Anus and lower rectum diseases are the most common clinical diseases, and the treatment of these diseases has a history of thousands of years. At present, in domestic anorectal surgery, especially in the anorectal surgery of various hospitals of traditional Chinese medicine, anus and lower rectum diseases account for more than #"/. In recent years, the anatomy of the anal canal has been re-understood, and the physiological function of the pelvic floor and rectum has been improved. , Has promoted the development of diagnosis and treatment of such diseases.
1 The evaluation of rectal and anal function provides an objective basis for the grasp of surgical indications and the evaluation of surgical efficacy
Although China has accumulated considerable experience in the treatment of anal diseases and lower rectal diseases, surgical treatment often brings some complications, such as anal incontinence after hemorrhoids and anal fistula surgery, and decreased bowel control ability after rectal cancer surgery. In the past, these complications were thought to be an inevitable result of surgery. However, if the function of the rectum and anal canal is evaluated before and after surgery, the occurrence of complications can be reduced. The evaluation of rectal and anal function generally includes anorectal pressure measurement, pelvic electromyography, intrarectal ultrasound and defecography. Anorectal pressure measurement mainly evaluates the sphincter function of the rectum and anal canal. If anorectal pressure measurement is performed before hemorrhoid surgery and the contraction function of the anal canal sphincter is found to decrease, the possibility of incontinence after the operation is significantly increased. Other methods of treatment can be considered and try to No surgical treatment . Perform anorectal pressure measurement before surgery for rectal cancer: If the anal sphincter function is decreased, the anus should be expanded gently during the operation to avoid aggravating postoperative incontinence; if the anal sphincter function is significantly reduced or even incontinence has occurred, it is not suitable for low anus preservation Combined abdominal and perineal resection should be performed during surgery, otherwise the patient's defecation after surgery cannot be controlled and the quality of life will be low. The author has encountered patients with low rectal cancer who cannot control their stool after anus preservation and need a stoma. If anorectal pressure measurement can be performed before surgery, this complication can be avoided. The role of intrarectal ultrasound in the diagnosis and treatment of diseases of the anus and lower rectum has attracted more and more attention, and it has become an important standard for the selection of rectal cancer surgery and low anus preservation surgery. Intracavitary ultrasound examination can provide an important basis for judging the direction of the fistula of anal fistula, the location of abscess around the anorectum, and the end of the sphincter after injury. The examination of pelvic floor electromyography is widely used in the classification of outlet obstructive constipation and is a specific indicator of abnormal contraction of the puborectalis muscle . In the past, defecography was mainly used in the diagnosis of outlet obstructive constipation. Recently, it has also been used in the judgment of the internal opening and fistula of anal fistula, and the evaluation of the ability of the anal canal to control stool after anal incontinence sphincter repair. Recently, some people apply defecography to patients with anastomotic leakage or preventive stoma after low rectal cancer, to judge the healing of the anastomosis before the stoma is returned, but if the anastomotic leakage is not healed, the barium enters the anastomosis A leaky fistula will affect the healing of the leak. The author has encountered anastomotic leakage after the stoma! In patients with the leakage still not healed, it may be related to the residual barium in the fistula of the anastomotic leakage.
2 The concept of hemorrhoids and hemorrhoids challenges the traditional treatment of hemorrhoids. The understanding of the nature of hemorrhoids has long been controversial. The modern view is that: hemorrhoids are pathologically enlarged anal cushions in the lower rectum, and anal cushions are normal structures composed of Treitz muscle, blood vessels and connective tissues. It is a normal physiological anatomy for everyone. The function of anal cushions is closely related to human fine control. It is related; hemorrhoids can be divided into symptomatic hemorrhoids (someone called hemorrhoids) and asymptomatic hemorrhoids. The latter does not require treatment, and only hemorrhoids need treatment. Therefore, the treatment of hemorrhoids is to relieve the symptoms caused by hemorrhoids rather than eliminate hemorrhoids. itself. This shows that the previously claimed "treatment of hemorrhoids" is a wrong concept. For the treatment of hemorrhoids, keep in mind marino's famous saying: Do not treat signs without anal symptoms, and do not treat anal symptoms without signs. For the treatment of hemorrhoids, according to its principle, it is divided into non-surgical anal pad fixation, anal pad suspension and anal pad resection. Non-surgical anal pad fixation includes sclerosing agent injection, band ligation, laser, microwave, freezing, etc., but the most commonly used are injection therapy and band ligation, with few complications and positive effects . Hemorrhoid surgery, which is popular all over the world, is PPH. Its essence is an anal cushion suspension operation. After the rectal mucosa is removed, the prolapsed anal cushion is suspended to improve the symptoms of hemorrhoids such as prolapse and bleeding. The operation has attracted worldwide attention since its inception in 1998, but its long-term efficacy needs further observation. There have been reports of PPH complications such as rectovaginal fistula, persistent anal pain, and even death due to rectal perforation . The author's experience believes that the operation is not completely painless, so it is currently only suitable for ring-shaped hemorrhoids with degree III-IV prolapse. Conventional hemorrhoid surgery such as Milligan-Morgan surgery is still one of the main methods of hemorrhoid surgery. Hemorrhoid ring resection, or Whitehead surgery, is currently rarely used due to many complications.
3 Surgical treatment of constipation must strictly grasp the surgical indications
Constipation is divided into slow transit constipation, outlet obstructive constipation, and mixed constipation. Indications for surgery in patients with long-term severe slow transit constipation: ①There is definite evidence of no tension in the colon; ②No obstruction at the outlet; ③Sufficient anal canal Tension; ④No clinically obvious anxiety, depression and mental abnormalities; ⑤No clinical evidence of diffuse bowel motility, such as irritable bowel syndrome. The surgical methods are: ①Total colectomy and ileum and rectal anastomosis. This is a classic surgery to treat slow transit constipation, with a curative effect of 50%-100%, but there are certain complications, such as refractory diarrhea in 1/3 of the cases, and recurrence of constipation in 10%. ②Subtotal colectomy and blind and rectal anastomosis, because of the preservation of the cecum and ileocecal valve, the operation is simple, and can reduce diarrhea and other complications. However, the results of the report are different. It is believed that the left cecum often dilates and causes abdominal pain. A few scholars believe that cecal stool refluxes to the ileum, and ileitis can also cause diarrhea. ③ Some other surgical methods such as subtotal colectomy and regurgitation, sigmoid colon anastomosis, partial colon resection, etc. are not effective and are not used much. The postoperative effect of slow transit constipation combined with outlet obstruction is not good. For outlet obstructive constipation, surgical indications should be more stringent. Indications for anterior bulging surgery: ① Anterior bulging defecography diameter ≥ 4cm; ② Defecation angiography has barium retention, unable or only partial emptying; ③ Rectal and (or) vaginal symptoms up to 12 months Above; ④Although the dietary fiber content is 35g, the rectal or vaginal symptoms cannot be relieved for up to 6 weeks; it is necessary to use fingers to support rectal emptying through the rectum and/or vagina and/or perineum. The following points are not suitable for surgery: ① those with slow colonic transport; ② those with abnormal anal sphincter contraction, such as pelvic floor spasm syndrome, anal spasm; ③ those who use laxatives or enema to help defecation. Those who have the above medical history have poor results. The abnormal contraction of the puborectalis muscle is mainly treated by conservative treatment and biofeedback treatment. Surgical treatment is only used when it is combined with prerectal bulge or the treatment is ineffective [5-6].
4 Anus-preserving surgery for low rectal cancer should emphasize both radical remedy and function preservation. With the application of double stapling, there is no difficulty in the anastomosis technique for low rectal cancer, so anus-preserving surgery for low rectal cancer has become fashionable, but its existence is soon discovered The problem of high recurrence rate and poor bowel control after surgery. Therefore, the principle of radical tumor resection and good function preservation must be strictly followed when performing low anus preservation surgery: ①After tumor resection, it is necessary to ensure that the inferior resection margin is 2cm away from the tumor, and it is difficult to ensure the complete resection of <2cm. ②The classification of the tumor must be considered. Poorly differentiated tumors, especially mucinous carcinoma, cannot be used for low anus preservation. ③Preoperative intracavitary ultrasound, CT, and/or MRI have found metastasis of lymph nodes around the rectum and tumor invasion of surrounding organs, which is already locally advanced, and low anus preservation surgery is not suitable. ④It must be emphasized to retain good functions
Anus. If the function of the anal sphincter is poor, the ability to control stool will be poor after surgery, which is almost equivalent to an in situ stoma, which will cause great pain to the patient. Therefore, the function of the anal sphincter should be fully evaluated before the low anus preservation operation. If the preoperative anorectal pressure measurement indicates that the anal sphincter function is low, the patient will have more bowel movements after the low anus preservation, which will seriously affect the quality of life. In addition, if possible, pelvic floor electromyography should be performed as a basis for low anus preservation. It must be borne in mind that the closer the rectal cancer is to the anorectal ring, the more difficult it is to deal with, and the more comprehensive evaluation is required before surgery. ⑤Total mesorectal resection with preservation of pelvic autonomic nerves should be the basic criterion for rectal cancer surgery. For a long time, the high local recurrence rate after rectal cancer surgery has been a major problem that plagued surgeons. British surgeon Heald studied rectal resection specimens and found that even if rectal tumor metastasis to the distal end is limited to 0.5 cm, the metastasis in the loose tissue behind the rectum (mesorectum) can still reach more than 4 cm, so the local recurrence of rectal tumor The root cause is the lack of clearance of the mesorectal tissue rather than the insufficient distance of the distal end. Heald proposed that all adipose tissue, lymphatic tissue and blood vessel tissue must be sharply removed along the presacral fascia and proper rectal fascia space during rectal cancer surgery, that is, all the mesorectum is removed. This surgical method is called total mesorectal resection (TME) . In 1993, Heald reported for the first time the follow-up results of 152 cases of low rectal cancer undergoing TME surgery, and the 5-year local recurrence rate was reduced to 2.6% (4/152). In rectal cancer surgery, the lower hypogastric nerve and pelvic nerve plexus are easily damaged, and the incidence of postoperative sexual dysfunction and urinary dysfunction is high. Under the premise of ensuring radical resection, the autonomic nerve preservation TME operation will increase the local recurrence rate. And the incidence of postoperative sexual function and urinary dysfunction decreased significantly.
In recent years, for early rectal cancer, especially early rectal cancer near the anorectal ring, local resection can achieve the purpose of preserving the anus, but local resection is only suitable for highly differentiated tumors where the tumor invades the mucosa and submucosa without lymph node metastasis For poorly differentiated tumors even in Dukes A stage, local resection should not be performed. Sengupta et al.  analyzed 41 studies on local resection of rectal cancer published by MEDLINE and found that the local recurrence rate of T1 tumors after local resection was 9.7% (0-24%), and that of T2 was 25% (0～67). %), T3 stage is 38% (0-100%). After postoperative radiotherapy and chemotherapy, the local recurrence rate of T1 tumor was 9.5% (0-50%), T2 stage was 13.6% (0-24%), and T3 stage was 13.8% (0-50%). Tumor recurrence is related to low differentiation, lymph node metastasis, and positive margins. Recurred tumors can be resectioned radically. The tumor-free survival time after local resection is 0.1 to 13.5 years. The author believes that local resection of T 1 tumors can achieve Satisfactory local control and tumor-free survival, but prospective studies are needed to determine whether T2 tumors are suitable for local resection, and T3 tumors are not suitable for local resection.
5 Imaging examination of complex anal fistula can reduce the blindness of surgery
Complex anal fistula is one of the most difficult operations in anorectal surgery. Due to the limited knowledge of the fistula before the operation, part of the fistula may be missed during the operation and the operation may fail. Anal fistula angiography can provide information such as the path of the fistula and the location of the internal orifice. However, in most cases, complex anal fistulas have a closed fistula, and the contrast agent cannot be injected and cannot be displayed, and ordinary angiography cannot show the relationship between the fistula and the anal sphincter. At present, the .A1 three-dimensional imaging technology is applied to the diagnosis of anal fistulas. Since MRI can distinguish normal tissues, chronic inflammation tissues and muscle tissues, the fistula can be visualized without using contrast agents, thus overcoming the inability of contrast agents that cannot be injected. Show the shortcomings of fistula. But because MRI is not very popular, and the price
Relatively expensive, currently limited in applications.
Changhai Hospital of Second Military Medical University Yu Dehong, Jin Heiying