2021年2月19日星期五

preparation h hemorrhoids,PPH treatment of hemorrhoids-minimally invasive surgery that the patient desires

    Hemorrhoids (haemorrhoids) is a common anal disease, and it is known as "nine hemorrhoids in ten people" in the enterology department. With the continuous improvement of people's living standards and the continuous improvement of people's quality of life, the incidence of hemorrhoids is indeed getting higher and higher, and it is bothering people's lives. The treatment of hemorrhoids is divided into surgical treatment and non-surgical treatment. Non-surgical treatment is aimed at relatively mild hemorrhoids and can achieve clinically asymptomatic effects after drug treatment; surgical treatment is aimed at non-surgical treatment and cannot achieve the treatment of pain relief. And the effect is obvious.

    There are various surgical treatments for hemorrhoids. The most common ones include the classic "hemorrhoid external stripping and internal ligation", and the newer "stapling prolapse and hemorrhoid circumcision (PPH)". Let’s talk about it today. Novel PPH:

    (1) The concept of PPH:

    PPH is "Stapled Haemorrhidpexy (SH)" proposed by Longo in 1998, also known as "Procedure for Prolapsed Hemorrhoids (PPH)". It is based on the anal cushion theory. , A new technique for the treatment of annular prolapsed hemorrhoids with a stapler.

    PPH is a stapler hemorrhoids circumcision, which is suitable for all kinds of hemorrhoids with circular prolapse, especially patients with severe internal hemorrhoids and partial rectal mucosal prolapse. The principle is: to retain the anal cushion, part of the internal hemorrhoids and the hemorrhoid mucosa and submucosal tissues are circularly removed and anastomosed at the same time, an instant anastomosis is performed. It not only blocks the blood supply of hemorrhoids, but also suspends and fixes the slip tissue, and restores the pathological state of the anorectal to the normal anatomical state.

    (2) Scope of application

    It has a very ideal therapeutic effect on mixed hemorrhoids, ring hemorrhoids, severe hemorrhoid prolapse, and rectal prolapse. Used for the treatment of internal hemorrhoids of degree III and IV.

    (3) Principle of operation

    Use a special circular stapler to insert into the rectum through the anus, circularly excise the mucosa and submucosa tissue of the intestinal wall at the lower end of the rectum, and perform an anastomosis at the same time as the excision, so that the prolapsed anal cushion is lifted and the anal cushion is restored to its normal anatomical position. The "suspension" function cuts off the arterial blood branch supplying the hemorrhoids at the same time, and plays the "cut-off" function, so as to achieve the goal of radical cure.

    (4) Surgical steps

    In the first step, the PPH stapler is inserted into the painless area about 4 cm above the junction of the rectum and anal canal for treatment.

    In the second step, the PPH stapler is used to excise part of the internal hemorrhoids, supra-hemorrhoid mucosa, and submucosa tissue in a circular shape, and the anastomosis is completed instantly, blocking the bleeding of the hemorrhoids supplying blood vessels, and at the same time suspending and fixing the slipped tissue.

    In the third step, the blood vessel supply of the hemorrhoids is cut off, the internal hemorrhoids and the external hemorrhoids automatically shrink, thereby eliminating the root cause of hemorrhoids, avoiding the recurrence of hemorrhoids, and achieving the purpose of treatment.

    (5) Technical advantages

    1. Safety: There is no need to remove the anal pad, and the normal function of the anus is preserved to the greatest extent to avoid complications such as anal stenosis and anal incontinence. 2. Painless: Pull back the hemorrhoids that have prolapsed from the anus, and cut off the blood vessels that provide blood to the hemorrhoids, without damaging the perianal skin, so there is almost no pain after the operation.

    3. Less trauma and quick recovery: The circular stapling of the mucosa is a non-open wound, with less bleeding, eliminating the trouble of dressing change after surgery, and returning to normal life quickly.

    4. Scope of diagnosis and treatment: ring hemorrhoids, multivalve hemorrhoids, huge isolated hemorrhoids, mixed hemorrhoids, ring hemorrhoids, incarcerated hemorrhoids, rectal mucosal prolapse, prolapse, etc.

    5. Suitable for: Because of less damage, it is especially suitable for middle-aged and elderly people, white-collar workers who pay attention to efficiency, and those who have relapsed in traditional treatment, and patients with mild prolapse and rectal mucosal prolapse.

    (6) Contraindications

    It is not recommended for pregnant women, children, intractable constipation, pelvic tumors, portal hypertension, Bu-Ka syndrome or those who cannot tolerate surgery.

    (7) Matters needing attention

    The treatment mechanism of PPH is to circularly remove a section of the mucosa above the hemorrhoids, and at the same time anastomose the rectal mucosa at the far and near ends, so that the prolapsed anal pad tissue is lifted. In addition, due to the removal and anastomosis of the mucosa, part of the blood supply is also blocked. The hyperplasia and expansion of the blood vessels in the anal cushion area partially shrink due to the decrease in blood supply, so as to prevent its sagging. The best indications should be three-stage hemorrhoids, circular mixed hemorrhoids, and low rectal mucosal prolapse is also an indication.

    As a new treatment method, because it does not damage the anal cushion area tissue and does not affect its reflection on defecation, the closing and pressurizing effect of the anal cushion on the anus is not affected. Therefore, theoretically, this treatment method is in line with The principles of modern hemorrhoid treatment.

    Judging from the results of the surgery, the short-term effect is good. The problem is that the method has not been introduced in China for a long time, and the long-term effect remains to be seen. There are also some complications, such as postoperative hemorrhage, anastomotic infection, etc. In addition, we also found from some reports that some complications are quite serious. , Including intestinal fistula, rectovaginal fistula, pelvic infection caused sepsis, etc., and there are reports of death. According to foreign experts, some cases have relapsed after 16 months.

    (8) Surgery comparison

    Non-surgical treatment: diet therapy, oral medication, topical medication, injection therapy, haemorrhoid therapy, infrared therapy, cryotherapy, laser therapy, etc.

    Traditional surgical treatment: the removal of hemorrhoids by external stripping and internal ligation is the most commonly used treatment for severe hemorrhoids in recent years. Traditional surgical treatments have problems such as postoperative pain and long hospital stay and healing time. (9) Complications

    1. The incidence of anastomotic bleeding is still about 50% after the device is improved. For treatment, use 0/2 absorbable sutures under anoscope to make hemostatic sutures across the anastomosis.

    2. Anastomotic cracks and concurrent bleeding are divided into intraoperative cracks and postoperative cracks. Intraoperative cracks are commonly caused by excessive nail cut spacing and instrument operation errors. Postoperative cracking is common when the nail cutting is not strong enough, the nail cutting spacing is too large, or the nailing is not tight, and the cutting is incomplete. Postoperative anastomotic infection and postoperative constipation are caused by multiple factors. Anastomotic dehiscence is divided into full and partial dehiscence, but the treatment method is the same, that is, according to the original operation concept, restore the original state of the operation, and implement the anastomotic stoma reinforcement suture. A small part of the crack without bleeding symptoms does not need surgical treatment and can heal naturally.

    3. Delayed fall of anastomotic nails. The symptoms are related to the state, depth and position of the intraoperative nailing. Hemostatic sutures can also make it difficult for the anastomotic nails to fall off deeply. This complication is rare when the anastomosis is located in the mucosal layer of the lower rectum. The general incidence is about 20%. Treatment: Two to three weeks postoperatively, it is clamped out under anoscope.

    4. Postoperative external hemorrhoid edema and subcutaneous thrombosis under the anastomosis are often related to partial cracking of the anastomosis. If it is mild, it can be treated with external medicine, and thrombectomy should be performed if necessary. Prolapse of external hemorrhoids is often accompanied by partial anastomotic cracking, and no improvement has been seen with topical drugs. Ligation or surgical resection may be considered for remedy.

    5. Postoperative infection around the anastomosis and submucosal hematoma, abscess formation, and rectovaginal fistula are mostly related to miscutting, dissection, and lax disinfection caused by irregular suture of the anastomosis during the operation. The wrong operation of double purse-string suturing causes disordered tissue structure around the anastomosis, which is also a factor for infection. Small hematomas can be absorbed naturally. When an abscess is formed, it should be incised and drained as soon as possible in the rectal cavity. Submucosal infection at the lower end of the anastomosis is prone to form an anal subcutaneous fistula. When the deep infection above the anastomosis is delayed, complicated perirectal infections and pelvic floor infections and rectovaginal fistulas are easily formed, and these complicated complications can affect It is very serious for the patient. Perirectal infections and severe pelvic infections can cause necrotizing fasciitis and septic shock. If these are not handled in time and improperly handled, the patient’s life will be at risk; For female patients, it is not worth the gain, because it not only affects the quality of life of the patient, but also brings great pain to the patient's body and mind.

    6. The incidence of postoperative anastomotic stenosis is 1-5%, and it is often a simple linear stenosis. The occurrence of this disease is related to the patient's scar constitution. At the same time, it is also related to the excessive involvement of anastomotic suture, anastomotic infection and excessive hemostatic suture treatment. Treatment method: high-frequency electric knife under anoscope, multi-quadrant shallow incision, loosen the narrow ring.

    7. Postoperative pain It is common to have lower abdomen pain on the first day after surgery, which is normal. When the anastomosis is too low, touching the anal epithelial nerve or the anastomotic purse-string suture is too deep to bring into the muscular layer of the intestinal wall or more hemorrhoid tissue can cause anal spasm and pain. After two or three days, the wound will heal and it will improve naturally. Do necessary analgesic treatment after surgery.

    8. A small amount of hemorrhage in the anal canal in a short period of time after the operation. A small amount of hemorrhage in the anal canal in a short period of time after the operation is related to the fall of the staple. Long-term broken rectal bleeding must be examined by colonoscopy. Patients suffering from internal hemorrhoids and constipation must exclude the colon before surgery Organic disease and colon cancer.

    9. Postoperative anal papillary hypertrophy around the anastomotic stoma should be considered related to anastomotic stimulation. Treatment method: If related diseases around the anastomotic stoma are found during the operation, it is better to deal with it together. In case of anal canal spasm, proper anal expansion should be done.

    10. Anal bulging pain and discomfort refers to the pain of perianal bulging that is closely related to the operation after surgery. It is also a common clinical symptom. This anal bulging pain and discomfort is a transient normal reaction. As the wound progresses and the wound is gradually healed, the pain of anal bulging will eventually disappear naturally. Of course, there are some such pains that cannot disappear, but it is rare.

    (10) Misunderstandings in the implementation of PPH surgery

    1. PPH surgery for the treatment of internal rectal prolapse and outlet obstructive constipation, it can be said that the implementation of PPH surgery not only solves the prolapse of hemorrhoids, but also takes into account the treatment of partial rectal mucosal relaxation. For patients with internal rectal prolapse, PPH surgery to remove the loose mucosa of 2-75px width cannot completely improve the symptoms, because the rectal mucosa is lax, the pelvic floor drops, pelvic floor spasm, rectal protrusion and anal sphincter spasm, etc. Outlet obstructive constipation caused by many factors cannot be cured so easily.

    2. The role of PPH surgery in the treatment of rectal protrusion. At present, doctors have conducted clinical investigations on this. We say that PPH surgery can treat the prolapsed hemorrhoids while supporting and fixing the relaxation of delayed intestinal mucosa or rectal protrusion. effect. Throughout the classification of rectal protrusion and various surgical methods, especially for moderate and severe rectal protrusion, PPH surgery cannot be replaced, so simple and easy.

    3. In PPH operation, it is necessary to be extremely cautious when performing the initial internal hemorrhoids, especially young female patients. Because the patient is unmarried, it is not possible to perform digital examinations, and the rectum and vaginal septum of young women are tight. Blind injury.

    4. PPH surgery is used to remove wide-base polyps in the rectum or to close the internal opening of the internal fistula. Semicircular or focal rectal mucosal resection is often used. It is only used in very special circumstances. Currently, TEM surgery has been carried out. The treatment of diseases is more advantageous and safer.

    (11) Strictly mastering the indications of surgery is the key to preventing surgical complications

    (11) PPH surgery is only applicable to the second and third stages of internal hemorrhoids and some mixed hemorrhoids dominated by internal hemorrhoids. This is the experience summarized by most clinicians in the surgical practice, which is suitable for severe internal hemorrhoids promoted by early PPH surgery There are discrepancies. The doctors found that severe internal hemorrhoids could not be exposed under anoscope at first, which made it difficult to suture the purse string in the rectum. The poor exposure could easily lead to blind nail cutting. In addition, because the staple cartridge of the stapler is narrow and cannot accommodate much tissue, it is easy to cause complications such as incomplete nail cutting, bleeding, mucosal avulsion, and anastomotic opening. Therefore, a squat inspection is required before surgery, and the surgeon must personally observe its prolapse and determine the stage. PPH surgery is more suitable for hemorrhoids prolapse and hemorrhoids in the second and third stages. Although some mixed hemorrhoids with ring-shaped varicose veins are mainly internal hemorrhoids prolapse, if the operation is reluctant, it is easy to cause edema, thrombosis and recurrent hemorrhoids prolapse of the external hemorrhoids after surgery, resulting in poor treatment effects. (12) Strict operation routines, skilled operation techniques

    1. Surgeons must pass professional training, have the necessary theoretical knowledge, and pass simulation equipment operation training, and the necessary admission system.

    2. Must be familiar with the selection of surgical instruments and surgical indications.

    3. The surgical operation needs to be rigorous and the operating steps are standardized. The focus is on the selection and depth of the purse-string suture operation. Certain experience is required. If the suture is too deep, it will easily cause damage to the posterior wall of the vagina.

    4. The hemostasis and suture method is standardized and reliable, so as not to cause subsequent bleeding. Hemostasis suture helps to strengthen the anastomosis, but too much suture can also cause the delay of the staple falling off and increase the possibility of anastomotic scar stenosis.

    5. After placing a drainage tube to observe that there is no rectal bleeding for two to three minutes, the operation can be ended.

    Not all hemorrhoids are suitable for the treatment of PPH, and not all hemorrhoids are suitable for the treatment of PPH.

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