Clinical application of Doppler ultrasound guided hemorrhoid artery ligation
Abstract: In order to explore the clinical application value of Doppler-guided ultrasound hemorrhoid artery ligation (DG-HAL) in the treatment of anal diseases, the ultrasound Doppler hemorrhoid therapy instrument was used to treat 31 cases of hemorrhoids and cured 20 Cases (64.52%); the disappearance rate of bleeding symptoms reached 96.88%, and the disappearance rate of prolapse symptoms reached 60.00%. The results show that Doppler ultrasound guided hemorrhoid artery ligation is a low-invasive, minimally invasive surgical procedure, which is safe, effective, less painful, and less complication.
Keywords： Hemorrhoids; Doppler ultrasound guided hemorrhoidal artery ligation
1. Clinical data
1. Data source: The data of this group started from the introduction of Doppler ultrasound guided hemorrhoid artery ligation (DG-HAL) in our hospital in January 2013, and it meets the indications of this operation and voluntarily accepts the operation (plan) Of outpatients or hospitalized patients with hemorrhoids, as observation objects. For the elderly, infirm and out-of-town patients, it is generally recommended to be hospitalized, while the rest are treated in outpatient clinics.
2. Case selection criteria:
Diagnosis criteria: According to the "Interim Standards for Diagnosis and Treatment of Hemorrhoids" established by the Anorectal Surgery Group of the Chinese Medical Association in 2000.
(1) Internal hemorrhoids of degree Ⅰ, Ⅱ, and Ⅲ, and degree of internal hemorrhoid bleeding;
(2) Mixed hemorrhoids
(1) Anal infection
(2) Malignant tumors.
(3) Simple inflammatory external hemorrhoids, thrombotic external hemorrhoids.
(4) Patients with coagulation mechanism disorders.
3. General information: 21 cases in this group, including 22 males and 9 females, the youngest is 21 years old, the oldest is 67 years old, and the average age is 53.5 years; 17 cases of internal hemorrhoids, including 6 cases of grade I internal hemorrhoids and 8 cases of internal hemorrhoids grade II , 3 cases of Ⅲ degree internal hemorrhoids, 14 cases of mixed hemorrhoids.
(1) Instrument Using the hemorrhoid artery ligation ultrasonic Doppler diagnostic instrument produced by Austria A.M.I.
(2) Preoperative preparation Preoperative examination is the same as general hemorrhoid surgery. The blood, urine routine, liver and kidney function, and blood coagulation were checked. Outpatients were enema with Huili enema, and inpatients were cleaned in the morning.
(3) Position and anesthesia According to the patient's age and physical condition, the lithotomy position or lateral position is adopted, and lumbar spinal anesthesia or local anesthesia is used. The loose anus can be surface anesthetized with lidocaine gel.
(4) After the surgical procedure is successfully anesthetized, use 0.5% iodophor or chlorhexidine tincture to routinely disinfect the surgical field skin, lay a sterile towel sheet, and then use 0.5% chlorhexidine or 0.5% iodophor cotton ball to disinfect the anal canal And the lower part of the rectum. Examine the fingers and expand the anus to both fingers, connect the sterilized special anoscope and the ultrasonic Doppler hemorrhoid artery diagnostic instrument, and place it in the anorectal canal, and place the ultrasonic Doppler probe on the dentate line 2 to 3 cm Rotate the anoscope along the longitudinal axis of the anorectal canal, look for the hemorrhoidal artery under the guidance of the Doppler ultrasound hemorrhoid artery diagnostic instrument, and use 0.5% iodophor or 0.5% chlorhexidine when the ultrasound Doppler signal is obvious. Use cotton balls to sterilize the surgical operation window in the anoscope (every needle must be sterilized). Through the window, use 2 0 absorbable sutures and strong 1/2 bends to suture the hemorrhoidal artery with an "8". According to ultrasound The depth of the hemorrhoidal artery detected by the Puller hemorrhoid artery diagnostic instrument determines the depth of the needle. With the help of the thread pusher, the sutured blood vessel is ligated. After all the hemorrhoid artery ligation is completed, the anoscope is rotated again to check the ligation effect. I am not satisfied Sew again. Withdraw the anoscope 0.5 cm and repeat the above operation, but ensure that the ligation point is at least 0.5-1 cm away from the tooth line. After all hemorrhoidal artery ligation is completed, exit the ultrasound Doppler anoscope and use your fingers to check the position of the suture. , Put 5g of Kangtai ointment into the anus after operation.
For prolapsed internal hemorrhoids, after ligation of the hemorrhoidal artery under ultrasound Doppler guidance, the prolapsed internal hemorrhoids are sutured with a "8" shape with 2 0 absorbable sutures and fixed to the submucosa above the top of the hemorrhoids.
(4) Postoperative treatment Let the patient rest for about 2 hours after the operation, and then go home without any abnormalities. Or be hospitalized for observation as needed. Put Kangtai ointment into the anus twice a day, 2g each time, to eliminate the discomfort symptoms of anal swelling, reduce inflammation and stop bleeding; start eating 8 hours after the operation, and routinely use antibacterial drugs for 3 days. Follow-up and re-examination were carried out at the prescribed time after operation.
3. Observation indicators
(1) Curative effect index and score
(1) Mild: The amount is small, only the toilet paper is bloody. Score 1 point.
(2) Moderate: Dripping blood in the stool, the amount is less than 10 ml. 2 points
(3) Severe: Dripping or spurting blood in the stool, and the blood volume in the stool is more than 11 ml. 3 points
2. Get out
(1) Mild: There is a mass prolapsed from the anus during defecation and can be taken in by itself after defecation. 1 point
(2) Moderate: A mass in the anus prolapses during defecation, and manual reduction is required. 2 points
(3) Severe: In addition to the prolapse of a mass in the anus during defecation, there is also a prolapse of a mass in the anus when walking or increasing abdominal pressure (such as coughing, etc.) activities. Score 3 points.
(2) Side effects indicators
(1) Degree I: The pain is mild, no need to take analgesics.
(2) Degree II: The pain can be relieved with general analgesics.
(3) Degree III: The pain is severe, and morphine analgesics are needed to relieve the pain.
2. Defecation and urination
3. Body temperature and blood condition
(3) Efficacy judgment standard
1. Recovery: bleeding and prolapse symptoms disappeared.
2. Significant effect: more than 70% of the symptoms of bleeding and prolapse disappeared.
3. Effective: the symptoms of bleeding and prolapse disappear more than 50%.
4. Ineffective: less than 49% of the symptoms of bleeding and prolapse disappeared.
(4) Observation time of curative effect: all treatment cases were observed for 1 week. The scores of curative effect indicators on the 7, 15, and 30 days were recorded during follow-up, and the average value of 3 times was taken as the statistical result.
Fourth, the result
In this group of 31 cases, 20 cases were cured, accounting for 64.52%; 1 case was markedly effective, accounting for 3.22%; 10 cases were effective, accounting for 32.22%.
In this group of cases, after treatment with this method, only 2 cases had blood in the stool on the 7th day, and no bleeding occurred in the other patients. The disappearance rate of bleeding symptoms reached 96.88%. In 19 cases with prolapse symptoms, 10 cases disappeared after treatment, and 7 cases improved significantly. The disappearance rate of prolapse symptoms reached 60.00%.
The average length of stay for 10 inpatients was 4.5 days.
2. Side effects
Only one case of non-infectious second-degree anal pain related to surgery occurred after operation. The rest had no obvious anal pain. One case developed anal pain, fever, elevated blood picture, and obvious tenderness under the local mucosa of anal digital examination on the 3rd day after the operation. After the application of antibiotics, the symptoms disappeared on the 7th day after the operation. None of the remaining patients had fever or abnormal blood picture. None of the 31 patients had anal dysfunction such as defecating dysfunction and had no abnormal urination.
1. About the mechanism of Doppler ultrasound guided hemorrhoid artery ligation
The mechanism of DG-HAL operation mainly has the following aspects: (1) After ligating the arteries, the blood entering the internal hemorrhoids is blocked. Since the venous return is not compromised, the inflow/outflow ratio will be reduced at the same time. In this way, hemorrhoids will shrink, and bleeding and pain will disappear. (2) As the tension decreases, the connective tissue will also regenerate, thereby promoting the contraction of hemorrhoids. (3) After ligation, chronic inflammation is caused locally, resulting in tissue fibrosis, which makes the mucosa and submucosal adhesion and fixation, the hemorrhoid atrophy disappears, and ultimately leads to a significant reduction in hemorrhoid prolapse. This entire process supports the "high tension hemorrhoid pad" theory [1~2]. (4) After ligation, the rectal mucosa and suprahemorrhoidal artery may be directly sutured and fixed to the muscular layer, which prevents the anal cushion from moving downward and suspends and resets the prolapsed anal cushion. Because the ligation site is high and most of the anal cushion tissue is preserved, the postoperative response is significantly reduced.
In 1975, Thomson put forward the theory of lower anal cushion and gradually gained recognition. For the surgical treatment of hemorrhoids, there is also a consensus. Asymptomatic hemorrhoids do not need treatment. The purpose of symptomatic hemorrhoids treatment is to eliminate or relieve symptoms, mainly to correct the pathophysiological changes, rather than radically cure the anal pad with pathological changes. It is based on the concept of painless and minimally invasive that the Japanese scholar Morinaga K reported for the first time in 1995 that hemorrhoids were performed using a proctoscope (Moricorn) with an ultrasound Doppler probe combined with an ultrasound Doppler flow meter. Arterial ligation, hemorrhoid artery ligation using Moricor is considered simple, safe, and very effective. 
2. Regarding the indications of DG-HAL surgery
Many researchers have conducted follow-up studies on the treatment of hemorrhoid artery ligation for patients with degree I to IV hemorrhoids. They believe that the best indication for hemorrhoid artery ligation is II to III degree internal hemorrhoids or mainly II to III degree internal hemorrhoids. Mixed hemorrhoids[5~8]. Lienert M and Ulrich B believe that non-prolapsed hemorrhoids are the most ideal indication for hemorrhoid artery ligation . We believe that any internal hemorrhoids with bleeding symptoms are indications for hemorrhoid artery ligation, and other causes in the anorectal area. Sometimes the acute bleeding caused by DG-HAL can be used as a good adjuvant treatment. DG-HAL has a certain suspending effect on prolapsed hemorrhoids, but its long-term effects need to be further studied.
In this group of data, 19 patients had symptoms of prolapse. We used DG-HAL surgery while adding a suspension method, which greatly improved the degree of prolapse.
3. Evaluation of DG-HAL technique
This group of data shows that DG-HAL has the advantages of simple operation, accurate hemostasis, a certain suspension effect in the near future, and less intraoperative and postoperative complications. This operation has minimal damage to the patient and can even be in local anesthesia. It is performed under no anesthesia, which further reduces the negative reactions that may occur after the operation and shortens the healing time. Compared with the traditional ligation therapy, the postoperative complications are significantly reduced. We counted 230 cases of third-degree internal hemorrhoids and mixed hemorrhoids treated by traditional external resection and internal ligation in our department from January to December 2013. The incidence of anal pain was 46%, the incidence of urinary retention was 6%, and the incidence of anal edema The rate was 16.8%, and the average length of stay was 8 days. The incidence of anal pain in the DG-HAL procedure used in this group was only 2%; there was no case of anal edema and urinary retention.
Hemorrhoidal artery ligation is an extension of traditional ligation therapy and an upgrade of traditional ligation therapy. It locates the hemorrhoidal artery more accurately and blocks blood flow more directly. The exact curative effect of hemorrhoid artery ligation, its shorter hospital stay, lower complication rate and lighter postoperative pain make it more suitable as a rapid treatment surgical procedure, and it also meets the minimum invasive surgical procedure Requirements.