2021年1月28日星期四

hemorrhoids or anal cancer,Progress in diagnosis and treatment of anal marginal edema after hemorrhoid surgery

    Anal edema (edema of crissum) is one of the common complications after hemorrhoid surgery. Anal marginal edema is the symptoms of edema, congestion, bulging and falling pain in the anal canal and skin of the anal margin (1). The edema tissue is transparent, and blood stasis can be seen for a while, usually on the anus side, even for a week. Once the postoperative anal edema occurs, it will bring great pain to the patient and prolong the course of treatment, which will affect the wound healing.

    1. Reason

    1. Anatomy

    Hemorrhoid surgery is close to the dentate line of the anus, which can easily damage the dentate line. Because the small arteries and veins in the submucosa near the dentate line are connected by direct anastomosis to form cavernous veins, the small branches of the external hemorrhoidal venous plexus and the internal hemorrhoidal venous plexus also communicate with each other. When internal hemorrhoids are ligated and injected, the hemorrhoid tissue is congested or sphincter spasm after hemorrhoid surgery. The special structure of the dental line can cause the blood and lymph flow below the dental line to be blocked and form anal edema.

    2. Surgery

    2.1 Poor operation timing is more common in inflammatory external hemorrhoids, incarcerated hemorrhoids, and thrombotic external hemorrhoids that are not fully controlled and rushed for surgery. Postoperative inflammation aggravates and forms inflammatory edema. Masahiro Takano (2) believes that acute incarcerated hemorrhoid surgery may cause the spread of infection and even hemorrhage is a "hypothetical complication" and advocates surgical treatment, but if there is an infection, the author believes that the inflammation needs to be controlled first.

    2.2 The concept of aseptic weakness is often due to non-compliance with the principles of aseptic operation, leading to incision infection and inflammatory edema.

    2.3 Improper drug injection: During local anesthesia, the drug is injected too much or too shallowly under the skin of the anal margin, causing edema of the external hemorrhoid venous plexus as a last resort; internal hemorrhoids sclerosing injection drugs are injected below the dental line by mistake. Local anesthesia inadvertently damages the blood vessels in the anus, causing subcutaneous hemorrhage and edema after surgery.

    2.4 Incomplete resection Hemorrhoid tissue, especially varicose vein tissue and thrombus, is not completely peeled off. The internal veins and lymphatic network of the remaining hemorrhoid tissue are destroyed, and the veins and lymphatic drainage are obstructed, causing edema. Wang Yanmei, An Ayue et al. (3) think that it mostly occurs in the preserved skin bridge and the external hemorrhoid area when the internal hemorrhoids are ligated and the external hemorrhoids are not treated.

    2.5 Inappropriate ligation of mixed hemorrhoids with external stripping and internal ligation to make a V-shaped incision. Before stripping to the tooth line, clamp the stump of the external hemorrhoid and the base of the internal hemorrhoid with hemostatic forceps and ligate together. The pain sensitive area is distributed outside the tooth line. Inappropriate will cause severe pain, sphincter spasm, obstruction of venous and lymphatic drainage, and edema. Dai Shudong et al. (4) According to the theory of anal cushion, the external stripping and internal ligation with preserving dentition reduces the occurrence of postoperative anal edema compared with traditional external stripping and internal ligation, but ligation should be avoided in the painful area outside the dentition.

    2.6 Poor incision drainage usually occurs in cases where the incision is too short. Duan Haitao et al. (5) believe that the distal end of the original incision should be radially extended to reduce the tension of the incision during hemorrhoid surgery. Shi Renjie et al. (6) believed that the incision was too short due to factors such as the loosening of the anal canal during anesthesia and the displacement of the anal canal. As a result, the incision was all retracted above the anal skin line after the operation, and the wound was not drained smoothly, resulting in edema.

    2.7 Incision with high tension, such as excessive skin resection, small width of skin bridge, traction and compression of the anal skin and subcutaneous tissue during suture, affecting lymphatic and venous return, resulting in edema, Arbman G⑺ study believes that the incision suture is more likely to occur edema It is related to the inability of the sphincter muscle to relax well; the hemorrhoid surgery did not make a tension-reducing incision, Duan Haitao et al. ⑺ Three types of “V”-shaped, distal extension and two-side parallel tension-reducing incisions were used to prevent anal edge edema and achieved good results; The posterior skin tissue (skin bridge) is not reset in time, the dressing is too tight, and the anal skin and skin bridge cannot return to their normal positions after the anesthesia disappears, resulting in the anal canal skin or skin bridge being incarcerated in the anus, venous and lymphatic drainage obstacles, Formation of edema.

    2.8 Improper operation of the operation Unskilled operation, clamping of tissues during operation, too long operation time, aggravation of local damage, etc. can cause anal edema.

    3. Objective reasons

    3.1 Acute incarceration of hemorrhoids, gangrenous hemorrhoids, etc. require emergency surgery. Potential infections may cause postoperative inflammatory edema; for mixed hemorrhoids with a large range, the operation will lead to large defects in the anal canal, pressure imbalance at the defect, and residual skin bridge tissue squeezing into the area. The defect causes edema.

    3.2 Some patients are afraid of pain after the operation, and the surgical trauma causes sphincter spasm. They cannot defecate normally. The stagnant stool compresses the blood vessels, which makes the venous and lymphatic drainage obstacles and forms edema.

    2. Prevention

    After analyzing the causes of anal edema after hemorrhoid surgery, Zou Yujuan et al. (8) put forward three preventive measures, which are summarized as follows:

    1. Prevention is the priority. Carefully plan the surgical incision before operation, and do a good job of comprehensive prevention in three links before operation, during operation and after operation.

    Clean the enema before the operation so that the patient will have a bowel movement 24 hours after the operation. For incarcerated hemorrhoids, thrombotic external hemorrhoids, inflammatory external hemorrhoids, etc., inflammation should be actively controlled before surgery, and surgery should be performed after the inflammation is controlled.

    Intraoperative aseptic operation, design the operation plan according to the condition, perform the operation order, sacral anesthesia must pass, try to reduce the local anesthesia again after sacral anesthesia, or the amount of medicine should not be too much during local anesthesia, the action is gentle and accurate, the incision is flat, Radial incisions keep the tension balance on both sides of the wound mesothelial bridge. If the skin bridge has a greater degree of movement, you can use sutures to fix 1 to 2 stitches. The decompression incision is appropriately extended to allow smooth drainage and avoid excessive hemorrhoid ligation, otherwise it will cause blood Lymphatic circulatory disorders cause postoperative edema. For hemorrhoids, subcutaneous thrombosis and varicose veins should be removed carefully. If anal stenosis, part of the internal sphincter should be cut off appropriately to reduce the influence of sphincter spasm on local blood circulation. Injection of sclerosing agent should be on the tooth line. After the injection, massage can be used to disperse the medicine evenly. After the operation, check the bleeding on the wound and fully stop the bleeding. The anus should be pressurized for 24 hours.

    Control the stool for 24 to 48 hours after the operation, eat more fruits and vegetables, and appropriately give laxative drugs to prevent dry stools and squatting in the toilet for too long, which may cause anal edema after struggling; however, do not use harsh agents, which can cause diarrhea. Repeated bowel movements can also cause anal edema. Appropriate use of antibiotics to prevent infection after surgery. Strictly perform aseptic operations when changing dressings, wash the sitz bath first, act gently when changing dressings, clean the wound thoroughly, place the drainage strip in place, and massage perianal appropriately.

    2. Surgical exploration Mixed hemorrhoid circumcision has been eliminated due to many postoperative complications; domestic treatment mostly uses external resection and internal ligation, but it is still impossible to avoid postoperative anal edema.

    Anal marginal edema is based on the mechanism of the gate closing effect of the internal anal sphincter. Zhang Zhenyong et al. (9) observed cutting off part of the internal sphincter to prevent the occurrence of anal marginal edema after hemorrhoid surgery; in order to reduce postoperative anal pain and pressure bandaging caused high pressure in the anal canal Xu Qiuling et al. (10) used drainage gauze to wrap a small catheter in the anal canal to reduce the pressure of the anal canal and rectum, and improve the local microcirculation. According to the special anal cushion circulation structure on the anal tooth line, Rong Chun and Rong Xinqi⑾ believed that the anal suspension Cushioning and preoperative expansion of the anus can help local blood and lymphatic drainage in the anal canal; Li Jianping, Zhao Ke, etc. ⑿ Using orthotopic skin flap grafting with tooth thread retention plus partial internal sphincterotomy preserves the local anatomy and physiological functions, and does not block blood and Lymphatic circulation can prevent edema after hemorrhoid surgery; on the basis of continuous exploration, the country is also absorbing international advanced technology, such as Wen Yuling, etc. ⒀The use of Takano Masahiro method to treat multiple mixed hemorrhoids reduces the occurrence of anal marginal edema.

    Three, treatment

    Once postoperative anal edema occurs, it must be actively treated to relieve the patient's pain and promote the healing of the incision. Clinical treatment is often both internal and external.

    1. Internal treatment: Clearing away heat, detoxifying and removing dampness, replenishing qi and moisturizing the intestines, promoting blood circulation, removing blood stasis and relieving pain. Commonly used Liangxue Dihuang Decoction, Cistanche Runchang Pills, Changfeng Powder. Commonly used cork, scutellaria, atractylodes, honeysuckle, raw atractylodes, cistanche, paeonol, red and white peony, Citrus aurantium, big belly bark, corydalis, etc. The modern clinical use of Xiaotuozhi⒁, Aimailang⒂, Maizhiling⒃, etc., has certain effects in preventing and treating edema after hemorrhoid surgery. The effect of these drugs is to reduce vascular permeability, increase venous return and improve postoperative edema after hemorrhoids.

    2. External treatment

    Traditional Chinese medicine sitz bath Commonly used Sophora flavescens, Phellodendron chinense, Atractylodes japonicus, Sophora japonicus, Madder, Galla chinensis, Lychee grass, Puxiao, Angelica, Red spoon, Milky Way, Xuanhu and other decoction 1000ml first smoke and then wash.

    External application of ointment: Scutellaria Ointment and General Xiaozhong Powder are commonly used to adjust the application. The effect is remarkable. For inflammatory edema, ofloxacin gel can be used for external application, or Mayinglong hemorrhoid ointment, compound Yuhong ointment, Qingliang ointment, etc.

    Medicinal liquid wet compress Inflammatory edema combined with congestion and edema can be washed with metronidazole injection (the effect of reducing wound pain and promoting healing ⒄) and then wet compress with 50% magnesium sulfate gauze or hypertonic saline gauze. The effect is accurate.

    Anal plug medicine For smaller anal marginal edema that can be returned to the anus with your hands, intra-anal Sepji hemorrhoid suppository and other suppositories that can clear away dampness and heat and reduce swelling, the effect is accurate.

    Drug injection Davies J⒅ uses local injection of botulinum toxin to relieve sphincter spasm and prevent anal edema.

    Surgical treatment   For those with severe edema, which may not disappear for a long time, or with residual hemorrhoids and subcutaneous thrombosis, surgical trimming can be performed again.

    3. Other therapies: There are clinical reports on Qigong therapy (retracting anus exercise), He-Ne laser, microwave, magic lamp, infrared, etc.

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