Clinical study of segmental ligation and suspension for treatment of circular mixed hemorrhoids
[Abstract] Objective To investigate the clinical efficacy of segmented ligation and suspension in the treatment of circular mixed hemorrhoids. Methods Forty patients with circular mixed hemorrhoids were divided into two groups: 20 patients in the treatment group used segmented ligation and suspension, and 20 patients in the control group used traditional external stripping and internal ligation. The wound healing time and complications were observed after operation, and both were followed up for 2 years to observe the recurrence. Results The postoperative curative effect of the treatment group was better than that of the control group, the healing time was shorter than that of the control group, and the complication rate and recurrence rate were lower than the control group. Conclusion The segmental ligation and suspension procedure preserves the tooth line to the maximum extent, can maintain the normal position of the anal cushion, and reduces the postoperative complications and recurrence rate. It is a reasonable and effective procedure for the treatment of circular mixed hemorrhoids.
[Key words] Annular mixed hemorrhoids; segmented ligation and suspension; external stripping and internal ligation
The treatment of annular mixed hemorrhoids is a difficult problem in the anorectal department. Although traditional external stripping and internal ligation are widely used, the postoperative wounds are large, slow healing, prone to anal stenosis, anal discharge, and decreased ability to control stool. Complications, but now the more popular stapler promucosal circumcision (PPH) is difficult to promote in the grassroots due to its high cost. From December 2004 to December 2006, our hospital used segmented ligation and suspension to treat ring mixed hemorrhoids and achieved good results. The report is as follows.
1 Clinical data
1.1 General information Selected 40 cases of circular mixed hemorrhoid surgery patients admitted to this hospital during the above period, 23 males and 17 females; aged 22-73 years (56.5±7.9) years old; no metabolic and endocrine diseases were checked at the time of enrollment. According to the order of selection, they were randomly divided into 2 groups: treatment group: 20 cases, 12 males and 8 females; age (57.1±8.5) years; 13 cases within 5 years of disease course, 7 cases over 5 years. There were 20 cases in the control group, including 11 males and 9 females; age (56.8±7.4) years; 11 cases within 5 years and 9 cases over 5 years. The gender composition and age distribution of the two groups are comparable.
1.2 Treatment method Treatment group: Mainly adopt internal hemorrhoid ligation and external hemorrhoid peeling. Based on the characteristics of circular internal hemorrhoids and external hemorrhoids, the hemorrhoids are naturally divided into 4 to 5 segments of ligation and peeling. The specific operation method: the patient takes the stone cutting position, fully exposes the anus, routinely disinfects the perianal drape, and uses 1% lidocaine 10-20 mL perianal infiltration anesthesia. After the anesthesia takes effect, routinely disinfect the anus and expand the anus. Perform stripping and ligation at the obvious natural segmentation of the hemorrhoids, use hemostatic forceps to lift the external hemorrhoids, make a "V"-shaped incision along the notch of the external hemorrhoids, cut the skin and mucous membrane, bluntly peel to the tooth line, clamp the internal hemorrhoids to the sphincter In the upper part, the "8" shape of the 7th line runs through the suture; the same method is used to treat the mixed hemorrhoids in the rest of the hemorrhoids, and the skin bridge must be more than 1 cm between the two strips of the mixed hemorrhoids. At the preserved skin bridge, ligate the hemorrhoid artery with a 2/0 long-term absorbable thread at the 0.5cm of the upper pole of the hemorrhoid, pass the suture needle through a small amount of muscle layer, and leave the thread long. Use Alice to lift the hemorrhoid, one of them Re-thread the needle through the upper pole of the hemorrhoid through the submucosa obliquely through the submucosa 0.5 cm from the left edge of the hemorrhoid, and then through the same point on the right edge of the hemorrhoid, and then through the upper pole of the hemorrhoid, and finally tighten the two thread ends to fix the place. For internal hemorrhoids, treat the remaining hemorrhoids in the same way. Finally, if there are still protruding hemorrhoids, you can choose arc-shaped incision to remove part of the skin tag and peel off the venous mass according to the hemorrhoid body, trim the skin flap, align the wound surface, and strive to cover the anal canal with a smooth and beautiful skin. Sphincter relaxation is added for anal stenosis. Control group: The internal and external hemorrhoids were treated according to the traditional external peeling and internal ligation method.
1.3 After treatment, control bowel movement for 2 to 3 days after operation, give liquid or semi-liquid diet, routinely inject antibiotics, and fumigate and wash with traditional Chinese medicine No. 1 after stool (our department's self-developed prescription, composed of Sophora flavescens, Phellodendron amurense, Haier tea, Chinese gall , Aconitum, camphor, frankincense, myrrh and other traditional Chinese medicines, mix according to the mass ratio of 20:20:10:5:10:10:15:15, weigh 180g of the crude drug mixed in this ratio, add 500ml of water, and decoct for 30min , Filter and concentrate the crude drug decoction to 1.0g/ml and store it at 4°C. Dilute it to 2000mL with heated water when used, fumigate with hot air for 5min after defecation every day, and sit in a bath for 20min when the liquid drops to 38-40°C. Soak the lesions of the anus. 2 times a day) sit in the bath, then disinfect the wound with 0.2% Xinjieermei cotton ball, and change the dressing of Mayinglong Musk Hemorrhoid Ointment. During the treatment, fasting spicy fried products to avoid overwork and keep the stool smooth.
1.4 Efficacy evaluation criteria  Cure: the symptoms disappear, the prolapsed hemorrhoids are eliminated, and the anal function is normal; improvement: the symptoms are relieved, and the prolapsed hemorrhoids are reduced; ineffective: there is no change in symptoms and signs. The evaluation standard of anal function is according to Hiltunen standard. Normal: the anus controls stool, intestinal fluid, and intestinal gas normally; partial anal incontinence: the anus cannot control loose stool, intestinal fluid, and intestinal gas. Or contaminate underwear; complete anal incontinence: the anus cannot control the formed stool.
1.5 Statistical analysis Using x2 test.
2.1 Comparison of clinical efficacy see Table 1.
Table 1 Comparison of curative effect of 21d after operation in 2 groups Example (﹪)
Group n cured and improved, invalid
Control group 20 7 (35) ① 13 (65) 0
Treatment group 20 14 6 0
Note: ①Compared with the treatment group, P<0.05.
2.2 Postoperative complications are shown in Table 2.
Table 2 Comparison of postoperative complications in the 2 groups Example (﹪)
Group n Wound edge edema Residual external hemorrhoids Stool bleeding Anal effusion Anal stenosis
Control group 20 14 (70) ① 13 (65) ① 12 (60) ① 7 (35) ① 2 (10) ①
Treatment group 20 1 (5) 2 (10) 7 (35) 1 (5) 0
Note: ①Compared with the treatment group, P<0.01.
2.3 Wound healing time and recurrence after 2 years. The healing time of the control group was (20.20±2.64) days, 5 cases of recurrence after 2 years accounted for 25%; the healing time of the treatment group was (18.43±2.30) days, and 1 case of recurrence after 2 years accounted for 5% . The healing time and recurrence rate of the two groups were significantly different (P<0.05)`
Hemorrhoids are a common and frequently-occurring disease in clinical practice. In the past, they were thought to be caused by varicose veins under the mucous membrane of the anal canal. Local masses formed by stasis of subcutaneous blood vessels around the anus . Due to the inconsistency of the doctrine recognition, it leads to the diversity of clinical operations. The important principle of modern treatment of hemorrhoids is to protect the anal cushion and restore the pathologically enlarged and displaced anal cushion . According to the theory of anal cushion, in 1998, Longo et al. proposed a new method for the treatment of Ⅲ and Ⅳ degree prolapsed internal hemorrhoids through circular resection of the lower rectal mucosa and submucosa tissue . PPH is designed based on this mechanism. The main treatment mechanism is not to treat the hemorrhoids itself, but to remove the rectal mucosa above the hemorrhoid area. Through traction, the prolapsed hemorrhoids are pulled back into the anus to achieve the purpose of treatment. However, because it did not remove the hemorrhoids itself, only the rectal mucosa of 2 to 3 cm was removed. Although the short-term curative effect has been well reported by various clinical operators, its long-term curative effect has not been objectively recognized and reported. The sample data of the center is further verified. For some patients with severe external hemorrhoids, PPH surgery has no good countermeasures, and sometimes it is necessary to assist traditional external hemorrhoid resection. In addition, PPH surgery requires the use of special expensive equipment, which is not yet widely used by primary medical units.
Annular mixed hemorrhoids are the most serious hemorrhoids in the clinic. It causes the anal canal to lose its normal physiological structure, the tooth line disappears downward, and the original physiological function no longer exists, so it has certain clinical characteristics. The treatment methods mainly include incision and ligation, external stripping and internal ligation, and laser treatment. However, it is more difficult to treat circular mixed hemorrhoids with these therapies. There are two problems: one is that it cannot treat more than 3 circular external hemorrhoids, and the rest External hemorrhoids and internal hemorrhoids are prone to edema, which must be treated in stages, and they are easy to recur, which affects the curative effect. It adds pain to the patient and fails to achieve the purpose of a thorough treatment. Second, it is difficult to retain enough skin and mucosal bridges and a large number of scars. Formation, it is easy to cause the anal caliber to become smaller and narrow anal . Therefore, circular mixed hemorrhoids should be removed intermittently, and should be divided into at least 3 segments. Generally, the resection can exceed 1/2 of the entire circumference of the anal canal, but should not exceed 3/5. If the area of the anal canal skin is the same, keep The greater the number of skin bridges in the anal canal, the less the impact on the anal caliber, and there is no significant age difference. Segmented ligation and segmented ligation and suspension were established based on these principles and the size and distribution of hemorrhoids. Staged ligation of female hemorrhoids is effective, and the advantages of preserving the sub-hemorrhoid area suspension treatment are obvious: ① Hemorrhoid artery ligation blocks the dilated blood vessels of hemorrhoids and makes them atrophy and disappear. ②The anal cushion suspension returned to its normal position. After the anal cushion was moved up, the external hemorrhoids were also significantly reduced, and the wound area of the external hemorrhoid incision was also significantly reduced. ③The foreign body stimulation of the absorbable thread further fixes the suspended anal cushion. Although the hypertrophy and lowering of the anal cushion are the pathological basis of symptomatic hemorrhoids, the unrestricted removal of the anal cushion will inevitably lead to the loss of the normal physiological function of the anorectal .Because the dentate line area is the inducing area of defecation movement, this operation method should remove the anal cushion as little as possible, and only ligate and suspend the hemorrhoid artery. The dentate line area is not damaged, and the skin and mucous membrane, ATZ epithelium, is retained to the greatest extent. Make the anus maintain the original shape and restore the original sensory function to the greatest extent, and maintain normal defecation activities . It protects the fine bowel control ability of the anus, thereby effectively avoiding the occurrence of anorectal mucosal ectropion, anal stenosis, and sensory anal incontinence . The subcutaneous varicose vein masses between the incisions of the external hemorrhoids are selectively peeled off, which significantly reduces the postoperative perianal skin tags and wound edge edema, improves the cure rate of circular mixed hemorrhoids, and reduces the postoperative recurrence rate. This is beyond the reach of traditional methods.
The following problems should be paid attention to during the operation of this operation: (1) According to the shape of the hemorrhoids, first design the segment position and number. The larger hemorrhoids of the ring mixed hemorrhoids are mostly located in the mother hemorrhoid area at the 3, 7 and 11 point of the lithotomy position. The rest are sub-hemorrhoids, and the segmentation is mainly carried out with these larger hemorrhoids as the center, generally divided into 3 to 5 segments.
(2) The number and position of the anal canal skin bridges and mucosal bridges should be appropriate during the operation. Generally, 3 to 5 of them should be retained. The positions should be as far as possible in the natural depressions of the lobes, and they should be more evenly distributed. The width of the bridge is not less than 0.5 cm, and the width of the mucosal bridge is not less than 0.2 cm. These are conducive to the growth of the skin and mucous membrane of the anorectal canal, the distribution is complete, and the formation of local scars is reduced.
(3) The position of the apex of hemorrhoid ligation should not be on the same horizontal plane but in a staggered curve to ensure that the wound after the internal hemorrhoid falls off is staggered and tooth-like, so as to prevent postoperative annular scar contracture and cause anal stenosis.
(4) Selectively cut off part of the internal sphincter at the incision on one side of the anus, which not only reduces the pressure of the anal canal and rectal neck, prevents postoperative recurrence; but also relieves the postoperative internal sphincter spasm, avoiding severe local pain and Occurrence of edema. But it should not be cut too much to avoid sequelae such as postoperative anal relaxation and rectal mucosal ectropion .
(5) When suturing the hemorrhoids with the first stitch, there must be more tissue to be sutured, usually 1/3 of the hemorrhoid body, sometimes 1/2, so that when the two ends are ligated together, the tissue can be prevented from being torn . In addition, the suturing should be close to the vascular clamp to prevent the anorectal stenosis caused by the suture being too wide.
The results of this study show that this procedure has the advantages of definite curative effect, high one-time cure rate, fewer complications, and low price. It is a good procedure for the treatment of annular mixed hemorrhoids.
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