Overtreatment of anorectal disease
(Transfer from Director Zhang Qingru)
In many years of clinical practice of anorectal diseases, it is common for some anorectal doctors to over-treat common anorectal diseases, which not only increases the pain and economic burden of patients in treatment, but also often causes undue complications. Some medical publications or in the society can also see that overtreatment is used as an introduction to experience, which is quite harmful. I raised this question five years ago. This phenomenon is still prominent, so I will discuss it again with my colleagues. We discuss.
Common anorectal diseases: refers to anorectal diseases such as hemorrhoids, anal fistulas, prolapsed anus, anal fissures, rectal polyps, and perianal condyloma acuminatum.
① Treatment that is contrary to physiology.
② Overcorrect treatment.
③ Repeat treatment (cumbersome treatment).
④ Treatment beyond objective conditions (including technology, equipment, economy, patient's overall condition and willingness).
⑤ Fraudulent treatment.
Fraudulent treatment has three characteristics:
For the purpose of extorting money.
Use false advertising as bait.
Take over-treatment as a means.
The implementation route is divided into three steps:
Korean anoscope takes pictures.
Charge one by one according to the name of the disease marked in the picture.
All kinds of auxiliary treatment methods are put together, and the bill is calculated by the minute.
Two principles are violated:
①The industry principle of incurable asymptomatic hemorrhoids.
② The medical ethics principle of "medicine is benevolence, honesty is the foundation".
2. Overtreatment of hemorrhoids
Regarding the occurrence mechanism of internal hemorrhoids, in recent years, the theory of "anal cushion downward movement" has become the consensus of domestic and foreign scholars and has been written into textbooks. The human body’s lower rectum and upper dentinal mucosa tissue is very thick, with a large number of blood vessels, dilated veins, smooth muscle, collagen fibers and elastic connective tissue fibers. It is called "anal cushion" or "anal cushion" for short, and the anal cushion is on the right front. The three places on the right and left are the most developed. It is like a soft cushion under the metal wine bottle cap, which helps the sphincter to seal the anal canal and maintain the self-control function of the anus. Hemorrhoids are called hemorrhoids if the submucosal supporting tissues are degenerated, loosened, or broken, combined with forced defecation, diarrhea, and increased abdominal pressure, and most or all of the pathological obesity of the anal cushion moves down, and symptoms such as blood in the stool, prolapse, and pain occur, it is called hemorrhoids. It can be seen that the pathological changes of the anal cushion are the anatomical basis for the occurrence of internal hemorrhoids, but the main physiological function of the anal cushion determines that it cannot be removed at will. Therefore, we are forced to choose conservative treatment for internal hemorrhoids, and only consider surgical treatment when conservative treatment is ineffective. Common surgical therapies include sclerotherapy, re-adhesion and fixation of the lowered anal cushion in place, rectal mucosal suspension, lower rectal mucosal circumcision (P·P·H) or partial anal cushion resection, etc. .
1. The following treatments belong to the overtreatment of internal hemorrhoids:
①Circumcision of internal hemorrhoids, such as Kiose circumcision which has been abandoned.
② Three or more cauterization or cryotherapy.
③Injection of a large number of necrosis agents or a large number of hemorrhoids containing arsenic.
Several injection drugs are injected simultaneously. According to reports, a hospital gave a young patient an injection to treat internal hemorrhoids (blood routine and procoagulant time are normal), and 1ml of sclerosing agent (refined salt 5g, glycerol 70ml, water for injection to 100ml) was injected into the base of hemorrhoids, and then internal hemorrhoid injection oil (4g of alum, 4g of salt, 14ml of Andrographis paniculata injection, 2g of procaine, 100ml of glycerin) 1ml is injected into the hemorrhoids. From the eighth day to the fifteenth day after the operation, there were four consecutive heavy bleedings, each of which was 100-300ml (including pig liver-like blood clots). Check the injection site for a large area of 2.5-3cm necrotic lesions with active bleeding points. Escaped after rescue.
Internal hemorrhoid injection can use one medicine, never use two medicines, and can use small doses and never use large doses under the premise of ensuring the cure.
2. Several issues to be clarified in the treatment of internal hemorrhoids:
Conservative therapy is preferred.
Hemorrhoids cannot be cured.
The cure standard for hemorrhoids is the disappearance of symptoms.
Surgical treatment should try to protect the tooth line.
In the treatment of mixed hemorrhoids, sufficient anal skin and mucosal bridges should be reserved.
3. Overtreatment of anal fistula
1. Blindly expand the resection range of the inner mouth.
Anal fistulas are mostly caused by self-ulceration of perianal abscess or contraction of the abscess cavity after incision and drainage. Most of the primary lesions of abscesses are infections of the anal glands located in the anal crypts. Therefore, many anorectal surgeons advocate expanding the scope of resection of the internal opening during anal fistula surgery, with the intention of removing the primary lesion-the anal gland. I think the infected anal gland has become a part of the anal fistula. During the operation, we only need to find the correct internal opening, cut the tube and all the branches, and keep the drainage flow smoothly. The anal gland is a subtle anatomical structure that can only be identified under a microscope. It deliberately expands the scope of resection of the internal mouth, thinking that the infected anal gland has been removed, which is very blind. As a result, the incision is too large and deep, and it is easy to bleeding And prolong the healing time.
The late Zhang Qingrong, a well-known expert on anorectal diseases, summarized the recurrence rate of 3580 cases of anal fistulas performed by eight doctors from 1964 to 1984 between 1% and 6.3%. We have treated 460 cases of various anal fistulas in twelve years, followed up 300 cases, and the five-year recurrence rate was 1.5%. During the operation, the internal mouth was not enlarged and the recurrence rate was not high.
2. Excessive removal of tissues around the duct.
First of all, some doctors deliberately cut the connective tissue at the bottom and wall of the lumen after opening the lumen, making the wounds deep and wide. It doesn't have to be so. Therefore, these connective tissues are vital tissues. As inflammation disappears and circulation improves, they will gradually absorb soften or become normal without affecting healing.
Secondly, there are complex anal fistulas with many ducts. The connective tissue between the ducts is removed at the same time, so that the wound is too large, not only slows healing, but also the scar is too large, resulting in deformation of the anus. The same is true for the connective tissue between the ducts.
3. Improper application of thread-hanging therapy.
Thread hanging therapy is only suitable for high anal fistulas. Low anal fistulas do not require threading treatment. Thread hanging for high anal fistulas will naturally fall off within 7-10 days, and the thread will not fall off over time. At this time, the thread has no drainage effect and no cutting effect. At this time, the sphincter has firmly adhered to the surrounding tissues at the place where the thread is hooked, and the remaining part that is not hung up can be cut off and the thread is off.
I have seen the thread hanging for one month, and the thread is not removed or tight. The wound is edema and granulation proliferates, filling the wound, and the thread is wrapped and the thread is not trimmed. This is obviously improper treatment.
4. The wound of anal fistula can be sutured.
All the wounds of low anal fistula and some wounds of high anal fistula can be sutured, and some can be healed by one initial stage, and the wound can be reduced and the treatment time can be shortened for those who cannot heal one stage. Suture requirements: complete hemostasis, complete removal of rotten flesh, no branch tube, antibiotic solution to wash the wound, full-thickness suture without leaving dead space.
4. Overtreatment of anal fissure
1. Anal fissure posterior incision, the incision height exceeds the tooth line.
2. Lateral internal sphincterotomy, making more than two incisions.
3. All internal sphincter muscles are cut off.
4. Thread hanging therapy to treat anal fissure.
5. Suture treatment for anal fissures and gaps. However, it is possible to remove anal fissures and sentinel hemorrhoids for lateral suture.
6. A preliminary attempt to treat anal fissure by simply expanding the anus with fingers.
5. Overtreatment of perianal condyloma acuminatum
1. Applying corrosive cream or large area resection, causing large area skin damage around the anus.
2. Extensive use of interferon.
6. Overtreatment of severe prolapse
Simply take a lot of traditional Chinese medicine treatment.
As an anorectal specialist, you must be familiar with various treatments for common anorectal diseases, and choose the best treatment according to the patient's condition. The best treatment method refers to a simple, safe, painless and economical treatment method that aims to achieve the best curative effect. Prominent consideration, not to damage the anus shape, protect the anus function, the surgical method or minimally invasive surgery is better.
I put forward the idea of “guide the surgical treatment of anal diseases with the concept of plastic surgery” 15 years ago, and Mr. Li Yunong advocated “anal cosmetology”, and the two agreed. Let us explore this goal together.