2020年12月24日星期四

hemorrhoids ligation,Consensus of Chinese Experts on Hemorrhoid Ligation Treatment (2015 Edition)

    Rubber Band Ligation (Rubber Band Ligation)

    🔹More than 50 years of history

    🔹In 1963, Barron first reported hemorrhoid rubber band ligation

    🔹First-line treatment commonly used in Western countries

    Hemorrhoids apron band ligation therapy (domestic)

    🔹In 1974, Lu Qi, Zhejiang, developed an attracting band ligation device, and its attracting part is mainly composed of an electric attractor

    🔹In 1997, Shanghai Yu Dehong and others made attracting and pulling ligators

    🔹Fujian Deng Zhengming uses the principle of cupping to form negative pressure suction to change the electric suction into a cupping-like device

    🔹In 2010, Lu Zhonghua invented an automatic negative pressure hemorrhoid ligator (patent number ZL201010611509.1)

    Won the national invention patent

    Hemorrhoids band ligator first generation

    Hemorrhoids band ligator second generation

    Hemorrhoids band ligation device third generation

    Hemorrhoids are common and frequently-occurring diseases of the anus. There are many ways to treat hemorrhoids, each with its advantages and disadvantages. Simple, minimally invasive, low-cost and effective surgical methods have always been the goal pursued by anorectal surgeons at home and abroad. Hemorrhoids apron band ligation is a method of elastic ligation using a rubber ring. A small apron is used to enclose the upper pole area of ​​the internal hemorrhoid through an instrument, and the continuous elastic binding force of the apron is used to block the blood supply of the internal hemorrhoid and induce inflammation , Make local tissue fibrosis, scar formation, and achieve the purpose of treatment.

    Blaisdell first used band ligation to treat internal hemorrhoids in 1954 [1]. In 1962, Barron made improvements and published an article reporting the good effect of hemorrhoid band ligation [2]. After that, hemorrhoid band ligation began to be obtained clinically. Wide range of applications. After decades of development and improvement, the ligation equipment has evolved from the initial surgical forceps ligation to the later special apron ligation device, including pull-in ligation equipment and suction ligation equipment, and some scholars use endoscopes to apply glue. Strap ligation treatment.

    Clinical practice and more and more professional literature have confirmed that band ligation has good short-term and long-term effects on hemorrhoids. MacRae [3] conducted a Meta analysis of common treatments for hemorrhoids and concluded that apron ligation is the most effective non-surgical treatment for hemorrhoids. Bartizal and Sloberg [4] conducted a short-term follow-up of 670 patients with a total of 3028 apron ligation treatments, and reported that their complications were only seen in pain and bleeding, the probability of pain occurring was about 4%, and the obvious bleeding was about 1%. Forlini[5] found through long-term follow-up of 206 patients with Ⅱ~Ⅲ internal hemorrhoids that 90% of the patients had their symptoms disappeared after 1 year, and 69% of patients were still asymptomatic after 10 to 17 years, and only 3% of patients needed further surgery , Lu et al. [6] also reached similar conclusions on 368 patients who followed up for 2 to 11 years. Sekowska [7] reported that the effective rate of rubber band ligation for second-degree hemorrhoids was 89%, and the effective rate of third-degree hemorrhoids was 85.2%. Bayer et al. [8] followed up 2934 patients with II to III degree hemorrhoids with rubber band ligation during 12 years. 79% of the patients were completely cured by the ligation, 18% of the patients required re-ligation, and only 2% of the patients required further treatment. Hemorrhoidectomy. Iyer [9] reported that 805 patients were treated with rubber band ligation, the symptom relief rate was 80.2% and there was no significant difference in the effective rate of hemorrhoids in different degrees. At present, apron band ligation has become the first choice for the treatment of symptomatic hemorrhoids [10, 11].

    Although hemorrhoid ligation is simple and convenient, it still needs standardized operation to achieve good results and reduce the incidence of complications. Therefore, all the experts of the Hemorrhoid Bandage Treatment Expert Group of the China Integrated Traditional Chinese and Western Medicine and Colorectal Diseases Committee discussed and reached a consensus, aiming to standardize the clinical application of hemorrhoid banding treatment.

    1. Indications and contraindications for hemorrhoids with rubber band ligation

    1

    Indications

    Hemorrhoid ligation treatment is suitable for hemorrhoids with prolapse and bleeding symptoms, including internal hemorrhoids of degree I, II, and III and mixed hemorrhoids. After the internal hemorrhoids of mixed hemorrhoids are ligated, the lifting effect causes the mucosa to retract, and the prolapse of external hemorrhoids can also be improved to varying degrees.

    2

    Contraindications for ligation of hemorrhoids

    ①Severe heart, liver, kidney disease and coagulation dysfunction (including ongoing anticoagulation therapy);

    ②Have a history of pelvic radiotherapy;

    ③Severe immunodeficiency[12];

    ④Serious infection or inflammatory disease in rectum and anal canal;

    ⑤Recent (within 3 months) history of sclerotherapy injection.

    2. Hemorrhoid rubber band ligation treatment operation

    1

    Ready to work

    1. Preparation of the patient

    ①Inquire the medical history in detail, exclude the contraindications related to surgery, and pay attention to the lesions that cause the main complaint;

    ② Check before routine treatment, including electrocardiogram, coagulation, etc.;

    ③ Routine digital anorectal examination and anoscopy, with early warning symptoms, such as advanced age, history of gastrointestinal tumors, blood in the stool, melena, etc. [10], colonoscopy and related examinations are recommended before treatment to rule out colorectal related diseases.

    ④ Empty stool before treatment;

    ⑤Conversations must be paid attention to before treatment. The operation process of ligating hemorrhoids, the discomfort that may be caused, and how the patient cooperates must be explained in detail, and informed consent must be obtained.

    2. Preparation of venue and items

    ①The hemorrhoid rubber band ligation treatment needs to be carried out in an independent consulting room, pay attention to protecting the privacy of patients;

    ② Good light source conditions are required;

    ③Special anus speculum for band ligation;

    ④Good lubrication;

    ⑤Special ligature (drawing or suction type), suction type usually needs to be connected with special negative pressure suction equipment (negative pressure range 0~0.10KPa), it is recommended to use a disposable minimally invasive hemorrhoid cover with negative pressure and light source Tie device

    ⑥The size and inner diameter of the apron used should be appropriate, and the elasticity and toughness should be moderate. The quality of the apron is one of the key factors for successful treatment.

    2

    treatment

    1. Treatment position

    Hemorrhoid rubber band ligation treatment can choose lateral position, folding knife position and bladder lithotomy position according to the patient's condition and operator's habits.

    2. Operation steps

    ①Sufficient lubrication and moderate anus expansion;

    ②Exploratory evaluation: including size and distribution of hemorrhoids;

    ③Ligation site: First select the most severe lesion for treatment, usually 1-2cm above the dentinal line, which is located on the supramucosa of the hemorrhoids. After ligation, the rubber ring should be completely above the dentinal line. After inhaling the target tissue, release the negative pressure, observe the range of the inhaled mucosa, repeat it many times to obtain a satisfactory position and then activate the apron to complete the banding. It should be noted that if the ligation site is too low, it will cause unbearable pain, and multi-point ligation on the same plane or adjacent sites can easily cause tissue damage, bleeding, and apron slippage due to excessive tension. It should be combined with lesions and The distribution of the anal cushion is reasonably arranged at the ligation position;

    ④Take the inhalation banding device as an example, the negative pressure suction control is between 0.08~0.09KPa, and the diameter of the mucosal ball formed by banding is about 0.6~1.0cm.

    ⑤The number of ligation should be 1 to 3 at a time. A large number of clinical observations believe that compared with ligating a single hemorrhoid at a time, the discomfort of ligating 3 hemorrhoids at a time will increase, but this will not increase the main complications. It means that it is safe to ligate more than 3 internal hemorrhoids in a single ligation [13];

    ⑥ Drugs can be given to the anus after the banding is completed.

    3

    Postoperative treatment

    1. Intensify visits within half an hour after surgery to monitor vital signs such as heart rate and blood pressure.

    2. Postoperative dietary-related guidance should be strengthened, and laxatives, bulking agents, and stool softening drugs should be given appropriately.

    3. Explain that the patient should avoid forced defecation after the operation.

    4. It can be treated with symptomatic drugs such as swelling and pain relief. Warm water bath and effective anal cleaning and anal suppositories can relieve local symptoms.

    5. The hemorrhoids fall off about 1 week after banding, and the wound can basically heal in 3 to 4 weeks. The ideal banding interval is about 4 to 6 weeks [10].

    6. Regular outpatient follow-ups after treatment, need to understand the patient's defecation, blood in the stool and the improvement of symptoms after treatment, and give symptomatic treatment. If the symptoms are not improved well, the bandage treatment can be repeated.

    3. Treatment of intraoperative complications

    1

    Visceral nerve reflex

    Caused by anus expansion and mucosal stretching, it is mainly manifested as lower abdominal discomfort, accompanied by nausea, dizziness, chest tightness, heart palpitations, cold sweats, and pale complexion. Changes in physical signs can be manifested as a slower heart rate and lower blood pressure. Treatment method: Rest well before treatment and eat a normal diet. If the above conditions are found during the treatment, stop the operation immediately and lie supine for more than 30 minutes to recover on their own. Symptomatic treatments such as ECG monitoring, oxygen inhalation, and intravenous atropine injection can be given in emergency situations. Special attention should be paid to patients with previous cardiovascular diseases and elderly patients who have relatively poor compensatory ability. They need to be operated carefully, closely observed, shorten the operation time as much as possible, and appropriately reduce the number of bandings.

    2

    Bleeding

    Hemorrhoids with rubber band ligation is non-invasive, so bleeding is rare, and most of them are bleeding from the ligation of the mucosa, which can be self-healing. If hemorrhoids bleeding is treated again, double hemorrhoids can be ligated at the bleeding point with a good hemostatic effect.

    3

    Ligation position deviation

    The main purpose is to grasp the exact position of the ligation. If the position of the apron is deviated during the operation, too high or too low, the apron can be removed with ordinary stitching scissors or vascular forceps, and the ligation is repeated.

    Fourth, postoperative complications and treatment

    1

    Postoperative bleeding

    Bleeding is almost a problem encountered by various treatment methods of hemorrhoids. The bleeding that requires surgical intervention after banding generally occurs in 1 to 3% [4,14]. The hemorrhoid ligation itself can stop bleeding immediately. Because it takes about 1 week for the hemorrhoids to fall off, the ends of the wound blood vessels have been embolized. When the hemorrhoids fall off and before the wound is healed, there is usually a small amount of bleeding, mainly blood capillary oozing, which can heal by itself. Large bleeding is rare. Visible mucosal bleeding can also be compressed to stop bleeding. For example, heavy bleeding caused by dry and hard stools or vigorous defecation, it is mostly caused by active blood vessel bleeding caused by wound tears, and bleeding points are usually sutured to stop bleeding, which is often completed during the examination without anesthesia. However, patients with severe hemorrhage who encounter difficulty in individual exploration or who cannot determine the location of the bleeding point should be decisively sent to the operating room for careful exploration under good anesthesia, and suspicious bleeding points should be stitched one by one.

    2

    Postoperative anal bulge

    Intraoperative and postoperative bowel movements, anal bulging and discomfort are the most common complications. Rest lying supine for about 30 minutes after treatment can be relieved. Part of the symptoms can last for several days, but the symptoms are mostly mild, and can often be relieved by taking a bath and oral analgesics. After the operation, the patient should be informed of the cause of the postoperative bowel movement, and the bowel movement should be controlled as much as possible. Intraoperative use of local anesthetics cannot significantly reduce the occurrence of this symptom [15].

    3

    Postoperative anal pain

    Occasionally, postoperative pain in the anus is common. The skin of the anal canal below the dentate line is often involved in ligation. It is very important to identify the dentate line during treatment. If necessary, it can be treated with analgesic drugs, and more tolerable.

    4

    Postoperative infection

    It has been reported in the literature that there is a rare risk of fatal infection in the treatment of hemorrhoids with rubber band [16-19]. Most patients have immunodeficiency or related underlying diseases. Therefore, accurate assessment before treatment is the key to prevent serious infections. For patients with low immunity or high risk factors for systemic infection, antibiotics can be used preventively before and after treatment. If the patient has progressively worsened anorectal pain, perineal pain, scrotal swelling, or difficulty urinating after treatment, emergency medical examination and treatment are required. This may be a sign of increased local infection. Physical examination if there are symptoms such as fever, scrotal perineum swelling, ulcers, rectal examination shows ulcers, exudate, edema and even loss of tissue activity on the bandage wound, and CT/MRI of the pelvis reveals perirectal fluid and gas accumulation. Should consider the possibility of serious infection and even gangrene [20]. The causes of fatal infections are not yet clear, and cases with better prognosis benefit from early detection and active intervention.

    5

    External hemorrhoid thrombosis

    After ligation of internal hemorrhoids, the corresponding part of external hemorrhoids may be blocked due to venous reflux, and thrombosis may occur. The incidence is about 2 to 3% [21]. If thrombosis is formed, pain relief, sitz bath, etc. can be used to slowly heal by itself. Surgical removal of blood clots and hemorrhoids.

    6

    Rubber ring slips or breaks

    Rubber ring slippage or rubber ring breakage may occur at any time during the banding operation. Choosing high-quality rubber ring can reduce the risk of fracture and slippage. Apron slippage is common in the first bowel movement after surgery. Dry and hard stools or forced defecation are the inducements that cause the apron slippage. Therefore, it should be routinely placed in laxatives, expanders, or stool softening drugs after surgery. If the rubber ring slips or breaks and affects the treatment effect, the banding can be repeated 3-4 weeks after the first treatment.

    7

    fever

    It is common in clinical practice that transient body temperature rises after band ligation, most of which are low fever, the specific cause is unknown, and most of them relieve themselves. If fever persists, short-term oral antibiotics should be given to prevent systemic infection, and fever and local symptoms of banding should be closely observed.

    8

    Ulcer formation

    After bandaging, the rubber ring may fall off and form a local wound. In rare cases, ulcers may occur, and sometimes anal fissures may occur. In the treatment, conservative treatments such as topical drugs, sitz bath physiotherapy, and analgesics can be given first. If the anal fissure has not healed for a long time, it can be treated with surgery according to the anal fissure.

    The full text of this consensus has been published in the 12th issue of the Chinese Journal of Gastrointestinal Surgery, 2015

    Peng Hui

    Anorectal Lean School-Group Owner

    【Social work】

    Member of the Third Council of the World Federation of Anorectal Disease Professional Committee

    Member of the Anorectal Physician Branch of the Chinese Medical Doctor Association

    Member of the First Transanal Endoscopic Minimally Invasive Surgery Professional Committee (Study Group) of the Colorectal Tumor Professional Committee of the Chinese Medical Doctor Association

    Member of TEM (Transanorectal Minimally Invasive Surgery) Group of Colorectal Cancer Professional Committee of Chinese Anti-Cancer Association

    Member of the Standing Committee of the Anorectal Professional Committee of the Guangdong Society of Chinese Medicine

    Member of the Working Committee of Gastrointestinal Surgery Doctors of the Guangdong Medical Association

    Medical expert member of the South China Famous Medical Association of Guangdong Provincial Society of Clinical Medicine

    European Journal of Gastroenterology & Hepatology

    Techniques in coloproctology Reviewer

    【Medical Specialty】

    He focuses on the diagnosis and treatment of anorectal benign and malignant diseases, and is good at the diagnosis and treatment of pelvic floor disorders, intractable constipation, complex anal fistulas, hemorrhoids, anal fissures, and benign and malignant tumors of the colon and rectum.

    【Visit time】

    For online appointment registration, please select "Integrated Chinese and Western Medicine Anorectal Clinic"

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