Rectal prolapse, called prolapse in Chinese medicine, is one of the intractable diseases in anorectal surgery, with an incidence of 0.4% to 2.1% in foreign countries and 0.4% to 1.9% in China, mostly seen in children, the elderly and frail, or young adults with diarrhea and constipation. Generally the course of the disease is long and seriously affects physical and mental health. At present, Western medicine treatment of rectal prolapse mainly adopts surgery, such as rectal suspension fixation, rectosacral anterior ligament fixation, etc.. Although the efficacy of surgery is certain, it can only be carried out in large hospitals with good conditions, and the surgery is complicated, traumatic, with many complications and certain risks.
Summarizing the review of our hospital over the past 20 years, using a combination of Chinese and Western medicine to treat 300 cases of rectal prolapse, the efficacy is satisfactory, less trauma, fewer complications, simple operation, suitable for grassroots development, can be used for reference.
I. Diagnosis (this disease refers to the unified standard formulated by the National Anal Academic Conference in 1975)
1.Grade I: Rectal mucosa prolapses out of the anus when defecating or increasing abdominal pressure.
Ⅱ degree: when defecating or increasing abdominal pressure, the whole rectum prolapses out of the anus.
Degree III: When defecating or increasing abdominal pressure, the whole layer of the anal canal and rectum or part of the sigmoid colon prolapses out of the anus. The length of prolapse should be indicated for all kinds of prolapse diagnosis.
2.Prolapse of the rectum, judgment of the function of the anal sphincter
(1) Good function of anal sphincter: Self-controlled defecation, strong sphincter contraction and good anal closure.
(2) Poor function of anal sphincter: usually mucus overflows out of the anus, sometimes loose stool cannot be controlled, sphincter contraction is weak, and the anal opening is not closed tightly.
(3) No anal sphincter function: usually gas and dilute stool can not be controlled, sometimes dry stool can not be controlled, sphincter muscle atrophy, no contraction force of the anus, the anus can not be closed.
3.The efficacy standard of rectal prolapse
(1) healed: Ⅰ degree prolapse symptoms disappear, rectal mucosa no longer prolapse out of the anus; Ⅱ, Ⅲ degree prolapse, rectal whole layer no longer prolapse out of the anus.
(2) Improvement: symptoms basically disappear and prolapse is significantly reduced.
(3) invalid: no significant change after treatment.
4, rectal prolapse postoperative reaction observation standards
(1) Pain, fever and urinary disorder are the same as the postoperative criteria for hemorrhoids.
(2) Cramping or persist for several days.
5.The criteria for judging the function of anal sphincter after rectal prolapse
(1) Improvement of anal sphincter function: those with no anal sphincter function before surgery become poor or good sphincter function, those with poor sphincter function before surgery become good.
(2) Poor anal sphincter function: postoperative anal sphincter function is reduced compared with that before surgery, and those with good anal sphincter function before surgery become poor or no sphincter function.
6.Long-term efficacy criteria: No recurrence after 2 to 3 years of follow-up is considered as long-term cure.
Second, the treatment method anesthesia choice: local anesthesia, sacral anesthesia, lumbar anesthesia can be.
Drugs for injection: Chinese medicine hemorrhoid elimination injection (national approved drug number), used with 0.5% lidocaine to form a 1:1 solution before use.
Special surgical instruments: one set each of 8cm and 14cm long trumpet-shaped anoscope, one each of No. 5 dental needle and lumbar puncture needle, 10ml syringe, etc.
1, rectal internal and external injection therapy (also called double-layer injection) will be injected into the rectal submucosa or around the rectum after diluting the Chinese medicine anti-hemorrhoid injection with an equal amount of 0.5% lidocaine to produce local fibrosis, so that the separated rectal mucosa and muscle layer adhesion fixed, the outer wall of the rectum and the surrounding tissues produce fibrosis to play the role of adhesion fixed, to achieve the purpose of rectal prolapse cure.
(1) Indications for rectal submucosal injection: Ⅰ and Ⅱ degree rectal prolapse with normal function of anal sphincter. It is mostly used for adolescents and can be performed simply by intrarectal injection.
Contraindications: proctitis, diarrhea, perianal inflammation and persistent abdominal pressure increasing diseases.
Key points of operation: take a lateral or truncated position, disinfect with local iodophor, lay sterile towel, after local anesthesia or sacral anesthesia, choose a special 14 cm long trumpet-shaped anoscope, lumbar anesthesia puncture needle connected to a 10 ml syringe, draw 10 ml of 1:1 anti-hemorrhoid solution, look at the loose rectal mucosa, at the uppermost end of the rectal mucosa, equivalent to the junction of rectum and sigmoid colon below, circumferentially select 3 to 5 planes, or longitudinally select 4 ～to 6 rows. Select 3 points in each plane, staggering the distance of each point, inject 0.5 to 1.5 ml of medicine in each point, do not pierce too deeply into the muscle layer, or inject too shallowly into the mucosa to avoid ineffectiveness or necrosis. The total amount is generally 20-40ml, (the amount of prolapse time increased, more than once can be injected 1:1 elimination of hemorrhoid spirit 80ml). After the injection, the index finger enters the anus for repeated massage, so that the drug is evenly dispersed, and the injection should not produce hard knots locally. The anal area should be fixed with a small venting tube and a pagoda-shaped gauze.
Postoperatively, give antimicrobial medicine orally or intravenously for 3 days to prevent infection.
(2) Indications for extra-rectal injection: II and III degree rectal prolapse, simultaneous extra-rectal injection after intra-rectal injection.
Contraindications: enteritis, diarrhea, acute inflammation around the anus.
Operation points: After lumbar anesthesia or local anesthesia, use a slender lumbar puncture needle and 10ml syringe to draw in 10ml of 1:1 anti-hemorrhoid solution.
a First anorectal left and right injection, at a distance of 1.5cm from the anal verge, 3 and 9 points into the needle, piercing the skin, subcutaneous, into the sciatic rectal fossa, about 4-8cm into the pelvic rectal gap. At this time, the index finger of the other hand into the rectum, carefully touch the tip of the needle site, to determine the tip of the needle outside the rectal wall, in order to ensure that the tip of the needle does not pierce the rectal wall, to the tip of the needle outside the rectal wall can slide freely shall prevail, and then slowly back the needle while pushing the drug, inject 6 ~ 8ml of drugs, so that the drug is fan-shaped evenly dispersed. Inject the opposite side with the same method, and inject a total of 10～20ml of drug on both sides.
b anorectal posterior wall injection, along the rectal posterior wall into the needle, piercing 4 ~ 8cm, to reach the posterior rectal space, at this time, the other hand index finger into the rectum, carefully touch the tip of the needle site, to determine the tip of the needle outside the rectal wall, and then the needle deeper 2-3cm, in order to ensure that the tip of the needle does not pierce the rectal wall, to the tip of the needle outside the rectal wall can slide freely shall prevail, inject 5 ~ 10ml of drugs.
The anterior rectal wall injection, depending on the degree of prolapse, in general, middle-aged women, prolapse is accompanied by posterior vaginal wall bulge, at this time must be carried out anterior rectal wall injection, needle entry point, from the perineum (rectovaginal) between the needle, piercing 4-8 cm, the other hand index finger into the vagina, touch the tip of the needle between the rectovagina, you can slowly back the needle while pushing the drug, injection volume 4-8 ml. The total amount of medicine injected outside the rectum is 20-40 ml. After the injection, the anus should be fixed with a small ventilator and a small gauze. Routinely give prophylactic antimicrobial oral medication or intravenous drip for three days after the operation.
2, rectal mucosal tightening This method can only be used as an adjuvant treatment for rectal prolapse by internal and external rectal injection, and the efficacy is not good when used alone. Rectal mucosal tightening can be performed after the completion of internal and external rectal injection.
Indications: Patients with prolapse for a long time, poor anal sphincter function, or with mixed hemorrhoids, and obvious rectal prolapse with mucosal buildup visible after injection.
Key points of operation: at rectal points 3, 7 and 11, lift the relaxed mucosa with tissue forceps, clamp a large curved vascular clamp at the base, and suture ligation with No. 7 silk or absorbable suture under the clamp. After ligation, the anus is dilated with the fingers and the rectum must pass smoothly through the two transverse fingers, which can avoid the difficulty of defecation after surgery. The number of ligature points is determined according to the mucosal relaxation, generally not more than three ligatures at a time, too much is likely to cause rectal stenosis and defecation difficulties.
Postoperative treatment: appropriate use of antibiotics, less slag diet, daily drug changes.
3.Indications for anal tightening: applicable to patients with anal sphincter dysfunction or rectal prolapse without anal sphincter function, which can be performed directly after rectal injection or rectal mucosal tightening inside and outside the rectum.
Contraindications: Patients with enteritis, diarrhea, acute perianal inflammation, and combined serious medical diseases.
Key points of operation: take a truncated or lateral position, repeatedly disinfect the perineal skin and anal canal, make a diamond-shaped incision outwardly at the posterior mid-pubic line to excise the skin subcutaneous tissue without cutting the sphincter, lift the mucosa and submucosa above the pubic line with tissue forceps, and clamp it with a large curved vascular forceps below the tissue forceps, at this time, pay attention to keep the anal opening smoothly through 2 fingers, and then ligate it with absorbable sutures throughout. The sphincter exposed by the wound outside the pubic line is closed with absorbable thread for u-sutures and finally the skin is closed with silk sutures. If, after posterior tightening, anal tightening is felt to be unsatisfactory, anterior anal tightening can also be performed simultaneously in the anterior part of the anus in the same way.
Postoperative treatment: intravenous drip antibiotics to prevent infection, less slag diet to control stool for 3 days, daily wound and drug change once.
4.Care and regimen
(1) Prepare the skin around 15-20 cm of the anal opening one day before surgery, and ask the patient to wash the area with warm soap and water after the skin preparation.
(2) Enema with 1000 ml of warm soap and water once in the evening and morning before surgery. Measure T and P in the morning of surgery.
(3) Ask the patient to rest in bed for three days after surgery and control the bowel movement for 72 hours.
(4) If the anus is distended or swollen after surgery, give the patient pain-relieving drugs as prescribed by the doctor.
(5) Sometimes there is hypothermia 2-3 days after surgery, if it does not exceed 38℃ and there is no local infection, it is absorption fever and can be treated without special treatment.
(6) Ask the patient to abstain from eating cold and irritating food, and to eat a semi-liquid diet or a diet with less residue within 24 hours after surgery.
(7) Before the first bowel movement, use warm soap and water enema to soften the stool and avoid excessive force during bowel movement.
(8) To prevent postoperative complications, routinely enter antibacterial drugs for three days after surgery as prescribed by the doctor, or for one week for the elderly and frail.
5. Postoperative adjuvant treatment 1.2.3 Postoperative adjuvant treatment Postoperative identification and typing of oral Chinese medicine
(1) Zhongqi subluxation treatment: benefit qi, nourish blood, ascending and fixing off Example formula: tonifying Zhong Yi Qi Tang with reduction of sizzling Yingqi 15g Dang Shen 10g Atractylodes macrocephala 10g Poria 10g Citrus aurantium 10g Chai Hu 8g Bai Shao 10g Sheng Ma 10g.
(2) Treatment of dryness of the intestines: tonifying the middle and benefiting the qi, moistening the intestines and opening the bowels Example formula: Ma Ren Wan plus or minus Sheng Di 12g Cistanches 10g Fire Ma Ren 12g Yu Li Ren 10g Fried Citrus Aurantium 6g Astragalus 12g Sheng Ma 6 Chai Hu 6g Medlar 10g Xuan Shen 10g Raw Licorice 5g.
(3) The treatment of damp-heat injection: clear heat and dampness Ge Gen 5g Radix Rehmanniae 10 fried Dampness 5g fried Scutellariae 8g fried Atractylodes 10g Coix seeds 10g Poria 10g raw licorice 6g.