Li Chunyu1 Nie Min2 Wang Jun1 Liang Jian1
【Abstract】Objective To evaluate the clinical application value of stapled hemorrhoids (PPH). Methods 56 cases of acute incarcerated hemorrhoids were surgically treated with a special round hemorrhoid stapler. Results The average operation time was 10 minutes, and the average hospital stay was 4 days. 97% of the patients were satisfied with the results of the operation. Common postoperative complications: 18 cases of urinary retention (32.1%), 39 cases (69.6%) without anal pain on the postoperative day, 17 cases (30.4%) with anal pain, and 3 cases with blood in stool 5-9 days after operation (5.4 %) 1 case was cured with suture hemostasis, and 2 cases improved after conservative treatment. There were 14 cases (25%) of lower abdominal discomfort and pain, and 8 cases (14.3%) of stool frequency increased. Follow-up: 2 weeks-20 months, no recurrence, anal stenosis, fecal incontinence occurred, and the effect was good. Conclusion PPH treatment of incarcerated hemorrhoids is an innovative technology. Compared with traditional surgery, it has the advantages of safety, effectiveness, less postoperative pain, shorter hospital stay, less injury, faster recovery, lower recurrence rate, and less complication rate. It is expected to replace traditional surgery. Surgical therapy, but the long-term effect needs further observation.
【Key words】Incarcerated hemorrhoids Hemorrhoid fixation Stapler
Incarcerated hemorrhoids are acute and painful. The traditional treatment method is mainly external stripping and internal ligation. Although this method is safe and effective, the postoperative pain is severe, the hospital stay is long, and complications such as anal stenosis may occur . In particular, severe anal pain can cause many hemorrhoids. The patient was daunted. In 1998, Longo first proposed precedure for prolapse and hemorrhoids (PPH) for the treatment of prolapsed internal hemorrhoids. Since June 2001, we have used stapled hemorrhoids to treat 56 cases of acute incarcerated hemorrhoids. A satisfactory short-term effect has been achieved.
1 Materials and methods
1.1 Clinical data
1.2 Surgical instruments
Using the PPH round hemorrhoid stapler (PPH01) of Johnson & Johnson, Inc., including 33mm stapler (HCS33), anal canal dilator (CAD33), anal mirror ligator (PSA33) and threader (ST100), Vicryl 2 /0 Absorbable catgut, all specially made for PPH surgery.
1.3 Surgical methods
Preoperative bowel preparation is the same as general anal surgery. After the sacral anesthesia is successful, the patient takes the lithotomy position, and routinely disinfects the skin and intestinal cavity of the perineum with iodophor (female patients also perform vaginal disinfection). Lay a towel and fully expand the anus with the internal plug of a special circular anal canal dilator. Insert the anal dilator (CAD33) and fix it with No. 7 silk thread. After removing the internal plug, look for the dentate thread. Use gauze to push the external hemorrhoids into the anus as much as possible to reduce residual skin tags after surgery. Insert the anal mirror ligature (PAS33) through CAD33. The height of the suture needle is about 2 to 3 cm above the dent line. Use Vicryl 2/0 absorbable gut to suture clockwise along the submucosa from 3 o’clock for a week, At 1cm below the first purse line, make the second purse-string suture clockwise from 9 o'clock. Female patients should be careful not to sew the mucous membrane of the back wall of the vagina. Expand the special PPH stapler (HCS33) to the maximum, insert its head end above the two purse-string sutures, tighten the sutures one by one and tie the knots, and use the thread holder (ST100) through the side hole of the stapler Pull out the suture and pull the ligature forcefully toward the handle to place the sutured and ligated mucosa and submucosa into the cavity of the HSC33 head. At the same time, rotate clockwise to tighten the stapler and open the safety device (female The patient must have a digital vaginal examination to prevent vaginal rectal fistula) and then fired, close the HCS33 state for about 30s (which can strengthen the hemostatic effect). Rotate the stapler 180 degrees in the opposite direction, gently pull it out, and carefully check whether there is bleeding at the anastomotic site. For active bleeding, use 2/0 catgut or #4 silk suture to stop the bleeding.
Treatment of external hemorrhoids: For patients with thrombosis, the thrombus can be removed first, and then anastomosis can be performed. For larger skin tags, simply remove the skin tags after anastomosis.
Fast or give liquid food on the postoperative day, apply antibacterial, hemostatic drugs and intravenous fluids appropriately, start semi-liquid food the next day, and pull out the drainage tube. It is generally observed for 3 to 7 days and followed up regularly.
The operation time was 6-20 minutes, with an average of 10 minutes, and the hospital stay was 2-8 days, with an average of 4 days. In this group, the anastomosis was successful at one time, the anastomotic circle was complete, and the width of the excised specimen was 1.5-2.8cm, with an average of 2.0cm. Within 2 days after operation, 48 patients had prolapsed hemorrhoids and completely retracted into the anal canal. 8 patients had severe local edema and incomplete retraction. After 2 weeks, they basically retracted and the stool thickness was normal. The effective rate was 100%. Postoperative urinary retention occurred in 18 cases (32.1%), 39 cases (69.6%) had no anal pain on the postoperative day, 17 cases (30.4%) had anal pain, and 3 cases (5.4%) had blood in the stool 5-9 days after operation. Hemostasis was cured by suture and 2 cases improved after conservative treatment. There were 14 cases (25%) of lower abdominal discomfort and pain, and 8 cases (14.3%) of stool frequency increased. Follow-up: 2 weeks to 20 months, no recurrence, anal stenosis, fecal incontinence occurred.
The incidence of hemorrhoids in China is about 46% . The treatment of incarcerated hemorrhoids is tricky. The traditional surgical methods mainly include external stripping and internal ligation, and segmented ligation. The disadvantages of these operations are the long duration of pain, slow wound healing, long hospital stay, and anal stricture. Disease, which brings great pain to the patient. Some people describe the patient's self-reported defecation as painful as "glass slag discharge", thus limiting the application of the above-mentioned surgery. In 1975, Thomson  first proposed that the downward movement of the "anal cushion" is the basis for the formation of hemorrhoids, and hemorrhoids cannot be formed without prolapse and downward movement. In response to this new theory and doctrine, in 1998, Italian scholar Longo  proposed a new PPH treatment for severe hemorrhoids, with satisfactory curative effect, and soon it was popularized and applied at home and abroad.
PPH is to use special surgical instruments and staplers to circularly remove the rectal mucosa and submucosa tissue with a width of about 2cm above the dentate line, and then anastomose the rectal mucosa, so that the prolapsed anal cushion can be suspended upward and retracted to the original position. The local anatomical relationship between the anal mucosa and the anal sphincter can eliminate the symptoms of hemorrhoids prolapse and play a "suspension" role; at the same time, it cuts off the terminal branches of the inferior rectal arteries and veins, reduces the blood supply of the hemorrhoids, and makes the hemorrhoids gradually shrink , It removes hemorrhoid bleeding and plays a role of "stopping flow".
PPH is a new surgical method. Although the procedure is simple, each degree may directly affect the effect of the operation, and even cause the operation to fail. The hemorrhoid stapler is expensive, cannot be reused, and requires experienced surgeons and skilled surgical skills to operate. According to clinical experience, the following points should be noted: (1) Anesthesia: This is the basis of surgery. It is advisable to choose sacral or spinal anesthesia to obtain anal relaxation and fully expose the surgical field. (2) Anus expansion: It is best to use a special circular anal dilator plug to expand the anus to avoid damaging the anal sphincter and at the same time facilitate the insertion of the anal canal dilator. (3) Purse string suture: This is the key to the effect of surgery. The results of this group show that the height of the purse string suture should be about 2 to 3 cm on the dentate line to ensure that the anastomosis is within 1 to 1.5 cm of the dentate line. If the suture is too high, the pulling and suspending effect on the anal cushion will be weakened, and the hemorrhoids will be incompletely retracted, which will affect the surgical effect; on the contrary, if the suture is too low, it will easily cause postoperative pain and bleeding. In severe cases, sensory stool will occur incontinence. The depth of the purse string suture is in the submucosa, sometimes up to the superficial muscle layer. Too shallow can easily cause mucosal avulsion, incomplete anastomotic circle, and affect the effect of surgery; too deep can easily damage the sphincter, cause anastomotic stenosis or fecal incontinence, especially women should pay special attention to recto-vaginal fistula. The double purse string suture can remove the excess rectal mucosa, which has a stronger effect on the upward traction and suspension of the anal cushion. At the same time, the removal of the tissue is even and symmetrical, and the effect is good. (4) Vaginal rectal fistula: This is the most serious complication of PPH surgery. Foreign cases have reported cases of rectovaginal fistula caused by PPH. The reason is that the purse-string suture is inserted too deep into the muscle layer, and the rectum and vagina are trapped when the stapler starts. interval. We believe that for female patients before purse-string suture anterior mucosa and stapler anastomosis, the surgeon must use the left hand to perform routine vaginal examinations, and should not pull in the posterior wall of the vagina to avoid the formation of a recto-vaginal fistula. (5) Anastomotic inspection: After the operation, the anastomosis should be checked carefully to prevent postoperative bleeding. Anastomotic bleeding was seen in 20 cases (35.7%) in this group, mostly at 3, 7, and 11 points. For active bleeding, stitches are needed to stop the bleeding. For bleeding, local compression is needed to stop bleeding. (6) Place drainage tube: Place a plastic tube at the postoperative anastomosis, which can effectively reduce the pressure in the anorectal canal, prevent anastomotic leakage, reduce abdominal distension, and facilitate the observation of postoperative bleeding.
Because this operation does not remove the anal cushion that functions to close the anal canal finely, there is no perianal incision, and the anal sphincter is not damaged. It can protect the anal function to the greatest extent. Compared with traditional surgery, it has: (1) Postoperative pain is light or no pain. (2) The operation time is short, with an average of 10 minutes. (3) Fast recovery after operation. (4) The hospital stay is short, with an average of 4 days for discharge. (5) Less postoperative complications. (6) No anal stenosis and anal incontinence. (7) The recurrence rate of hemorrhoids is low. (8) The anus is beautiful in appearance.
In short, PPH is a new technique for the treatment of hemorrhoids. Compared with traditional surgery, it is safe, effective, practical, and reliable. It is expected to replace traditional surgery. Its short-term effect is relatively positive, but the long-term effect needs to be further demonstrated.
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2 Longo A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with a circular stapling device: a new procedure. Proceedings of the 6th world congress of endoscopic Surgery. Rome, Italy, 1998, June 3-6
3 Shi Zhaoqi, Song Guangrui, Hu Bohu, Editor-in-Chief. Chinese Colon and Anal Diseases. Zhengzhou: Henan Science and Technology Press, 1985. 631.
4 Thomson WHF. The nature of hemorrhoids piles. Br J sung, 1975, 62(7): 542.
5 Fu Chuangang, Zhang Wei, Wang Hantao, etc. Stapler circular hemorrhoidectomy. Chinese Journal of Practical Surgery, 2001, 21(11): 654.
About the author: Li Chunyu (1966-), male, Liaoning, professor, master tutor, mainly engaged in clinical research on anorectal diseases.
Website: China Anorectal Physician Network (www.zggc.org; www.zggcys.com); China Anorectal Health Network (www.zggcjk.com)
Published "Shanxi Medical Journal" 2006, 35(11): 1033-1034.