Research progress on the effectiveness of cutting ligation combined with PPH in the treatment of mixed hemorrhoids
[Abstract] Based on the theoretical basis and clinical literature research of the cut ligation and PPH operation, it is proved that the cut ligation combined with PPH is a more effective mixed hemorrhoid surgery treatment method that conforms to the modern treatment principles and therapeutic purposes of hemorrhoids.
[Key words] PPH operation, cut and ligation, mixed hemorrhoids, effectiveness, research progress
1. Current status of research on the effectiveness of incision ligation
1.1 Progress in basic theoretical research
Traditional Chinese medicine ligation therapy is to ligate or ligate the base of internal hemorrhoids with silk thread to make internal hemorrhoids shrink and fall off and heal. Its advantage is that it is simpler than western medicine surgical resection, and the patient's pain is less. The disadvantage is that it cannot treat external hemorrhoids.
Beginning in the 18th century, about from the Morgagin era, the discovery of anatomy gave the modern concept of hemorrhoids. Hemorrhoids were considered to be varicose veins under the anal mucosa, and various explanations were proposed , which developed into hemorrhoids. According to the theory of varicose veins, hemorrhoids are soft venous masses formed by congestion, expansion and flexion of the hemorrhoidal venous plexus under the rectal mucosa and under the skin of the anal canal [4, 5]. In 1937, Milligan et al. first created external stripping and internal ligation on this basis. (Millian-Morgan technique), there are a variety of improved techniques. Incision ligation is an improved Millian-Morgan procedure, and it is also a procedure based on the traditional theory of hemorrhoids and varicose veins. This kind of surgery has a better effect on internal hemorrhoids with isolated prolapsed hemorrhoids. V-shaped incisions need to be made on the skin on both sides of the base of the hemorrhoid. The mucosa above the dentate line needs to be sutured with absorbable sutures, and the part below the dentate line is not sutured. After it heals on its own, the recovery time is longer, which takes 4 to 5 weeks, and the postoperative pain is more obvious. The disadvantage of this operation is that only 3 hemorrhoids can be processed at a time, and a certain mucosal bridge needs to be preserved between the excised wounds, otherwise it will easily cause anal stenosis after the operation, and the surgical wounds will heal slowly, which generally takes about 4 weeks(6) , 7].
1.2 Research progress in clinical practice
Wang Huaijun  used overlapping sutures in the traditional hemorrhoid ligation therapy to prevent the risk of incomplete tissue ligation and postoperative bleeding, and the drainage of hemorrhoids below the dental line was relieved and the edema was reduced, achieving satisfactory results.
Yao Qing  treated 85 cases of mixed hemorrhoids with incision ligation. Not only the short-term curative effect is satisfactory, but the recurrence rate is low.
Jing Xiangchuan  used cutting ligation and injection plus lateral resection to treat circular incarcerated mixed hemorrhoids, maximizing the preservation of mucosal bridges, skin bridges, and anal epithelium, and lateral sphincter resection to relieve the spasm of the internal sphincter and prevent wound edema And relieve pain. At the same time, an appropriate amount of Xiaozhiling is injected into the normal mucosa between the hemorrhoids to cause local adhesions, prevent mucosal eversion, and enhance the long-term curative effect.
Li Shuaijun, Xiong Zhiyan, He Zhimao, Li Chunmei, Rong Xinqi, Li Zhengxing In order to evaluate the safety and superiority of incision ligation in the treatment of mixed hemorrhoids, 120 cases of mixed hemorrhoids were treated with incision ligation and external resection and internal ligation. The results showed that Scissor ligation has the advantages of shortening the operation time, less intraoperative bleeding, and low postoperative scarring, which can better maintain the shape and function of the anus .
2. Current research status of the effectiveness of PPH
2.1 Progress in basic theoretical research
Since the 1970s, the research on the nature of hemorrhoids has made breakthrough progress . In 1975, Thomson first proposed that "hemorrhoids are a normal anatomical structure common to everyone." The theory of anal cushions laid the foundation for the modern concept of hemorrhoids, pointing out that anal cushions have special mucosal epithelium, abundant arteriovenous anastomosis and a large number of Treitz muscle fibers. In 1994, Lorder further proposed the theory of downward shifting of the anal cushion, thinking that internal hemorrhoids are pathological hypertrophy or displacement of the anal cushion. In response to this new theory and theory, in 1998 Italian scholar Longo proposed procedure for prolapse and hemorrhoids (PPH). The essence of the operation is to use a special stapler to circularly remove a certain width of the lower rectal mucosa and submucosa tissue above the severely prolapsed hemorrhoids, and at the same time perform an anastomosis of the distal and proximal mucosa, so that the prolapsed anal pad or internal hemorrhoids are suspended upward Hanging and pulling, no longer prolapse. Due to the operation, the superior rectal artery and the middle rectal artery branch that are located in the submucosa and supply hemorrhoids are cut at the same time. The blood supply of postoperative hemorrhoids is reduced, and the hemorrhoids gradually atrophy about 2 weeks after surgery . The operation is widely carried out for its advantages of light postoperative pain, simple operation, and no anal incontinence. Based on the modern concept of hemorrhoids, the main purpose of PPH is to suspend the prolapsed anal cushion and block blood flow . Domestic Yao Liqing started to apply this technology in July 2000, and it was quickly promoted in China due to its ideal curative effect.
2.2 Research progress in clinical practice
The short-term effects of PPH surgery showed that postoperative anal pain was significantly reduced, and even some patients had no pain at all, and the hospital stay was shortened. Domestic clinical studies have shown that: PPH and milligan-morgan surgery for the treatment of grade Ⅲ to Ⅳ hemorrhoids, the two groups have respectively 89% and 81% in symptom improvement, in terms of pain index, number of injections of analgesics, hospitalization time, and recovery time, etc. On the other hand, the PPH group was significantly better than the control (P. Another clinical study showed that PPH and mi1ligan-morgan surgery for the treatment of grade Ⅲ to Ⅳ hemorrhoids, the average postoperative hospital stay in the PPH group was (3.O3±1.49) days, the control The average postoperative hospital stay in the PPH group was (5.08±2.12) days, and the postoperative hospital stay in the PPH group was significantly shorter than that in the control group (P. PPH surgery patients did not require routine bathing, dressing changes, and strict dietary restrictions. Patients need to take a bath and change dressing and pay great attention to diet, which prolongs the course of the disease.
Xiao Shubang  observed 165 cases of mixed hemorrhoids treated with PPH. The results showed that the operation time was 11 to 23 minutes, with an average of 15.37 minutes, and was discharged 3-5 days after surgery. During the follow-up period of 1-20 months (average 11 months), the clinical symptoms of all patients disappeared, the anal marginal hemorrhoids disappeared in the anal examination, and the internal hemorrhoids disappeared in the anoscopy.
Tan Hong, Zheng Jinjian  Both groups of patients recovered, but the average length of hospital stay, average return to work, average duration of treatment and postoperative pain, postoperative bleeding, postoperative edema, etc., stapled prolapse and hemorrhoid mucosal circumcision ( PPH surgery) was significantly better than the mixed hemorrhoids external stripping and internal ligation group.
Yao Liqing et al.  performed a total of 352 PPH operations from July 2000 to July 2003. Among them, 313 patients were followed up for an average of (27.03±7.4) months. The results showed that only 14 patients (4.5%) were postoperative There is still a small amount of bleeding, but it is significantly better than before the operation, and can be relieved by medication. The remaining preoperative symptoms, such as pain, prolapse, etc., are completely cured; only 2 cases of patients with rectal mucosal prolapse, after surgery The second PPH operation was performed in 1 month, and there were no other cases of recurrence.
Hu Ming, Lei Jian, Zheng Wenbo, Huang Jiongqiang  and other studies have shown that most patients with prolapsed internal hemorrhoids, mucous membranes and skin tags immediately retracted into the anal canal, but patients with severe prolapse may still have part of the prolapse at that time. Internal hemorrhoids, mucous membranes and skin tags remain outside the anal canal, and can be completely retracted into the anal canal from the second day to 2 weeks after surgery.
3. Current research status of incision ligation combined with PPH
3.1 Progress in basic theoretical research
The modern concept of hemorrhoids believes that: hemorrhoids, anal pads or anatomical hemorrhoids, are the normal anatomical structure of the anal canal . Therefore, the purpose of treatment of hemorrhoids is not to eliminate the hemorrhoids itself, but to reduce or eliminate their symptoms. The purpose of surgery is to eliminate symptoms and protect the preserved normal tissues, not radical surgery . The indications of PPH surgery are based on the "Guidelines for the Clinical Diagnosis and Treatment of Hemorrhoids (2006 Edition)" formulated in July 2006 : Internal hemorrhoids of degree III and IV with annular prolapse and degree II internal hemorrhoids with repeated bleeding. In clinical practice, not all hemorrhoids prolapse are ring-shaped prolapses. Most hemorrhoids prolapse are uneven. If PPH is used alone, the anal cushion cannot be completely reset, and these pathological anal cushions will not be treated. Is unreasonable. Therefore, when we treat mixed hemorrhoids, we apply cutting ligation on the basis of the PPH operation to reset the anal cushion as much as possible, and deal with the pathological anal cushion that cannot be restored. This effectively protects the normal tissues and effectively The symptoms are eliminated.
3.2 Progress in clinical practice
Because of its narrow indications, many patients in clinical practice require this less painful and short-term surgical method. Therefore, many doctors in clinic modify PPH surgery to treat hemorrhoids, which broadens the surgical indications of PPH surgery. , And achieved good results.
Liu Kebin  performed partial hemorrhoidectomy in 80 cases of circular mixed hemorrhoids, followed by standard PPH surgery. Results: The anus was smooth and no edema after defecation, no hemorrhoids prolapsed or foreign body sensation in the anus was seen after defecation, no narrowing of the anal canal and anal stenosis. Conclusion: The results show that circular mixed hemorrhoids can be treated with PPH plus partial hemorrhoidectomy, with satisfactory curative effect and feasible.
Wang Xiaopeng, Jin Chunmin, Wu Zhongde et al. compared 35 cases of grade III and IV mixed hemorrhoids treated with PPH plus external hemorrhoidectomy with 35 cases treated with PPH alone during the same period. The results showed that there was no statistically significant difference between the two groups in terms of operation time, postoperative complications, and postoperative hospital stay. The results show that PPH plus external hemorrhoidectomy can expand the scope of indications for simple PPH surgery and improve patient satisfaction .
Four, problems and prospects
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