2020年10月18日星期日

preparation h hemorrhoids,Progress in the treatment of hemorrhoids

    In recent years, there has been a lot of research on the pathogenesis and treatment of hemorrhoids. With people's deepening understanding of the nature and mechanism of hemorrhoids, great changes have taken place in the concept and methods of hemorrhoid treatment. The progress of its clinical treatment is summarized as follows.

    l Pathogenesis of hemorrhoids

    ll Theory of Varicose Veins The theory of varicose veins is mainly derived from the fact that dilated veins are observed in the hemorrhoid tissue. It is believed that the basic pathological changes of hemorrhoids are discontinuous vein dilation, people's upright posture, constipation, increased venous pressure, and in addition Gravity and excessive abdominal pressure increase, and blood return is blocked to expand the venous plexus to form hemorrhoids. Parks (1956) recognized that the hard stool blocks the proximal venous return and caused the stasis and dilation of the anal vein. Graham-Stewart (1963) [1] modified Parks' theory, thinking that hard work caused an increase in abdominal pressure and prevented venous return.

    1.2 Cavernous Vein Theory In 1976, Japanese anatomist Haruo Miyazaki conducted an in-depth study of the rectal and anal vessels and found that the terminal branches of the superior rectal artery, inferior rectal artery, and anal artery and vein were concentrated near the dentate line. These small arteries are directly connected to the corresponding venules in the submucosa of the dental line. He called the blood vessels that directly communicate with arteries and veins as cavernous veins. The cavernous blood vessels have a weak muscle layer, less elastic fibers and more collagen fibers. Under pressure such as defecation, the cavernous veins can expand and cause hemorrhoids.

    1.3 The theory of vascular hyperplasia This theory is based on the similar structure of hemorrhoid tissue and cavernous tissue.

    of. In 1963, Stelzne revised the theory of vascular proliferation and put forward the concept of rectal cavernous body, thinking that hemorrhoids are caused by the proliferation of rectal cavernous body. Others, through histological research, believe that hemorrhoids are hemangioma caused by vascular proliferation.

    1.4 The theory of anal cushion downward movement In 1975, Thomson[2] proposed the theory of anal cushion downward movement. He believed that the anal cushion is the normal anatomical structure of the anal canal. It is located on the left, right front and right posterior sides, and consists of expanded venous plexus and smooth muscle (Treitz's). Muscle) and elasticity and knot tissue, the main function is to assist the sphincter to close the anus. When Treitz’s muscle gradually degenerates and ruptures, the anal cushion will lose support and move down to form hemorrhoids or hemorrhoids.

    1.5 Theory of Hemorrhoid Hernia Some scholars have observed hemorrhoids excised specimens and found that the connective tissue in the hemorrhoids is broken, which connects the hemorrhoids with the loose anus. It is proposed that hemorrhoids are formed by the anorectal skin and rectal mucosa accompanied by or submucosal vascular plexus, which is formed by the anorectal orifice composed of muscle fascia. It is considered that hemorrhoids are a kind of hernia. As long as the supporting structures and functions of the anal muscles and fascia are intact, no abnormal tissues will come out of the anus, and hemorrhoids are unlikely to occur.

    1.6 The doctrine of bacterial infection Some people take blood cultures of external and internal hemorrhoids. Escherichia coli grows. During the operation, it is found that the blood clots in the hemorrhoids extend to a higher position and bacteria are also present. It is believed that the venous wall is repeatedly stimulated by inflammation, proliferates and loses elasticity, resulting in poor venous return and hemorrhoids.

    2 Non-surgical treatment of hemorrhoids

    2.1 Dietary Fiber Therapy Dietary fiber cannot be digested and absorbed by digestive juice in the stomach and small intestine, but after it reaches the colon through the ileocecal valve, it can preserve considerable water, thereby increasing the amount of colon content, that is, increasing the amount of feces The water content can stimulate the movement and transmission function of the colon, and can also soften the stool. The main drugs are osmotic or expansive laxatives such as lactulose, dumic and psyllium. Moesgaard conducted a prospective, double-blind trial of osmotic laxative and placebo in patients with hemorrhoids who had bleeding and pain during defecation. It was found that there was a significant statistical difference between the two in the improvement of clinical symptoms within 6 weeks (P< 0.025), so he recommended the use of high dietary fiber and osmotic laxatives as the initial treatment of hemorrhoids [3] [4]

    2.2 Oral drugs include two types of microcirculation regulators and non-specific drugs. In recent years, based on the theory of anal cushions, some microcirculation regulators have achieved satisfactory results in alleviating or eliminating the symptoms of hemorrhoids for the pathophysiological changes of hemorrhoids. Commonly used drugs are geraniolin (Aimalang), compound ginkgo biloba extract capsules (Jingkefu), Molini extract tablets (Xiaotuozhi-M), hydroxyrutin (can be used for pregnant women), compound reed Ding, horse chestnut extract (escin) (Maizhiling), hemorrhoid blood capsules. Non-specific drugs include analgesics, stool softeners, hemostatic drugs, anti-inflammatory drugs [3] [4].

    2.3 Local medication Chinese medicine fumigation and bathing method, external application method, plug medicine method, and hemorrhoid method.

    2.4 Sclerotherapy injection method Terrell first applied quinine and urea hydrochloride injection for internal hemorrhoids in 1813, and achieved significant results. Mitchell is considered a pioneer of injection therapy. In 1871, he used 1/3 of carbolic acid and 2/3 of olive oil to treat internal hemorrhoids, and achieved good results. China started in the 1950s, especially the injection of Kuzhi method, which was developed on the basis of the traditional Chinese medicine Kuzhi San therapy. The most influential one is Xiaozhiling.

    The sclerotherapy injection therapy is simple and easy to implement, and the cost is low. It can treat hemorrhoids and bleeding after ligation in the first stage, and can also be used for patients with internal hemorrhoids after anticoagulation treatment.

    2.5 Anal expansion In 1968, Lord [5] promoted the application of anal expansion to treat internal hemorrhoids. The method was to insert the two fingers of one hand and the index finger of the other hand into the anus, gently expand the anus and tear off the fiber band (commonly used in the third period of hemorrhoids), expand the anus to The anus can hold more than 4 fingers. Greve and Hubens study showed that the intraanal pressure decreased after anal expansion, but there is a risk of anal incontinence, especially in elderly patients, so it has been rarely used in the United States, but it is still used in the United Kingdom. Konsten [6] reported that nearly half of patients with anal expansion therapy (Lord’s roocdure) had anal incontinence after 17 years, and believed that anal expansion therapy for internal hemorrhoids should be abandoned.

    2.6 Ligation Blaisdell first reported internal hemorrhoid ligation therapy (silk thread) in 1954. In 1962, Barron improved the technique and applied rubber band ligation, which is one of the most widely used methods of treating internal hemorrhoids in the world. The literature reported that the incidence of bleeding after apron ligation was 1%, the incidence of abscess was 1%, and the incidence of anal stenosis was 0.5%. Salvati reported that the cure rate was 80% after 5-15 years of follow-up. [7]

    2.7 Freezing In 1969, Lewis first reported the application of liquid nitrogen (-196 degrees) to freeze internal and external hemorrhoids at the same time. The disadvantage is that it is difficult to eliminate external hemorrhoids, the healing time is long, and it is accompanied by pain and secretions. This method is now obsolete [7].

    2.8 Infrared coagulation treatment In 1979, Neiger first reported the application of infrared coagulation to treat internal hemorrhoids. Leicester et al. compared infrared therapy and ligation therapy through a randomized study, and believed that infrared therapy was effective for hemorrhoids in stage I and stage II. A meta-analysis of a study conducted by Johanson and Rimm of infrared therapy, apron ligation and sclerotherapy indicated that the long-term effect of apron ligation is more effective than the other two methods, but due to pain and other rare complications, they believe Infrared therapy should be selected for the treatment of stage I and II hemorrhoids. The experience of scholars such as Salvati advocates band ligation rather than infrared therapy [7].

    2.9 Laser In 1987, Sanker and Jaffe used laser to treat stage I and II hemorrhoids to coagulate the hemorrhoids. The method is similar to infrared coagulation therapy [7].

    2.10 Electrotherapy In 1987, some gastroenterologists introduced the method of electrotherapy to treat internal hemorrhoids. Electrotherapy can be used for hemorrhoids in all phases. In a prospective comparative study in 1991, Wright et al. found that the recent follow-up results of electrotherapy were better than drug treatment, but The results of long-term follow-up are still uncertain [7].

    2.11 Bipolar thermocoagulation treatment Griffith applied this technique to treat stage I.Ⅱ hemorrhoids in 1987, the purpose is to necrosis the hemorrhoid tissue by heating. In 1996, Dennison et al. applied this method to treat more than a thousand cases of internal hemorrhoids, and considered it superior to apron ligation or infrared coagulation therapy, but there was no long-term follow-up result [7].

    2.12 Microwave thermocoagulation therapy Use microwaves to generate high-frequency heat, promote local blood circulation, and make hemorrhoid vascular plexus cells degeneration and fibrosis, achieving the effect of hemostasis and hardening. First and second-degree internal hemorrhoids, inflammatory internal hemorrhoids, and thrombotic external hemorrhoids have the best effect, while those with severe prolapse of third-degree internal hemorrhoids and circular hemorrhoids have poor results. According to clinical reports, the effective rate of microwave treatment of internal hemorrhoids is 93.02%, and that of external hemorrhoids is 78.43%. Yan Bingan and other combined treatment of 300 patients, a cure rate of 98% [7].

    2.13 Radiofrequency Therapy Radiofrequency also belongs to the category of high-frequency electricity. When it acts on the tissue, it can produce a high temperature of 60-80 degrees, which can make the surface of the hemorrhoid tissue coagulate and necrosis, form blood clots, and have a good hemostatic effect. Only used for the treatment of internal hemorrhoids [7].

    2.14 Magnetic field therapy The principle is to form a magnetic field around the lesion to accelerate blood circulation in the lesion and restore the physiological state of the tissue. It has a significant effect on bleeding and inflammatory internal hemorrhoids. The recurrence rate is high [7].

    2.15 ZZ Anorectal Comprehensive Therapy Apparatus is a multifunctional therapeutic apparatus that is successfully developed by using the high-frequency capacitance field to generate endogenous heat on the organism and the electrolysis of direct current in the organism to facilitate direct current drug ion introduction. The electrode clamp of this instrument is used to clamp the base of hemorrhoids, which can reach a high temperature of 200 degrees for 3-5 seconds, which can close the blood vessels and dry and coagulate the tissues, but no tissue carbonization. The coagulated hemorrhoids will fall off after 3-5 days. The purpose of treatment. It is suitable for internal hemorrhoids, external hemorrhoids and mixed hemorrhoids of various degrees. For larger mixed hemorrhoids, the treatment should be divided and intermittent according to the situation. The external hemorrhoids should not exceed 3 at a time. This therapy does not require ligation to treat internal and external hemorrhoids, and the possibility of recurring blood is extremely small. According to clinical reports, the effective rate of treating various types of hemorrhoids with this therapeutic apparatus is 68-87%. The method is simple, less painful and fast healing [8].

    2.16 Copper ion electrochemical treatment In 1998, many domestic hospitals used copper needle indwelling combined with electrification therapy (copper ion electrochemical method) for bleeding and prolapse of hemorrhoids. As a result of clinical application, copper ion electrochemical therapy is effective in the treatment of hemorrhoids bleeding and prolapse. The surgical method is simple and the trauma is small. The operation and treatment can be completed in the outpatient clinic without the risk of serious complications. Therefore, it is also considered as one of the treatments for hemorrhoids. A new method [9].

    In 1995, MacRae and Mcleod made a meta-analysis of non-surgical treatment methods, and believed that apron band ligation should be recommended as the first choice for the treatment of stage I and II hemorrhoids, because the application of apron band ligation is similar to the application of sclerotherapy or infrared treatment. Compared with, seldom need further treatment [7].

    3 Surgical treatment of hemorrhoids

    Hemorrhoidectomy is currently the most commonly used method for the treatment of stage III and IV hemorrhoids. The surgical principles include removal of the prolapsed vascular pad or combined with the reduction and reconstruction of the anal canal epithelium.

    At present, the most commonly used is Milligan-Morgan's open resection in 1937, which is the basis of many improved surgical methods. In 1956, Parks introduced a submucosal hemorrhoidectomy (semi-open operation) to reconstruct the anal canal, which is believed to better retain the sensory control function and reduce postoperative pain. Method: Clamp the skin and mucosal junction with vascular forceps, make an incision along the periphery of the vascular forceps, and make a vertical incision about 3~5cm upwards. The incision is divided into a Y-shape at the end, and the hemorrhoid plexus is separated under the mucosa with scissors and separated along the inner side. The surface of the sphincter was stripped of the submucosal tissue of the hemorrhoid plexus, and the pedicle was inserted through the suture near the plane of the anorectal ring, the hemorrhoid plexus and submucosal tissue were removed, the mucosa of the dentate line was sutured, and the internal sphincter was covered with an incision. The purpose is to preserve as much as possible the tooth line and the mucous membrane on the tooth line to protect the sensory control function. In 1959, Ferguson and Heaton reported a closed hemorrhoidectomy. The advantages of this procedure are light pain, fast healing, and retain the sensory function of the anal canal, but it is prone to incision dehiscence and infection. It is most commonly used in the United States.

    A prospective randomized controlled study by Hosch compared Parks hemorrhoidectomy and Milligan-Morgan surgery, and believed that Parks surgery alleviated postoperative discomfort, shorter hospital stay, faster recovery to work, and more economical [10].

    A prospective randomized study by Arbman and Seow-choen compared open and closed hemorrhoidectomy, respectively, and concluded that closed surgical incisions are prone to dehiscence (50%) and infection, and have a long healing time. Compared with open surgery, there is no advantage. Therefore, Milligan-Morgan surgery is still a valuable treatment, and it is currently the most commonly used in Europe [11] [12].

    The latest Doppler ultrasound guided hemorrhoidal artery ligation (DG-HAL). The essential points of this operation are high, accurate and selective ligation of the artery supplying hemorrhoids. For this reason, an anoscope has been specially developed, which can be equipped with a side-viewing Doppler ultrasound probe side-viewing doppler head. Through the guidance of Doppler ultrasound, the mucosa near the anal canal from above the anus can be determined The lower arteries can also be sutured or ligated through the window above the Doppler ultrasound probe. The success of the arterial suturing can be judged by the arterial Doppler ultrasound display. Since the venous return is not damaged, the inflow/outflow ratio will be reduced at the same time. In this way, the hemorrhoids will fall off, and the bleeding and pain will disappear. Moreover, as the tension decreases, the connective tissue will also regenerate, thereby promoting the contraction of the hemorrhoids, and eventually leading to the final shedding of the hemorrhoids. Attila Bursics et al. reported in 2003 that the one-year follow-up results of DG-HAL surgery were no different from conventional closed hemorrhoidectomy, and its shorter hospital stay, lower complication rate, and lighter postoperative surgery Pain makes it more suitable as a one-day surgery (1-day surgery), and at the same time, it also meets the minimum invasive surgical requirements [15].

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