2021年1月21日星期四

hemorrhoids or anal cancer,Current status of diagnosis and treatment of diseases around anal canal

    Current status of diagnosis and treatment of diseases around anal canal

    Hemorrhoids, anal fistulas and anal fissures are the main diseases around the anal canal and are an important part of anorectal surgery. Its importance is that these diseases account for a large proportion of anorectal surgery diseases, and the second is the fact that they are located in an important part of the digestive tract when dealing with these diseases.

    1. Internal hemorrhoids

    Because the etiology of hemorrhoids is complicated and the nature of hemorrhoids is far from true understanding, it is reflected in a variety of treatment methods. We believe that the choice of treatment methods should be based on the doctor's personal technical ability and experience and the medical conditions of the hospital, combined with the specific condition and physical condition of each patient. Judging from the various hemorrhoids treatment methods published in the "Chinese Journal of Anorectal Diseases" in 2000, this is the basic principle of individualized treatment. Of the 25,302 hemorrhoids reported throughout the year, 9,077 (36%) were surgically operated. 18,275 cases used a variety of non-surgical treatments.

    1.1 Surgical treatment of hemorrhoids

    Hemorrhoidectomy is an effective treatment for hemorrhoids. Early hemorrhoidectomy mostly uses the Milligan-Morgan method, and now there are many improved hemorrhoidectomy methods. However, it can be seen that in the reports of 9077 cases of hemorrhoidectomy in China, it seems that it has become a consensus to minimize the damage to the anal canal anatomy and protect the physiological function of the anal canal. Hemorrhoidectomy with different names consistently proposes that a considerable width of "skin bridge" or "mucosal bridge" must be preserved between the two hemorrhoids and to avoid damage to the dental line. It must be pointed out that the dental line of patients with prolapsed internal hemorrhoids who have repeatedly prolapsed is often squeezed out of the anal margin, losing the normal relationship between hemorrhoids and dental line. If you don't recognize it carefully during the operation, you will damage the tooth line too much. It is reported in the literature that the use of gastric Helicobacter pylori methylene blue (HP MB) staining solution to stain the anal canal epithelium can show the light blue transitional epithelial area of ​​the anal canal, which is quite beneficial to protect this area from loss.

    1.1.1 Surgical treatment of incarcerated hemorrhoids   Earlier, I was very worried about the resection of incarcerated hemorrhoids. It is because of fear that emergency surgery will cause infection to spread to the portal vein. However, removing the infected lesion to prevent the spread of inflammation is a basic surgical principle. Active excision helps prevent the spread of inflammation. According to this principle, the treatment of incarcerated hemorrhoids has mostly tended to emergency surgical resection. In order to eliminate the edema and facilitate the resection, 3000U of hyaluronidase can be dissolved in 40mL of normal saline before the operation, evenly injected under the perianal skin, gently rubbed for a while, the tissue edema gradually subsided and then the operation was quite smooth. After hemorrhoidectomy, supplemented with lateral partial internal sphincterotomy is more effective. If the incarcerated internal hemorrhoids have become strangulated due to blood flow disorders, and the hemorrhoids have turned black and necrotic, the use of antibiotics must be considered. In this case, although the hemorrhoids are not removed, sometimes the hemorrhoids become necrotic and swollen, resulting in the so-called "home-made hemorrhoidectomy". There are 369 cases of incarcerated hemorrhoids in the 9077 cases of hemorrhoid surgery in China, which are mainly excised by emergency surgery. The healing time was 15-28 days, with an average of 20 days. Healing time is slightly longer than normal hemorrhoid surgery.

    1.1.2. Treatment of thrombotic external hemorrhoids   Thrombotic external hemorrhoids are formed by thrombosis of small veins outside the anal margin. After cutting the skin, a complete enveloped blood clot can be peeled off, and sometimes there are many small miliary thrombi underneath it. A few domestic scholars claim that thrombotic external hemorrhoids are subcutaneous hematomas. This is a misunderstanding because subcutaneous hematomas are diffuse congestion of subcutaneous tissue. 3 to 4 days before the onset of thrombotic external hemorrhoids, the pain is severe and should be removed surgically without suture. After 3 to 4 days, the pain turns lighter, you can use Chinese medicine decoction to fumigate and wash.

    1.1.3. Internal hemorrhoidectomy plus internal sphincter incision   Recently, it has been reported in China that 38% of patients undergoing internal sphincter incision during hemorrhoidectomy have reduced postoperative pain. In fact, as early as 160 years ago, the American leader Kilsy was excited about this additional operation and suggested that the side incision is better. Smyruis et al. compared this with those who only underwent hemorrhoid surgery, and compared them with the integral method. He stipulated that if there is no pain after operation and do not need analgesics, score 1 point; for general pain and need to take analgesics, score 2 points; for severe pain of third degree and need narcotic analgesics, score 3 Minute. The comparison results are shown in Table 1.

    Table 1   Comparison of pain scores between the incision group and the control group (cases/min)

    Ⅰ degree

    Ⅱ degree

    Ⅲ degree

    Incision group

    11/11

    3/6

    2/6

    Control group

    2/2

    8/16

    6/18

    The domestic literature pointed out that similar to the statistics of Smyrius, the postoperative pain degree of patients with partial sphincter sphincter sphincter was 32.35%, degree II was 11.77%, and degree III was 0. The pain patients in the control group were 48.28%, 24.14% and 3.45%. It shows the value of internal sphincter cut in hemorrhoidectomy. We believe that the positive measure to reduce postoperative pain lies in the operation itself. Operate gently and carefully separate the tissues during the operation. Take care not to ligate the skin of the anal canal. There is no entanglement between the hemorrhoids. Measures such as minimizing the exposed surface of the anal canal and reducing hemostatic ligation can significantly reduce postoperative pain. When the internal sphincter is cut, the sphincter tension should be evaluated in advance before deciding whether to use this auxiliary method.

    1.2 Injection therapy for hemorrhoids

    Most domestic injection therapies use the Kuzhiye developed from the traditional Chinese medicine Kuzhi therapy. If the concentration of the drug is high, a large amount is a necrotic agent. However, when the concentration is low and the dosage is small, it becomes a hardener. The injection therapy of hemorrhoids is different from the injection therapy of the lower limb vein. The role of the former is that injection into the hemorrhoid plexus causes local inflammatory reactions.

    According to early studies, due to the influence of the patient's walking and changes in body position, the injection often loses a large part of the needle hole quickly, and only a small amount of liquid medicine remains. Moreover, the medicine in the injection is not a decisive factor. For example, the insertion of drug-free glutinous rice strips into hemorrhoids can cause the same tissue reaction and therapeutic effect as the medicine-containing hemorrhoids.

    Xiaozhiling is the most commonly used hemorrhoid injection in China and has achieved good curative effects. However, during our injection, the largest amount of Xiaozhiling injection was as high as 60-70 mL, and we emphasized that the "four-step injection method" must be used. It is generally believed that when the concentration of the drug solution is the same, the larger the amount of the drug used, the more poor the efficacy. A large amount can only mean that the toxicity of the drug is low. In terms of injection methods, we believe that it is sufficient to inject the injection into the hemorrhoids or to inject some liquid medicine above the hemorrhoids first. The first step of the so-called four-step injection method is to inject into the arterial pulse on the hemorrhoid, the second and third steps are respectively injected into the submucosa and the lamina propria of hemorrhoids, and the fourth step is to inject into the "sinus vein" area. In fact, these steps may be difficult to do at all.

    The Chinese hemorrhoid injection method has paid attention to pathological observation and comparison with surgical resection. Has now entered a new stage. The problem is that we need to formulate a unified observation standard, strengthen long-term follow-up work, conduct reliable investigations of long-term efficacy, and finally make appropriate evaluations.

    1.3. Questioning the doctrine of downward movement of the anal cushion

    1.3.1. The theory that the three anal pads evolve into hemorrhoids cannot explain the diversity of hemorrhoids. The distribution of the three anal pads cannot explain the clinical diversity of hemorrhoids. Statistics of 1000 cases of internal hemorrhoid surgery in Tianjin Binjiang Hospital: 3 female hemorrhoids (three pads) on the left, right anterior and right posterior accounted for only 10.1% of 101 cases, and even 12 cases had hemorrhoids only on the right front. The positional arrangement of the remaining 877 hemorrhoids is not regular at all. Therefore, the Sandian theory cannot explain the diversity of hemorrhoids.

    1.3.2. The first symptom of hemorrhoids is bleeding rather than prolapse. The basis of this theory is that the anal cushion slides down to occupy hemorrhoids, and prolapse is the first symptom of hemorrhoids. As we all know, first-degree and second-degree internal hemorrhoids are treated for bleeding. St. Mark’s Hospital JPS Thomson introduced that 75% of the patients with 1 to 2 degree internal hemorrhoids who sought treatment due to bleeding in the hospital were treated with injection therapy. It is important to know that prolapse is a characteristic of third-degree internal hemorrhoids.

    1.3.3. Hemorrhoid hemorrhage is not the bleeding of the lamina propria   WHF Thomson proposed that hemorrhoid hemorrhage is the bleeding of the capillaries of the hemorrhoid mucosa propria propria. This is one of the significant errors in his paper. Hemorrhoid bleeding is sometimes spray-like, and the blood volume can be large. It is difficult to achieve this level of bleeding due to membrane capillary bleeding. In this regard, Goligher commented that the serious mistake of Thomson's paper was to recognize prolapse as the first symptom, and failed to provide a satisfactory explanation for hemorrhoid bleeding.

    1.3.4. Hemorrhoids are disease rather than normal tissue. The theory of "hemorrhoids is not disease" considers the anal cushion to be normal tissue. "No symptoms" hemorrhoids are normal tissues rather than disease. This is the result of a hemorrhoids non-diseasor who changed the formula of anal cushion → hemorrhoids to anal cushion = hemorrhoids. In fact, there is no "symptomatic hemorrhoids" clinically. It's just that slight changes such as anal canal irritation and anal wet stains when the hemorrhoids first appear are not for the patient's attention. Even if there are no symptoms, the hemorrhoids that Thomson imagined to move down through the pathological process cannot be regarded as normal tissue.

    1.3.5. The theory of descending anal cushion is not the conclusive conclusion of the etiology of hemorrhoids. From the above questions, it can be seen that Thomson's descending anal cushion theory cannot be regarded as the conclusive conclusion of the etiology of hemorrhoids, and some statements are wrong. No wonder Goligher said when commenting on this doctrine that it was an "iconoclastic view" (iconoclastic view). The true cause of hemorrhoids needs more in-depth research.

    2. Anal fistula

    Surgery’s definition of Jian is “a tube connecting both ends of the epithelial tissue”. The simple form of anal fistula is that there is an external opening on the skin outside the anus, an internal opening near the tooth line of the anal canal, and a granulation tissue tube formed by fibrous tissue in the middle.

    Modern medicine believes that anal fistula is caused by anal gland infection in the anal sinus near the dental line of the anal canal. This gland infection first forms a perianal abscess and then evolves into a fistula. Therefore, it shows that perianal abscess and anal fistula are two stages of a disease. Perianal abscess is the initial stage of anal fistula, which is the acute stage. Anal fistula is a chronic process of inflammation, which is the late stage of abscess.In order to emphasize the relationship between the two, Eisenhammer in South Africa advocated labeling perianal abscesses with "fistulative" to show the difference from general abscesses. The anal fistula is defined as "glandular" to highlight the characteristics of anal gland infection. We believe that trauma, anal fistulas complicated by Crohn's disease, and perianal abscesses and fistulas caused by other specific causes should be excluded from the scope of this disease, and the "submucosal fistula" (Milligan-Morgan classification) and "external sphincteric fistula" in anal fistula "(Parks classification) should not be included in this disease. Obviously, it is a sinus tract like "internal fistula" and "internal blind fistula". It is not logical and logical to call it a fistula.

    2.1 The outcome of perianal abscess

    According to our experience, the evolution of perianal abscess can have the following patterns:

    a. Self-ulceration and drainage or prolonged healing by incision and drainage to form a fistula.

    b. Healed after draining, after repeated attacks, and finally a fistula.

    c. Subsides after antibiotics, fistula occurs repeatedly later.

    d. Rely on tension to drain the pus from the internal ostium to form the sinus tract, the so-called internal ostia.

    e. In rare cases, inflammation subsided after antibiotics were used.

    From this development model, the vast majority of perianal abscesses will evolve into fistulas sooner or later. Because the time from abscess to fistula formation is uncertain, the fistula formation rate reported by each isenhammer is 87%. According to statistics, 168 cases of 172 abscesses with incision and drainage formed anal fistula, and the fistula formation rate was 97.7%. In the 14 cases of spontaneous abscesses, fistulas were as high as 140 cases (98.6%). In addition, Carbot et al. reported that the fistula rate of 36 cases of perianal abscess was 100%. The author has recorded the 63-year interval between abscess and fistula. Due to the fact that the rate of fistula formation is high, in recent years, most clinical treatments for perianal abscesses have taken one-time radical treatment to reduce the pain of the patient's second operation.

    2.2. Treatment of perianal abscess

    From 1998 to 2000, 62 articles on the treatment of perianal abscess were published in the "Chinese Journal of Anorectal Diseases"; 35 of them (58%) were treated with rubber bands (4 of which were treated with No. 10 silk thread). Achievement. There were 16 articles of Chinese medicine dressing changed by incision and drainage. It can be seen that the clinical attitude towards abscess treatment is positive. We believe that when formulating a treatment plan, the principle of individualization should prevail: the depth of the abscess and whether the internal mouth can be confirmed is a prerequisite. When deciding whether to cure it all at once, you must carefully search for the inner mouth and avoid blind search. Lockhart-Mummery believes that it is very difficult to find the connection between the abscess cavity and the anal canal when there is inflammation and edema around the abscess. We agree with this view.

    For those with a lower abscess, we use a one-time incision to clean the abscess cavity, trim the incision, and change the dressing after the operation. Some people use antibiotics before and after the operation to suture all the incisions. However, the use of rubber bands to hang the line is the choice of most authors. It must be pointed out that whether it is open drainage, debridement and suture, or thread-hanging therapy, it is difficult to ensure that the perianmus abscess can be cured at one time. Therefore, before treatment, this possibility should be fully estimated and explained to the patient and their family members to obtain their consent.

    2.3. Anatomical confusion related to anal fistula

    The anal fistula's anatomical basis includes three parts: dental line (anal sinus), perianal space and anal canal muscles. The clinic is very confused about the current concept of anal canal muscle anatomy.

    We found that the anatomy of the external sphincter in several anorectal works published in China in recent years is a three-part concept proposed by Milligan-Morgan in 1934. In fact, this idea has been replaced by the new ideas of Eisenhammer, Goligher and others in the 1950s. Goligher et al. believe that the external sphincter is a non-layered muscle mass included in a muscle sheath, and the internal sphincter forms two tube-shaped muscle groups nested together. This concept has been widely accepted in the West. The monographs of Goligher Corman and others all list the concept of dividing the external sphincter into three parts as history. This new breast concept was introduced to China in 1964. A study by Zhang Dongming and others in China in 1984 also confirmed this theory. To this day, domestic monographs are so cold that the new anatomical viewpoints in the 1950s and the old ideas in the 1930s are confusing. Another thing that is quite incomprehensible is that these monographs doubly highlight the Egyptian Shafik's "three muscle loop" and "central gap". In fact, these theories are difficult to prove and cannot be applied to clinical work. Shafik said that "the anus is also a vagus epithelial cell infection caused by Philippine epithelial injury". After an abscess formed in the so-called central space, it spreads along the "central tendon" to other spaces. "Anal fistula is difficult to cure because these vagus epithelial cells have not been removed."Theories like these are not only vague in concept, but also difficult to understand. How does the infection "combine with epithelial cells" and how to explain the "central" of the "central space"? Clinical phenomenon? Why is there no "central space infection" surrounding the end of the anal canal? How to distinguish the three "muscle loops" clinically? None of these can be verified clinically. So both Goligher and Corman pointed out that "based on clinical experience, Shafik is not supported The said vagus epithelial cells are just some fragments of anal gland tissue appearing on the tissue section. In 1993, Gravoglia rejected the "three muscle loops" theory with his own experiments. We earnestly hope that the majority of clinicians can understand this historical truth of anal canal anatomy.

    2.4. Treatment of anal fistula

    In the domestic treatment of anal fistula, thread-hanging therapy is often used. Recently, some authors have reported the success of the "internal mouth enucleation, mucosal flap forward" operation. A small number of low-position simple anal fistulas are still treated with resection or resection and suture.

    2.4.2. Thread-hanging therapy: The Chinese thread-hanging therapy has been perfectly recorded in the middle of the 16th century. In the Ming Dynasty, Xu Chunfu used silk threads to hang plumb. The treatment mechanism is "the medicine thread is going down day by day, the intestinal muscles grow, the water flows along the thread, the sore hole is not penetrated, and the goose tube disappears." Now the thread is hanged with rubber band elastic material or thick silk thread soaked in traditional Chinese medicine. Moreover, various treatment methods are used for fistulas. Very advanced.

    After hanging the rubber band, Zheng Taijin and others used compound comfrey ointment gauze to change the dressing of the local sore. After the external fistula was cleaned up, the whole layer was sutured. However, Jin Dingguo et al. changed the dressing of the external wound after hanging the rubber band, 66 cases were cured at one time, and only 4 cases of exudate were followed up for 4 years.

    Thick silk thread soaked in traditional Chinese medicine is a major advantage of Chinese thread-hanging therapy. The simple one is just "Boiled Coriander Roots", and the complicated one is Liaocheng Shen Changxing uses nearly 40 Chinese herbal decoctions. Zhuang Zaixin's medicinal line is made by simmering in the decoction of rhubarb, cork, croton, sanyu, coriander, dahliae, frankincense, and myrrh. His method of hanging the thread is also unique. When hanging the thread, the sphincter is divided into 2 to 3 strands and ligated separately. This is compared with the rubber band hanging method. The pain degree and duration, the time of detachment, and the wound healing time are better than the control. group.

    2.4.2. Internal mouth enucleation surgery” From the concept of "Mucous flap advancement" proposed by Noble in 1920 and the concept of closing the internal mouth of anal fistula put forward by Ilting 10 years later, some basic principles have been proposed for sphincter preservation surgery. Parks succeeded in the "internal mouth enucleation" operation in 1961. Since then, various improved surgical methods have continued to appear. Due to the advantages of traditional medicine, Chinese scholars are leading the way in the method and effect of enucleating the inner mouth with gut sutures and freeing the nearby mucosa to form a forward flap to cover the original inner mouth. The external pipeline is twisted with Hongshengdan medicine or with Hongshengdan as the main oil to remove the pipe, to obtain a good effect. Another group of researches in Chengdu is the "thirsty dragon benjiang" medicine. It is better than the control group in terms of recurrence rate and partial incontinence rate.

    2.4.3. Removal of internal orifice and fistula   Zhou Jianhua et al. treated 38 cases of anal fistula with internal orifice resection and closure and fistula removal. 1 case recurred, and the color was improved by the same operation. Huang Youji used the fistula to be completely removed to the inner mouth, and 4/0 gut suture was used to suture the inside of the stripped wound, and the coal to the burned stump, and the tunnel wound after the removal of the tube was fully drained. Twenty-seven cases of anal fistula were treated, and 2 cases recovered after recurrence. Hong Yuanfu et al. used a curved incision to peel off the intact fistula and close the internal opening. Sometimes the sphincter was transected. After the fistula was removed, the two ends were properly stitched together, and the incision was finally sutured. They used this method to treat 51 cases with good results.

    According to our experience, although the treatment of fistulas that can not only eradicate the primary lesions and ducts, but also preserve the structure and function of the anal canal is a long-term goal, some of the above surgical methods are not applicable to all cases; superficial and simple Lay-Open surgery is sufficient for anal fistulas, and we still use Hanley surgery for the treatment of high hoof fistulas. Sometimes only a thick line can be tied to the sphincter to mark the inner mouth, and a second surgical incision is made after 2 to 3 weeks.

    Finally, it should be reminded that some authors refer to the posterior bilateral curved fistula as a horseshoe fistula. In fact, the name of the horseshoe (Horseshoe) type is more appropriate. Furthermore, in recent years, the topics of articles about anal fistula surgery have become more and more complicated. For example: segmental fenestration, bridge retention, scraping, incision, thread-hanging, and exclusion drainage for the treatment of high-complex iron-foot-type anal fistula". In fact, it is just thread-hanging therapy, and there is no need to include surgical measures in the topic.

    3. Anal fissure

    Anal fissure is an oval skin ulcer below the midline of the anal canal and below the tooth line. It is fundamentally different from certain specific ulcers such as chancre, tuberculous ulcer, and Crohn's disease.

    3.1. Current status of domestic treatment of anal fissure

    According to statistics, 91 articles on the treatment of anal fissures were published in the Chinese Journal of Anorectal Diseases in the past three years. Among them, 50 (54%) of the internal sphincter were cut. There are 14 articles about injection of various drugs under the anal fissure. The rest of the articles are conservative treatments except for plastic surgery and photoelectric mechanical treatment. Recently, there are 5 reports on the treatment of topical glycerol trinitrate (GTN) that have been widely reported abroad. It is said to have a good effect on the initial anal fissure. However, topical application of botulinum toxin (batalenum toxin) and calcium antagonist nifedipine gel (nimodipcnegel) has not been reported in China.

    3.2. Re-discussion of the doctrine of comb tape

    In 1981, the author introduced the theory of foreign articular bands and the discussion of the properties of the muscles at the base of anal fissure in a review. Now reviewing the above 90 articles, many authors still insist on cutting off the sphincter band and external sphincter during anal fissure surgery. Due to different experimental experiences, this kind of cognitive problem is bound to exist. However, as early as the 1950s, the theory of the sphincter belt and the properties of the sphincter had been replaced by new ideas. CN Morgan et al. stated that Miles’ "Clamella doctrine has never been accepted by people in St. Mark’s Hospital". Studies by Esehammer and Goligher in the 1950s proved that the lamella is actually a somewhat fibrotic internal sphincter. The external sphincter muscle is never cut off during anal fissure surgery. The Hamburg of St. Mark’s Hospital vividly compared the appearance of the internal and external sphincter muscles as easily distinguishable as the difference between chicken breast and thigh. CN Morgan corrected the fact that he and Milligan had mistaken the lower edge of the internal sphincter for the external sphincter in the early years, and he concluded that the term "commentum band" can no longer be used in anorectal writings. And "to draw attention to the widespread errors in the understanding of the anal muscles." According to our clinical observations, only smooth membranous tissues can be seen after the internal sphincter is cut, and the external sphincter, described as chicken thigh meat, is not visible at all. At this time, the external sphincter has been pushed out of the surgical field under anesthesia and surgical traction and expansion. It is almost impossible to cut the outer bracket. The subcutaneous part of the elliptical external sphincter is difficult to cut into any muscle in the triangular horizontal space behind the anus.

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