In the clinical practice of anorectal disease for many years, I have seen some anorectal doctors over-treating common anorectal diseases, which not only increases the pain and economic burden of patients in treatment, but also often leads to undue complications. Some medical journals or society can also see excessive treatment as experience introduction, blackmail, quite harmful, I raised this issue five years ago, the phenomenon is still prominent, so again for a discussion, and colleagues to discuss.
I. Concept
Common anorectal disease: refers to hemorrhoids, anal fistula, prolapse, anal fissure, rectal polyps, perianal acromegaly and other anorectal diseases.
Excessive treatment
①Treatment that goes against physiology.
(2) Treatment that is overkill.
③Repetitive treatment (tedious treatment).
④Treatment beyond objective conditions (including technology, equipment, economy, overall patient condition and willingness).
⑤ Fraudulent treatment.
Fraudulent treatment has three characteristics.
With the purpose of obtaining money by fraud.
False advertising as a bait.
Overtreatment as a means.
Its implementation route is divided into three steps :
Korean anoscopic photo-taking.
Charge for each disease name as indicated in the chart.
All kinds of auxiliary treatments together and billed by the minute.
Two principles are violated.
①The principle of the industry that does not treat asymptomatic hemorrhoids.
The actual fact is that you can find a lot of people who are not able to get a good deal on this.
Over treatment of hemorrhoids
The mechanism of internal hemorrhoids has become a consensus among scholars at home and abroad in recent years, and has been written into textbooks. The lower part of the human rectum and the upper part of the dentate line have a very thick mucosal tissue with a large number of blood vessels, dilated veins, smooth muscle, collagen fibers and elastic connective tissue fibers, which is called the “anal cushion” or “anal cushion”. It resembles the soft cushion under the cap of a metal bottle, which helps the sphincter to close the anal canal and maintain the self-control function of the anus. If the submucosal support tissue degeneration, relaxation, fracture, combined with forceful defecation, diarrhea, increased abdominal pressure and other factors, the anal cushion pathological hypertrophy part or all down, appearing blood in the stool, prolapse, pain and other symptoms, only called hemorrhoids. It can be seen that the pathological alteration of the anal cushion is the anatomical basis for the occurrence of internal hemorrhoids, but the main physiological function of the cushion determines that it cannot be removed at will. Therefore, we prefer conservative treatment for internal hemorrhoids, and consider surgery only when conservative treatment is ineffective. Commonly used surgical treatments include sclerotherapy, reattachment and fixation of the downwardly displaced anal cushion in place, rectal mucosal suspension, lower rectal mucosal loop (P・P・H surgery) or partial anal cushion excision, etc.
1. The following therapies are excessive treatments for internal hemorrhoids.
①Circumcision of internal hemorrhoids, such as Kiose circumcision which has been abandoned.
②Cautery or cryosurgery in more than three places.
(iii) Mass necrotizing agent injection or mass arsenic-containing hemorrhoid insertion.
Several injectable drugs were injected simultaneously. It was reported that a hospital injected a young patient for the treatment of internal hemorrhoids (blood routine and procoagulation time were normal) with 1ml of sclerosing agent (refined table salt 5g, glycerin 70ml, and water for injection added to 100ml) injected into the base of hemorrhoids, and then 1ml of internal hemorrhoid injection oil (alum 4g, table salt 4g, Andrographis paniculata injection 14ml, procaine 2g, and glycerin 100ml) injected into the body of hemorrhoids. Starting from the eighth to the fifteenth postoperative day, there were four consecutive hemorrhages, each in 100-300ml (containing pig liver-like clots), and a large 2.5-3cm necrotic lesion with active bleeding points was examined at the injection site, which was extricated by resuscitation.
Internal hemorrhoid injection can use one drug, never two drugs, and small doses, never large doses, under the premise of ensuring cure.
2, treatment of internal hemorrhoids need to be clear on several issues.
Preferred conservative therapy.
Hemorrhoids cannot be cured.
The standard of cure for hemorrhoids is the disappearance of symptoms.
Surgical treatment should try to protect the tooth line.
Individualized treatment.
Treatment of mixed hemorrhoids should preserve adequate anal canal skin bridges and mucosal bridges.
Third, excessive treatment of anal fistula
1, blindly expand the scope of excision of the internal orifice.
Most of the anal fistulas are caused by contraction of the pus cavity after the perianal abscesses are self-collapsed or incised and drained. Most of the abscess primary lesions are infected anal glands located in the anal saphenous fossa, so many anorectal surgeons advocate expanding the scope of resection of the internal port during anal fistula surgery, with the intention of removing the primary lesions —- anal glands. I believe that the infected anal gland has become part of the anal fistula duct and can be healed during surgery by finding the endograft, dissecting the duct and all the branches, and keeping the drainage open. The anal gland is a subtle anatomical structure that can only be identified under a microscope. Deliberately expanding the scope of excision of the internal opening, thinking that the infected anal gland has been removed, is very blind and results in an incision that is too large and too deep, prone to bleeding and prolonged healing time.
The late Zhang Qingrong, a famous anorectal specialist, summarized the recurrence rate of 1% – 6.3% after 3580 cases of anal fistula surgery by eight doctors during 1964 —- 1984. We treated 460 cases of all types of anal fistulas in twelve years, with a follow-up of 300 cases and a five-year recurrence rate of 1.5%. The recurrence rate was not significantly higher during the surgery without an enlarged resection of the internal opening.
2. Excessive excision of tissues around the canal.
First of all, some doctors, after dissecting the lumen, deliberately remove the bottom of the lumen and the connective tissue of the wall, so that the trauma is deep and wide. In fact, this is not necessary. Thus, these connective tissues are viable tissues that will gradually absorb and soften or normalize as the inflammation disappears and circulation improves, without affecting healing.
Secondly, in complex anal fistulas with many tubes, the connective tissue between the tubes is removed at the same time, making the trauma too large, which not only heals slowly, but also the scar is too large, leading to anal deformation.
3, the improper application of hanging wire therapy.
The thread therapy is only suitable for high anal fistula. The low anal fistula does not need to be treated with thread. The high anal fistula hanging line, 7-10 days natural off the line, more than the time does not take off the line, then the line does not drainage role, there is no cutting role. At this time, the sphincter is firmly attached to the surrounding tissues, so the unattached remnants can be cut off and disconnected.
I have seen the thread hanging for a month, not to go to the line nor tight line, the trauma edema granulation proliferation, full of trauma, wrapped around the hanging line is not trimmed, which is obviously improper disposal.
4, anal fistula trauma can be sutured.
The entire trauma of low anal fistula and part of the trauma of high anal fistula can be sutured, part of which can be healed in one phase, and those who cannot be healed in one phase can also reduce the trauma and shorten the treatment time. The sutures require: complete hemostasis, thorough removal of putrefied flesh, no branched tubes, antibiotic solution to flush the trauma, and full sutures without leaving a dead cavity.
IV. Overtreatment of anal fissure
1. posterior anal fissure incision with the height of the incision exceeding the tooth line.
2.Lateral internal sphincterotomy, making more than two incisions.
3.All of the internal sphincter is cut.
4.Hanging thread therapy for anal fissure.
5.Anal fissure and fissure stitching treatment. However, excision of anal fissures and sentinel hemorrhoids for transverse suturing is possible.
6.Preliminary attempts to treat anal fissures by simple finger dilation.
V. Excessive treatment of perianal acromegaly
1, coated with corrosive cream or large area excision, resulting in large area of perianal skin damage.
2, the large number of interferon use.
Six, excessive treatment of severe prolapse
A large number of Chinese herbal medicine treatment alone.