Yu Hong Xia Gengyuan Yao Chenghan Zou Ximing
【Abstract】 Objective To investigate the method and curative effect of stapled circular hemorrhoidectomy (PPH). Methods A special circular stapler was used to treat 70 cases of severe internal hemorrhoid prolapse. Results The average operation time was 15 minutes, and the average postoperative hospital stay was 2.6 days. The incidence of postoperative complications: 15 cases (21.4%) of lower abdomen discomfort, 19 cases (27.1%) of blood in the stool, 36 cases (51.4%) of anal orifice pain. The results of the operation were satisfactory after a follow-up of 2 to 16 months. Conclusion The stapled hemorrhoids circular resection has the advantages of good curative effect, low complication rate and quick recovery.
[Keywords]: hemorrhoids surgery stapler
1.1 General information and methods There are 48 males and 22 females in this group, aged from 25 to 86 years, with an average of 52.3 years old. The course of disease was 3 to 36 years, with an average of 13.6 years. All 70 cases had been treated with drugs, of which 6 had been treated with internal hemorrhoid sclerotherapy, and 7 had been treated with hemorrhoidectomy, but they recurred after surgery. All patients had circular protruding internal hemorrhoids, all underwent circular resection of stapled hemorrhoids, and 7 cases of them underwent skin tag removal due to protruding anal skin tags.
1.2 Apparatus Use Johnson & Johnson’s hemorrhoidectomy stapler, including 33mm stapler, anal canal dilator, anal mirror suture device, and threader.
1.3 The indications for surgery are mainly grade III and IV circular internal hemorrhoids, but the conservative treatment is invalid for acute incarcerated hemorrhoids and rectal prolapse. It can also be used for patients whose internal hemorrhoids have a large amount of bleeding and whose conservative treatment has failed. Since this operation requires an imported special stapler, the cost is relatively high, and it is generally not used for isolated prolapsed internal hemorrhoids.
1.4 Surgical method: Routine bowel preparation before surgery. 52 cases in this group used oral 50% magnesium sulfate 100ml and warm boiled water 1500ml in the afternoon before surgery for mechanical bowel preparation. 18 cases used clean enema 2 to 3 hours before surgery. 46 cases received low spinal anesthesia and 24 cases received continuous epidural anesthesia. Take the bladder lithotomy position. Routine disinfection (for female patients at the same time for vagina disinfection) spread towels. After applying paraffin oil to the inner core of the anal canal dilator, slowly rotate and insert it. Dilate the anus to accommodate the dilator. Three non-traumatic forceps were used to clamp the anal canal ring with small prolapse and mild mucosal eversion. Insert the annular anal dilator, take out the inner core, and adjust the anal dilator to make the prolapsed mucosa fall into the dilator sleeve as much as possible. The dentate line is exactly flush with the inner mouth of the anal canal dilator, and the dilator is sutured to fix it. Place the anal mirror ligature. Anal mirror suture device can cover the prolapsed mucosa within 270 degrees on the rectal wall, and 90 degree prolapsed mucosa can be seen in the cavity, so the suture is easier. Make a circle of purse-string sutures clockwise from the 3 o'clock of the lithotomy site at 3 to 4 cm from the tooth line with No. 7 silk thread. Then make the second purse-string suture about 1cm below the first purse-string suture from 9 o'clock at the stone cutting site clockwise. In order to improve the effect of hemorrhoid retraction, the lower purse strings of 31 cases were sutured 2.5 to 3 cm on the tooth line. Expand the hemorrhoid stapler to the maximum. Extend the head end to the ends of the two purse strings, and tighten the stitches one by one inside and then outside. The sutures were held by the thread holders through the side holes of the hemorrhoid stapler. The end of the thread is drawn and knotted. The entire stapler sleeve is gradually tightened and extended into the anal canal. At the same time, pull the ligature forcefully toward the handle to make the prolapsed mucosa and submucosa tissue enter the sleeve. Firing and keeping the stapler closed for about 60 seconds can play the role of forming titanium nails and compressing hemostasis. Partially open the stapler and remove the stapler at the same time. After the operation, the anastomotic site was checked by an anoscopy. If there is bleeding and poor closure, a stitch can be added locally. If the anal dilator is taken out, if the skin tag is obvious, the skin tag can be removed without suture. Give intravenous fluids and antibiotics on the same day. They can be discharged after 1 to 3 days of observation in the hospital.
2.1 Curative effect The anastomosis was successful in all patients. The complete rate of excision anastomotic ring was 97%. The operation time is 9-25 minutes, with an average of 15 minutes. The main reason for the prolonged operation time in some patients is the bleeding of the anastomosis and the prolonged time due to stitching. The average postoperative hospital stay was 2.6 days (2 to 5 days).
2.2 The relationship between the position of the anastomosis, the width of the resected tissue and the retraction of hemorrhoids. In the early 16 cases, the Johnson & Johnson literature introduced a single purse-string suture at 4-6cm on the tooth line. The width of the resected tissue was 1.5cm on average, and the distance between the anastomotic position on the tooth line was greater than 3cm . Among them, 7 cases had complete hemorrhoids retraction, and 9 cases had incomplete hemorrhoids retraction recently. Later, 23 cases had a double purse on the dentinal line, the width of the removed tissue was 1.9cm on average, and the anastomosis was located 2～3cm on the dentinal line. Among them, 16 cases of hemorrhoids completely retracted and 7 cases of recent incomplete retraction. In the other 31 cases, the hemorrhoids with anastomosis located 1 to 2 cm on the tooth line were completely retracted.
2.3 Surgical complications ① Discomfort and pain in the lower abdomen: 15 cases (21.4%) showed symptoms at the time of tightening and firing of the stapler and within 8 hours after the operation, and no special treatment was relieved. ②Anal orifice pain: 36 cases (51.4%) of which 25 cases used analgesics for one day. In 7 patients with skin tag removal due to obvious anal tags, the pain lasted for 2 to 7 days. ③ Postoperative blood in the stool: 19 cases (27.1%) generally had low bleeding, lasting for 2 to 5 days, and stopped after topical medication. Only 1 case had a large amount of bleeding of about 1000ml, and it improved after blood transfusion and local adrenaline sand strips. ④ Urinary retention: 47 cases (67.1%) received retention catheterization for 24 hours.
2.4 Follow-up 70 patients were followed up for 2-16 months, 98% of the patients were satisfied with the results of the operation. The average return to normal working time is 7.3 days (4-8 days). 5 patients (7.1%) developed thrombotic external hemorrhoids within 3 months after the operation, which may be related to the blocking of the arteriovenous blood vessels of the anal canal. All of them resolved after topical medication. No fecal incontinence, narrow anastomotic stoma, and recurrence of internal hemorrhoids were found.
PPH is the treatment of severe prolapsed internal hemorrhoids by circular resection of the lower rectal mucosa and submucosa tissue. This operation moves the anal cushion up to reset and retract the prolapsed internal hemorrhoids. Blocking the arteries and veins of the anal canal reduces the blood supply to the anal cushion after the operation, the hemorrhoids gradually atrophy, and the normal anatomy of the anal canal mucosa is restored. As there is no incision in the perianal skin, the postoperative pain is lighter. At the same time, the anal cushion is preserved and the ability to control stool after surgery It is unaffected, and there are no complications such as anal stenosis and fecal incontinence, making the surgical treatment of hemorrhoids more perfect.
The advantages of this operation: ①The effect is good, and the preoperative symptoms can be cured or significantly improved. ②Short operation time, 15 minutes on average, and short hospital stay, 2.6 days on average. ③ Since he does not remove the anal cushion, his bowel control ability will not be affected after surgery. ④ The skin of the anus is not removed. Although there are complications such as lower abdomen and anal pain and urinary retention after the operation, the symptoms are mild and the recovery is faster. ⑤After the operation, the patient can quickly return to normal life and work. ⑥ There were no serious complications such as anal stenosis and fecal incontinence after the operation.
The depth and position of the purse-string suture in the surgical operation determine the scope and position of the stapler resection. In female patients, the retractor should not be located on the anterior wall of the rectum, and the suture should be too deep. At the same time, when suture the purse string and before the stapler is fired, check whether the back wall of the vagina is sewn and pulled into the stapler to prevent the vagina The posterior wall was removed together, causing postoperative rectovaginal fistula. This group of cases shows that the purse-string suture is 3~4cm above the dentate line, which can make the anastomosis exactly 1~2cm on the dentate line, and the hemorrhoid retraction effect is best. The position is too low so that the anastomosis site involves the anal pad, which is prone to bleeding and pain after surgery. If the position is too high, the upward traction and suspension of the anal cushion caused by the operation will be weakened, and the effect of the operation will not be obvious or even invalid.
The anal canal dilator plays a role in protecting and expanding the anal cushion during the operation, but if it is placed too deep, it will hinder the cutting and suspension of the anastomosis in the direction of the anal cushion. Therefore, push the hemorrhoids into the anal canal dilator as much as possible, and adjust the inner mouth to be flush with the tooth line to ensure the surgical effect.
PPH operation blocked venous return, and acute thrombosis of external hemorrhoids was prone to occur in the short term after surgery. 5 patients (7.1%) were relieved by conservative treatment. Patients often treat thrombotic external hemorrhoids as recurrence of internal hemorrhoids and should be treated and explained in time.
The new PPH technology has been developed for a short time at home and abroad, and there are few literature reports on the long-term follow-up effect. Through the treatment and follow-up of 70 patients in this group (2 to 16 months), it is believed that the operation is technically safe and effective, the patient has mild pain, and quickly returns to normal work without recurrence after surgery. PPH is expected to become the main treatment for severe internal hemorrhoids.
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