PPH is the abbreviation of procedure for prolapse and hemorrhoids in English, and Chinese means "operation for hemorrhoids and rectal mucosal prolapse". It uses a special hemorrhoidectomy stapler to circularly remove the hemorrhoids and submucosa tissues, and at the same time anastomose the distal and proximal mucosa to treat internal hemorrhoids. Therefore, it is interpreted in China as "circumferential resection of stapled hemorrhoids" or "circular resection of stapled hemorrhoids."
Apparatus has been applied to anastomose tissues and organs for nearly 100 years. In 1908, the Hungarians Hultl and Fischer first used the suture device for gastrectomy. The stapler is suitable for end-to-end, end-to-side and side-to-side anastomosis in various operations such as esophagus, stomach, duodenum, small intestine, colon, rectum, and biliary tract.
In 1997, Pescatori et al. reported that transanal stapler rectal mucosal resection was used to treat rectal mucosal prolapse. Professor Longo from Palermo University in Italy first proposed PPH at the Rome World Congress in 1997, and formally wrote a report in 1998. The earliest development in Asia was Professor Xiao Jun from Singapore Hospital in 1999. The first domestic case was completed by Shanghai Yao Qingli in July 2000.
The theoretical basis of PPH is Thomson's "anal cushion theory" in 1975 and Londer's "anal cushion theory" in 1994. Anal cushion theory first believed that mild bulging of the lower rectal mucosa is present in everyone, not a hemorrhoid, but a physiological cushion that assists the anus to close. The anal cushion theory believes that this type of cushion is hypertrophic and shifts downward to be hemorrhoids.
The PPH method is to circularly excise the mucosa and submucosal tissues of the intestinal wall above the tooth line, and perform an anastomosis of the distal and proximal mucosa. On the one hand, the rectal mucosa with a width of 3 cm can be removed, and at the same time, the rectal anal canal tissue that moves downward can be suspended and pulled upward. On the other hand, due to the stimulation of the foreign body of the staple, the rectal mucosal tissue produces an inflammatory reaction, and the surrounding tissues of the rectum are scarred and fixed so that it no longer prolapses. It can tighten and fix the anterior wall of the rectum and reduce the degree of rectal protrusion. So the treatment principle of PPH can be summarized as:
Suspension: circular excision of the mucosa and submucosal tissues of the intestinal wall at the lower end of the rectum, so that the prolapsed anal cushion is suspended and pulled upwards. Restores the local anatomical relationship between the anal mucosa and the anal sphincter, and eliminates the basis of prolapsed hemorrhoids. Wood symptoms.
Devascularization: As the arteries supplying hemorrhoids in the submucosa are cut off at the same time, the blood supply of hemorrhoids decreases after the operation, and the hemorrhoids gradually atrophy about 2 weeks after the operation, which can reduce the impact of the traumatic backlog caused by the fecal mass on the mucosa. The main cause of hemorrhoid bleeding.
At present, it is generally believed that the main indication for PPH is II-IV degree internal hemorrhoids, that is, internal hemorrhoids with repeated prolapse. Jongen believes: "The most ideal indication is II and III degree hemorrhoids." Ren Donglin, a domestic scholar, believes that the ideal indication is third-degree hemorrhoids without anal skin tags. A domestic academic organization established the indications for PPH in 2005 as: 1. Ring-shaped prolapsed grade III and IV internal hemorrhoids, mixed hemorrhoids; 2. Prerectal bulge and internal rectal prolapse that cause functional outlet obstruction constipation .
1. It can better preserve the anal canal mucosal layer and anal cushion anatomical structure, restore the self-made defecation function of the anus, coordinate the activities of the internal and external sphincter muscles, reduce the pressure in the anal canal, and avoid postoperative anal stenosis, anal incontinence, fine bowel control and other complications The occurrence of disease.
2. Resection and anastomosis of the rectal mucosa and submucosa are located in the 2 cm area of the dentinal line. There are very few sensory nerves. At the same time, it avoids surgical damage to the anal canal skin and mucosal layer, which can significantly reduce postoperative anal pain and discomfort. The patient is basically uncomfortable.
A multi-center report of 1100 cases in Germany in 2000: The total complications (excluding long-term) were 9.8%, including postoperative bleeding, pain, urinary retention, thrombotic external hemorrhoids and so on. Retrieving 69 relevant reports included in the domestic Chinese database from 2000 to 2003, the occurrence of complications was as follows: 10.0% to 10.7% of patients had anal pain, 11% to 15% had urinary retention, and 10.0% to 11.5% had hematochezia.