Systemic treatment of inflammatory ring mixed hemorrhoids
Inflammatory circular mixed hemorrhoids are based on mixed hemorrhoids. The internal hemorrhoids prolapse outside the anus and fail to stimulate the anus in a timely manner, causing sphincter spasm, leading to hemorrhoidal vein and lymphatic drainage disorders, resulting in high edema of the hemorrhoids, massive thrombosis, and severe pain in the anus. Therefore, early surgery is recommended to relieve hemorrhoidal vein and lymphatic drainage. Segmented external stripping and internal ligation resection is one of the classic surgical methods for ring-shaped mixed hemorrhoids. The degree of satisfaction of patients after surgery varies. The main manifestations are edema and pain of the anal margin and discomfort of postoperative intraanal fall.
Since 2010, our department has performed external stripping and internal ligation injection treatment on 76 cases of inflammatory incarcerated mixed hemorrhoids. The postoperative systemic supportive treatment has been satisfactory. The report is as follows.
l. Clinical data
All 76 cases were in line with the diagnosis of inflammatory circular mixed hemorrhoids, 39 males and 37 females, aged 18 to 65 years, with medical history of 4 to 20 years, and incarceration for 1 to 11 days. Patients all have anal mass prolapsed, mostly in the shape of a ring, unable to be absorbed, anal squeezing pain, sharp increase in hemorrhoid volume, high local edema, thrombosis, and some with erosion, necrosis, oozing, and even secondary infection Happening. There were 28 cases with old anal fissure.
1). Preoperative preparation: All patients should complete relevant preoperative examinations, exclude surgical contraindications, and try to fast before surgery. Orally take 20 ml of cannabis oil 12 hours before surgery, or empty the intestines thoroughly with sodium phosphate enema 1 hour before surgery .
2). Surgical method: spinal anesthesia or local anesthesia, usually left or right decubitus position, conventional surgical area disinfection, put the prolapsed incarcerated hemorrhoids into the anus, disinfect the anal canal and check the anus, massage the anus with the fingers, then Expand the anus and relax the anus, observe the location, size, and number of hemorrhoids. According to the size of the circular mixed hemorrhoids, the condition and distribution of the external hemorrhoids, the incisions are designed, and three female hemorrhoids are selected as the external and internal ligation sites. For some primary hemorrhoids not in the female hemorrhoids, the primary hemorrhoids are selected as the ligation points. During the operation, make a "V"-shaped incision in the external hemorrhoid area at the same point. The length of the incision and the width of the hemorrhoid are 3:1. The subcutaneous tissue and varicose plexus are bluntly peeled to 0.3 cm on the tooth line, and the hemorrhoid base is clamped with large curved forceps In the section, the "8"-shaped suture under No. 7 wire forceps to ligate the hemorrhoids and peel the tissue, remove the external hemorrhoids together with the internal hemorrhoids that have been ligated, leave the marker thread, and return the hemorrhoid pedicle to the anus; about 1 cm of mucosa should be left between each ligated hemorrhoid Bridge, the ligation point is not on the same plane; for larger hemorrhoids that are fused into a mass in a semi-circle, the large hemorrhoids can be divided into multiple small hemorrhoids for treatment separately, and the subcutaneous tissue is fully peeled off from the incision to both sides thrombus. Trim the cutting edge and observe whether the incision is aligned. The incision is fully electrocoagulated to stop bleeding, and internal sphincter lysis is performed in the large "V"-shaped incision on the posterior side, and beware of anal stenosis. For the unligated hemorrhoid tissue and the swelling is still obvious under anesthesia, a longitudinal decompression incision should be made to avoid the formation of skin tags after the operation. After inserting an anoscope to clear the intestinal hemorrhage, take 20 ml of Xiaozhiling at a concentration of 1:1 and inject it into the maternal superior hemorrhoidal artery area at 3, 7, and 11 o’clock at the lithotomy position, especially the mucosa above the heavy area of the original incarcerated edema Lower injection. The excised wound can be injected with methylene blue long-acting analgesic for pain relief. The injection should be even, and the needle should not be inserted too deeply, for the best pain relief effect. An anal mirror is inserted into the anus to explore the intestinal cavity. After each hemorrhoid ligation point has no active bleeding points, a compound carrageenan suppository is inserted, the oil gauze is placed in the drainage, and the exhaust pipe is inserted in the anus (soft drainage Tube is appropriate), the tower-shaped yarn block is compressed, and the "D"-shaped bandage is pressurized and fixed.
3). Postoperative treatment: postoperative anti-infective treatment for 3 days, rest in supine position on the day of surgery, hot water bottle hot compress the lower abdomen throughout the process, actively prevent urinary retention, total fluid for 1 day, control stool for 24 hours, change to general food after 3 days; regular defecation , Can be taken orally with laxatives to soften the stool; take a Chinese medicine bath every day and after stool, microwave treatment once a day, use compound carrageenate cream and metronidazole sand strips to place in the anus, skin edge In case of edema, use magnesium sulfate injection to dilute the gauze strip and place the skin edge edema. If the patient has severe pain during defecation and poor defecation, it can be combined with nitroglycerin tablets to be ground into a powder and mixed with anti-inflammatory cream to apply to the wound at a concentration of 0.2%. Relieve cramping pain.
After 76 patients, 51 cases of squeezing pain disappeared, and 25 cases were significantly relieved. The average hospital stay is 7 days and the recovery is 20-25 days. No postoperative complications such as hemorrhage, infection, anal canal stenosis and fecal incontinence were observed. The stool control ability was good and the appearance was smooth.
Due to various reasons, the hemorrhoid tissue is clamped by the sphincter spasm, which obviously obstructs the blood flow and lymphatic return in the venous plexus. However, at this time, the arterial blood is still continuously input, causing the prolapsed hemorrhoids to increase in volume and the anal tissue Blood supply disorder, tissue edema, ischemia and hypoxia, causing accumulation of acidic metabolites in the tissue, further causing persistent internal sphincter spasm, leading to incarceration of hemorrhoids, and extremely painful patients. In the past, conservative treatments were used, and early local anesthesia was repeated. Although it is barely included in the anus, further elective surgery is needed.Emergency surgery for incarcerated hemorrhoids is safe and feasible, and is significantly better than elective surgery. Surgery removes the acute mixed hemorrhoids, can remove the mixed hemorrhoid tissue from the lesion, eliminate the prolapse, reduce the pressure and stimulation of edema and thrombus; cut off part of the sphincter can relieve the sphincter spasm, block the leading link of the pathological vicious circle, and make the anus Smooth circulation of blood and lymph to promote local body to establish and restore physiological balance on a new basis as soon as possible; by injecting appropriate amount of Xiaozhiling into the submucosa above the pulsating area of the suprahemorrhoidal artery and the area with severe edema of the lesion, the hemorrhoid tissue can be converged , Atrophy, relative fixation, can prevent postoperative complications and skin bridge edema, etc., and promote wound margin repair. Therefore, early and timely surgical treatment of incarcerated hemorrhoids is a positive treatment. The treatment with this method can quickly eliminate the lesion, relieve sphincter spasm, and improve blood and lymph circulation. The author has experienced in the clinical system treatment process: 1) During the operation process, spinal or sacral anesthesia should be performed as much as possible, the anus should be relaxed and fully exposed, and local infiltration anesthesia should not be used as much as possible to avoid postoperative anal edema; 2) pay attention The incisions should not be too wide or too wide to avoid excessive damage to the anal canal and the skin of the anal margin, which is not conducive to wound healing. Note that thrombus and clot should be removed thoroughly, and the hemorrhoidal venous plexus under the skin bridge should be removed as much as possible to avoid postoperative edema, pain or recurrence Surgery; 3) During the operation, avoid excessive traction and clamp the normal tissues of the wound margin, stop bleeding thoroughly, should not be too much packing, and place an exhaust tube to prevent the patient's lower abdomen from swelling; 4) The hemorrhoid base ligation point should not be at the same On the horizontal plane, hemorrhoids with larger hemorrhoids can be ligated in sections to prevent loose ligation and thread knots falling off; the ligation range should not be too large to reduce the tension of the anal canal, reduce tissue damage, and avoid postoperative anal edema and anal swelling; 5 ) 7-10 days after operation, patients are encouraged to eat more and do more levator anus exercises. It is advisable to form dry stools to expand the anus. Anal plug compound carrageenate suppository is used to repair the mucosa of the hemorrhoids in the anal area and avoid the patient's long-term discomfort and foreign body sensation in the anus.
 Zhang Dongming, Hemorrhoids[M], People's Medical Publishing House, 2004.277