Abstract OBJECTIVE:To observe the clinical efficacy of manual PPH surgery in the treatment of patients with cricoid mixed hemorrhoids. Methods:Eighty patients with cricoid mixed hemorrhoids were divided into the treatment group of manual PPH surgery and the control group of external peel and internal ligation, and the postoperative response and clinical cure time of the two groups were observed. Results:The efficacy of the treatment group was significantly better than that of the control group, with a significant difference of P<0.05< span="">or P<0.01. Conclusion: Artificial PPH surgery has good efficacy for patients with cricoid mixed hemorrhoids and is worth applying. The application of the anastomotic clutch for Prolapse and Haemorrhoids (PPH) has brought about a great change in the treatment of cricoid mixed hemorrhoids, and since July 2005, we have been using the PPH surgical model with a purely manual surgical approach for the treatment of cricoid mixed hemorrhoids, taking into account the economic and medical aspects. Since July 2005, we have been using the PPH surgical model to treat cricoid mixed hemorrhoids, and comparing with patients who underwent external peeling and internal ligation (Milligan-Morgan surgery) at the same time, we have achieved satisfactory results, which are reported as follows. 1. Clinical data 1.1 General data 40 patients in the treatment group and 40 patients in the control group were hospitalized, grouped according to the random number table method, 35 men and 5 women in the treatment group, 36 men and 4 women in the control group, age 28-65 in the treatment group, duration of disease 3-25 years, age 30-60 in the control group, duration of disease 4-22 years. The data of the two groups were tested by t-test, and there was no significant difference (P>0.05), which was comparable. 1.2 Diagnostic criteria Referring to the provisional criteria for the diagnosis and treatment of hemorrhoids revised in September 2002 by the Anorectal Surgery Group of the Chinese Medical Association’s Surgery Branch [1]. The selected mixed hemorrhoids were internal hemorrhoids fused together or poorly demarcated, and external hemorrhoids were varicose veins or connective tissue with or without thrombosis. 1.3 Judgment of efficacy The efficacy of surgical treatment in both groups was evaluated comprehensively in terms of postoperative first bowel movement and 4d and 7d anal pain (using the VAS method, i.e. 250px scale, self-selected by the patient according to the pain level, with 0 being no pain and 10 being extreme pain), dyspareunia, skin bridge edema, anal swelling sensation, anal unevenness, anal stricture, anal overflow, and mean healing time of the wound. 1.4 Statistical treatment The t-test was used for measurement data, and X2 test was used for counting data. 2. Treatment methods 2.1 Preoperative preparation Preoperative fasting for 6 hours, giving clean enema and asking the patient to empty it 1 hour before surgery, preparing the skin after drying in a warm water sitz bath. 2.2 Surgical method Treatment group: After successful epidural anesthesia, take a lithotomy position, routinely disinfect the towel, disinfect the anal canal and the end of rectum with iodophor cotton ball, and start the surgery after no lesion other than hemorrhoid by internal finger diagnosis. Use tissue forceps to hold the upper part of the internal hemorrhoid and the mucosa of the hemorrhoid laterally (as far as possible at the natural demarcation of the internal hemorrhoid), and use two vascular forceps on both sides of the tissue forceps to clamp the anal canal vertically and closely side by side, with the tips of both forceps more than 12.5px from the dentate line, and the longitudinal length of the clamped mucosa is generally about 37.5px, and cut the mucosa and submucosa between the two forceps, and operate in the same way about 50px from this point. Operation, lift the two ends of the vascular clamp, bend the vascular clamp on the tip of the two clamps, cut off the tissue on the bent vascular clamp, from the point of separation, use No. 4 silk thread continuous suture around the clamp to close the wound; the same method to deal with the rest of the internal hemorrhoids and hemorrhoids on the mucosa, so after more than 6 sections (including 6 sections) cut suture, the internal hemorrhoids department processing is completed; (2). The skin of the external hemorrhoid under the dentate line is cut radially with the anus, and the interhemorrhoidal groove is chosen as the incision site as far as possible, and the subcutaneous thrombus, varicose hemorrhoidal plexus and subcutaneous tissues are removed by subcutaneous peeling, and a small part of the skin bridge that cannot be leveled is excised. Care was taken to preserve as much of the external hemorrhoidal skin as possible. Control group: Anesthesia and disinfection were the same as in the treatment group. Clamp the skin of the external hemorrhoid part according to the size of the hemorrhoid to make a shuttle incision, bluntly plus sharply peel the external hemorrhoid tissue 7.5px above the dentate line, pull up the internal part of the hemorrhoid, clamp the base of the internal hemorrhoid parallel to the anal canal with curved vascular forceps, round needle No. 7 silk wire clamp down through and then 8-string ligation, cut off the stump. Considering the factors of leaving the skin bridge and mucosal bridge, some parts are directly ligated or not treated, and only subcutaneous vein destruction is done in the external hemorrhoid part, or trimmed to the appropriate length and width, and sutured with the mucosa docking on the dentate line. According to the anal loosening and tightening situation some patients were performed at 5 or 7 o’clock in the truncated position along the external hemorrhoid trauma with subcutaneous disruption of the external sphincter and the lower edge of the internal sphincter and compression bandaging. 2.3 Postoperative treatment Routine application of diclofenac sodium extended-release capsule 100J orally once a day for pain relief, gentamicin and metronidazole IV for a week to prevent infection, after defecation with our Chinese medicine self-prepared swelling and pain elimination lotion sitz bath and Jiuhua cream change twice a day. 3. Treatment results Referring to the efficacy and postoperative reaction observation standards formulated by the National Conference on Anal Surgery in 1975, etc., the results of the two groups are shown in Table 1, Table 2 and Table 3. Table 1 Comparison of VAS indices of anal pain after the first postoperative bowel movement, the 4th d and the 7th d in the two groups Group Number of cases (n) First postoperative bowel movement 4 d after surgery 7 d after surgery Treatment group 40 4.34±0.65 2.34±0.46* 1.56±0.21** Control group 40 4.76±0.62 3.78±0.52 3.24±0.36 P>0.05, P*<0.05, P**<0.001 in the treatment group compared with the control group Table 2 Postoperative reaction observation Postoperative time Symptoms and signs Treatment group Control group P(x2 test) Within 3 days Urinary dyspareunia 6 19 <0.01 Within 7 days Pi-bridge edema 3 20 <0.01 Anal swelling 26 30 >0.05 After 15 days Anal stricture 0 2 <0.05 Anal unevenness 2 18 <0.05 Anal overflow 2 15 <0.01 Table 3 Comparison of clinical healing time () Number of cases Treatment group (d) Control group (d) t-test 40 15.58±2.45 24.36±5.28 p<0.01 4. Discussion The reason why cricoid mixed hemorrhoids are called The key reason why hemorrhoids are difficult to treat is that it is difficult to balance anal function and appearance after surgery. From the perspective of protecting anal function, the anal canal skin, dentate line and mucosa of the hemorrhoidal area should be damaged as little as possible, but this may result in incomplete hemorrhoidectomy or unevenness of the anal canal; from the perspective of anal appearance, the obvious internal and external hemorrhoidal tissues should be removed as thoroughly as possible, so that the damage to the anal canal skin, dentate line and mucosa is easy to be too large, and the mucosal prolapse and anal stenosis that occur as a result are common in clinical practice, and in serious cases, they cause irreversible anal The damage to the anus is irreversible in severe cases. It is the clinician's unremitting pursuit to explore the best possible surgical method for the treatment of cricoid mixed hemorrhoids, which has led to the emergence of many procedures, the more representative ones being the external peel and ligation (Milligan-Morgan procedure) and the PPH procedure introduced from abroad in recent years. The external peeling and internal ligation is a classic procedure for treating mixed hemorrhoids for more than 60 years, but there are still shortcomings such as postoperative pain and long healing time. Especially for the treatment of circumferential mixed hemorrhoids, postoperative complications such as pain, bleeding, incomplete treatment and other sequelae are easy, and the trauma is large and slow to heal. PPH surgery was firstly reported by Italian scholar Longo in 1998 as a new method to treat hemorrhoids by using hemorrhoidal anastomosis, which has the advantages of less bleeding, less postoperative pain and faster recovery, etc. Since it was introduced into China in 1999, it was soon accepted and recognized by more anal pathologists in China, but the biggest obstacle to its application is that the device is expensive, which is difficult for ordinary patients to afford, so it is difficult to be popularized. We have explored through a lot of clinical practice, and based on the theory of inferior displacement of the anal cushion, we have taken a purely manual operation of circumferential suturing of the upper part of the internal hemorrhoid body and part of the suprahemorrhoidal mucosa for the treatment of cricoid mixed hemorrhoids, which we call manual PPH surgery. This procedure takes the meaning of circumferential hemorrhoidopexy and PPH surgery but with some variations, it is not like the traditional circumferential hemorrhoidopexy in which the internal and external hemorrhoid tissues are extensively excised, nor is it like the PPH surgery in which the internal and external hemorrhoids are not treated; instead, the upper part of the internal hemorrhoid body and part of the suprahemorrhoidal mucosa are circumferentially excised, the loose and downward moving anal cushion is moderately stretched, and the subdental tissues such as varicose veins and loose skin of the protruding external hemorrhoids are indirectly lifted to make them The hemorrhoid can be repositioned, and the external hemorrhoid can be treated appropriately to restore the morphology and function of the anus. Compared with PPH surgery, this procedure reduces the cost of treatment, avoids extensive excision and ligation damage, and protects the mucosa and skin above and below the dentate line. Since there is less damage to the skin and muscle under the dentate line, the nerve damage is light, the blood and lymphatic circulation is smooth, the incidence of anal pain and edema is reduced accordingly, and the healing time is shortened accordingly; the mucosa is neatly aligned and in a higher position after mucosal excision, and it is less likely to form mucosal stenosis compared with large internal hemorrhoid nucleus suture, which ensures the smooth recovery of anal function and helps shorten the clinical healing time. In addition, because this procedure basically does not damage the dentate line, it protects the anal receptors of pain, touch, cold, pressure, tension, friction, etc. These receptors have a fine sense of discrimination, which helps anal self-control.