In recent years, with the continuous deepening of the study of perianal diseases, people have put forward an almost completely new concept of hemorrhoids. In order to enhance the clinical surgeon’s understanding of hemorrhoids and standardize its treatment, we invited some experts to make a discussion through the above discussion can be clearly seen, although in recent years on the hemorrhoids of the research has made great progress, but because of hemorrhoid pathogenesis, anatomy and pathophysiology of hemorrhoids is far from being clear, the clinical understanding of hemorrhoids is still controversial. 1, on the definition of hemorrhoids Professor Tang Zongjiang (Guangxi Medical University Affiliated Hospital No. 1): in the previous textbooks (Surgery. Beijing: People’s Health Publishing House, 1994), the definition of hemorrhoids is still controversial. Beijing: People’s Health Publishing House, 1994.494): “Hemorrhoids are masses caused by varicose veins of the upper and lower rectal venous plexus on both sides of the dentate line, and as a result, bleeding, embolism, or mass prolapse”, emphasizing the varicose veins of the upper and lower rectal venous plexus on both sides of the dentate line. Review of recent literature, “hemorrhoids diagnosis and treatment of provisional standards” (Chinese Journal of Surgery, 2000, 12: 891) on “hemorrhoids is the anal cushion pathologic hypertrophy, displacement and perianal subcutaneous vascular plexus stagnation of blood flow formation of the mass,” emphasizing the anal cushion pathologic hypertrophy, displacement. Although the latter is now accepted by most surgeons, its definition does not fully explain all the clinical manifestations of hemorrhoids (especially external hemorrhoids). According to the above definition, internal hemorrhoids should mostly occur in the truncal position at 3, 7, 11 points, however, in clinical practice, it is often seen that some patients, in addition to the above position, in the 1, 5, 9 points, etc. can also have different degrees of isolated internal hemorrhoids. Can this phenomenon be regarded as not only pathological hypertrophy and downward displacement of the anal cushion, but also hypertrophy and downward displacement of the mucous membrane adjacent to the anal cushion, which may be caused by the dysfunction of local arteriovenous anastomosis? Prof. Zhang Dongming (Anatomy Department, Second Military Medical University): To discuss the exact concept of hemorrhoids, first of all, we should understand the anatomy of the “anal cushion”. 1960s, a German scholar pointed out that the submucosal blood vessels of the anal canal are very complex and spongy. After the continuation, Stelzner further proved that the spongy gap in the special shape of blood vessels is essentially the result of direct anastomotic traffic of arteries and veins, called rectal spongiosa (copus cavernosum recti).Thomson (1975) in 42 cases of normal human anoscopy found that this spongiosa in the anal canal was arranged in the right anterior, right posterior and left, which was Y-shaped groove-like separation. shaped sulcal separations. He believed that, from a physiological point of view, the tissue in the rectum to play the role of cushion, help the anus closed tightly, so named “anal cushions” (anal cushions). Afterwards, he will cut off the hemorrhoidal tissue and “anal cushion” tissue comparison, found that by the expansion of the veins, Treitz muscle and connective tissue, so he had clearly put forward “hemorrhoids are normal structure of the anal canal (hemorrhoids are normal structure of the anal canal)”. The hemorrhoids are normal structure of the anal canal”. His statement invariably caused the concept of anal pads and hemorrhoids to be confused. After my recent repeated consideration, the modern definition of hemorrhoids should be “abnormal anal cushion tissue and the combination of symptoms called hemorrhoids”. Therefore, hemorrhoids itself is a disease, is the anal cushion abnormal clinical manifestations and consequences. Because the Chinese character for hemorrhoid has the radical “疒”, it already indicates that it is a disease, which is essentially different from normal anal cushion tissue. Prof. Ai Zhongli (Zhongnan Hospital of Wuhan University): About 1.5~2.0cm above the dentate line in the anal canal, spongy tissues rich in characteristic blood vessels are distributed in a ring shape, forming 3 parts of thickened submucosal elevations. In the truncal view, the three bulges were located in the right anterior, right posterior and left sides of the anal canal. Microscopically, they contain blood vessels, smooth muscle and elastic connective tissue. Its function is to cooperate with the anal sphincter to ensure the normal closure of the anal canal, and to discriminate gas, water and stool finely, which has been recognized by Thomson (1975) as “anal cushions”. Therefore, the anal cushions are a physiologic concept. Pathological changes in the anal cushions and hypertrophy and downward displacement of hemorrhoids, the reasons are manifold. For example: (1) the destruction of the elastic structure of the anal cushion. Such as Treitz muscle degeneration (after 30 years old) until the degenerative changes; in addition, long-term constipation, diarrhea, pregnancy and anal sphincter power malfunction, etc., can make the Treitz muscle overextension and rupture, resulting in the downward displacement of the anal cushion. (2) The arterial and venous anastomotic plexus in the anal cushion has an obstacle to the regulation of blood volume, causing blood stagnation in the anal cushion. This pathological hypertrophy and displacement of the anal cushion and the blood stagnation in its vascular plexus form a mass that is internal hemorrhoids. In severe cases, bleeding, pain, prolapse, incarceration and other symptoms can be combined. Therefore, hemorrhoids is a pathological concept must not be confused with the anal cushion. Xia Zhiping editorial (Chinese Journal of Practical Surgery editorial board): from the external view of internal hemorrhoids, prolapsed tissues are lesions of the anal cushion, hemorrhoids of the “anal cushion down” theory, may be due to this indisputable fact. However, I think that the “anal cushion” doctrine can not explain all the hemorrhoids. Leaving aside the external hemorrhoids, clinically 1, 2 stages of internal hemorrhoids to bleeding, and many patients hemorrhoidal bleeding jet, bleeding can be very large. This symptom of early hemorrhoids is the “anal cushion shift” doctrine can not be explained. In order to distinguish between the anal cushion and hemorrhoids in the clinic, the symptomatic hemorrhoids will be called hemorrhoids,” advocates the “anal cushion downward” theory of the “Interim Standards for Hemorrhoidal Diagnosis and Treatment. I personally believe that the idea of strictly distinguishing between the anal cushion and hemorrhoids is right, but the use of “hemorrhoids and hemorrhoidal disease” to distinguish between inappropriate, for two reasons: (1) “symptomatic hemorrhoids called hemorrhoidal disease”, implying that asymptomatic hemorrhoids is not a disease, thus wrongly recognizing the Asymptomatic hemorrhoids is the anal cushion, the conclusion of hemorrhoids is the anal cushion, resulting in a “stolen concept” error. (2) Hemorrhoids itself is a disease, covering the anal cushion submucosal arteriovenous anastomosis “sinus” regulatory dysfunction, and the anal cushion of pathological prolapse. The word “hemorrhoidal disease” is an unnecessary repetition of the word disease, easily misunderstood as hemorrhoids plus hemorrhoidal complications of the “syndrome”. For example, “tumor”, many benign tumors in the body is asymptomatic, do not need treatment, but can not say that “tumor” is not a disease; need to be treated “tumor” do not need to call The tumor is also not called “tumor disease”. To sum up, the concept of hemorrhoids fails to involve “bleeding”, at least incomplete. Furthermore, according to the previous definition of hemorrhoids and the location of hemorrhoids, clinical manifestations, divided into internal hemorrhoids, external hemorrhoids and mixed hemorrhoids. The doctrine of “anal cushion displacement” can only define internal hemorrhoids and cannot explain external hemorrhoids. External hemorrhoids, whether from the site of occurrence or pathological changes, have nothing to do with the anal cushion; even thrombosed external hemorrhoids, there is no internal hemorrhoidal bleeding clinical manifestations. Precisely, external hemorrhoids is the tooth line to the far perianal subcutaneous vascular plexus thrombus formation of local masses, the performance of local severe pain. Provisional standards for the diagnosis and treatment of hemorrhoids with “and perianal subcutaneous vascular plexus blood flow stagnation formation of lumps” will be defined in the category of hemorrhoids, is obviously very far-fetched. Although there is no direct statement that external hemorrhoids are not hemorrhoids in the literature, there is a statement that “mixed hemorrhoids are hemorrhoids with an external component”. In other words, external hemorrhoids are not hemorrhoids, they are unnamed “external components”. Therefore, in my personal opinion, the doctrine of “anal cushion” can be used to define hemorrhoids, subject to the necessary additional explanation. “External hemorrhoids” is another disease, should not be included in the category of hemorrhoids. 2, about hemorrhoid staging Professor Zhang Dongming: about hemorrhoids need to be staged, is currently the world is still debating the issue. Although countries have their own different staging method, but there are also those who oppose staging. The reason for the opponents is that the staging of hemorrhoids mainly focuses on the clinical manifestations of internal hemorrhoids and has no pathological basis. In other words, the clinical manifestations of hemorrhoids and the pathological changes in the anal cushion do not coincide, so that the classification of hemorrhoids has no obvious clinical value, Thomson’s 1981 book Colorectal Disease emphasized that “the classification of hemorrhoids is neither clinically nor scientifically meaningful. (1990) bluntly does not advocate staging and suggests that internal hemorrhoids should be divided into five categories according to their symptoms, i.e., hemorrhagic hemorrhoids, thrombosed hemorrhoids, internal hemorrhoids, external hemorrhoids, and acute hemorrhoids. My personal opinion, since the clinical manifestations of hemorrhoids do not coincide with the pathological changes in the anal cushion, it is better to divide them into different types instead of rigid staging. Prof. Tang Zongjiang: “Hemorrhoid diagnosis and treatment of provisional standards” on the grading of hemorrhoids, mainly for internal hemorrhoids. That is, according to the clinical manifestations of internal hemorrhoids (bleeding, pain, prolapse and ingrown hemorrhoids, etc.), they are divided into 4 degrees (I, I, II, III, IV), with no pathological basis. If the main purpose of grading is to choose the treatment method and facilitate the comparison of the efficacy of different treatment methods, it is better to classify internal hemorrhoids into several types according to their clinical manifestations. For example, blood type, prolapse type and prolapse of internal hemorrhoids strangulation embedded type. 3, the treatment of hemorrhoids Ai neutral professor: in view of the recent update of the concept of hemorrhoids, the previous variety of treatment of “hemorrhoids” method should take a cautious attitude (except external hemorrhoids). The principle of treatment: asymptomatic hemorrhoids, I agree with the United States Marino Professor put forward: “Do not treat the symptoms without anal signs, and do not treat the anal signs without symptoms. For hemorrhoids with comorbidities, the treatment should be selected according to the patient’s symptoms: (1) physical therapy: diet to drink more water, eat more fiber-rich foods to keep the bowels open; pay attention to dietary hygiene, prevention of diarrhea; and warm-water sitz baths and so on. (2) Drug therapy: such as the protection of intestinal mucosa suppositories, ointments and oral medications, and can make the hypertrophic anal cushion atrophy of sclerosing agent injections and other therapies. (3) Surgical therapy: the choice of surgical procedures, in addition to external hemorrhoids, attention should be paid to the abandonment of the wrong view of radical hemorrhoidectomy, especially the serious destruction of the physiological function of the anal cushion of the ring resection of the procedure. Professor Tang Zongjiang: asymptomatic hemorrhoids do not need treatment, this claim is correct. 50% of the normal population suffers from hemorrhoids, of which only 5% show symptoms of blood in the stool, hemorrhoidal prolapse. The hemorrhoid without symptoms is also a disease. However, no treatment is required; on the symptoms of the “resting” hemorrhoids, there is no need to intervene in the treatment of hemorrhoids, through changes in dietary structure, to develop good defecation habits can be controlled hemorrhoids recurrence. For those who have blood in the stool, dripping blood or jet-like bleeding, with or without internal hemorrhoidal prolapse, the above treatment can be carried out at the same time, the local drug treatment. If the effect of medication is not obvious, the proven sclerotherapy can be used. The specific method is through the injection of drugs to the internal hemorrhoids and submucosa, so that the local production of aseptic inflammatory reaction, for the submembranous tissue fibrosis, so that hypertrophy and even prolapse of hemorrhoids to a certain extent, atrophy, reset and fixed, and continue to play the role of the anal cushion. Professor Ai neutral: sclerotherapy is limited to internal hemorrhoids with comorbidities, and should not be used for incarcerated internal hemorrhoids. The site of injection should be limited to the dilated vascular plexus of submucosal blood stagnation. It is appropriate to use staged injection, the amount of medicine is moderate, to follow the principle of rather owe than over, in order to reduce the complications of medication. For a wide variety of surgical treatment of hemorrhoids (internal hemorrhoids), it is currently believed that there are not many surgical procedures that comply with the above principles (do not destroy or minimize the destruction of anal cushion tissue). In the lighter cases, there is a tendency to inject sclerosing agents into the hemorrhoids and submucosa, or to infrared irradiation, which causes submucosal fibrosis and achieves hemostasis and fixation of the anal cushion. In the severe cases, the consistent opinion is the radical excision of abandoned hemorrhoids, especially the radical excision of circumferential hemorrhoids. At present, for the prolapse of serious, even can not be returned to the embedded hemorrhoids, the conditions of the unit began to use anastomosis rectal mucosal circumferential resection (PPH). This method was proposed by Italian surgeon Antonio Longo in 1993. He is through a kind of anastomosis to the dentate line 3cm (above the anal cushion) rectal mucosa circular excision for a week, so that the prolapsed anal cushion upward, to achieve the purpose of the treatment of anal cushion prolapse; at the same time, also cut off, ligated the lower rectal artery, vein terminal branches, so that the blood supply of the hemorrhoids that have not been resected to reduce the hemorrhoidal hemorrhoidal gradual atrophy (10 ~ 15 days after the operation), to achieve the therapeutic purpose. Our hospital is the earliest hospital in China to carry out PPH surgery, and 82 cases have been clinically completed so far (Chinese Journal of Practical Surgery, 2001, 38:342). The average operation time is 9min (8~12min). The average operation time was 9min (8~min). The effective rate was 100%, and nearly half of the patients (36/82) had no pain after the operation; none of them had anal incontinence, perianal infection or anastomotic stenosis. Prof. Yao Liqing (Zhongshan Hospital, Fudan University): According to the new concept of hemorrhoids in recent years, the principles of treatment for hemorrhoids (internal hemorrhoids): (1) Asymptomatic hemorrhoids need no treatment. (2) For symptomatic hemorrhoids, treat the triggering factors of hemorrhoids (constipation, diarrhea, etc.), and then alleviate the problem by adjusting the dietary structure to keep the bowels unimpeded. (3) For those whose bleeding is the main manifestation of mucosal damage, it is advisable to treat them with drugs such as rectal mucosal protectants. (4) Surgery should be considered when the above treatments are ineffective. The principle is to try to form hemorrhoids on the anal cushion tissue without destructive operation. We hope that the majority of clinical surgeons in the Department of Anorectal Medicine will continue to make unremitting efforts to further improve the level of research and clinical treatment of hemorrhoids.