2020年12月17日星期四

hemorrhoids picture,Complications after PPH

    PPH (procedure for proplase and hemorrhoids), namely prolapsing hemorrhoids, also known as stapled hemorrhoidectomy or prolapsing hemorrhoids, anal pad suspension, is a rectal surgery reported by Italian scholar Longo in 1998 A new method of circular resection of lower mucosa and submucosa tissues for the treatment of Ⅲ and Ⅳ degree circular prolapsed internal hemorrhoids. Based on the modern concept of hemorrhoids, the theory of "anal cushion" was put forward in anatomy and physiology, which produced this revolutionary surgical method. After this surgical method was introduced to China in 2000, it has been quickly promoted due to its short operation time, less bleeding, light postoperative pain, low recurrence rate and quick postoperative recovery. Although it is reported in the literature that PPH surgery is better than traditional hemorrhoidectomy in terms of operating time, intraoperative blood loss, postoperative pain, and hospitalization time, there are still reports of complications during the several years of clinical promotion. Therefore, while our clinicians are proficient in surgical operations, they should also be good at analyzing the causes of surgical complications, and further research to solve clinical problems in the prevention and treatment of complications. The following describes the possible complications after PPH:

    1. Intraoperative complications

    (1) Abdominal pain

    Some patients complain of discomfort or cramping pain in the lower abdomen when firing the stapler, and occasional changes in vital signs such as slowed heartbeat and drop in blood pressure, which are mostly transient and can be tolerated by the patient, and are more common in intraoperative tightening or The moment the stapler is fired, it can relieve itself after releasing the stapler. The mechanism of discomfort or pain is mostly related to the intestinal wall being involved during the anastomosis, the suspension is too tight, and the visceral nerve is stimulated. We believe that the main reasons are: the intestinal wall muscles are stretched during the resection of the rectal mucosa, more tissue is removed, the purse string suture is deeper, part of the intestinal wall muscles are directly removed, the anesthesia is insufficient, and the visceral nerve tension is too high. When abdominal pain occurs during operation, 654.2 intravenous infusion and intramuscular injection of Dulan Ding and Phenogen can be used.

    (Two) bleeding

    Bleeding immediately after intraoperative anastomosis is divided into obvious bleeding, pulsatile bleeding and bleeding from anastomotic tears. Among them, bleeding caused by anastomotic tear is one of the serious complications during the operation. If there is obvious bleeding or pulsatile bleeding during the operation, silk sutures can usually stop the bleeding. The common reasons for this are: ①The position of the purse string suture is shallow, only under the mucosa, and there is less tissue pulled in, or even the mucosa is cut, the anastomotic tissue is thin or missed, and the tissue between the feet of the staple "B" is thin. Can not effectively suppress bleeding. ②Rough operation when removing the stapler after anastomosis. ③The hemorrhoid mucosa was not completely cut during the firing of the stapler. Excessive traction during the removal of the stapler caused the anastomotic opening to tear and cause hemorrhage.

    2. Postoperative complications

    (1) Anal bulging feeling

    Lin Lingli et al. randomly divided 200 patients with grade III-IV circular mixed hemorrhoids from June 2002 to May 2005 and randomly divided them into PPH combined hemorrhoidectomy group (referred to as PPH group) and open external stripping Internal ligation group (referred to as traditional group), 100 cases in each group. Postoperative observations showed that the PPH group had less postoperative pain, significantly reduced the number of analgesic medications, lower incidence of anal marginal edema, less anal fluid, and no anal stenosis, which were significantly better than the traditional group. However, the incidence of postoperative anal swelling in the PPH group was significantly higher than that in the traditional group. The causes may be: ①Inflammatory edema of the anastomosis occurred during the healing process. ②Rectal functional damage. ③ Invasion of the submucosal nerve nodules in the rectum. The purpose of applying antibiotics and compound carrageenate suppositories after surgery is to relieve symptoms.

    (B) Anastomotic bleeding

    Anastomotic bleeding after PPH is the most common complication. It usually occurs within 24 hours after surgery. It may be caused by incomplete rectal mucosa removed during surgery or bleeding from the anastomosis. Domestic Chen Jianying et al. reported that the incidence of anastomotic bleeding after PPH was as high as 30%, and some bleeding had to be operated to stop the bleeding due to ineffective drug treatment. The main causes of postoperative anastomotic bleeding are: ①Incomplete hemostasis during the operation or the arteries are compressed and not sutured after the anastomosis is completed. This type of bleeding usually occurs within 12 hours after the operation. ②The anastomosis position is too low or the internal hemorrhoids are too large. Part of the anal cushion tissue is removed during the operation. When the patient uses force to relieve the stool, individual staples fall off and cause mucosal bleeding. ③Turning the knob of the stapler too tightly during anastomosis may cause necrosis of the rectal mucosa; or too loosely, causing the staple to be easily torn off, and bleeding after the anastomosis is split.

    (3) Residual skin tags

    It is reported that there are still 38.8% of small skin tags after operation. The common reasons are: ①For anal skin tags with mainly internal hemorrhoids and mucosal prolapse, the postoperative effect of PPH is ideal, but for external hemorrhoids, After PPH, skin tags often remain, and the effect is worse than that of internal hemorrhoids. ②The submucosal tissue of the purse-string suture is not enough to reach the required level for downward pulling, or the purse-string suture is incomplete, and the depth of the submucosal tissue is uneven. ③ Huge mixed hemorrhoids, especially those with severe mucosal prolapse.

    (4) Anastomotic stenosis

    Postoperative anastomotic stenosis is mostly caused by scar contracture at the anastomotic site, and there are few reports of this complication. According to the statistics of the hospital, the incidence rate does not exceed 1%. We believe that because the anastomosis of PPH surgery is generally a thin rectal mucosal layer, it will not cause severe stenosis when scars are formed, unless the anastomosis is severely inflammatory or the anastomosis is unsatisfactory, which makes the scar formation wider and deeper, making the anastomosis The possibility of stenosis is increased.

    The main reasons are: ①The anastomotic position is higher. According to our observations, the patients with anastomotic stenosis after PPH are more common in those with higher anastomotic positions; there is basically no stenosis in the anastomoses with lower positions or even close to the tooth line. On this point, our observations and understandings are quite different from those of other scholars, because before that, most scholars attributed to the low anastomotic position. We believe that the traditional external stripping and internal ligation surgery is far lower than the PPH surgery, but it does not cause more postoperative anal stenosis. Combined with the clinical observation results, we believe that the high position is the main reason for the anastomotic stenosis . ②Inflammation: Anastomotic stomatitis is the most important factor leading to anastomotic stenosis, especially in poor quality staples, which are prone to anastomotic nails outcropping without falling off, leading to anastomotic stomatitis, which can cause anastomotic tissue hyperplasia, thickening, and spasm. ③The purse string suture is too deep, and the intestinal wall muscle tissue is nailed too much.

    In this regard, we mainly adopt the following treatment methods: one is intraoperative prevention, and the other is regular postoperative review. From experience, it is more appropriate to review about half a month after surgery. At this time, the anastomosis is basically healed but the tissues are not yet aging. Appropriate local massage during the digital examination will help prevent the anastomoses from being narrow. The third is to expand the anus. When the early stenosis anastomotic tissue is not yet aging, the anus can be enlarged with the index finger or rectalscope. Fourth, the anastomotic nails were taken out under the rectoscope with hemostatic forceps, and the anus was enlarged after the nails were taken. Fifth, if the stricture is severe, and the tissue is completely aging, the anus enlargement with fingers or a rectoscope is no longer effective, and the anastomotic stricture should be relaxed under anesthesia.

    2.5 Recto-vaginal fistula Recto-vaginal fistula is a serious complication after PPH surgery. The main reasons are: ①The purse-string suture is too deep and the rectum is resected. ②The posterior wall of the vagina before the closed stapler is pulled into the stapler to damage the vaginal wall. ③ Anastomotic infection.

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