I. What are hemorrhoids? Hemorrhoids are masses formed by pathological hypertrophy and displacement of the anal cushion and blood stasis in the perianal subcutaneous vascular plexus. –The Prevalence of Hemorrhoids – Diagnostic criteria vary greatly in the results of the Provisional Standards for the Diagnosis and Treatment of Hemorrhoids developed in 2000 in China. Nine out of ten people have hemorrhoids. Chinese epidemiological survey 1975-1977: The prevalence of anorectal diseases was 59/1%, hemorrhoids accounted for 87/25% of them. Chinese epidemiological survey in 2015: The incidence of anorectal diseases at this stage is about 50%, and hemorrhoids account for more than 90% of them. Foreign: 4/4% – Kaidar-PersonO,PersonB,WexnerS (2007). 86%–HaasPA,HaasGP,SchmaltzS,FoxTAJr (1982). Second, theories related to hemorrhoids 14 theories of modern modern medicine. The doctrine of erectile tissue, the doctrine of sinusoidal veins, the doctrine of descending rectal canal, the doctrine of imbalance of rectal canal forces, the doctrine of metaplasia, the doctrine of sphincter dysfunction, the doctrine of declining hemorrhoidal venous pump function, the doctrine of varicose veins, the doctrine of vascular proliferation, the doctrine of infection, the doctrine of altered pressure gradients, the doctrine of hemorrhoidal hernia formation, the doctrine of branching of the inferior rectal artery, the doctrine of anal canal stenosis The main theories of hemorrhoids, abnormal expansion of the venous plexus Abnormal expansion of the arteriovenous anastomosis, prolapse of the anal cushion and surrounding connective tissue, and increased tension of the internal sphincter (increased fibrous tissue) The varicose veins theory of hemorrhoids: Hemorrhoids are soft venous masses made by stasis, dilation, and flexion of the varicose plexus protruding from the rectum under the rectal mucosa and the skin of the anal canal, and consequently cause bleeding, embolism, or mass protrusion. It is thought to be a lesion of the vessel itself. When relaxation, fracture, hypertrophy, or prolapse of the anal cushion occurs, it then complicates the stasis and varicosity of the venous plexus and gradually forms hemorrhoids. The theory of inferior displacement of the anal cushion of hemorrhoids suggests that: hemorrhoids are the displacement of the anal cushion; the anal cushion is a normal structure with a rich arterial blood supply and direct access to the dilated venous space; the anal cushion helps seal the anal canal and make the anus self-contained; constipation and nuisance destroy the supporting structures of the anal cushion, causing congestion and displacement of the anal cushion; increased intra-anal pressure during defecation caused by tension of the internal sphincter can intensify congestion and displacement of the anal cushion. Third, the classification of hemorrhoids. The classification of hemorrhoids is commonly used in China: internal hemorrhoids (stage I, II, III, IV), external hemorrhoids (varicose veins, connective tissue, thrombotic, inflammatory), and mixed hemorrhoids. IV. Diagnosis and treatment. Chinese guidelines: 1. Chinese Society of Traditional Chinese Medicine (CCM) guidelines for the treatment of common diseases in Chinese anorectology. 2.Guidelines of the Colorectal Surgery Group of the Chinese Society of Medical Surgery. Treatment strategy: 1. Guiding ideology: the interests of patients are paramount. 2. No medication → medication → non-surgical treatment → simple surgery → complex surgery. Treatment principles: 1. Asymptomatic hemorrhoids do not require treatment. 2.The purpose of treatment of hemorrhoids: focus on eliminating and reducing their symptoms. 3.Relieving the symptoms of hemorrhoids is more meaningful than changing the size of the hemorrhoid body, and should be considered as the standard of treatment effectiveness. 4, the doctor should use reasonable non-surgical or surgical treatment according to the patient’s condition, his experience and medical conditions. Treatment methods: 1.Chinese medicine treatment. 2.Chinese medicine internal treatment method. 3.Treatment by identification: internal Chinese medicine soup, adult medicine, single test prescription. Six types of evidence: – “Chinese Medicine Industry Standard of the People’s Republic of China”: wind injury to intestinal ligaments, damp-heat injection, qi stagnation and blood stasis, spleen deficiency and qi trapping, yin deficiency and intestinal dryness, large intestine solid heat. Commonly used Chinese patent medicines: Diyu Huaijiao Pills, Liu Wei Anti-Hemorrhoid Pills, Hemorrhoiditis Dispersing Tablets, Zhi Kang Capsules, Naked Flower Purple Pearl Dispersible Tablets, Hemorrhoid Pills, Hemorrhoid Blood Capsules, Anti-Swelling Hemorrhoid Tablets, Hemorrhoid Ning Tablets, Hemorrhoiditis Dispersing Punch, etc. The external treatment method of Chinese medicine: 1, suppositories nano-anal method (internal hemorrhoids). 2.External application method: (inflammatory external hemorrhoids, thrombosed external hemorrhoids or various kinds of hemorrhoids after surgery) raw muscle red jade cream, Ma Yinglong musk hemorrhoid cream, anal Thai ointment, etc. 3.Fumigation method: compound rhubarb soup, hemorrhoid inflammation Ning fumigation agent, and toxin removal soup. Acupuncture treatment: Withered hemorrhoid therapy: Chinese herbs with corrosive and astringent effects are made into a bulking agent and applied directly to the surface of the hemorrhoid nucleus, causing it to gradually necrotize, dry up and fall off. 1958 – Arsenic-free withered hemorrhoids nails are treated conservatively by Western medicine. (1) Oral western medicine. With the development of the theory of the inferior displacement of the anal cushion, some drugs targeting the physiological changes in the blood vessels of hemorrhoids have made progress in relieving or eliminating the symptoms of hemorrhoids. Microcirculatory modulators: grass rhinoceros fluid tablets, hydroxy rutin, compound rutin and other non-specific drugs: analgesics, stool softeners, hemostatic drugs and anti-inflammatory drugs. They are used after hemorrhoid surgery to promote venous and lymphatic reflux, eliminate free radicals, reduce the permeability of the vessel wall and edema, and promote fibroblast production and wound healing. (2) Injection therapy. Origin: Injectable therapy started in 1869 in western countries, and was modified by Andrem in 1879 and is used today. Theoretical basis: Sclerosing drug is injected into the nucleus of hemorrhoids, producing sterile chemical inflammation, causing the anal cushion to adhere and fix with the muscle layer of the rectal wall above it, and strengthening the supporting effect of the anal cushion tissue. At the same time, the action of the drug causes damage to some of the sinusoidal veins, forming intravascular thrombi subsequently causing the hemorrhoid nucleus to atrophy and fall off. After the introduction of injection therapy in China, the combination of Chinese and Western medicine injection methods has made it more effective. Shi Zhaoqi invented the hemorrhoid elimination injection. In addition, there are 603 injection from Nanjing, and Paeonia Bui injection from An Ahh. Injection therapy is mainly for internal hemorrhoids, and a few are used for external hemorrhoids. (3) Ligature method. The rubber ring ligation method: A special rubber ring is put into the root of the internal hemorrhoid to block the blood flow of the hemorrhoid, which causes ischemia, necrosis, detachment and healing. It has limitations and is only suitable for internal hemorrhoids of degree I, II and III, and cannot eliminate the root cause of hemorrhoids. Automatic hemorrhoid ligation (RPH): The development of science and technology has led to the creation of RPH, which has a mucosal ligation method on the hemorrhoid and a joint ligation method. Since the site of ligation is the suprahemorrhoidal mucosa, the anal cushion rises and is fixed to a certain extent. (4) Physiotherapy. Infrared coagulation therapy: I and II degree internal hemorrhoids, causing fibroplasia and sclerosis and atrophy of the hemorrhoid mass. The method is simple, the treatment time is short and no hospitalization is required, but the recurrence rate is high. Copper ion electrochemical therapy: copper needles are placed into the nucleus of hemorrhoids, connected to electric current, and the physical and chemical effects are used to harden and necrotize the local tissue, which can form fibrous tissue around the venous plexus, encasing and protecting the anal cushion. This method is safe and effective and is suitable for outpatient use. Hemorrhoid treatment apparatus: electrolysis, electrocoagulation, electrocautery, so that the nucleus of the hemorrhoid eventually atrophies. V. Surgical treatment of hemorrhoids. 1.Traditional surgical methods: (1) External peeling and internal ligation (open) (Milligan-Morgan procedure): A: Clamp and pull outward the external part of the hemorrhoid. B: Clamp and pull the external hemorrhoid part outward to fully expose the nucleus. C:A “V” shaped incision is made on both sides of the external hemorrhoid. D: along the lower part of the skin of the external anal sphincter and the internal sphincter upwards. (2) Closed hemorrhoidectomy (Ferguson procedure): A: fully expose the hemorrhoid tissue and cut the skin and mucosa:. B:Peel the hemorrhoid nucleus along the lower part of the external anal sphincter skin and the internal anal sphincter. (3) Circumferential hemorrhoidectomy (Whitehead procedure): A: Suture the supra-arterial area of the hemorrhoid, followed by circumferential incision of the mucosa above the dentate line, and gradually separate the mucosa of the lower rectum into a mucosal sleeve:. B:Cut out the hemorrhoid nucleus above the suture site. C:Strip the submucosal venous plexus. D:The mucosal sleeve is pulled down evenly so that the lower edge of the mucosal sleeve is aligned with the upper edge of the incision at the dentate line and then sutured. E:The surgery is completed. (4) Submucosal hemorrhoidectomy (Parks procedure): a: After local anesthesia, a “Y” shaped incision is made along the dotted line mark in the figure:. b:Peel the submucosal tissue containing the hemorrhoid nucleus along the surface of the internal sphincter and suture through the root of the hemorrhoid nucleus. c:Excision of the hemorrhoid nucleus. d:Partial suturing of the anal canal mucosa and open drainage of the skin incision. 2.Other surgical treatments (1) Modification of hemorrhoid surgery —- Minimally invasive surgery. How to choose minimally invasive surgery? The treatment of hemorrhoids cannot be confined to a certain method, and different surgical methods should be selected according to the local anorectal examination and the systemic condition: the best indications for PPH, TST, RPH, internal hemorrhoid injection; the former surgical methods can be combined with external hemorrhoidectomy or HCPT, etc.; TST should be selected for non-circular hemorrhoids, and PPH, TST plus external hemorrhoidectomy is appropriate for circumferential hemorrhoids. (2) Clutch suprahemorrhoidal mucosal circumcision (PPH surgery) a:Prolapsed hemorrhoid nucleus. b:Fixed dilator in the anus. c:One loop of uniform suture under the rectal mucosa. d:The head end of the anal anastomosis is inserted against the staple seat to the top of the purse string for loop tying. e:Prolapsed mucosal group. Clinical application should be strictly controlled by the indications: 1. PPH indications: Circumferential prolapsed hemorrhoids, internal hemorrhoids ≥3. The advantages of legendary PPH: does not affect anal function; mild pain; short course of treatment. Problems with anal function after PPH: inability to drain and hold. 2.Doppler-guided hemorrhoid artery ligation (DG-HAL procedure): Longitudinal continuous suture fixes the prolapsed hemorrhoid nucleus in the submucosa, Doppler-guided hemorrhoid artery ligation minimally invasive surgery is not a panacea. The Milligan-Morgan procedure remains the gold standard procedure for the treatment of hemorrhoids and has an irreplaceable status. Just because a new surgical approach has emerged, the traditional external peel-and-stick procedure should not be discarded. The Milligan-Morgan procedure is preferred for those with embedded hemorrhoids and massive thrombosis in the nucleus pulposus. You cannot blindly exaggerate the minimally invasive role of PPH etc. and consider it a painless procedure. In fact, no matter which minimally invasive procedure is performed, as long as it is a surgery, there will be trauma and postoperative pain and discomfort.