidal artery) and anal artery (inferior hemorrhoidal artery), and the superior rectal artery generally does not participate.  The course of the inferior rectal artery and anal artery has no anatomical relationship with the location of the PPH circumcision. Moreover, the arteriovenous in the circumcision area was cut in situ at the same time, and the blood inflow and outflow ratio did not decrease after the end anastomosis . The arteriovenous collateral circulation would be repaired simultaneously and synchronously, so the blood in the distal tissues after circumcision The reduced supply has no pathophysiological basis.
The blood supply of the anal pad after PPH circumcision did not substantially decrease, and the pathological hemorrhoids that were lifted into the anal canal after circumcision did not have sufficient anatomical and physiological basis due to reduced blood supply and gradual atrophy.
3. PPH does not really play a therapeutic role in accordance with the anal cushion treatment concept
"Protection of physiological anal pad tissue" and "treatment of symptomatic anal signs" are currently recognized treatment concepts for hemorrhoids in the world [3, 7]. PPH mechanically pulls the pathological anal cushion into the anal canal after shortening the intestinal mucosa. Such treatment of "anal signs" is not to protect the physiological anal cushion, but to disappear or hide the pathological anal cushion visually or formally. In other words, PPH protects the pathological anal cushion! The way to improve clinical symptoms through such "treatment" of anal signs is contrary to the treatment concept under the Thomson anal cushion theory.
4. Discussion on the application value of PPH
1. PPH is still a sign of progress in anorectal circumcision technology: as early as 1887, Whitehead in the United Kingdom pioneered hemorrhoid circumcision, after which Klose modified it to cork stopper method, but failed to promote it due to complications. In 1987, American scholar Peck first created the circumcision device. The target of circumcision was still hemorrhoid tissue, and Whitehead defect still existed. Longo moved the circumcision layer up to the intestinal mucosa according to Thomson's theory of protecting anal cushions. Although there are many controversies, the obvious advantages of the circumcision technique have been demonstrated after continuous application [7,10]: less complications, less pain, The course of treatment is short.
2. Re-recognition of the indications of PPH: Some domestic scholars are committed to expanding the research of indications of PPH, relaxing the scientific positioning of its treatment mechanism. The author believes that the indications of PPH treatment will be very limited: for pathology Irreversible stage III to IV hemorrhoids, PPH cannot reverse its pathological state; for hemorrhoids with loose and slipping intestinal mucosa, PPH cannot prevent the anal cushion from moving down [6,9]; and stage I to II hemorrhoids are not PPH Indications [3,5,13]; circular mixed hemorrhoids with obvious external hemorrhoids can not solve the problem with PPH alone. Then, only "circular hemorrhoids with symptoms of internal hemorrhoids in stage Ⅱ~Ⅲ but relatively mild pathological changes (sinusoid blood vessel destruction)" is the only indication for PPH. During this period, there was no reasonable explanation for the treatment of hemorrhoid bleeding symptoms.
3. Take comprehensive treatment measures on the basis of PPH: Zhao Baoming and others used injection therapy combined with PPH to increase the adhesive fixation and hemostatic effects ; Zhang Shengben and others cooperated with injection and suture to strengthen the fixation and release effect on the muscular layer. Patients with intestinal mucosal prolapse have achieved better results ; some people routinely cooperate with external hemorrhoidectomy after PPH; some people cooperate with modified "MM" surgery, and some advocate the removal of individual hypertrophic anal pads before PPH surgery to prevent long-term surgery Bleeding etc. The author believes that excessive use of other methods violates the original expectation of PPH with less pain and a short course of treatment . According to the news of the 12th National Anorectal Conference of the Chinese Society of Traditional Chinese Medicine that has just ended: Longo, the founder of PPH, is conducting research on the circumcision muscle layer, which undoubtedly enhances the efficacy of PPH fixation .
4. Improved PPH method: Most domestic scholars have found that the treatment effect of circumcision of the mucosal segment by Longo method alone is not ideal at the initial stage of PPH application . Data show that in recent years, most PPH users in China have moved the circumcision layer down to remove part of the hemorrhoid tissue, which has significantly improved the short-term treatment effect of hemorrhoids [2, 9, 16]. However, the long-term efficacy, how to position the treatment principle, Whitehead defects and complications, and the economic cost and clinical benefit compared with traditional methods need further research.
PPH has been applied for 8 years, but its long-term efficacy is still not an ideal objective conclusion. Most scholars are cautious[2,6-7,9,14], they have doubts about the recurrence of hemorrhoids after circumcision, many Experts have proposed to varying degrees the ambiguity of the mechanism of PPH treatment of hemorrhoids [2,14]. Therefore, the prospect of further improvement of PPH's "suspension and cut-off" action method needs to be discussed.
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Corresponding author: Liu Chuan connected, Email: firstname.lastname@example.org; 13111182220