2021年2月22日星期一

what does a hemorrhoids look like,Why doesn’t Dr. St Mark’s like "PPH"?

    Author Dr. Xing Yunli, Anorectal Surgery

    During my exchange visit in St Mark’s hospital in the United Kingdom, I discussed PPH surgery for hemorrhoids with the world's leading anorectal expert, Professor Phillips. PPH and the emerging TST stapler surgery are developing rapidly in China, and controversy continues.

    Professor Phillips and other doctors in St Mark’s hospital said categorically "I don’t like it, we don’t use it."

    why? The simplest and most direct answer is-the postoperative effect is the same. Why do we need to use surgical instruments with severe damage and aggressiveness for patients?

    PPH operation is a stapler surgery designed by Italian scholar Longo to treat prolapsed internal hemorrhoids and rectal mucosa. It uses a stapler to complete the resection and anastomosis operation at one time. It was used in 1998 and entered the country around 2002. In the trend of minimally invasive surgery, PPH is known as the new technology of "minimally invasive treatment of hemorrhoids". Under the vigorous promotion of Johnson & Johnson in the United States, it is called safe, painless, and small in damage. It is applied to various anorectal diseases, including hemorrhoids and anal fissure , Anal fistula, anal nipple and so on. Now it is widely used until the flood, beyond the scope of the original design concept of the device.

    Should PPH be used? How should it be used? What are the problems after use? In fact, there have been controversies in domestic anorectal academic circles. Domestic doctors have a large patient group, a large amount of operations, and a strong voice in the international academic community.

    PPH is defined as a stapled prolapse and hemorrhoid mucosal circumcision or stapled hemorrhoid fixation. A special round stapler is inserted into the rectum through the anus, and the lower rectal mucosa and submucosal tissues are circularly removed. The hanging anal cushion is lifted up to restore its normal anatomical position, and at the same time, it cuts off the arterial blood branch supplying the hemorrhoids, and achieves the purpose of treatment through "suspension" and "cut-off".

    TST operation is a selective hemorrhoid resection and anastomosis developed on the basis of PPH and according to the distribution characteristics of hemorrhoids. The stapler used is the same as that of PPH. Partial resection of hemorrhoids and hemorrhoids is achieved through various anoscopes with different numbers of windows. Mucosa can avoid some inevitable postoperative complications and sequelae of PPH surgery.

    I also use staplers in my clinical work, and I mostly use TST. In my experience, the biggest advantage of stapler surgery is that it closes the wound, thereby reducing the irritation to the wound during defecation. The patient’s pain is significantly reduced and the healing of internal hemorrhoids is accelerated.

    During the operation of the stapler operation, more rectal mucosa and hemorrhoids will be removed. There must be many uncontrollable factors in the use of instruments during the operation. The possible complications of conventional hemorrhoid surgery, such as pain, difficulty urinating, bleeding, infection, etc., PPH stapler surgery also exists, and it adds other serious complications that may occur, such as urgency, anal burning sensation and persistent severe pain , Rectal perforation, rectal-vaginal fistula and rectal stricture (TST surgery can avoid rectal-vaginal fistula and stenosis), septic complications, etc. During the recovery process, the anastomosis has wound inflammation reaction, and it takes about 2 weeks to 2 months to recover. After recovery, patients will feel uncomfortable because of the retention of titanium nails.

    I never think that the stapler surgery is more of a minimally invasive surgery than the classic external stripping and internal ligation surgery. Doctors from St Mark's Hospital in the UK also insist that the stapler surgery is severely damaged and aggressive. From the perspective of humanistic care To protect the patient's physiological function angle, the stapler is not considered to be a beneficial surgical tool and method for the patient, and it is not recommended. The classic external stripping and internal ligation surgery can have the same effect of improving symptoms. Of course, the minimally invasive external stripping and internal ligation operation is preferred.

    We believe that for hemorrhoid surgery, the classic external stripping and internal ligation is the first choice, and PPH or TST should be selected as appropriate in the case of circular prolapsed internal hemorrhoids or rectal mucosal prolapse.

    Protecting anal function and avoiding unnecessary damage is the starting point for patients to choose treatment.

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