1.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 Provisional Standards for the Diagnosis and Treatment of Hemorrhoids developed in China in 2000 The prevalence of hemorrhoids–different diagnostic criteria and widely varying results. Kou Yuming, Department of Anorectology, St. Mark’s Hospital, Beijing l Nine out of ten people have hemorrhoids l Epidemiological survey in China 1975-1977: l The prevalence of anorectal diseases is 59.1%, and hemorrhoids account for 87.25% of them. l Chinese epidemiological survey in 2015: l The prevalence of anorectal diseases at this stage is about 50%, and hemorrhoids account for more than 90% of them. l Abroad: l 4.4% – Kaidar-Person O, Person B, Wexner S (2007). l 86%–Haas PA, Haas GP, Schmaltz S, Fox TA Jr (1982). II. Theories related to hemorrhoids 14 theories of modern medicine: erectile tissue theory, sinus venous theory, rectoanal descending theory, rectoanal force imbalance theory, metaplasia theory, sphincter dysfunction theory, hemorrhoidal venous pump function decline theory, varicose veins theory, vascular proliferation theory, infection theory, pressure gradient change theory, hemorrhoidal hernia formation theory, inferior rectal artery branching theory, anal canal Stenosis theory The main theory of hemorrhoids, abnormal dilatation of the venous plexus, abnormal swelling of the arteriovenous anastomosis, prolapse of the anal cushion and surrounding connective tissue, and increased tension of the internal sphincter (increased fibrous tissue) ・ Varicose veins theory of hemorrhoids l Hemorrhoids are soft venous masses formed by bruising, dilatation, and flexion of the varicose plexus protruding from the rectum under the rectal mucosa and the skin of the anal canal, and as a result, bleeding, embolism, or mass protrusion. l It is thought to be a lesion of the vessel itself. When the anal cushion is relaxed, broken, hypertrophied, or prolapsed, it is then complicated by stasis and varicosity of the venous plexus, and gradually forms hemorrhoids . The theory of inferior displacement of the anal cushion of hemorrhoids is that: l Hemorrhoids are the displacement of the anal cushion; l The anal cushion is a normal structure with a rich arterial blood supply and direct access to the dilated venous space; l The anal cushion contributes to the sealing of the anal canal and the self-control of the anus; l Constipation and nuisance destroy the supporting structure of the anal cushion, causing congestion and displacement of the anal cushion; l The increase in intra-anal pressure during defecation caused by tension of the internal sphincter can aggravate the congestion and displacement of the anal cushion. 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. The Chinese guidelines 1. The Chinese Society of Traditional Chinese Medicine Guidelines for the Treatment of Common Diseases in Chinese Anorectal Medicine 2. The Guidelines of the Colorectal Surgery Group of the Chinese Society of Medical Surgery l Guiding principle: the interests of patients are paramount l No medication → medication → non-surgical treatment → simple surgery → complex surgery Treatment principles l Asymptomatic hemorrhoids do not require treatment. l The aim of treatment for hemorrhoids is to eliminate and reduce their symptoms. l Removing the symptoms of hemorrhoids is more meaningful than changing the size of hemorrhoids, and should be considered as the standard of treatment effectiveness. 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 Chinese medicine internal treatment method l Discriminatory treatment: internal consumption of Chinese medicine soup, adult medicine, single test prescription. l Six types of evidence: – “Chinese Medicine Industry Standard of the People’s Republic of China”: l Wind injury to intestinal ligaments, damp-heat injection, Qi stagnation and blood stasis, l Spleen deficiency and Qi trapping, Yin deficiency and intestinal dryness, and large intestine solid heat. l Commonly used Chinese patent medicines: Diyu Huaijiao Pills, Liu Wei Anti-Hemorrhoid Pills, Hemorrhoid Dissipation Tablets, Zhi Kang Capsules, Naked Flower Purple Pearl Dispersible Tablets, Hemorrhoid Pills, Hemorrhoid Blood Capsules, Decongesting Hemorrhoid Tablets, Hemorrhoid Ning Tablets, Hemorrhoid Inflammation Dissipation Punch, etc. The external treatment method of traditional Chinese medicine l Suppositories nano-anal method (internal hemorrhoids) l External application method: (inflammatory external hemorrhoids, thrombosed external hemorrhoids or various post-operative hemorrhoids) l Bio-muscle red jade cream, Ma Yinglong musk hemorrhoid cream, anal tai ointment, etc. l Fumigation method: compound rhubarb soup, hemorrhoid inflammation Ning fumigant, dispel poison soup l Acupuncture treatment l Withered hemorrhoid therapy: Chinese herbs with corrosive and astringent effects are made into a dispersion and applied directly to the surface of the hemorrhoid nucleus, causing it to gradually necrosis, dry up and fall off . l 1958 – Arsenic-free withered hemorrhoid nail 2. Western conservative treatment (1) Oral western medicine l With the development of the theory of inferior displacement of anal cushion, some drugs targeting the vascular physiological changes of hemorrhoids have made progress in relieving or eliminating the symptoms of hemorrhoids. l Microcirculation regulators: herbal rhinoceros fluid tablets, hydroxy rutin, compound rutin, etc. l Non-specific drugs: analgesics, stool softeners, hemostatic drugs and anti-inflammatory drugs. l Used after hemorrhoid surgery to promote venous and lymphatic reflux, eliminate free radicals, reduce the permeability of the blood vessel wall and edema, and promote fibroblast production and wound healing. (2) Injection therapy l Origin: In 1869, injection therapy began in Western countries, and was modified by Andrem in 1879 and is used today. l Theoretical basis: The injection of sclerosing drug into the hemorrhoid nucleus produces sterile chemical inflammation, which makes the anal cushion adhere to the muscle layer of the rectal wall above it and fix it, 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 method makes it more effective. Shi Zhaoqi invented the hemorrhoid elimination injection. In addition, there are 603 injection from Nanjing and Paeoniae injection from An Ahh. The injection therapy is mainly for internal hemorrhoids, and a few are used for external hemorrhoids. (3) Ligature method l Ligature 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, shedding and healing. It is limited and only suitable for I, II and III degree internal hemorrhoids, 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 l Infrared coagulation therapy: I and II degree internal hemorrhoids, so that the hemorrhoid mass occurs fibroplasia, sclerosis and atrophy. The method is simple, the treatment time is short and no hospitalization is required, but the recurrence rate is high. l 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. l Hemorrhoid treatment apparatus: electrolysis, electrocoagulation, l electrocautery, so that the nucleus of the hemorrhoid eventually atrophies. 3. Surgical treatment of hemorrhoids (1) Traditional surgical procedure External peeling and internal ligation (open) (Milligan-Morgan procedure) A: Clamp and pull the external part of the hemorrhoid outward; B: Clamp and pull the external part of the hemorrhoid outward to fully expose the nucleus; C: Make a “V” shaped incision in the skin on both sides of the external hemorrhoid. D: upward along the lower part of the external anal sphincter and the internal sphincter Closed hemorrhoidectomy (Ferguson procedure) A: fully expose the hemorrhoidal tissue and cut the skin and mucosa; B: peel the hemorrhoidal nucleus along the lower part of the external anal sphincter and the internal anal sphincter; Circumferential hemorrhoidectomy (Whitehead procedure) A: suture the superior hemorrhoidal artery area, followed by a circular mucosal incision above the dentate line, and gradually separate the mucosa of the lower rectum B: cut off the hemorrhoid nucleus above the suture site; C: peel off the submucosal venous plexus; D: pull down the mucosal sleeve evenly so that the lower edge of the mucosal sleeve is aligned with the upper edge of the incision at the dentate line and sutured; E: completion of the operation Submucosal hemorrhoidectomy (Parks procedure) a: make a “Y” shaped incision along the dotted line mark in the figure after local anesthesia; b: make a “Y” shaped incision along the inner dentate line b: peel the submucosal tissue containing the hemorrhoid nucleus along the surface of the internal sphincter and suture the root of the hemorrhoid nucleus through; c: excise the hemorrhoid nucleus; d: partially suture the anal canal mucosa and open the skin incision for drainage. (2) Other surgical treatments Modification of hemorrhoid surgery —- Minimally invasive surgery How to choose minimally invasive surgery The treatment of hemorrhoids cannot be confined to a certain method, different surgical methods should be chosen according to the local examination of the anorectum and the systemic condition:Best indications for PPH, TST, RPH, internal hemorrhoid injection; the previous surgical methods can be combined with external hemorrhoidectomy or HCPT, etc.; non-cirrhotic hemorrhoids TST is chosen, and PPH, TST plus external hemorrhoidectomy is appropriate for circumscribed hemorrhoids. (1) Anastomotic suprahemorrhoidal mucosal circumcision (PPH procedure) a: prolapsed hemorrhoids b: endoanal fixation dilator c: rectal submucosa uniformly sutured in a circle d: anal anastomosis head end against the nail seat inserted to the top of the purse string for circumcision and knotting e: prolapsed mucosal group Clinical application to strictly grasp the indications: , PPH indications: ring-shaped prolapsed hemorrhoids, internal hemorrhoids ≥ 3. , Legendary advantages of PPH: does not affect anal function; mild pain; short course of treatment. , PPH post-operative anal function problems: unable to drain and unable to 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 Dr. Kou Yuming suggests that the role of minimally invasive surgery should not be exaggerated to deny traditional surgery. You can’t abandon the traditional external peel-and-stick procedure just because a new surgical approach has emerged. 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 to be 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 post-operative pain and discomfort. This article is authorized by Dr. Yuming Kou.