Objective: To explore the clinical application of PPH plus external hemorrhoidectomy. Methods: PPH plus external hemorrhoidectomy for the treatment of 35 cases of mixed hemorrhoids with grade Ⅲ-Ⅳ and 35 cases of PPH operation alone were compared. Results: There were no statistically significant differences between the two groups in terms of operation time, postoperative complications, and postoperative hospital stay. Conclusion: PPH plus external hemorrhoidectomy can expand the scope of indications for simple PPH surgery and improve patient satisfaction.
Keywords: PPH; external hemorrhoidectomy; hemorrhoids
Investigation of Clinical Application about PPH plus External Hemorrhoidectomy
The Coloproctological Dept. of Suzhou TCM Hospital
Abstract：AIM: To investigate the clinical application about PPH plus External Hemorrhoidectomy in the treatment of hemorroids. METHODS: 35 cases of the mixed hemorrhoids at Ⅲ-Ⅳdegree treated by PPH plus External Hemorrhoidectomy was compared with the other 35 cases by single PPH at the corresponding time period. RESULTS: Two groups have no difference in statistics on operating time,complication after operation,hospitalization time after operation. CONCLUSION: PPH plus External Hemorrhoidectomy can expand the indication of single PPH,and also can meet all patients' satisfaction.
KEY WORDS: PPH; External Hemorrhoidectomy; hemorrhoid
The procedure for prolapse and haemorrhoids (PPH) is a new procedure for the treatment of severe hemorrhoids based on the theory of lower anal cushion and is one of the most important developments in hemorrhoid surgery in recent years. According to the interim specification of PPH operation , its indications are internal hemorrhoids of degree III and IV with circular prolapse and degree II internal hemorrhoids with repeated bleeding. However, there are few patients with simple internal hemorrhoids in clinical practice, and the most common ones are mixed hemorrhoids and internal hemorrhoids with connective tissue external hemorrhoids. For this reason, our department has performed partial resection of external hemorrhoids on the basis of PPH surgery for these patients for more than a year, and compared it with PPH alone in terms of operation time, postoperative complications and postoperative hospital stay. The results reported below:
1 Materials and methods
1.1 Materials: From May 2005 to April 2006, 35 patients with grade III and IV internal hemorrhoids and internal hemorrhoids with recurrent bleeding and PPH alone were selected as group I; those with grade III-IV were admitted Patients with mixed hemorrhoids or internal hemorrhoids with connective tissue external hemorrhoids, who had ≤3 external anal hemorrhoids after manual recuperation, combined with PPH plus external hemorrhoidectomy, were selected 35 cases as group II. The average age of patients in group I was 51.4 years, and the average age of patients in group II was 52.5 years. Both groups selected 15 male cases and 20 female cases. There was no significant statistical difference between the two groups.
1.2 Methods: Preoperative preparation: routine blood test, coagulation function, electrocardiogram, enema every night before surgery, fasting in the morning.
Intraoperative operation: use intraspinal anesthesia, take the right or left decubitus position. All use the HJZ 32 PPH stapler produced by Suzhou Frankman Medical Equipment Co., Ltd. Use a circular anal expander to expand the anus, and place a transparent anal mirror under the guidance of the anal expander and fix it. Under the exposure of the anal mirror suture device, make a single purse-string suture on the 2.5-4.0cm submucosa of the dentate line. The purse-string stitches are kept at the same level, and the needles are inserted in the original position from the needle exit point, usually 7-8 stitches. (Start at 6 o'clock, 1 stitch of mucosal suture for pulling at 12 o'clock) Unscrew the circular stapler to the maximum position, introduce the nail anvil head and place it on the purse string, tighten the purse string and tie it up. Pull the purse string and puller wire out of the side hole of the stapler. Tighten the stapler while pulling. When the marking line enters the 1/3 area behind the firing window, fire the stapler, loosen the handle, and wait for 40s. Unscrew the stapler 1/2 turn and then exit, check the removal of the mucosal ring Integrity and anastomosis. In case of active bleeding, use absorbable sutures to stop bleeding. Group Ⅰ was operated according to the above steps, and group Ⅱ was operated according to the above steps. According to the condition of the skin tag on the anal margin, a fusiform incision was made to remove 1-3 external hemorrhoids under the tooth line. Rectal mucosal protective suppositories (compound carrageenate suppositories) were placed in both groups. After 6 hours after the operation, the fluid was fluid, and antibiotics were infused for 3-5 days.
Statistical processing: χ2 test was used for counting data, t test was used for measurement data.
The operation procedures of the two groups of patients were smooth, no anesthesia accidents, no primary and secondary hemorrhage, and were cured and discharged. Statistical analysis was performed in terms of operation time, postoperative complications and postoperative hospital stay, and no significant statistical difference was found. The comparative data are shown in Table 1 and Table 2. The observation standards for postoperative pain and edema refer to the unified standards established by the National Anorectal Academic Conference in 1975. Pain: Ⅰ°: Slight pain in the anus, no need to deal with it. Ⅱ°: Anal pain, no obvious painful expression, it can be relieved by taking general analgesics. Ⅲ°: The pain in the anus is severe, and there is a painful expression. Meperidine (Meperidine) is needed to relieve the pain. Edema: Ⅰ°: local mild edema, which does not affect activity. Ⅱ°: Local edema is obvious and movement is blocked.
Table 1 Comparison of operation time and postoperative hospital stay between the two groups (x±s)
Operation time (min)
Postoperative hospital stay (d)
Table 2 Observation and comparison of postoperative complications between the two groups (cases)
Urinary retention (catheterization)
Since Longo proposed PPH surgery to treat severe hemorrhoids in 1998, tens of thousands of cases of PPH surgery have been carried out at home and abroad. Its short-term curative effect is positive. Although there is still a lack of follow-up reports of long-term curative effects, PPH surgery has been widely accepted clinically because of its short operation time, small trauma, quick recovery, and no pain or slight pain. PPH surgery has obvious advantages compared with traditional external stripping and internal ligation surgery. In clinical practice, a considerable number of patients are satisfied with the results of surgery. In addition to whether the original bleeding and prolapse symptoms disappear or improve, the following two points are often considered: one is postoperative pain, and the other is the appearance of the anus. PPH surgery alone is more common in clinical practice for patients with grade III-IV mixed hemorrhoids and internal hemorrhoids with connective tissue external hemorrhoids with obvious external hemorrhoid skin tags. External hemorrhoids often remain after surgery, which reduces patient satisfaction; and there are also clinicians. Worrying that the addition of external hemorrhoidectomy during PPH surgery will aggravate postoperative pain and make PPH surgery lose its advantages. Therefore, it is not advisable to use PPH surgery for such patients and stick to traditional external stripping and internal ligation, not only rejecting some patients from PPH surgery Outside the door, it suffered severe pain and artificially restricted the development of PPH.
In recent years, our department has adopted PPH plus external hemorrhoidectomy for mixed hemorrhoids and internal hemorrhoids with connective tissue external hemorrhoids of grade Ⅲ-Ⅳ. Through clinical observation and comparison of nearly 100 cases, it is found that although individual incisions have been added, the trauma is not large, the recovery is still relatively fast, and there is no significant increase in postoperative pain, and the appearance of the anus is flat, which improves the satisfaction of most patients. It also expands the indications of PPH surgery for hemorrhoids. Therefore, we believe that PPH plus external hemorrhoidectomy can expand the scope of indications for pure PPH surgery in the treatment of hemorrhoids. Through the observation of larger specimen volume and longer-term clinical follow-up in the future, PPH surgery is expected to replace the traditional external stripping and internal ligation surgery and become the gold standard for hemorrhoid surgery.
1 Yang Xinqing, Han Jin, "Summary of Symposium on Stapling and Hemorrhoid Mucosal Stapling" Chinese Journal of Surgery, 2002, 40 (10): 795-796