In 1997, Longo proposed the concept of procedure for prolapse and hemorrhoids (PPH). In June 2000, Professor Yao Liqing completed the first PPH operation in China. Based on the modern concept of hemorrhoids: when blood vessels in the submucosal layer are congested due to dysregulation or the supporting tissues of the anal cushion Parks ligament and Treitzs muscle are broken, the anal cushion moves down and the anal cushion is called hemorrhoids. PPH is to remove the rectal mucosa above the dentate line in a circular shape to move the anal cushion up, block the blood supply of hemorrhoids, control bleeding symptoms and shrink the remaining part of hemorrhoids, so as to achieve the purpose of curing hemorrhoids.
1 Common complications after PPH
2 Comparison of short-term complications after PPH and traditional methods
Racalbuto et al. reported that the comparison of 50 cases of PPH and Milligan-Morgan (MMH) surgery showed that: PPH has less pain (average painkiller 2.60 vs 15.9 tablets) and faster return to normal activities (08 04 vs 16. 9 d). Mehigan et al. reported that 85% of patients with PPH treatment were satisfied with postoperative symptom control, while MMH hemorrhoidectomy accounted for 75%. Since the initiation of PPH surgery, in 4 domestic comparative studies of PPH and MMH surgery with a large number of cases, the comparison of operation time, pain index injection analgesic frequency, hospitalization time, recovery time and postoperative complication rate have shown PPH is better than MMH group. Schmidt et al. reported that 80 cases of similar patients treated with PPH and traditional surgery were compared. The complication rate of PPH was 4%, while that of traditional surgery was 11%. Che-ethamb reported that the incidence of tense and severe after PPH was 31%, and he believed that it was caused by the anastomotic ring stimulating sphincter spasm. HO et al. randomly divided the 119 cases of prolapsed hemorrhoids into the traditional open electrosurgical resection and electrocoagulation (diathermy, DT) group of 62 cases and the PPH group of 57 cases. The preoperative incontinence score, anorectal pressure measurement, and intrarectal ultrasound were performed. Re-examination was performed 3 months after the operation to reassess the pain index, the demand for analgesics, the quality of life, and the treatment cost. The results showed that the operation time of DT hemorrhoidectomy was shorter than that of the stapler, and the hospital stay was the same in the two groups. The pain index of DT during defecation within 2 weeks after surgery was higher than that of the PPH group, and the demand for analgesics was more than that of the PPH group within 6 weeks. That is, the short-term efficacy PPH group has advantages, but the long-term effects and long-term complications cannot be evaluated.
3 Comparison of long-term complications after PPH and traditional hemorrhoidectomy
Pavlidis et al. randomly divided 80 patients into two groups and followed up for more than 2 years. 95% of the patients in the PPH group were satisfied with postoperative symptom control, while the satisfaction rate of the MMH hemorrhoidectomy group was 89%. Ebert et al. followed 214 patients after MMH for 54 months, 68% of the patients had no obvious symptoms. After some optimistic reports about PPH surgery, in recent years, there have been reports that are not optimistic. 38% of patients have rectal-vaginal fistulas after PPH surgery, fatal pelvic infections and no significant improvement in 19 months. The retrospective investigation of Pescatori and Aigner on the application of PPH over the past 10 years showed that the incidence of rectal stenosis and severe pelvic infection requiring a bypass stoma is more common than traditional hemorrhoidectomy. However, the serious complications caused by traditional hemorrhoidectomy do not require a bypass stoma. Due to postoperative complications such as chronic anal pain, bleeding and hemorrhoid prolapse, the probability of reoperation one year after PPH is reported to be up to 11%, and there is a higher recurrence rate in the treatment of grade IV hemorrhoids. Rectal pain is usually intractable dull pain and accompanied by a sense of urgency, which may be due to the fibrosis around the anastomosis affecting the autonomic nerve endings of the rectal ampulla. Recently, Jayaraman and Colqu-houn confirmed that after PPH in a meta-analysis It will bring a higher reoperation rate (OR=2·3) compared with traditional hemorrhoidectomy, and its only advantage is to reduce pain; therefore, traditional hemorrhoidectomy is still the method of choice for the treatment of hemorrhoids. In a retrospective investigation of a large sample, the incidence of serious life-threatening complications after PPH can be as high as 1/1200. Usually, sepsis caused by PPH is rare. However, some scholars have reported complications such as abscesses, fistulas, and retroperitoneal sepsis. Intracavitary ultrasound confirmed that the damage of PPH to the anal sphincter is similar to that of traditional hemorrhoidectomy. Studies have shown that 23% of patients after PPH have urinary urgency and increased defecation frequency, and 5% of patients have difficulty defecation and feeling of unclean stool. Cheetham has similar reports. In 2004, Nisar et al. emphasized the potential destructive complications of PPH in a meta-analysis, and believed that traditional hemorrhoidectomy is the gold standard for hemorrhoid treatment.
4 Problems and prospects of PPH
To analyze the current status of PPH surgical treatment, we need to pay attention to the following issues: (1) PPH indications are narrow. It is used for severe annular prolapsed internal hemorrhoids, and other diseases of the colorectal should be excluded. The Provisional Regulations of the Anorectal Surgery Group of the Chinese Medical Association Association of Anorectal Surgery for the treatment of hemorrhoids with PPH: The indications of PPH are internal hemorrhoids of degree III and IV with annular prolapse, and internal hemorrhoids of degree II with repeated bleeding. (2) Prevention and treatment of serious complications. The operation of stapler hemorrhoid fixation is simple and easy to master, but there are still many complications in the application process, such as bleeding, pain, urinary retention, infection, and rectovaginal leakage. In addition, hemorrhagic shock caused by severe bleeding has also been reported. Although serious complications are individual phenomena, they should arouse enough attention. (3) High medical expenses. Foreign studies have shown that due to the recurrence of hemorrhoids and hemorrhoid symptoms after PPH, the reoperation rate is higher than that of the traditional operation, which increases the medical cost, and the medical cost of the PPH operation itself is higher than that of the traditional operation. (4) The long-term effect of PPH operation needs to be confirmed. Longo believes that the advantages of PPH are: it does not damage the normal structure of the anus, the patient has less pain, and the wound recovery only takes 3 to 4 days after the operation. Recent studies by Greco and Hzboubi have shown that due to chronic inflammation and fibrosis, the anal cushion has lost its function, even if the anal cushion is moved up through PPH, it also loses its anal cushion function and anal bowel control ability. In short, the short-term and long-term studies on the postoperative complications of PPH show that inappropriate application of PPH will lead to serious postoperative complications and a higher recurrence rate; the theoretical basis of PPH surgery needs to be verified by long-term clinical observations Therefore, the advantages of PPH surgery have yet to be judged by long-term follow-up and large-sample multi-center randomized controlled studies.