Chengdu Anorectal Specialist Hospital Liu Jianxin
Capital Medical University Chaoyang West Hospital Li Hengshuang
Chengdu Wenjiang Hospital of Traditional Chinese Medicine Su Weiping
Chengdu Dayi County Hospital of Traditional Chinese Medicine Yang Jihong
Negation is one of the three laws of materialist dialectics, and it is the driving force for the development of everything. The process of scientific development is the process of constantly denying errors with correctness, denying superficiality with profoundness, denying vagueness with accuracy, and denying blankness with innovation. Medicine is a science and is also subject to this law.
The liner theory proposed by Thomson (1975) currently serves as the mainstream anatomical basis for hemorrhoids and is unanimously regarded as normal human tissue by most scholars. Padding is a pronoun for hemorrhoids. What does it have to do with the symptoms of hemorrhoids? Keighley, a famous British anorectal disease expert, pointed out: Hemorrhoids are anal pads, not a disease. Only when symptoms such as bleeding, prolapse and discomfort are combined can they be called a disease, that is, hemorrhoids. The theory of padding is a kind of progress in history. Because of its appearance, hemorrhoids were cut and pierced when they were seen in the past; various chemicals were even used to corrode and necrotize them; and the phenomenon of electrocautery and freezing to destroy them has been curbed. And put forward that the protective pad, the purpose of treating hemorrhoids is only to eliminate the symptoms, because the pad theory basically negates the theory of hemorrhoids and varicose veins, the effective sclerosing and atrophy therapy in the past has been ignored. Expensive PPH surgery is highly praised and marked with the latest technology. It only eliminates hemorrhoids, one of the most common degenerative symptoms in humans, at a cost that exceeds the cost of radical rectal cancer surgery. The equipment manufacturers have made a lot of money, and the hospitals have also obtained good benefits.
Hemorrhoids, which are mainly characterized by bleeding, prolapse, incarceration, and pain, are definitely a type of disease that plagues humans. But the research on the nature of hemorrhoids really makes us fall into deep confusion. Excuse me, why do patients who do not have these symptoms come to the hospital? I am here to solve these problems that trouble me, not to listen to you explain what it is called, but why it has these problems, what method will you take to solve the problem for me, can it not recur?
Why do internal hemorrhoids bleed? Early internal hemorrhoids and second-stage hemorrhoids are easy to bleed, but third-stage hemorrhoids and even late internal hemorrhoids are not easy to bleed. Can the theory of padding explain it?
The theory of padding can only reflect part of the anatomical structure of internal hemorrhoids. Can mixed and external hemorrhoids be ignored? Does the fusion of the vascular network inside and outside the tooth line exist?
Varicose veins are a positive fact, and increase with age. Varicose veins that occur in the lower limbs are degenerative diseases. Varicose veins that occur in the anus are physiological rather than pathological phenomena, and there is no scientific basis.
Why do hemorrhoids or pads prolapse? Can the theory of padding give an explanation for the etiology?
What is science? Science should be as close to the truth as possible without self-contradictory knowledge system. Human cognition is restricted by the scientific level of the times, and any cognition cannot be completed at once without errors. World-class experts such as Wu Jieping and Chen Zhongwei all confessed their mistakes in medical practice. This is a scientific attitude of seeking truth from facts. This is true of anyone who respects science. They perfect themselves by denying mistakes or imperfections.
The cushion theory has been popular for more than 30 years. What has it brought to the majority of patients? What progress has been brought to our medical science? In the book "Hemorrhoids" edited by Professor Zhang Dongming, ten points are summarized on the basis of the anal cushion theory.
1. Dilated hemorrhoidal veins are physiological rather than pathological.
2. Portal hypertension appears as rectal varices, not hemorrhoids.
3. Hemorrhoid venous blood can return to the heart through the perforating veins on different planes. There is no scientific basis for the claim of blood stasis.
4. The so-called "3, 7, 11 maternal hemorrhoid area" is actually the inherent morphological pattern of the anal cushion, which has nothing to do with the branch pattern of the suprahemorrhoidal artery.
5. The model embryonic stage of the anal cushion already exists. Adults have confirmed that the rectal pillars (10-14) are relatively concentrated, with different sizes and numbers.
6. The size of anal cushion varies greatly among individuals and is related to the opening and closing of the arteriovenous anastomosis tube and the amount of blood supply in the cushion. Changes every hour of the day.
7. No varicose veins were found in the histological section of hemorrhoids. There is no significant difference in histology between the hemorrhoidectomy specimen and the normal anal cushion of the cadaver.
8. As the age grows, the supporting tissues age, and the anal cushion moves down, which is normal degenerative degeneration. The hemorrhoidectomy specimens were compared with normal anal pads at the age of hemorrhoids (after 18 years of age), and the histological findings were the same (treitz muscle rupture, vasodilation).
9. The anal cushion can provide 15%-20% of the resting pressure of the anal canal, and has the function of maintaining stool self-control.
10. The anal cushion epithelium belongs to the ATZ epithelium, which has multiple functional chemical and mechanical receptors.
1. For the above reasons, we first questioned whether hemorrhoids varicose veins are physiological rather than pathological. The relationship between hemorrhoid varicose veins and age is not completely linear. I have seen many cases of hemorrhoids in children with advanced internal hemorrhoids. It was confirmed by examination that the effective passage area of the rectum was narrowed due to the wide rectal valve in the middle and lower rectum, and the resistance to defecation was too large. The long-term struggle resulted in mixed hemorrhoids, congestion and swelling and prolapsed outside the anus, accompanied by severe rectal mucosal prolapse. Long-term increase in abdominal pressure leads to dilation of hemorrhoidal veins, and fatigue damage caused by long-term over-stretching of elastic fibers in the blood vessel wall should be able to find anatomical evidence.
2. The hemorrhoid vein can return to the heart through the perforating vein on different planes, and there is no "blood stasis". When the long-term defecation disorder, the defecation time is prolonged, and the pelvic floor tissue is always in a state of high tension, will the hemorrhoidal veins return to the heart so easily?
3. The so-called 3, 7 and 11 o'clock maternal hemorrhoid area has nothing to do with the branch pattern of suprahemorrhoidal artery. Then the branches of the suprahemorrhoidal artery penetrate into the mucosa of the intestinal wall and must be arranged in a dendritic manner, and there must be a difference between the concentrated distribution area of small branches and the caliber of the marginal capillaries. In addition to the arteries, veins and their anastomosis, among the four layers of the intestinal wall tissue, the submucosa is the connective tissue including the treitz muscle. Besides, is there any separation? It is not related to the blood supply.
4. The pattern of the anal cushion is related to the rectal column, so why are there only 3, 7 and 11 o'clock in the 10-14 rectal column and the rectal column is prone to congestion into hemorrhoids, and there are few other parts?
5. No varicose veins were found in the histological section of hemorrhoids. Please see the example below:
The above illustrations are cut-away views of different hemorrhoid areas for newborns, nine-year-old children, 28-year-olds, and 70-year-olds. You can clearly see the venous dilatation of different age groups. Hemorrhoids are degenerative changes. Isn't degenerative disease a disease? Coupled with clinical symptoms, can it deny its existence as a disease?
6. The cause of degenerative changes is not just a factor of age. I often see that there are no hemorrhoids in people in their 60s and 70s. It is even more difficult to explain that some patients with severe constipation do not have hemorrhoids. Therefore, there are more factors to consider for the causes of hemorrhoids.
7. Can anal cushions provide 15%-20% of the resting pressure of the anal canal? When children do not have'hemorrhoids' or the pad protrusions are just rectal columns of basically the same size, does the anus close incompletely? Does the increase in hemorrhoid volume mean that the resting pressure of the anal canal also increases? The larger the hemorrhoids, the easier it is to contaminate. How to explain underwear?
To sum up, the occurrence and development of hemorrhoids, such as bleeding, prolapse, and incarceration, are not only explained by physiological degenerative changes. We believe that if hemorrhoids are not treated as a disease, then we have adopted so many methods for treatment without a solid theoretical basis. Thousands of tens of thousands of dollars (PPH surgery) to only eliminate a little "normal structure" symptoms to explain to the majority of patients, and there may be recurrence.
The author and colleagues have conducted 20 years of research on why hemorrhoids relapse after surgery since 1989, and came to the conclusion that hemorrhoids are caused by congenital anatomical changes in the rectum that lead to relatively narrow and excessively large rectal anal canals. The resistance to defecation causes the rectal and anal canal tissues to lose support and slide down. Internal hemorrhoids are mucous membranes or cushions that move down, and external hemorrhoids are anal canal valgus, and both are accompanied by long-term venous pressure increase caused by blood vessel tortuosity and expansion. The tortuosity and expansion of blood vessels mentioned here exist regardless of internal hemorrhoids and mixed hemorrhoids; external hemorrhoids are different, and the mechanism of varicose-type external hemorrhoids is the same as above; while connective tissue external hemorrhoids are mostly epidermis formed on the skin of the anal canal after inflammatory edema is absorbed; thrombotic external hemorrhoids It is still on the basis of external hemorrhoids and varicose veins, the blood forms a "vortex" through which the platelet attached to the wall condenses thrombosis, which is characterized by the presence of the envelope, that is, the expanded blood vessel wall. It is not the rupture of blood vessels as mentioned in some textbooks. Blood infiltrates into the skin from ruptured blood vessels to form stasis, and it is impossible to have a capsule.
This conclusion can explain the mechanism of hemorrhoid bleeding. The relative narrowness of the rectal and anal canal, the large resistance of the discharge tract, the prolonged defecation time, and the formation of hemorrhoidal varicose veins. During defecation, when congested hemorrhoids encounter relatively high pressure in the anal canal neck, they form squeezed capillaries and rupture and bleeding of small blood vessels. During anoscopy, the expansion of the anoscope relieves the pressure of the anal canal. There is no fecal pushing force and the hypertonic pressure in the blood vessels is lost. Naturally, hemorrhoids cannot be seen to bleed. In the third and fourth stages of hemorrhoids, the resting pressure and diastolic blood pressure of the anus are decreased, the sphincter is loosened, and the hemorrhoids protrude out of the anus at the beginning of defecation. Naturally, the hemorrhoids will not bleed easily without squeezing. The loss of support and displacement of the rectal and anal canal tissue is confirmed by pathological anatomy, especially the discovery in 1953 (Treitz's muscle), which is a major discovery. But it does not explain why Treitz's muscle ruptures.
We often use a popular saying: The anus is turned over. People with very unobstructed stools are not easy to get hemorrhoids. This is common knowledge. Through long-term anorectal practice, we have found that every patient with hemorrhoids also has rectal mucosal prolapse, as well as congenital variations such as wide rectal valve. Prolapse of the rectal mucosa and "downward movement of the cushion" are all secondary to excessive resistance to defecation, so everyone may agree. So how can there be no sequelae and recurrence if only secondary problems are treated clinically but the original cause is not resolved? People ignore the original cause of defecation disorders. The instigator is defecation disorders. Hemorrhoids and mucosal prolapse only play a role in fueling the flames. Some scholars define this situation as hemorrhoidal constipation. So what does the popular liner theory say? The pathological enlargement of the liner and the downward movement are hemorrhoids, so why does it move downward? From the etiological point of view, it only expresses a prolapse phenomenon, but does not reveal its essence. It is just a result. The theory that the result is a kind of hemorrhoids is logically unreasonable. Now I have asked again, why should hemorrhoids (pads) be considered normal tissues to destroy them like heinous enemies?
PPH surgery no longer cuts the hemorrhoids, instead of cutting the rectal mucosa of the hemorrhoids, can it solve the defecation disorder? Don't forget that mucosal prolapse is also secondary. The essential problem remains unsolved. In addition, PPH operation is said to block the superior hemorrhoidal artery, but according to modern anatomy, Gray (1989) and Parnaud (1976) the hemorrhoidal artery in the hemorrhoidal area is not only from the superior rectal artery, but also from the rectal sigmoid artery (19.7%) and the inferior rectal artery ( 72.4%) and anal artery. These components sometimes dominate in the hemorrhoid area, and can even partially or completely replace the superior rectal artery. What's more, the branches of the superior rectal artery are all located outside the muscular layer of the rectal wall, instead of running under the mucosa. Its blood supply range only reaches the middle and lower rectum, and generally does not reach the hemorrhoid area. Then the theoretical basis of the PPH operation is simply to remove part of the hemorrhoid mucosa, and the scars formed after the anastomosis play a hanging role on the hemorrhoids (pad). It does not involve hemorrhoidal varicose veins and hemorrhoidal artery blood supply, let alone solve the defecation resistance and eliminate the effect of external hemorrhoids. An operation with major theoretical flaws, we should reflect on its rationality.
During the diagnosis and treatment of constipation, we found a large number of rectal stenosis, rectal flexure, rectal pocket formation, rectal protrusion, and rectal scoliosis caused by rectal valve widening, increased number, and close spacing. These patients rarely have hemorrhoids up to the level of the anal canal. In patients with hemorrhoids, the stenosis plane is almost in the middle and lower flaps of the rectum, and the anal canal is relatively short. In this way, the resistance of defecation can overcome the restriction of the anal canal and cause anal ectropion and prolapse of hemorrhoids. The loose mucous membrane in the rectum is stretched and the bowel disorder is relieved. Here we mention a phenomenon: at the beginning of the project to determine why hemorrhoids recurred after surgery, the author had performed thoracic and knee rectal microscopy on 35 12-year-old pupils in a class. No hemorrhoids were found, and it did not matter "Y The "type" groove exists, and the shape of the rectal column is clearly visible. In the long-term anorectal practice thereafter, thoracic and knee rectal microscopy, as long as thoracic and knee hemorrhoids are almost invisible in adult hemorrhoid patients, let alone "Y-shaped" grooves. Therefore, when I teach clinically, I often ask students to observe the side anoscopy first, and then let them look at the chest and knees. It is not a concept at all. When the patient is asked to work hard, the rectal mucosa also comes off. It has also appeared, which tells us from the other side the objective existence of varicose veins and mucosal prolapse caused by pressure during defecation.
It is not easy to get hemorrhoids due to high-level stenosis of the rectum and defecation disorders caused by changes in the structure of the colon. Those with congenital anal canal lengthening, excessive anal tension, and anal fissure patients with anal stenosis are not easy to get hemorrhoids. This is what we have observed It is a common phenomenon that only those with relatively narrow middle and lower rectum and short anal canal are most likely to get hemorrhoids.
Absolute truth is a limit, which can only be approached infinitely and never reached. It is the goal pursued by therapeutics to achieve the greatest curative effect with minimal trauma or side effects. Once the old problems are solved, new ones will come out. In this case, the negation process of negation in the medical field will never end. We adopt thoracic and knee rectal valve suture, longitudinal suture of hemorrhoids, suspension sclerotherapy, external hemorrhoid vein needle electrode destruction, and connective tissue external hemorrhoidectomy based on the principles of plastic surgery to expand the effective passage area of the rectum and fix it. The prolapsed rectal mucosa and hemorrhoids (pad) reduce the blood supply to the hemorrhoid area and partially shrink the varicose veins through fibrosis in the hemorrhoid area. Such a minimally invasive, painless, and bloodless operation can completely eliminate hemorrhoids from symptoms to morphology and greatly reduce the chance of recurrence. To achieve the greatest social benefit with the smallest economic investment is human health.