Abstract: Objective To explore the prevention and management of complications of prolapse and hemorrhoids (PPH). Methods 147 cases of severe hemorrhoids were treated with modified hemorrhoidal mucosal circumcision and nailing, and the relationship between the surgical skills and postoperative complications was analyzed. Results All the prolapsed hemorrhoid tissues immediately retracted completely after the operation. Different degrees of abdominal discomfort, dysuria, pain, swelling in the anus, and hot sensation were the main pain points of the patient on the day of the operation, which lasted 1 to 16 days and disappeared. 36 Cases had intermittent blood in the stool from the 1st to 12th day after operation, which disappeared after conservative treatment. There was no recurrence of anastomotic stenosis, anal incontinence, and prolapse during the follow-up period of 1 to 37 months. Conclusion The improved PPH operation method can prevent, reduce or even eliminate various postoperative complications.
Keywords: hemorrhoids/surgery; circumcision and nailing of hemorrhoids (PPH), complications; prevention and treatment
1 Clinical data and methods
1.1 General information
6 cases of internal hemorrhoids in stage Ⅱ, 25 cases in stage Ⅲ, 31 cases in stage Ⅳ, 50 cases of mixed hemorrhoids predominantly internal hemorrhoids, 17 cases of mixed hemorrhoids predominantly external hemorrhoids, 18 cases of mixed hemorrhoids comparable to internal and external hemorrhoids, of which 1 or more are huge There were 66 cases of severe hemorrhoids with type internal hemorrhoids; all patients had two (including two) or more prolapsed hemorrhoids (occupying more than 1/4 of the anus), of which 117 cases were circular.
Adopt the supporting equipment produced by Johnson & Johnson, including the disposable round hemorrhoid stapler PPH01 or
03. Anal canal dilator, anal mirror suturing device and threading device, as well as "2-0" Prolene purse string with needle at both ends and "3/0" Vicryl absorbable hemostatic thread.
1.3 Surgical methods
Preoperative preparations include oral preparation of compound mannitol half a day before surgery, fasting for 6 hours, water for 4 hours, taking the bladder lithotomy position under spinal anesthesia, and establishing intravenous access. The drip rate is generally not more than 80 drops/min. The operation is carried out in accordance with the operating steps recommended by Johnson & Johnson, but there are important technical improvements: ① The position of the purse-string suture is not determined by the dentate line, but by the position of the upper edge of the hemorrhoid, the size of the hemorrhoid or the position of the dentate line. The position of the upper edge of the hemorrhoid is used as the main positioning basis. The dentate line is still clearly visible. We refer to the size of the hemorrhoid and the dentate line to determine the position of the purse-string suture. The dentate line is fuzzy or has completely disappeared Yes, we take the position of the upper edge of the hemorrhoid as the main basis, and then refer to the size of the hemorrhoid to determine the position of the purse-string suture. For smaller hemorrhoids, we design the anastomosis directly above the hemorrhoid, 1.5 at the upper edge of the hemorrhoid. Purse-string suture is performed at cm～2.5cm. For larger and huge hemorrhoids, consider partial excision of the upper end. Generally, purse-string suture is performed at 0.5cm～1.5cm of the upper edge of the largest hemorrhoid; ②, when fixing the anal dilator , Use non-traumatic forceps to pull the skin of the anal canal to expose the internal hemorrhoids, and it must be appropriate, because if the hemorrhoids are exposed too much, the suspension effect will be poor, and too much hemorrhoids in the anus will affect the vision when sewing the purse; ③ , When the purse-string is sewn, after loosening the traction forceps, use the index finger or non-traumatic forceps to wrap the gauze to push the hemorrhoids and the prolapsed anal canal tissue into the rectum as much as possible, because when the hemorrhoids are too large, the fixed anal canal dilator will Tightly squeeze it on the anal canal. If you do not push this part of the hemorrhoids in first, rotating the stapler tail knob alone will not pull the center rod up, and the effect will be unsatisfactory; ④, emphasize on tightening the stapler At the same time, it is necessary to continue to pull the purse-string forcefully and the stapler must be received the tightest before firing.
The appearance was observed after the operation. 21 cases of larger hemorrhoids were trimmed and the incisions were sutured, while 13 cases with only a few small skin tags were left untreated.
The operation time was 8 to 45 minutes, with an average of 21 minutes. After the PPH operation, all the hemorrhoids prolapsed from the anus of all patients were immediately retracted, and the effect was immediate and the effect was significant. The resected tissue was in 146 cases with a complete circle, 1 case was incomplete, 83 cases were uniform in width, and 64 cases were inhomogeneous. The width was 2.1 to 4.6 cm, with an average of 3.6 cm. 83 patients were very satisfied, 61 were satisfied, 3 were basically satisfied, and none were dissatisfied.
2.2 Complications and treatment
Abdominal discomfort, difficulty urinating, pain, sensation of falling into the anus, and hot discomfort are the main pains on the day after PPH. For the first 40 patients, we only performed symptomatic treatment for pain and urinary retention. The feeling of swelling in the anus or hot discomfort was not dealt with. After 107 patients, we routinely took 2 tablets of Colotril 5-8 hours after surgery to relieve the above symptoms. After operation, 36 patients had intermittent blood in the stool from 1 to 12 days, most of which were caused by dry stool. One case of hemorrhage was cured by conservative treatment. Twenty-three patients who did not urinate 4 to 13 hours after the operation were treated with urinary catheterization, and the catheter was removed on the second day. On the second day, one case of external hemorrhoids with thrombosis was removed under local anesthesia. Follow up for 1 to 37 months without anal incontinence, recurrence of prolapse, and anastomotic stenosis.
Since the stapler used in PPH is more expensive, and China is still a developing country, the number of hemorrhoid patients who can accept and bear the procedure is still very limited. Therefore, it will take time to develop this technology widely, and it is lacking and difficult to organize multi-centers. The study of large numbers of cases has not yet formed a mature operating standard, which has also led to various complications after surgery. According to Wang Jianping statistics  The incidence of blood in the stool is 10.0-38.5%, and the anal pain is 10.0-80.7%. 13.8-18.8% need to use analgesics, urinary retention 17-65%, lower abdominal discomfort 21.1-23.9%, dysuria 5.8-15.4%; because PPH surgery is more expensive than traditional resection surgery, patients have higher expectations, so even if it is better than traditional The minor complications of surgery will also affect the satisfaction of patients. How to avoid and prevent postoperative complications of PPH is an important part of improving patient satisfaction.
3.1 "Bleeding" Bleeding is the most dangerous complication of PPH surgery, including intraoperative bleeding and postoperative bleeding. Fu Chuangang reported  52 patients showed a little bleeding at the anastomotic site after pulling out the stapler, including 30 patients with 1 to 3 pulsatile bleeding; Yao Liqing  believed that postoperative bleeding was caused by PPH. One of the 3 major complications. According to our statistics, 60 of the 147 cases had hemorrhage at the anastomotic stoma, including 48 cases of oozing blood and 12 cases of pulsatile hemorrhage, accounting for only 40.8%. The analysis of the reason why we had less anastomotic bleeding during the operation may be related to our rotation. While tightening the stapler, continue to pull the purse-string with force until the surgeon and the assistant with the strongest strength can no longer turn the knob. As the stapler is being tightened, the purse-string is being pulled continuously, so There are relatively more tissues entering the staple window of the stapler. The "2-0" purlin purse string has a high tensile strength and can be pulled with complete confidence. 103 of the 147 cases have the red line in the indicator window. The bottom line, the other 44 cases all reached the back 1/3 near the bottom line, indicating that the tissue entering the staple window was squeezed very tightly, and the staple foot of the stapler was also very short, so the staple was firmly nailed after firing and there was little bleeding. Through the improvement of our operation technology, the average width of the tissues cut by PPH reaches 3.6cm, and the retraction effect is remarkable. Even for huge and severe hemorrhoids, the anastomotic situation can be clearly seen, and all anastomotic bleeding can be seen directly The "3/0" Vicryl absorbable thread is stitched in a "8" shape. The bleeding stops immediately and hemostasis is complete. 36 patients had intermittent blood in the stool from the 1st to 12th day after the operation, including 1 case of massive hemorrhage. The size of the hemorrhoids in this patient was significantly different. During the operation, we hoped to cut the tissue in the smaller hemorrhoids, so the needle was intentionally inserted in the smaller hemorrhoids. The hemorrhoid mucosa was wounded and the cut tissue was not a complete circle. At that time, there was no bleeding, which was not treated. It caused heavy bleeding on the 5th day. The bleeding was stopped after being compressed by oil gauze, prompting the seam. Even the small hemorrhoids should not be inserted too shallowly during the purse. It must go to the submucosa. Otherwise, the hemorrhoids may be torn and the hemorrhoids may be left with hidden dangers of bleeding. The residual hemorrhoids should be sutured and removed (4). We believe that prevention The key to massive bleeding after surgery is to handle the anastomosis well, and to avoid damage to the rectum and hemorrhoids. Therefore, when sewing a purse, the needle must be inserted into the submucosa. If you are not sure, it is better to be deep than shallow. Before inserting the tip of the stapler, first put your index finger into the top of the purse to test the tightness. Apply paraffin oil to the tip before inserting it. After firing, you should also act gently when pulling out the stapler to prevent damage to the mucosa. Or damage the mucosa and do a thorough suture to stop bleeding is a reliable guarantee to prevent postoperative bleeding. The other 35 cases of blood in the stool were caused by residual internal hemorrhoids or gaps in the anastomotic stoma. Dry stool is the main cause. Generally, the amount of bleeding is small, and the symptoms of internal hemorrhoids are bleeding. The color is bright red, dripping blood. Blood on the surface of the stool or wipe blood with toilet paper. All constipation can be relieved by dietary conditioning or oral Maren soft capsules. At the same time, the blood in the stool disappears after 1 to 4 days after intraanal embolization with tannin. Instruct the patient to keep the stool smooth and avoid spicy food. , It is not advisable to eat products that nourish qi and blood to prevent blood from flowing with qi and causing blood in the stool. It is worth mentioning here that for larger hemorrhoids, it is best to use Johnson & Johnson's stapler. We have used a domestic reusable stapler because the cut surface of the larger hemorrhoid was not nailed after firing. Hemorrhage .
3.2 Difficulty in urination Difficulty in urination is also one of the main complications after PPH, Fu Chuangang reported  of 52
Among the cases, 34 cases required urinary catheterization, accounting for 65.4%, but only 23 of the 147 cases of PPH we did were catheterized, accounting for only 15.6%. We believe that water was absent for 4 hours before surgery to cause mild dehydration. Drinking water only after seeing urine after surgery, intraoperative and postoperative fluid replacement is controlled within 750ml, which plays an important preventive role.
Pain Since PPH surgery is performed above the dentate line, it should not be painful in theory if it is performed purely PPH. However, in addition to 21 cases of trimmed external hemorrhoids, 15 cases have pain as the main complaint after surgery, there are also 5 cases of untrimmed external hemorrhoids also complained of pain, which may be caused by sphincter spasm, anus expansion, thrombosis, etc. The sphincter spasm is related to surgical trauma, low anastomosis, and the amount of muscle cut. Gentle operation, not too low anastomosis, and purse-string suture sneaking in the submucosa are important precautions to avoid postoperative pain.
3.3 Anastomotic stenosis and postoperative recurrence Anastomotic stenosis and postoperative recurrence are the other two that Yao Liqing (3) thinks
Major complications, we have also reported cases of recurrence 1 month after PPH in the outside hospital , but the 117 patients who underwent our operation were followed up for 1 to 37 months, and there was no short-term recurrence and anastomotic stenosis.
3.4 Discomfort of abdominal distension, sensation of falling into the anus, feeling of hotness.
Summarizing the clinical data of our 147 patients undergoing PPH surgery, different degrees of abdominal discomfort or hotness or sensation of falling stool in the anus are often the main pain points on the day after PPH. They occur sequentially, simultaneously or alternately, with varying degrees of severity. Among the 147 cases, 47 cases complained of abdominal distension and discomfort as the main complaint, 37 cases complained of hot sensation as the main complainant, 28 cases complained of feces sensation, and 15 cases complained of anal bulging. It is believed that this is a normal reaction after PPH, and it is inevitable, because PPH surgery cuts off the sensitive lower rectal mucosa or part of the pathological anal cushion and nails it, due to the huge mechanical nature of the firing The impact effect makes the anastomosis inevitably produce a kind of aseptic inflammatory reaction, with different degrees of hotness and swelling feeling. These feelings will vary with the size of the trauma, and also due to the individual differences in the patient’s perception. The severity is different, and due to the anesthesia, the patient will have difficulty urinating and unable to exhaust, resulting in abdominal distension and discomfort. As the anesthesia disappears, urination and gas discharge, various discomforts will be significantly improved 10 to 36 hours after surgery. But it will last for 1 to 3 days, and some people will disappear completely after only half a month. After realizing that this is a normal reaction after PPH, we routinely took 2 tablets of Kolotril tablets 5 to 8 hours after surgery to relieve the symptoms of the last 107 patients, which significantly reduced the suffering of patients and improved Improve patient satisfaction.
It can be seen from the above that the complications during and after PPH operation are not terrible, and the danger and pain caused by them can be prevented and alleviated by improving the operation technique. We believe that the upper edge of the hemorrhoid is the main basis for the positioning of the purse string. Close objects can make the operation convenient and easy to control; in addition, we also pay attention to the hemorrhoids and prolapsed anal canal tissue as far as possible into the rectum with the index finger or non-traumatic forceps after the purse string is sewn and the retractor is loosened. Push, while emphasizing that when tightening the stapler, we must continue to pull the purse-string forcefully and after the stapler is received the tightest, then fire it, although our purse-string suture should be 3.5cm～5.0cm from the dentate line. However, through these technical improvements, the loose mucosal tissue and part of the huge hemorrhoid tissue in the lower rectum can be pulled into the stapler and cut to the maximum. The retraction effect is very significant, and the anastomosis is also clearly exposed. The pulsating bleeding, oozing and occult hemorrhage of the anastomosis can be thoroughly treated to prevent massive bleeding after the operation. The results show that the method of deliberately lowering the anastomosis in pursuit of the recovery effect is not advisable or not If necessary, it will only increase complications and bring pain to the patient (the pain is severe, the anus is swollen and the stool is obvious, and the duration is long).
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------This paper has been published in Journal of the First Military Medical University, Issue 8, No. 1037-1039, 2005.