In recent years, with the continuous research on perianal diseases, an almost completely new concept of hemorrhoids has been proposed. In order to enhance the clinical surgeons’ understanding of hemorrhoids and standardize their treatment, we invited some experts to make a discussion Through the above discussion, it is clear that although the research on hemorrhoids has made great progress in recent years, the clinical understanding of hemorrhoids is still controversial because the pathogenesis, anatomy and pathophysiology of hemorrhoids are far from clear. 1, about the definition of hemorrhoids Professor Tang Zongjiang (The First Hospital of Guangxi Medical University): in the previous textbooks (Surgery. Beijing: People’s Health Publishing House, 1994.494): “Hemorrhoids are masses caused by varicose veins of the superior and inferior rectal plexus on both sides of the dentate line, and as a result, bleeding, embolism or mass prolapse”, emphasizing the varicose veins of the superior and inferior rectal plexus on both sides of the dentate line. In the recent literature, the provisional criteria for the diagnosis and treatment of hemorrhoids (Chinese Journal of Surgery, 2000, 12: 891), which emphasize pathological hypertrophy and displacement of the anal cushion and masses formed by stagnation of blood flow in the perianal subcutaneous vascular plexus, emphasize the pathological hypertrophy and displacement of the anal cushion. Although the latter is now accepted by most surgeons, its definition does not fully explain all clinical manifestations of hemorrhoids (especially external hemorrhoids). According to the above definition, internal hemorrhoids should occur mostly at 3, 7, and 11 o’clock in the truncated position; however, it is often seen in clinical practice that some patients can have isolated internal hemorrhoids of varying degrees at 1, 5, and 9 o’clock, in addition to the above-mentioned locations. Can this phenomenon be considered as a possible cause of mucosal hypertrophy and downward movement of the anal cushion in addition to the pathological hypertrophy and downward movement of the anal cushion, and the impaired regulation of the local arteriovenous anastomosis? Prof. Zhang Dongming (Department of Anatomy, Second Military Medical University): To discuss the exact concept of hemorrhoids, we should first understand the anatomy of the “anal cushion”. 1960s, a German scholar pointed out that the submucosal vessels of the anal canal were very complex and spongy. Thomson (1975) found in 42 normal anoscopies that these sponges were arranged in the anal canal in a right anterior, right posterior and left lateral pattern with Y-shaped grooves separating them. sulcus-like separation. He concluded that, from a physiological point of view, this tissue acts as a soft cushion in the rectum and contributes to the tight closure of the anus, hence the name “analcushions”. Later, he compared the excised hemorrhoid tissue with the “analcushions” and found that both consisted of dilated veins, Treitz muscle and connective tissue, so he clearly proposed that “hemorrhoids are the normal structure of the anal canal ( hemorrhoidsarenormalstructureoftheanalcanal”. His statement inadvertently caused confusion between the concepts of anal cushion and hemorrhoid. After my recent consideration, the modern definition of hemorrhoids should be “abnormal anal cushion tissue with symptoms called hemorrhoids”. Therefore, hemorrhoids are a disease in itself and are the clinical manifestation and consequence of the abnormal anal cushion. Because the Chinese character for hemorrhoid has the “疒” side, it is already a disease, which is essentially different from the normal anal cushion tissue. Professor Ai Zhongli (Wuhan University Central South Hospital): About 1.5-2.0 cm above the dentate line in the anal canal, there is a circular distribution of spongy tissue rich in characteristic blood vessels, forming a 3-part thickened submucosal bulge. In the truncated view, the three bulges were located in the right anterior, right posterior, and left sides of the anal canal, respectively. Microscopically, it contains blood vessels, smooth muscle and elastic connective tissue. The anal cushions have been recognized as “analcushions” by Thomson (1975), and their function is to cooperate with the anal sphincter to ensure normal closure of the anal canal and to delicately identify gas, water and stool. Therefore, the anal cushion is a physiological concept. The causes of pathological changes in the anal cushions that lead to hypertrophy and downward migration into hemorrhoids are multiple. For example, (1) destruction of the structural tissues that maintain the elasticity of the anal cushion. For example, the degeneration of the Treitz muscle (after 30 years of age) until degeneration occurs; in addition, long-term constipation, diarrhea, pregnancy and anus sphincter power malfunction can cause the Treitz muscle to overstretch and fracture, resulting in the downward migration of the anal cushion. (2) The arteriovenous anastomosis plexus in the anal cushion has an impaired regulation of blood volume, causing blood stagnation in the anal cushion. This pathological hypertrophy and displacement of the anal cushion and the mass formed by the stagnation of blood in its vascular plexus is called internal hemorrhoid. In severe cases, it can be combined with bleeding, pain, prolapse, and impaction. Therefore, hemorrhoids are a pathological concept that should never be confused with anal pads. Editor Xia Zhiping (Editorial Board of Chinese Journal of Practical Surgery): From the external view of internal hemorrhoids, the prolapsed tissue is mostly the diseased anal cushion, and the current doctrine of “subluxation of the anal cushion” of hemorrhoids may be due to this indisputable fact. However, I believe that the doctrine of “downward displacement of the anal cushion” cannot yet explain all hemorrhoids. The first two stages of internal hemorrhoids are often seen clinically as bleeding, and in many patients the bleeding is jet-like and can be very heavy. This symptom of early hemorrhoids cannot be explained by the doctrine of “inferior displacement of the anal cushion”. The provisional standards for the diagnosis and treatment of hemorrhoids, which advocate the theory of “inferior displacement of the anal cushion,” call symptomatic hemorrhoids hemorrhoids in order to distinguish between the anal cushion and hemorrhoids in clinical practice. I personally believe that the idea of strictly distinguishing anal cushions from hemorrhoids is correct, but the distinction between hemorrhoids and hemorrhoid disease is inappropriate for two reasons: (1) “Symptomatic hemorrhoids are called hemorrhoid disease,” which implies that asymptomatic hemorrhoids are not a disease, thus wrongly recognizing (1) “Symptomatic hemorrhoids are called hemorrhoids”, which implies that asymptomatic hemorrhoids are not diseases, thus wrongly admitting that asymptomatic hemorrhoids are anal pads, and concluding that hemorrhoids are anal pads, resulting in the error of “changing concepts”. (2) Hemorrhoids are a disease in themselves, including dysfunction of the submucosal arteriovenous anastomosis “sinus” of the anal cushion, and pathological prolapse of the anal cushion. The word “hemorrhoid” is unnecessarily repetitive and can easily be misinterpreted as a “syndrome” of hemorrhoids plus hemorrhoid co-morbidity. For example, many benign tumors in the body are asymptomatic and do not require treatment, but it cannot be said that “tumors” are not diseases; nor is it necessary to call “tumors” that require treatment The “tumor” that requires treatment does not need to be called “tumor disease”. In summary, the concept of hemorrhoids fails to involve “bleeding”, or at least is incomplete. In addition, according to the previous definition of hemorrhoids and the location and clinical manifestations of the occurrence of hemorrhoids, they are divided into internal, external and mixed hemorrhoids. The doctrine of “inferior displacement of the anal cushion” can only define internal hemorrhoids, but cannot explain external hemorrhoids. External hemorrhoids are not related to the anal cushion in terms of location or pathological changes; even thrombosed external hemorrhoids do not have the clinical manifestations of bleeding internal hemorrhoids. To be precise, external hemorrhoids are localized masses formed by thrombus in the subcutaneous vascular plexus far from the perianal line, showing severe local pain. The Provisional Standards for the Diagnosis and Treatment of Hemorrhoids defines external hemorrhoids in the category of hemorrhoids by the phrase “and masses formed by stagnant blood flow in the perianal subcutaneous vascular plexus”, which is obviously very far-fetched. Although there is no direct statement in the literature that external hemorrhoids are not hemorrhoids, there is a statement that “mixed hemorrhoids are hemorrhoids with an external component (hemorrhoidswithaexternalcomponent)”. The implication is that external hemorrhoids are not hemorrhoids, but an unnamed “external component”. Therefore, in my personal opinion, the doctrine of the “anal cushion” can be used to define hemorrhoids, subject to the necessary additional clarification. “External hemorrhoids are a separate disease and should not be included in the category of hemorrhoids. 2. The staging of hemorrhoids Professor Zhang Dongming: The need for staging hemorrhoids is still a matter of debate worldwide. Although each country has its own different staging method, there are also those who oppose staging. The reasoning of the opponents is that the staging of hemorrhoids is mainly for the clinical manifestations of internal hemorrhoids and has no pathological basis. In other words, the clinical manifestations of hemorrhoids are not consistent with the pathologic changes in the anal cushion, so it is believed that staging of hemorrhoids has no obvious clinical value. (1990) stated outright that he did not advocate staging and proposed that internal hemorrhoids be divided into five categories according to their symptoms, namely, bleeding hemorrhoids, thrombosed hemorrhoids, internal hemorrhoids, external hemorrhoids, and acute hemorrhoids. In my personal opinion, since the clinical manifestations of hemorrhoids are not consistent with the pathological changes of the anal cushion, it is better not to do rigid staging, but to divide them into different types. Prof. Tang Zongjiang: The Interim Standards for the Diagnosis and Treatment of Hemorrhoids has a grading of hemorrhoids, mainly for internal hemorrhoids. That is, they are classified into 4 degrees (Ⅰ, Ⅰ, Ⅱ, Ⅲ, Ⅳ degrees) according to the clinical manifestations of internal hemorrhoids (bleeding, pain, prolapse and impaction, etc.), with no pathological basis. If the main purpose of grading is to choose the treatment method and to facilitate the comparison of the efficacy of different treatment methods, it is better to divide internal hemorrhoids into several types according to their clinical manifestations. For example, bleeding type, prolapsed type and prolapsed internal hemorrhoids strangulated and embedded type, etc. 3, treatment of hemorrhoids Professor Ai Zhongli: In view of the recent update of the concept of hemorrhoids, a cautious approach should be taken to the wide variety of treatment methods for “hemorrhoids” (except for external hemorrhoids). The principles of treatment: for asymptomatic hemorrhoids, I agree with the American Professor Marino: “Do not treat symptoms without anal signs, and do not treat anal signs without symptoms”. For hemorrhoids with comorbidities, treatment should be chosen according to the patient’s symptoms: (1) Physical therapy: diet with more water and fiber-rich foods to keep the bowels open; attention to dietary hygiene to prevent the occurrence of diarrhea; and warm water sitz baths, etc. (2) Drug therapy: such as suppositories, ointments and oral drugs to protect the intestinal mucosa, and sclerotherapy injections that can make the hypertrophic anal cushion shrink. (3) Surgery: The choice of surgical procedure, except for external hemorrhoids, should pay attention to the abandonment of the erroneous view of radical excision of hemorrhoids, especially the annuloplasty procedure that seriously destroys the physiological function of the anal cushion. Professor Tang Zongjiang: It is correct to say that asymptomatic hemorrhoids do not require treatment. Fifty percent of the normal population has hemorrhoids, of which only 5 percent show symptoms of blood in the stool and hemorrhoid prolapse. An asymptomatic hemorrhoid is also a disease. The recurrence of hemorrhoids can be controlled by changing the diet and developing good bowel habits. For those with blood in the stool, dripping or spraying bleeding, with or without internal hemorrhoid prolapse, local medication can be administered along with the above treatment. If the effect of medication is not obvious, the proven sclerotherapy can be used. The specific method is to inject drugs into the internal hemorrhoids and submucosa, so that the local aseptic inflammatory reaction, for the submembrane tissue fibrosis, so that the hypertrophy and even prolapsed hemorrhoids in a certain degree of atrophy, reset and fixed, continue to play the role of anal cushion. Professor Ai Neutral: Sclerotherapy is limited to internal hemorrhoids with comorbidities and should not be used for embedded internal hemorrhoids. The site of injection should be limited to the dilated vascular plexus with blood stagnation under the mucosa. It is advisable to use staged injections with moderate amounts of medication, following the principle of rather under than over, in order to reduce complications with medication. Among the wide variety of surgical treatment of hemorrhoids (internal hemorrhoids), there are few surgical procedures that are considered to meet the above principles (no or minimal destruction of the anal cushion tissue). In the less severe cases, there is a tendency to inject a sclerosing agent into the hemorrhoid and submucosa or to infrared irradiate it to cause submucosal fibrosis for the purpose of hemostasis and fixation of the anal cushion. In severe cases, the consensus opinion is to abandon radical excision of hemorrhoids, especially of circumferential hemorrhoids. Currently, for embedded hemorrhoids that prolapse severely and cannot even be returned, units that are in a position to do so are beginning to use an anastomotic rectal mucosal loop excision (PPH). This method was proposed by Italian surgeon Antonio Longo in 1993. He used an anastomosis to remove the rectal mucosa 3cm above the dentate line (above the anal cushion) for one week, so that the prolapsed anal cushion can be moved upward to achieve the purpose of treating the prolapsed anal cushion; at the same time, the terminal branches of the inferior rectal artery and vein are also cut and ligated, so that the blood supply to the unresected hemorrhoid is reduced, which eventually leads to the gradual atrophy of the hemorrhoid (10-15 days after the operation) and achieves the purpose of treatment. Our hospital is the first hospital in China to carry out PPH surgery, and 82 cases have been completed clinically so far (Chinese Journal of Practical Surgery, 2001, 38: 342). The average operation time is 9 min (8-12 min). The efficiency is 100%, and nearly half of the patients (36/82) are pain-free after the operation; none of the cases had anal incontinence, perianal infection and anastomotic stenosis. Professor 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 do not require treatment. (2) For symptomatic hemorrhoids, the triggering factors of hemorrhoids (constipation, diarrhea, etc.) should be treated first, and then relieved by adjusting the dietary structure to keep the bowels open. (3) For those with bleeding as the main manifestation due to mucosal damage, treatment with medications such as rectal mucosal protectors is recommended. (4) Surgery should be considered for those who have failed in the above treatments. The principle is to try not to perform destructive operations on the anal cushion tissue where hemorrhoids are formed.