Current status of diagnosis and treatment of perianal diseases
Hemorrhoids, anal fistulas and anal fissures are the main perianal disorders and are an important part of anorectal surgery. The importance of these diseases is that they account for a large proportion of anorectal surgical diseases, and the fact that they must be taken into account when dealing with these diseases in the important part of the gastrointestinal tract where they are located.
1.Internal hemorrhoids
Since the etiology of hemorrhoids is so heterogeneous and the nature of hemorrhoids is still far from being truly understood, it is reflected in the wide variety of methods of treatment. We advocate that the choice of treatment method should be based on the doctor’s personal technical ability and experience as well as the medical conditions of the hospital, combined with the specific condition and physical status of each patient. This basic principle of individualized treatment is reflected in the various treatments for hemorrhoids published in the Chinese Journal of Anorectal Diseases in 2000. Of the 25,302 cases of hemorrhoids reported throughout the year, 9,077 (36%) were treated with surgery. 18,275 cases were treated with a variety of non-surgical therapies.
1.1, Surgical treatment of hemorrhoids
Hemorrhoidectomy is an effective treatment for hemorrhoids. Early hemorrhoidectomy mostly used Milligan-Morgan method, and now there are various methods of modified hemorrhoidectomy. However, it can be seen that in the report of 9077 cases of hemorrhoidectomy in China, there seems to be a consensus for minimizing the damage to the anatomical structure of the anal canal and protecting the physiological function of the anal canal. The variously named hemorrhoidectomies consistently suggest that a “skin bridge” or “mucosal bridge” of considerable width must be preserved between the two hemorrhoids when removing them and that damage to the dentate line must be avoided. It is important to note that in patients with repeatedly prolapsing prolapsed internal hemorrhoids, the dentate line is often extruded beyond the anal verge and the normal relationship between the hemorrhoid and the dentate line is lost. Without careful identification during surgery, there will be too much damage to the dentinal line. The literature reports that staining the epithelium of the anal canal with Helicobacter pylori methylene blue (HPMB) stain can reveal a light blue transitional epithelial area, which is beneficial in protecting this area from loss.
1.1.1, Surgical treatment of embedded hemorrhoids. Earlier, there was great concern about the excision of embedded hemorrhoids. This was because of the fear that acute surgery would cause infection to spread to the portal vein. However, excision of infected lesions to prevent the spread of inflammation is a basic principle of surgery. Aggressive excision helps prevent the spread of inflammation. The treatment of embedded hemorrhoids according to this principle has tended toward emergency surgical excision. In order to eliminate edema for excision, 3000 U of hyaluronidase dissolved in 40 mL of saline can be injected evenly under the perianal skin before surgery, and the surgery can be performed quite smoothly after the tissue edema gradually subsides. Hemorrhoidectomy is better supplemented by lateral partial internal sphincterotomy. If the embedded internal hemorrhoid has become strangulated due to impaired blood flow and the hemorrhoid mass has become black and necrotic, antibiotics must be strongly considered. In such cases, although not removed, sometimes the hemorrhoid mass is necrotic and swollen, resulting in the so-called “own hemorrhoidectomy”. There were 369 cases of embedded hemorrhoids in 9077 domestic hemorrhoid surgeries, with emergency surgical excision being the main cause. The surgical healing time ranges from 15 to 28 days, with an average of 20 days. Slightly longer than the general hemorrhoid surgery healing time.
1.1.2, Treatment of thrombosed external hemorrhoids. Thrombosed external hemorrhoids are formed by thrombosis of small veins outside the anal verge. The complete blood clot with envelope can be peeled out after cutting the skin, and sometimes there are many small thrombi of corn size underneath it. A few scholars in China claim that thrombosed external hemorrhoids are subcutaneous hematomas, which is a misconception because a subcutaneous hematoma is a diffuse bruising of the subcutaneous tissue. The pain is severe 3-4 days before the onset of thrombosed external hemorrhoids, so it is advisable to surgically remove them without suturing the incision. 3-4 days later the pain becomes milder and a Chinese herbal decoction can be used to fumigate them.
1.1.3. Internal hemorrhoidectomy plus internal sphincterotomy. Recently, it has been reported in China that 38% of patients with hemorrhoidectomy had their postoperative pain reduced by simultaneous internal sphincterotomy. In fact, more than 160 years ago, Kilsy in the United States of America developed this additional procedure and suggested that a lateral incision would be better, and Smyruis et al. compared this with those who had only hemorrhoid surgery, and compared it by the point method. He stipulated that those with no postoperative pain and no need for painkillers were scored 1 for degree I; those with average pain and need for painkillers were scored 2 for degree II; and those with severe pain and need for narcotic analgesics were scored 3 for degree III. The comparison results are shown in Table 1.
The domestic literature pointed out that similar to the statistics of Smyrius, the postoperative pain level of those with partial internal sphincter severance was 32.35% for degree I, 11.77% for degree II, and 0 for degree III, while the pain in the control group was 48.28%, 24.14%, and 3.45%, in that order. This indicates the value of internal sphincter severance in hemorrhoidectomy. We believe that an active measure to reduce postoperative pain lies in the surgery itself. Gentleness during surgery, careful separation of the tissue, care not to ligate the skin of the anal canal, no tangles between the hemorrhoids, minimizing the surgical exposure of the anal canal and reducing hemostatic ligatures can significantly reduce postoperative pain. Excision of the internal sphincter should be preceded by an assessment of the sphincter tone before deciding whether to use this adjunct.
1.2. Injection therapy for hemorrhoids
Most of the domestic injection therapies use the withered hemorrhoid solution evolved from the Chinese medicine withered hemorrhoid therapy. If the concentration of the drug is high and the dosage is high, it is a necrotizing agent. And low concentration and small dosage becomes sclerosing agent. Injection therapy for hemorrhoids is different from injection therapy for lower extremity veins. The former works by injecting the injection solution around the hemorrhoidal plexus causing a local inflammatory reaction.
According to early studies, due to the influence of patient movement and position changes, the injection solution is often quickly lost from the needle hole for the most part, and only a small amount of residual drug solution remains. Moreover, the drug in the injection is not the decisive factor, such as the insertion of a drug-free glutinous rice strip into the hemorrhoidal mass, causing the same tissue reaction and therapeutic effect as the drug-containing withered hemorrhoidal nail.
The most commonly used hemorrhoid injections in China are the ones that have been used most often and have achieved good results. However, we note that the most amount of Hemorrhoid Injection is as high as 60-70mL, and we emphasize the need to use the “four-step injection method”. It is generally believed that when the concentration of the drug is the same, the greater the amount of drug used, the worse the effectiveness. The larger the dosage, the lower the toxicity of the drug. In the injection method, we believe that it is sufficient to inject the injection solution into the hemorrhoid mass or inject some liquid above the mass first. The so-called four-step injection method is to inject the first step in the arterial pulsation on the hemorrhoid, the second and third steps should be injected in the submucosal and intramucosal layers of the hemorrhoid, and the fourth step should be injected in the “sinusoidal vein” area. In practice, these steps may be difficult to perform at all.
Our method of hemorrhoid injection has paid attention to pathological observation and comparison with surgical excision. It has entered a new phase. The problem is to develop uniform observation criteria, to strengthen long-term follow-up, to conduct reliable investigation of long-term results, and finally to make an appropriate evaluation.
1.3. Questioning the doctrine of inferior displacement of anal cushion
1.3.1, the theory that three anal pads evolved into hemorrhoids cannot explain the diversity of hemorrhoids The distribution of three anal pads can hardly explain the diversity of clinical manifestations of hemorrhoids. Statistics of 1000 cases of internal hemorrhoid surgery in Tianjin Binjiang Hospital: the three mother hemorrhoids (three pads) on the left, right anterior and right posterior accounted for only 10.1% or 101 cases, and there were even 12 cases with hemorrhoids on the right anterior only. In the remaining 877 cases, the position of the hemorrhoids was not arranged regularly at all. Therefore, the three-pad theory is unexplainable for the diversity of hemorrhoids.
1.3.2, the first symptom of hemorrhoids is bleeding rather than prolapse The basis of this doctrine is that the anal cushion slips down to reside in hemorrhoids and prolapse is the first symptom of hemorrhoids. It is well known that 1st and 2nd degree internal hemorrhoids are seen for bleeding. St.? JPSThomson of St. Mark’s Hospital describes that 75% of the total number of patients with internal hemorrhoids of the 1st to 2nd degree who seek treatment for bleeding are treated with injection therapy. It is important to know that prolapse is a characteristic of 3rd degree internal hemorrhoids.
1.3.3, hemorrhoid bleeding is not bleeding from the lamina propria WHFThomson proposed that hemorrhoid bleeding is capillary bleeding from the lamina propria of the hemorrhoid mucosa, which is one of the notable errors in his paper. Bleeding from hemorrhoids is sometimes jet-like and the volume of blood can be very large. It is difficult to achieve this level of bleeding due to the presence of membrane capillaries. In this regard, Goligher commented that the serious error in Thomson’s paper was the recognition of prolapse as the first symptom and the failure to explain hemorrhoidal bleeding satisfactorily.
1.3.4. Hemorrhoids are a disease and not normal tissue The “hemorrhoids are not a disease” theory considers the anal cushion to be normal tissue. “Asymptomatic” hemorrhoids are also normal tissue and not a disease. This is the result of the hemorrhoid non-disease theorists changing the formula of anal cushion → hemorrhoid to anal cushion = hemorrhoid. In fact, there are no “asymptomatic hemorrhoids” in clinical practice. It is only the slight changes such as irritation of the anal canal and wetness of the anal canal at the onset of hemorrhoids that go unnoticed by the patient. Even if there are no symptoms, the hemorrhoids that Thomson himself envisioned as having moved down through the pathological process cannot be described as normal tissue.
1.3.5 The doctrine of inferior displacement of the anal cushion is not a definitive theory of the etiology of hemorrhoids. From the points questioned above, it is clear that Thomson’s doctrine of inferior displacement of the anal cushion cannot be considered a definitive theory of the etiology of hemorrhoids at all, and some of the statements are wrong. It is no wonder that Goligher commented on this theory by saying that it is “an iconoclasticview”. The true etiology of hemorrhoids needs to be studied in more depth.
2. Anal fistula
The surgical definition of a fistula is “a tube that connects two open ends to the epithelial tissue”. The simple form of anal fistula is an external opening in the external skin of the anus and an internal opening near the dentate line of the anal canal, with a fibrous canal of granulation tissue in between.
Modern medicine suggests that anal fistulas are caused by an infection of the anal glands in the anal sinus near the dentate line of the anal canal, and that this glandular infection first forms a perianal abscess, which then evolves into a fistula. Therefore, it is suggested that perianal abscess and fistula are two stages of one disease. A perianal abscess is the first stage of a fistula and is the acute onset of the disease. Anal fistula, on the other hand, is a chronic process of inflammation and is already in the advanced stage of abscess. Eisenhammer of South Africa, in order to emphasize this relationship between the two, advocated the term “fistulogenic” for perianal abscesses to distinguish them from general abscesses. The definition of anal fistula as “glandular” is used to highlight the nature of the anal gland infection. We believe that anal fistulas complicated by trauma, Crohn’s disease, and other specific causes of perianal abscesses and fistulas should be excluded from the scope of this disease, and that “submucosal fistulas” (Milligan-Morgan classification) and “extrasphincteric fistulas” (Parks classification) of anal fistulas should be excluded. “(Parks classification) should also not be included in this disease. Fistulas such as “internal orifice fistula” and “internal blind fistula” are obviously sinus tracts and it is inconsistent and logical to call them fistulas.
2.1 Regression of perianal abscesses
In our experience the evolution of perianal abscesses can have the following pattern.
a. Self-extraction and drainage of pus or incision and drainage of delayed healing to fistula.
b. Healing after drainage of pus, followed by recurrent episodes and finally fistula.
c. The fistula is receding with antibiotics and then recurs.
d. By virtue of tension, the pus is removed from the internal opening to form a sinus tract, which is called an internal fistula.
e. In a very few cases, the inflammation subsides after antibiotics are administered.
This pattern of development shows that most perianal abscesses will sooner or later evolve into fistulas. Because the time from abscess to fistula cannot be determined, the fistula rate reported by each isenhammer is 87%, and some statistics show that 168 of 172 abscesses that were incised and drained formed anal fistulas, with a fistula rate of 97.7%, while up to 140 of 14 self-ruptured abscesses became fistulas (98.6%). Another report by Carbot et al. reported a 100% fistula formation rate in 36 cases of perianal abscesses. The authors have documented a 63-year interval between abscess and fistula. Due to this high fistula rate, most of the clinical treatments for perianal abscesses in recent years have adopted one-time curative measures to reduce the pain of secondary surgery for patients.
2.2. Treatment of perianal abscess
During the three years from 1998 to 2000, 62 articles on the treatment of perianal abscesses were published in the Chinese Journal of Anal Diseases; 35 of them (58%) were treated with rubber band hanging threads (4 of them with No. 10 silk threads) and achieved good results. Sixteen articles were published on the treatment of perianal abscesses with Chinese herbal medicine. It can be seen that the clinical attitude toward abscess treatment is positive. We believe that the principle of individualization should prevail in the development of treatment plans: the depth of the abscess and whether the internal opening can be confirmed are prerequisites. According to Lockhart-Mummery, it is very difficult to find the connection between the abscess cavity and the anal canal when there is inflammatory infiltration and edema around the abscess. We agree with this view.
In cases where the abscess is in a low location we use a one-time incision of the internal opening, cleaning the abscess cavity, trimming the incision, and changing the medication postoperatively, or some people close the entire incision with antibiotics before and after surgery. However, the use of rubber band hangers is the choice of most authors. It is important to note that whether open drainage, debridement and suturing or thread-hanging therapy is used, it is difficult to guarantee that a peri-muscular abscess can be cured in one visit. Therefore, this possibility should be fully estimated and explained to the patient and his family to obtain their consent before treatment.
2.3. Confusion about anatomical aspects related to anal fistula
The anatomical basis of anal fistula includes three parts: the dentate line (anal sinus), the perianal space and the anal canal muscle, and the clinic is very confused about the current concept of muscle anatomy in the anal canal department.
We found that the anatomy of the external sphincter published in several domestic anorectal works in recent years is based on the concept of three parts proposed by Milligan-Morgan in 1934. In fact, this concept has been replaced by the new concept of Eisenhammer, Goligher and others in the 1950s, who considered the external sphincter as an unstratified mass of muscle included in a myosheath, forming two sets of cylindrical muscles together with the internal sphincter. This concept has been widely accepted in the West, and monographs by GoligherCorman et al. have made history of the idea of the external sphincter being divided into three parts. This new thoracic concept was introduced to China in 1964, and in 1984 our study by Dongming Zhang et al. confirmed this theory. It is puzzling that domestic monographs are so indifferent to this new anatomical view of the 1950s and highlight the old concept of the 1930s. Another puzzling point is that these monographs highlight the “triple muscle collaterals” and “central gap” of the Egyptian Shafik. Shafik said that “the anal part is a Filipino epithelial injury causing a vagal epithelial cell infection”, which forms an abscess in the so-called central space and then spreads along the “central tendon” to other spaces. The reason for the difficulty of healing an anal fistula is that it is difficult to treat. “The difficulty of healing an anal fistula is due to the fact that these vagrant epithelial cells are not removed.” Theories such as these are not only vague but also difficult to understand. How does a trial infection “combine with epithelial cells” and how can the “central” of the “central space” be explained? How does the statement that epithelial damage to the anal canal resides in the fistula explain the clinical phenomenon of an anal fistula with an internal opening at the dentate line? Why is there no “central interstitial infection” around the end of the anal canal? How can the three “muscle collaterals” be clinically distinguished? None of these can be clinically verified. Therefore, Goligher and Corman pointed out that “clinical experience does not support Shafik’s claim that the vagal epithelial cells are merely fragments of anal gland tissue appearing on tissue sections. The “triple muscle collaterals” theory was rejected by Gravoglia in 1993. We earnestly hope that the majority of clinical workers will learn this historical truth about the anatomy of the anal canal.
2.4. Treatment of anal fistula
The treatment of anal fistula in China is more often done by hanging wire therapy. Recently, some authors have reported the success of the “internal port extraction and mucosal flap advancement” procedure. A few low-level simple anal fistulas are still treated by excision or excision with sutures.
2.4.2. Hanging wire therapy. The thread hanging therapy in China has been well documented in the middle of the 16th century. In the Ming Dynasty, Xu Chunfu used silk thread suspended by a hammer. The treatment mechanism is “medicine line under the day, the intestinal muscle with the long, water flowing by the line, not through the sore, the goose tube within the elimination.” Nowadays, the threads are made of elastic rubber bands or thick silk threads soaked with Chinese herbs. And there are various treatment methods for fistulas. It is very advanced.
After hanging the rubber band, Zheng Taijin and others change the local sore with compound comfrey ointment gauze, and clean the external fistula and close it with a full layer of sutures. In the case of Jin Dingguo and others, the external wound was opened and changed after hanging the rubber band, and 66 cases were cured at once, with only 4 cases of exudation at 4 years of follow-up.
The use of Chinese herbal medicine soaked thick silk thread is one of the major advantages of thread hanging therapy in China. The simple one is “coriander boiled thread”, while the complex one is decoction of nearly 40 herbs w soaked by Shen Changxing in Liaocheng. Zhuang Zaixin’s threads are made from a decoction of rhubarb, cypress, croton, elm, coriander, houttuynia, frankincense and myrrh. His method of hanging the thread is also unique. When hanging the thread, the sphincter is divided into two to three strands and tied separately, and in a control study with rubber band hanging, the degree and duration of pain as well as the time of dislodging and wound healing were better than those of the control group.
2.4.2, Internal orifice enucleation surgery. The concept of “mucosal flap advancement” proposed by Noble in 1920 and the concept of closing the internal orifice of anal fistula proposed by Ilting 10 years later put forward some basic principles for sphincter preservation surgery. The operation was successful. Since then, various improved surgical methods have emerged. Due to the advantages of combining traditional medicine, our scholars are in the leading position in the method and effect of the original endogastric opening, which was treated by closing the endogastric opening with intestinal sutures and freeing the nearby mucosa to make an anteriorly displaced flap to cover the original endogastric opening. The external canal was detubated with red raw tannin twist or with red raw tannin-based detubation oil, and very good results were obtained. Another group in Chengdu researched the decanalization medicine twist as “Thirsty Dragon Penjiang” elixir. In the recurrence rate, partial incontinence rate, etc. are better than the control group.
2.4.3. Endogastric and fistula excision surgery. Zhou Jianhua et al. treated 38 cases of anal fistula with suture closure after internal port excision and fistula rejection. 1 case recurred and was cured by the same surgery with color enhancement. Huang Youji used complete rejection of the fistula to the internal opening with 4/0 intestinal suture in the stripped wound, stone charcoal to the cauterized stump, and full drainage of the tunneled wound after rejection of the tube. Twenty-seven cases of anal fistula were treated, and two cases were healed by reoperation for recurrence. Hong Yuanfu et al. used a curved incision to peel off the complete fistula and suture the inner opening closed, sometimes also transecting the sphincter, removing the fistula and then properly butt-sewing the two severed ends, and finally suturing the incision closed. They treated 51 cases with good results using this method.
In our experience, although the treatment of fistulas has long been the goal of eradicating the primary lesion and canal while preserving the structure and function of the anal canal, some of the above-mentioned surgical methods are not applicable in all cases; superficial simple fistulas are adequately treated with the Lay-Open procedure, whereas we still use the Hanley procedure for high hoof fistulas. Sometimes it is only possible to tie a thick wire at the sphincter to mark the internal opening and to make a second surgical incision 2 to 3 weeks later.
Finally, it should be reminded that some authors refer to the posterior bilateral curvilinear fistula as a horseshoe fistula, when in fact the Horseshoe (commonly known as the horse’s paw) type is more aptly named. Furthermore, it should be recalled that the topics of articles reporting on anal fistula surgery have become increasingly mixed in recent years. For example, “Experience in the treatment of high-grade complex foot-iron fistulas with open windows and scraping and incision and hanging wire drainage”. In fact, it is only hanging wire therapy, there is no need to include surgical measures in the topic.
3, anal fissure problem
Anal fissure is an elliptical skin ulcer below the posterior midline dentition of the anal canal, which is essentially different from certain atopic ulcers such as chancre, tuberculous ulcer, and deep fissure of the anal part of Crohn’s disease.
3.1. Current status of domestic treatment of anal fissures
In the past three years, 91 articles on the treatment of anal fissures were published in the Chinese Journal of Anorectal Diseases. Among them, 50 articles (54%) were about cutting the internal sphincter of various kinds. There were 14 articles on injection of various drugs under anal fissure. The rest of the articles are conservative treatment except for surgical formation surgery and photomechanical treatment. Recently, five articles reported on the treatment method of topical glyceryl trinitrate (GTN), which has been reported extensively abroad. It is said to be very effective for initial anal fissures. However, local application of botulinum toxin (batalenumtoxin) and the calcium antagonist nifedipine gel (nimodipcnegel) have not been reported in China.
3.2. Re-discussion of the pectus carinatum theory
In 1981, the authors presented in a review a discussion of the pectineal band theory of foreign joints and the properties of the muscles at the base of the anal fissure. A review of more than 90 articles mentioned above now shows that many authors still insist on the idea of severing the pectineal band and external sphincter during anal fissure surgery. This problem of perception is bound to exist due to different experimental experiences. However, the pectineal band theory and sphincter properties were replaced by new ideas as early as the 1950s. In the 1950s Esehammer, Goligher and others demonstrated that the pectineal band was actually a somewhat fibrotic internal sphincter and that it was never the external sphincter that was severed during fissure surgery. St. Mark’s Hospital CNMorgan corrected his earlier mistake with Milligan of the lower border of the internal sphincter for the external sphincter, concluding that the term “pectineal band” could no longer be used in the anorectal literature. He concluded that the term “pectineal band” could no longer be used in the anorectal literature. He concluded that the term “pectineal band” could no longer be used in anorectal literature and “draws attention to a common error in the perception of the muscles of the anus”. According to our clinical observations, after cutting the internal sphincter, only the smooth membrane-like tissue is visible, and the external sphincter, described as a chicken leg, is not visible at all. At this point the external sphincter has been pushed out of the surgical field under anesthesia and surgical traction and expansion. Dissection of the external sphincter is almost impossible. The subcutaneous portion of the elliptical external sphincter is difficult to cut into any muscle in the triangular horizontal gap behind the anus.