Perianal disease is one of the most common diseases in humans, which seriously affects people's health and even life. In recent years, with the application of advanced science and technology at home and abroad, the medical community has carried out detailed studies on the anatomy, physiology, and pathology of the anus, and corrected some traditional misconceptions, such as: the pathogenesis of hemorrhoids---anal cushion downshift Doctrine; prerectal bulge---rectal mucosal prolapse theory, etc.
Hemorrhoids are one of the common and frequently-occurring diseases in clinical practice. There are still controversies about the cause of hemorrhoids. There are many traditional treatment methods, but most of them are various destruction methods for swelling and prolapsed hemorrhoids. The postoperative pain is severe, there are many complications, the clinical treatment effect is not good, and the recurrence rate is high. In the late 1990s, Longol and others reaffirmed the "anal cushion theory" and conducted more in-depth research. Put forward: Hemorrhoids are not a disease, but a normal anatomical structure of the human body. No treatment is needed for asymptomatic hemorrhoids, and no radical cure for symptomatic hemorrhoids. Developed a new method of using a stapler to treat hemorrhoids—procedure for prolaps and hemorrhoids (PPH). It brought about a'revolution' in the knowledge and treatment of hemorrhoids.
Hemorrhoids are one of the most common diseases in humans, and their incidence rates vary from domestic and foreign reports. There have been so-called "ten men and nine hemorrhoids" and "ten women and ten hemorrhoids" in Chinese folks, and they believe that the incidence of hemorrhoids is very high. But in fact it is not high. In 1977, 57,427 people were surveyed in 155 units nationwide, and the incidence of hemorrhoids accounted for 51.44%. 22% to 47% are reported abroad, and up to 80% are also reported. The symptoms of hemorrhoids are pain, bleeding and prolapse outside the anus, so hemorrhoids are traditionally considered to be varicose vein masses. The Greek word "Haemorrhoids" or "Pila" means bleeding and mass. However, in recent years, with the development of medical science, people have used advanced scientific methods to carry out more in-depth and detailed research on hemorrhoids, and the concept of hemorrhoids has changed. Hemorrhoids are regarded as "vascular anal pads" and are normal anatomy of the human body. In part, hemorrhoids are not a disease in themselves, but only when bleeding, pain, and prolapse occur under certain reasons.
Second, the cause
Anal Cushions, also known as Haemorrhoidal zone and Corpus covernosum recti, are the anatomical and physiological basis of the modern concept of hemorrhoids
1. The theory of downward movement of anal cushion
When the anal cushion is stimulated by some adverse factors, it stimulates sympathetic nerves, increases the secretion of amines, causes capillary spasm, tissue ischemia and hypoxia, releases histamine, telangiectasia, blood stasis, tissue edema, and severely localized Sexual necrosis, erosion and bleeding. The anal cushion is normally fixed by the Treits and Park muscles inside the internal sphincter. Congenital and genetic factors Treits muscle dysplasia and any cause of increased intra-abdominal pressure can cause Treits muscles to overstretch and rupture, and the capillary adjustment disorder in the anal cushion causes the anal cushion to move downward and hemorrhoids.
The investigation found that patients with hemorrhoids often have a family history, but no definite genetic evidence has been found. The incidence rate in developed countries is higher than that in developing countries, which may be related to food structure, bowel habits and environmental factors.
Third, the classification of hemorrhoids
1. Internal hemorrhoids
Located above the dentate line, the surface is covered by rectal mucosa. It is commonly found in the middle of the left, front right and back right, which is the so-called anal cushion. Bleeding, pain, and prolapse may occur at the onset.
2. External hemorrhoids
Located below the dentate line, the surface is covered by skin. Thrombotic external hemorrhoids are common, and the main symptom is pain.
Located near the dentate line, the surface is covered by the skin and mucous membrane junction tissue, with two characteristics of internal hemorrhoids and external hemorrhoids. Some people think that they are actually hemorroids with an external component.
Fourth, the staging of hemorrhoids
Chinese Medical Association of China
The main symptoms
No obvious clinical symptoms. Sometimes bleeding during defecation. Anal cushion hypertrophy and hyperemia can be seen under anal mirror
The anal cushion prolapses during defecation, and the anal cushion returns by itself after defecation, blood in the stool, or more severe blood in the stool
The anal cushion prolapses during defecation, and must be absorbed by hand after defecation. It can also be prolapsed due to fatigue or increased abdominal pressure, blood in the stool or severe blood in the stool
Hemorrhoids have been prolapsed for a long time and cannot be repaid. Most are circular or mixed hemorrhoids. The anal pads are mostly fibrotic and have blood in the stool, but rarely have severe blood in the stool.
Five, clinical symptoms
1. Blood in the stool
In the early stage of internal hemorrhoids and mixed hemorrhoids, painless blood in the stool is common, bright red in color, mostly stool or blood on paper, and sometimes anal drip or jet-like bleeding, which can stop by itself after a few days. Most of them bleed after drinking alcohol or eating irritating food.
2. Prolapse of hemorrhoids
Hemorrhoids prolapse usually occurs at a later stage, most of which occur during defecation. After the defecation, the hemorrhoids are absorbed by themselves, and then they need to be repaid by hands, and finally cannot be repaid or even incarcerated. Patients are often very painful, which seriously affects their work.
Early bleeding of internal hemorrhoids is often painless, and pain occurs only when inflammation, necrosis or incarceration occurs. Pain is the main symptom of external hemorrhoid thrombosis, which mostly occurs after the patient exerts force and alcohol. The patient has unbearable pain and cannot walk.
In advanced patients, prolapse of hemorrhoids for a long time, loose anus, discharge of secretions, itching and discomfort around the anus, and even rashes.
Six, differential diagnosis
According to the clinical symptoms of internal hemorrhoids and necessary anal examination, the diagnosis is not difficult, but it must be differentiated from the following diseases:
1. Rectal cancer
The most common clinical practice is to misdiagnose rectal cancer as hemorrhoids. The main reason is that the diagnosis is made based on symptoms alone, without careful digital rectal examination and anoscopy, which is also the main reason for delay in timely treatment of patients.
2. Rectal polyps
Low-lying pedicled rectal polyps protrude outside the anus and are often misdiagnosed as internal hemorrhoids. Polyps have pedicles and are circular movements.
3. Rectal prolapse
Rectal prolapse is circular and the surface mucosa is smooth. Digital rectal examination can often reveal anal sphincter relaxation. The prolapse of annular internal hemorrhoids is generally plum petal-like, and the sphincter is not loose.
Seven, treatment principles
1. In the first and second stages, hemorrhoids generally have no clinical symptoms, so no treatment is needed. If there is bleeding, conservative medical treatment can be taken.
2. Surgical treatment is required for stage III and IV prolapsed hemorrhoids or severe hemorrhoids with severe bleeding.
3. For incarcerated hemorrhoids, if inflammation occurs after more than 48 hours, conservative treatments such as anti-inflammatory, pain relief, and narcosis should be performed first, and surgery should be performed after the inflammation improves.
8. Surgical methods
(1) There are many traditional surgical methods
Injection method, electrocoagulation method, ligation method, etc. and the Buie method, Fansler method, Milligan-Morgan method, and Parks method named after some doctors abroad. The principle of these methods is one goal: to remove or surgically remove hypertrophic, prolapsed, and bleeding hemorrhoids. The result did cure some patients, but it also paid a price. It severely damaged the integrity of the human anal cushion, causing some unrecoverable complications such as anal stenosis, fecal incontinence, and recurrence of symptoms. In addition, the long operation time and postoperative pain also bring great pain to the patient.
(Two), rectal mucosal circumcision and anal cushion suspension (PPH)
PPH was proposed by Longo in 1998, also known as Longo technique. In fact, in 1990, Allegra had proposed the use of a stapler to remove annular hemorrhoids. In 1997, pescation reported the clinical use of stapler to treat rectal mucosal prolapse. Longo made improvements on this basis, further elaborated the mechanism of prolapsed hemorrhoids, and cooperated with Johnson & Johnson to form the current PPH operation.
PPH operation is to use a stapler to circularly remove the rectal mucosa about 3 cm above the dental line above the hemorrhoids, and complete the anastomosis at the same time, so that the lowered anal cushion can return to the normal physiological position and improve the self-control function of the anus. Reduce the internal pressure of the anal canal, eliminate the symptoms of hemorrhoid prolapse; do not damage the anal cushion tissue, retain the ability of the rectum to recognize the contents of the intestine, and will not cause complications such as anal stenosis, incontinence, and dysfunction of stool control that occur in traditional surgery ; Cut off the terminal branch of the inferior rectal artery, reduce the blood supply of the hemorrhoids, shrink the hemorrhoids, which is conducive to the treatment of bleeding hemorrhoids; the anastomosis is 1.5-2 cm above the dentate line, where there are few sensory nerves, and no postoperative Significant anal pain and discomfort will occur.
1. Surgery evaluation of PPH:
(1) The operation time is short, the average operation time after successful anesthesia is 10 minutes or less.
(2) There is little bleeding. As long as the operation is correct, there is generally no bleeding or very little bleeding.
(3) Postoperative pain is mild, because the anastomosis is above the tooth line, so there are few somatosensory nerves, no damage to the anal cushion, postoperative pain is light, generally no or rarely use analgesics.
(6) PPH has not been developed for a long time, and its long-term efficacy is still unknown. In addition, the cost of PPH stapler is relatively high, which increases the treatment cost of patients, and also prevents the PPH technology from being developed faster and more widely.
2. Indications and contraindications of PPH
(1) Indications of PPH: III-IV degree prolapsed annular hemorrhoids, severe bleeding II degree hemorrhoids, rectal mucosal prolapse, and early incarcerated internal hemorrhoids (within 48h).
(2) Contraindications of PPH: The entire anal cushion cannot move smoothly and the anal canal stenosis caused by the fibrosis of the rectal anal canal, the patients with external anal hemorrhoids and anal incontinence.
3. Complications of PPH and their prevention and treatment
(1) Pain. The Italian scholar Ravo reported 1107 PPH patients in 12 anorectal treatment centers, and 5% of the patients had severe pain.
Reasons: ①The purse string suture was too deep, resulting in mixed muscles in the excised tissue.
②Somatosensory neuropathic pain caused by the anastomosis close to the tooth line.
③ Postoperative anastomotic edema and pain.
④ Pain after removal of external hemorrhoids and skin tags.
(2) Thrombosis, the incidence rate reported by Ravo was 2.3%, which generally improved after conservative treatment.
(3) Urinary retention. It has been reported that 50% of patients after PPH have urinary retention. The reason is not clear. It may be caused by various factors such as anesthesia, and usually recovers spontaneously in a short time.
(4) Other complications, such as split anastomosis, rectovaginal fistula, rectal wall hematoma, etc. As long as the operation is careful, it usually does not happen.
4. Current status of PPH treatment of severe hemorrhoids at home and abroad
Since Longo invented the PPH technology to treat severe hemorrhoids in 1998, PPH surgery has been widely carried out in Europe and the United States. At present, developed countries have basically replaced the traditional hemorrhoid surgery method with PPH technology, which has become the gold standard for the treatment of severe hemorrhoids. At the end of 2003, there were a total of 250,000 cases worldwide, including 200,000 cases in Europe. At the beginning of 2006, about 30,000 PPH operations were reported in China.