2020年12月3日星期四

are hemorrhoids dangerous,Causes and countermeasures of complications after Ligasure hemorrhoidectomy

    Causes and countermeasures of complications after Ligasure hemorrhoidectomy

    Wang Ning

    Key words LigaSure, resection, complication

    Reasons and countermeasure of complications after LigaSure Hemorrhoidectmy.

    [Abstract] Objective To assess the reasons and countermeasure of the complications after LigaSure Hemorrhoidectmy. Methods Two hundreds and forty-six cases of Ⅱand Ⅳ degree haemorrhoids were treated with LigaSure from September 2007 to May 2010. The reasons and countermeasure of the complications were analyzed . Results Of the 246 patients, the operation time was between 5 and 25 min. Delay bleesing was found in 5 cases after operation. Anal pain was found in 34 cases and analgestic was necessaty. 8 patients had acute urinary retention and 12 patients had transient anal polyrrhea. Sensation of rectal unusual was found in 31 cases, residul cutaneous tag wans found in 16 cases and anal fistula was found in 1 case. Conclusion  LigaSure Hemorrhoidectmy is effective, safe, minimal invasive method and is the ideal choice to treat severe haemorrhoids .

    Keywords  LigaSure; Hemorrhoidectmy; complication

    The LigaSure resection carried out abroad in recent years uses LigaSure's unique vascular closure system, which has the advantages of less bleeding, simple operation, less trauma, light pain, and fast recovery [1-3]. However, as a traumatic treatment, some complications will still occur after the operation. Therefore, summarizing and analyzing the causes and countermeasures of the complications is one of the problems that need to be solved clinically. The following is a summary of 246 cases of complications after Ligasure resection performed in General Surgery Department of PLA General Hospital between September 2007 and May 2010:

    1. Materials and methods

    1.1 General information

    From September 2007 to May 2010, a total of 246 cases of LigaSure hemorrhoidectomy were performed in the surgical clinic of the PLA General Hospital, including 161 males and 85 females, aged 21-73 years, with an average of 42.6 years. Course of disease 1 to 45 years, an average of 17.6 years. Among them, there were 201 cases of Ⅱ~Ⅲ degree and 45 cases of Ⅳ degree. Sixteen patients had previously undergone surgery, and the remaining patients had not received surgery.

    1.2 Surgical methods

    On the evening before the operation and 30 minutes before the operation, give 20ml of Kaiseruna anal defecation. Lidocotomy was taken during the operation, and 1% lidocaine (including 1:200,000 epinephrine) was used for local infiltration anesthesia around the anus. After anesthesia, expand the anus to about 4 fingers, insert a 90° opening anoscope, clamp the hemorrhoids with Alice clamps, clamp with LigaSure clamps near the root, and electrocoagulate. After the host indicates that the coagulation is successful, remove the LigaSure clamps and approach the side to be removed. Cut the transparent coagulation band and repeat the above steps until the hemorrhoids are removed.In the case of bleeding during the operation, the LigaSure forceps can be loosened and clamped again until no bleeding occurs. After the operation, a mixture of 1% methylene blue and 1% lidocaine (1∶4) was injected locally around the wound, and compound carrageenate suppositories were routinely given to protect the wound while lubricating and laxative. Patients were followed up at 4h, 1 day, 3 days, 7 days, and 6 weeks postoperatively.

    2. Results

    The operation time of 246 patients was 5-25min (9.2±4.1min). Postoperative complications mainly include pain, bleeding, urinary retention, anal discharge, anal swelling, and the formation of new external hemorrhoid skin tags. Postoperative anal pain can be tolerated, 34 of which require oral tramadol for pain relief. No other blood coagulation methods were applied during or after the operation. 5 cases of massive bleeding occurred, all of which were secondary bleeding, of which 4 cases occurred about 7 days after the operation, 1 case occurred on the 14th day after the operation, and 3 cases were compressed The bleeding improved after hemostasis, and 2 cases required a second surgical suture. Urinary retention occurred in 8 patients after surgery, 6 patients resolved spontaneously after conservative treatment, and 2 patients needed catheterization. Another 12 people had transient anal discharge, but no obvious loss of defecation. They all resolved by themselves within 1 week after taking a bath in warm water. 31 cases of urgency or foreign body sensation in the anus after operation, no special treatment, generally no more than 72 hours. There were 16 cases of residual skin tags after operation. One patient had a simple anal fistula, and anal fistula resection was performed 3 months later. No anal stenosis was found after reexamination. During the follow-up period, no other serious complications occurred. According to the satisfaction survey, 176 people were completely satisfied, 52 people were basically satisfied, and 8 people were dissatisfied. Among them, 5 were patients with postoperative bleeding, 1 had severe postoperative pain, 1 had new skin tags after surgery, and the other had mixed hemorrhoidectomy. Anal fistula formed later.

    Table 1 Major complications after Ligasure hemorrhoidectomy

    Number of complications Proportion

    Pain 34 13. 8%

    Major bleeding 5 1. 6%

    Urinary retention 8 3.3%

    Anal discharge 12 4. 9%

    Swelling feeling 31 12. 6%

    Skin tag formation 16 6. 5%

    Anal fistula formation 1 0.4%

    3 Discussion

    The new type of tissue coagulation equipment LigaSure vessel sealer system has good coagulation characteristics and slight tissue damage. It has been applied to hemorrhoidectomy in foreign countries and achieved good clinical results. The LigaSure vascular closure system uses real-time feedback technology and intelligent host technology to output high-frequency electrical energy combined with the pressure of the vascular closure jaws to melt and denature the collagen and fibrin in the vessel wall and tissue bundle, and the vessel wall is fused and welded to form a zona pellucida , Resulting in permanent lumen closure [4]. Because LigaSure has little thermal damage, convenient operation, short time, and reliable closure of hemorrhoid blood vessels, LigSure hemorrhoidectomy has a good hemostatic effect and can significantly shorten the operation time. However, as a traumatic treatment, some complications still occur after surgery.

    Pain is the most common complication after anorectal surgery. Because there is no obvious eschar when the ligation fast vascular closure system is closed, and the heat conduction distance is short, the heat damage is small, the operation is convenient, the time is short, the closure of the nucleus nucleus is reliable, and the operation is almost bloodless, so the operation is on the anal mucosa The skin edema outside the anal margin is significantly reduced compared with traditional surgery, so Ligasure hemorrhoidectomy is less painful than traditional surgery. We found that the pain is more obvious on the night after the operation and the first defecation after the operation, and it is often relieved by a single analgesic treatment, which is significantly better than the previous conventional hemorrhoidectomy. Recent studies [5-6] also show that the incidence of pain and the use of analgesics after Ligasure resection are lower than those of traditional hemorrhoidectomy.

    Postoperative bleeding is one of the most serious complications after Ligasure hemorrhoidectomy. Bleeding within 24 hours after surgery is mostly original bleeding, and after 24 hours, bleeding is mostly secondary bleeding. Severe bleeding can lead to hemorrhagic shock. Postoperative bleeding, due to the restraint function of the anus. Make the blood flow back to the sigmoid colon or even the descending colon, and there is only a small amount of blood or no blood outflow from the anus; when the patient intends to defecate, the anus falls. Sudden discharge of a large amount of old blood and clots, the patient quickly collapsed and even shocked. 5 cases in this group were all secondary bleeding, of which 4 cases occurred about 7 days after surgery, and 1 case occurred on the 14th day after surgery. The reasons for its occurrence are analyzed as follows: ① wound infection, local tissue necrosis, and wound oozing blood; ② the ligation band is crusted and detached or split to open the blood vessel section; ③ the active bleeding point is not ligated during the operation. Because of the seriousness of postoperative bleeding, in the actual operation, we believe that the following issues need to be paid attention to: ① Surgery indications should be strictly grasped. Those with a history of hemorrhagic disease should not undergo surgery. Hypertensive patients should undergo surgery with their blood pressure under control; ②The Ligasure closing clamp does not have to clamp and resect the entire hemorrhoids, only 2/3 of the hemorrhoids can be closed and resected. Because of its thermal effect, it will spread to the blood vessels in the remaining hemorrhoids. The prohemorrhoids will gradually shrink about 3 weeks after the operation, and the closure band can be reduced at the same time Tension makes it difficult to split and hemorrhage; ③The LigaSure vascular closure system is mainly used for the removal of prolapsed hemorrhoids. Because of the wide jaws, the hemorrhoids that are not obvious to the prolapse may cause bleeding during the clamping process, and it is difficult to clamp the hemorrhoids again. It is not recommended to remove the hemorrhoids with unobvious prolapse. If treatment is really needed, consider giving injections of sclerosing agent; ④In the palpable area of ​​the mother hemorrhoids with arterial pulsation, if there is bleeding after closure, use absorbable thread in the middle of the closure zone Through the "8" stitching, only the clamp is used to close the hemostatic treatment is not reliable enough. ⑤ After moisturizing the stool, the stool should be kept soft, unobstructed, and not too hard. The use of compound carrageenate suppository after surgery has a good protective effect on the wound after LigaSure hemorrhoidectomy. In addition, the lubricating effect of carrageenate can also reduce the friction on the wound during defecation and reduce the possibility of postoperative bleeding.

    Urinary retention occurred in 8 people in this group, 7 of whom were between 20-35 years old, with a total incidence of 3.3%, which was significantly lower than traditional hemorrhoid surgery [7]. This may be related to the choice of local anesthesia and the rectum after Ligasure hemorrhoidectomy is generally not packed with gauze or cotton balls. The postoperative anal swelling sensation may be caused by surgical stimulation, dressing change stimulation or inflammatory stimulus. The prolapse of internal hemorrhoids can also cause the swelling sensation. Swelling is a symptom of rectal irritation. When the stimulating factor is removed, it will gradually relieve or even disappear: if the person is irritated by inflammation, it can be relieved after systemic or local treatment. The residual skin tags after Ligasure hemorrhoidectomy are mainly due to the need to leave enough skin bridges in order to avoid severe anal stenosis during hemorrhoidectomy. The result of this may be extra skin tags, but it will not cause symptoms or increase the risk of recurrence. Residual skin tags cause discomfort in patients and rarely require surgery to remove these skin tags. There were no complications such as anal stenosis and fecal incontinence in this group.

    The treatment effect of this group of cases is good, and there is no recurrence in the short term. Ligasure hemorrhoidectomy has the advantages of short operation time, good hemostatic effect, less trauma, fast recovery, and fewer complications. As a new method of treatment for hemorrhoids, its short-term effect is relatively positive, and its long-term effect is still Need to be further demonstrated.

    4. References

    1. Sayfan J, Becker A, Koltun L1. Sutureless closed hemorrhoidectomy :a new technique. Ann Surg ,2001 ,234(1):21

    2. Altomare DF. Tips and tricks: hemorrhoidectomy with LigaSure. Tech Coloproctol. 2009 Dec;13(4):321-2.

    3. Riegler M, Cosentini EP. LigaSure for hemorrhoidectomy. Dis Colon Rectum. 2004 Sep;47(9):1557-8

    4. Kennedy JS, Stranahan PL, Taylor KD et al. High-burst-strength feedback-controlled bipolar vessel sealing. Surg Endoscopy, 1998, 12: 876-878

    5. Tan EK, Cornish J, Darzi AW, et al. Meta-analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch Surg. 2007 Dec;142(12):1209-18

    6. Sakr MF. LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial.Tech Coloproctol. 2010 Mar;14(1):13-7.

    7. Macario A, Dexter F, Sypal J, et al. Operative time and other outcomes of the electrothermal bipolar vessel sealing system (LigaSure) versus other methods for surgical hemostasis: a meta-analysis. Surg Innov. 2008 Dec;15(4 ):284-91.

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