Abstract Objective: To explore the clinical effect of incomplete external stripping and internal ligation plus injection in the treatment of circular mixed hemorrhoids. Methods: The larger hemorrhoids were externally stripped and internally ligated, the smaller external hemorrhoids were excised or stripped, and the rest of the internal hemorrhoids and the lower rectal loose mucosa were injected with Shaobei injection. Results: 312 cases were cured, 301 cases, accounting for 96.47%; 11 cases were markedly effective, accounting for 3.53%. All are effective, the course of treatment is 12 to 20 days, with an average of 16.5 days. After half a year follow-up, there were 95 cases with follow-up results, 3 cases had occasional wet anus, no recurrence and sequelae. Conclusion: Incomplete external stripping and internal ligation combined with injection has a high cure rate for the treatment of circular mixed hemorrhoids, which can effectively preserve the skin bridge, protect the anal cushion, and avoid postoperative adverse reactions.
Circumferential mixed hemorrhoids is a clinically intractable disease. From December 1998 to June 2006, we used a number of improvements to traditional surgical methods and combined with Shaobei injection to treat 312 cases of annular mixed hemorrhoids. Satisfactory clinical effects have been achieved, and the report is now as follows.
1 materials and methods
1.1 Clinical data
Among the 312 cases, 214 were males and 98 were females; aged 21 to 76 years old, with an average age of 46.5 years; 84 cases of disease duration less than 5 years, 148 cases of 6 years to 10 years, 25 cases of 11 years to 20 years, and 55 cases of more than 20 years (State Administration of Traditional Chinese Medicine "Diagnosis and Efficacy Criteria for Diseases and Syndromes of Anorectal Medicine in Traditional Chinese Medicine") 274 cases of simple circular mixed hemorrhoids, 38 cases of circular mixed hemorrhoids incarcerated; 87 cases were treated with drugs, and 21 cases were treated with sclerotherapy 6 cases were treated with surgery.
1.2 Treatment methods
1.2.1 Preoperative preparation
Empty the stool, clean the anus, and eat a small amount of food. For hypertensive patients, phenobarbital sodium 0.2g was injected intramuscularly half an hour before surgery. 1.2.2 Surgical operation
Anesthesia and disinfection: The patient is placed in a lateral position, sacral canal block anesthesia is performed, and local infiltration anesthesia is performed for sacral hiatus deformities. Iodine and alcohol disinfect the perianal skin, and iodine disinfects the hemorrhoid area on the anal canal and dental line 3 times, and then fill the rectal cavity with 2 dry cotton balls.
Stripping point positioning method: Following the principle of "external hemorrhoids first, prolapse first, and incarceration first", select 3 to 5 of the most obvious external hemorrhoids as the peeling points. If there is no significant difference in the size of external hemorrhoids, choose the larger one The external hemorrhoids corresponding to the prolapsed internal hemorrhoids are the peeling points, or the incarcerated hemorrhoids are selected as the preferred peeling points. The tissue between the two peeling points is the skin bridge and the mucosal bridge to be preserved.
External hemorrhoids peeling method: Use tissue forceps to clamp the top of the external hemorrhoids and lift gently, cut the skin about 0.5cm away from the base of the hemorrhoids from the outer edge of the anal margin, and peel off the subcutaneous connective tissue and venous plexus to peel off the tissue Free to the anus to ligate the tooth line, and the incision should be gradually adducted when free. Pay attention to the ligation of the hemostatic point while peeling.
Ligation of internal hemorrhoids: Use large curved hemostatic forceps to clamp the base of the external hemorrhoids from free to the dentate line together with the upper 2/3 part of the internal hemorrhoids on the dentate line, and perform simple ligation or "8" penetration stitching at the lower end of the hemostatic forceps , Keep the 0.5cm long stump, cut off the rest, and then push it back into the anus. The two adjacent ligation points should be misaligned up and down.
Internal hemorrhoid injection: (1) Medicine: Shaobei injection (Beijing Sakura Pharmaceutical Factory, batch number: 981010), with a concentration of 1:1, that is, 1 part of Shaobei injection plus 1 part of 0.5% lidocaine. ⑵ Location ①Unligated internal hemorrhoids; ②Under the rectal mucosa at the upper end of the skin bridge; ③Under the loose mucosa at the lower rectum. ⑶Injection method: see Hemorrhoid injection. When the injection needle penetrates the hemorrhoid mucosa, the speed should be fast, and the needle should be withdrawn slowly to make the medicine evenly fill the hemorrhoid. After the injection, take out the dry cotton ball that filled the rectal cavity before the operation.
Rehabilitation of small incisions at the anal margin: trim the skin margins on both sides of the incision, peel off subcutaneously swollen veins and thrombi, and extend the incision to the outside of the anal margin appropriately, so that the external hemorrhoid incision is a fusiform radial outward. If the anal margin is still uneven, use a small incision to strip and trim the raised area. After the operation, the wound was filled with hemostatic sponge, and the tower-shaped gauze was fixed with pressure bandage.
1.2.3 Postoperative care
Stool can be discharged 24 hours after the operation. After the bowel movement, take a bath with Chinese medicine, apply a small amount of Jingwanhong to the wound, and apply petroleum jelly gauze.
1.2.4 Efficacy criteria
It is implemented in accordance with the "Diagnosis and Efficacy Standards of Chinese Medicine Diseases" [China Traditional Chinese Medicine Publishing House, 1994 First Edition] issued by the State Administration of Traditional Chinese Medicine in June 1994.
301 cases were cured, accounting for 96.47%; 11 cases improved, accounting for 3.53%. All are effective, the course of treatment is 12 to 20 days, with an average of 16.5 days. 3 cases of urinary retention occurred on the postoperative day, and 9 cases took Qiangtongding tablets for pain. No complications such as fever and anal bleeding.
Six months after the operation, there were 95 cases of follow-up results. 3 cases complained of occasional anal dampness, which improved after taking a bath with warm water, and the rest were normal.
3.1 Methods and problems
At present, surgery is mainly used to treat external hemorrhoids and mixed hemorrhoids. According to statistics from Japan's Takano Masahiro , the proportion of surgery is 59.5%. Milligan-Morgan's ligation resection is the most standard surgical procedure for the treatment of mixed hemorrhoids in the world. It is named after the surgical method of ligating the root vessels connecting the roots of internal hemorrhoids and removing the hemorrhoids. The earliest methods for removing hemorrhoids in China, except for dry hemorrhoids, were the earliest ligation treatments recorded in the Song "Taiping Shenghui Prescriptions for Hemorrhoids and Rat Milk Prescriptions for Hemorrhoids in the Anal" from 982-992 AD. Rat nipples fall unconsciously". At present, the most important method for the treatment of mixed hemorrhoids in China is external stripping and internal ligation.
In 1995, Morinaga and others in Japan reported using Doppler and a specially designed proctoscope to find and ligate the hemorrhoid artery to treat 105 hemorrhoid patients, which was considered a successful operation without pain and low complications. However, the clinical effect of this method needs to be further verified. At the same time, this method requires corresponding equipment and mastering certain related operation techniques, which is currently difficult to promote in China.
In recent years, based on the understanding of the anal cushion theory of hemorrhoids, domestic and foreign countries have adopted a circumcision therapy, using a special rectal stapler to perform a one-time circular resection and anastomosis on the upper end of the hemorrhoid, which is believed to block the hemorrhoidal artery and suspend it upward. The anal cushion thus plays a therapeutic role. This method is mainly suitable for internal hemorrhoids and rectal mucosal relaxation. The stapler is expensive, and postoperative complications are difficult to avoid. Currently, it is only used in a few units.
3.2 Selection and method of stripping point
The first step of circular mixed hemorrhoid surgery is segmentation. There is no clear principle and uniform standard in China. Junichi Iwataru of Japan  pointed out that the design question of where to be removed and where to leave for full-peripheral hemorrhoids is very important. Most scholars choose the three traditional maternal hemorrhoids .
Although both are circular, each individual will have different performances, and it is not practical to formulate a fixed segmentation pattern. The author proposes to identify the location of hemorrhoids, and determine the stripping point according to the following three principles: ① "Large first, then small, external size first, prolapse first, incarceration first", first remove the larger external hemorrhoids, if the external hemorrhoids are of equal size Regardless of the boundaries, the external hemorrhoids corresponding to the larger prolapsed or incarcerated internal hemorrhoids is the incision. ②3~5 o'clock is appropriate. ③At the same time, it is necessary to consider the balance of the 12 points of the front, back, left and right anus, and not all incisions should be concentrated on one side. First big and then small is to avoid miscutting "false hemorrhoids", which is the need to preserve the skin bridge; 3 to 5 points are to consider the needs of treatment and the protection of anal function; incision balance is to avoid postoperative edema and long-term effects.
3.3 The basis of incomplete stripping combined with injection
In 2000, the "Chinese Journal of Anorectal Diseases" reported in 25302 cases of hemorrhoids that 9077 cases were surgically operated. In these cases, 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 unanimously proposes that a considerable width of "skin bridge" or "mucosal bridge" must be kept between the two hemorrhoids when hemorrhoids are removed.
In the long-term clinical practice, the author has found that the anal marginal protrusions in the case of circular mixed hemorrhoids are not all hemorrhoids, and some are partly caused by the "false hemorrhoids" accompanying hemorrhoid prolapse. This situation is particularly prominent after defecation and after anesthesia. "False hemorrhoids" is to retain the skin bridge. In order to cut the "false hemorrhoids" by mistake, we designed the "incomplete external peeling and internal ligation" surgical method. When the external hemorrhoids are peeled off and the internal hemorrhoids are ligated, approximately 1/3 of the base is properly retained, so that no matter what the two hemorrhoids are There are unbounded grooves, and sufficient skin bridges and mucosal bridges are reserved. The advantage of incomplete internal ligation is that it can effectively protect the anal cushion and avoid excessive tension at the ligation point after shedding and bleeding.
The incompleteness does not affect the completeness of the treatment. The external hemorrhoids are stripped of the venous mass on both sides of the incision, and the still uneven skin bridge is trimmed by small incisions and the venous mass is destroyed, which can smooth the anal margin and prevent edema.
The adequate preservation of skin bridges and mucosal bridges also prevents postoperative anal and rectal stenosis.
3.4 Problems with Shaobei injection
Shaobei injection is suitable for the treatment of simple internal hemorrhoids in various stages . After local injection, it can produce a strong atrophic effect. Unlike the previous sclerosing agent, it does not produce local induration. The treatment of circular mixed hemorrhoids is coordinated with the surgical method. Shaobei injection is injected into the unligated small internal hemorrhoids and the loose rectal mucosa at the upper end of the skin bridge to ensure the thorough treatment of internal hemorrhoids and lift the anal margin while preserving the mucosal bridge and protecting the anal cushion. The skin bridge makes it evener.
3.5 Anal sphincter relaxation problem
Because there are more than 2 wounds in the external dissection and internal ligation of circular mixed hemorrhoids, the skin and anal margin tissue removed during the operation make the anal canal after healing tighter than before, and the elasticity is poor, which is likely to cause anal canal stenosis. Excessive ligation of internal hemorrhoids can also cause rectal stenosis. The most commonly used method to prevent postoperative anorectal stenosis is to cut off the internal anal sphincter during the operation to loosen the anal canal [5-6].
The internal anal sphincter is the most important muscle that maintains the normal resting pressure of the anal canal, and the decreased function of the anal sphincter is an important cause of hemorrhoids. Liu Aihua and others cut off the main anal nerves of the rabbits and continued to over-expand the anus with an anoscope, which can form pathological changes similar to human hemorrhoids in the anus. The author also observed in the clinic that some patients with anal sphincter damage and congenital anal sphincter relaxation are mostly accompanied by severe internal hemorrhoids. In addition, after the internal sphincter is cut, the pressure in the anal canal is unbalanced, the pressure at the fracture is low, and the skin bridges on both sides of the fracture are prone to edema. As a result, blind release will cause more relaxation of the anal sphincter, resulting in postoperative complications and affecting long-term efficacy.
In clinical practice, we do not cut off the internal anal sphincter to loosen the anal canal to prevent stenosis. Instead, we use a more scientific and reasonable design to minimize trauma to avoid postoperative stenosis, which is a more active method.