Clinical application of ultrasound Doppler-guided hemorrhoidal artery ligation: Abstract:In order to explore the clinical application value of ultrasound Doppler-guided hemorrhoidal artery ligation (DG-HAL) in the treatment of anal diseases, ultrasound Doppler hemorrhoidal therapeutic instrument was used to treat hemorrhoidal artery ligation of 31 hemorrhoidal diseases, and 20 cases (64.52%) were cured; the symptom disappearance rate of bleeding reached 96.88%, and the disappearance rate of prolapse symptoms reached 60.00%. The results showed that ultrasound Doppler-guided hemorrhoidal artery ligation is a minimally invasive surgical procedure with low invasiveness, which has the advantages of safety, effectiveness, less pain and fewer complications. Keywords: hemorrhoidal disease; ultrasound Doppler-guided hemorrhoidal artery ligation Since 1995, ultrasound Doppler-guided hemorrhoidal artery ligation (Doppler-guided hemorrhoidal artery ligation (DG-HAL)) has achieved success in developed countries such as Japan, Europe and the United States, as a simple, safe, effective, and low-invasive minimally invasive surgical treatment. DG-HAL, as a simple, safe, effective and less invasive minimally invasive surgical treatment, has been successful in developed countries such as Japan, Europe and the United States, and has obtained relatively satisfactory therapeutic effects. This technology has also matured in China, and the Department of Anus and Intestines of our hospital has introduced this technology since January 2013, and as of December 2013, 21 patients have been treated with ultrasound Doppler-guided hemorrhoidal artery ligation. -HAL) was introduced in our hospital in January 2013, and outpatients or hospitalized hemorrhoidal patients who meet the indications of this procedure and voluntarily accept this procedure (protocol) were taken as the observation subjects. If the patients are old and frail and out of town, hospitalization is generally recommended, while the rest are treated in outpatient clinics. 2, case selection criteria: Diagnostic criteria: according to the 2000 Chinese Medical Association Surgical Branch of Anal and Intestinal Surgery Group of the Chinese Medical Association formulated the “Interim Standards for the Diagnosis and Treatment of Hemorrhoids” for diagnosis. Indications: (1) Ⅰ, Ⅱ, Ⅲ degree internal hemorrhoids, Ⅵ degree internal hemorrhoid bleeding; (2) mixed hemorrhoids Contraindications: (1) anal infection (2) malignant tumors. (3) Simple inflammatory external hemorrhoids, thrombosed external hemorrhoids. (4) Patients with coagulation mechanism disorder. 3, general information: this group of cases 21 cases, of which 22 cases of male, female 9 cases, the age of the smallest 21 years old, the largest 67 years old, the average age of 53.5 years; 17 cases of internal hemorrhoids, of which 6 cases of internal hemorrhoids of degree Ⅰ, 8 cases of internal hemorrhoids of degree Ⅱ, Ⅲ degree of internal hemorrhoids of 3 cases, and mixed hemorrhoids of 14 cases. Second, treatment method (1) Instruments used Austria A.M.I. company production of hemorrhoidal artery ligation ultrasound Doppler diagnostic instrument. (2) Pre-operative preparation Pre-operative examination was the same as general hemorrhoid surgery. Blood, urine routine, liver and kidney function, blood coagulation four tests, etc., outpatients to Hui Li enema liquid enema, hospitalized patients in the morning of surgery clean enema. (3) Position and anesthesia, according to the patient’s age and physical condition, take the lithotomy position or lateral position, and use lumbar spinal anesthesia or local anesthesia. If the anus is loose, surface anesthesia with lidocaine gel can be used. (4) After successful anesthesia, use 0.5% chlorhexidine or chlorhexidine tincture to routinely disinfect the skin of the operation field, spread the sterile towel sheet, and then use 0.5% chlorhexidine or 0.5% chlorhexidine to disinfect the anal canal and the lower end of the rectum. Finger check and dilate the anus to two fingers, will be sterilized special anoscope and ultrasound Doppler hemorrhoidal artery diagnostic instrument connected, placed into the anorectal tube, so that the ultrasound Doppler probe placed in the dentate line 2 ~ 3 cm, along the anorectal tube and rectum longitudinal axis of the rotation of the anoscopy in the ultrasound Doppler hemorrhoidal artery diagnostic instrument guided to find hemorrhoidal arteries in the Doppler ultrasound signals received in the obvious place, and then 0.5% iodine vapour or 0.5% Chlorhexidine cotton wool balls. Sterilize the surgical window in the anoscope (each needle must be sterilized), through which the hemorrhoidal arteries are sutured with 2 0 absorbable sutures and strong 1/2 curved stitches in the shape of an “8”, and the depth of the needle is determined according to the depth of the hemorrhoidal arteries detected by ultrasound Doppler’s hemorrhoidal artery diagnostic instrument, and the vessels that have been sutured are ligated with the help of a thread pusher. After completing the ligation of all the hemorrhoidal arteries, the anoscope was rotated again to detect the ligation effect, and the unsatisfactory place was ligated again. Repeat the above operation by withdrawing the anoscope for 0.5 cm, but should ensure that the ligation point is at least 0.5-1 cm away from the dentate line. After completing the ligation of all hemorrhoidal arteries and withdrawing the ultrasonic Doppler anoscopy, the position of the suture was checked with a finger, and 5g of anal tylenol ointment was placed in the anus after the operation. For internal hemorrhoids with prolapsed hemorrhoid, after ultrasonic Doppler-guided hemorrhoidal arterial ligation, the nucleus of prolapsed hemorrhoids was made into “8” shape by using 2 0 absorbable sutures. For prolapsed internal hemorrhoids, after ultrasound Doppler-guided ligation of the hemorrhoidal artery, the prolapsed internal hemorrhoidal nucleus was sutured with 2 0 absorbable sutures in the form of an “8” suture, which was fixed in the submucosal layer above the apical hemorrhoidal core. (4) Postoperative disposition After the operation, let the patient rest for about 2 hours, and go home if there is no abnormality. Or hospitalized for observation as needed. The anus is placed into the anus twice a day, each time 2g, in order to eliminate the symptoms of intra-anal swelling and discomfort, anti-inflammatory and hemostatic; 8 hours after the operation, start eating, and routinely apply antimicrobial drugs for 3 days. Postoperative follow-up and recheck were carried out according to the specified time. Third, observation indicators (a) efficacy indicators and scores 1, bleeding (1) mild: small amount, just blood on the stool paper. Mark 1 point. (2) Moderate: blood dripping during stool, the amount is within 10 ml. (3) Severe: dripping or spurting of blood during stool, with a volume of 11 ml or more in one stool. 2. Prolapse (1) Mild: Prolapse of a mass from the anus during defecation, which can be incorporated by itself after defecation. (2) Moderate: Prolapse of a mass in the anus during defecation, requiring manipulation and repositioning. (3) Severe: In addition to prolapse of the mass during bowel movement, there is also prolapse of the mass when walking or increasing abdominal pressure (e.g., coughing, etc.). Mark 3 points. (II) Side effect indicators 1, pain (1) Ⅰ degree: pain is mild, no need to take pain medication. (2) Ⅱ degree: pain can be relieved by general painkillers. (3) Ⅲ degree: the pain is severe and requires morphine analgesics to relieve pain. (2) Defecation and urination (3) Temperature and blood (3) Criteria for judging the efficacy of treatment (1) Cured: all bleeding and prolapse symptoms have disappeared. (2) Significant effect: more than 70% of the bleeding and prolapse symptoms disappear. 3.Effective: more than 50% of bleeding and prolapse symptoms disappeared. Ineffective: bleeding and prolapse symptoms disappeared less than 49%. (D) Efficacy observation time: all treated cases were observed for 1 week. The efficacy index scores on the 7th, 15th and 30th days were recorded during the follow-up, and the average value of the three times was taken as the statistical result. Results 1. Efficacy In this group, there were 31 cases, 20 cases were cured, accounting for 64.52%; 1 case had obvious effect, accounting for 3.22%; 10 cases were effective, accounting for 32.22%. In this group of cases, after the treatment of this method, only 2 cases had blood in the stool on the 7th day, and the other patients did not have bleeding again. The symptomatic disappearance rate of bleeding reached 96.88%. Among the 19 cases with prolapse symptoms, 10 cases of prolapse symptoms disappeared and 7 cases of prolapse symptoms improved significantly after treatment. The disappearance rate of prolapse symptoms reached 60.00%. The average length of stay of the 10 hospitalized patients was 4.5 days. Side effects Only one case of non-infectious anal pain of degree II related to the surgery occurred after the operation. The rest of the patients had no obvious anal pain. 1 case had anal pain, fever, elevated blood count, and obvious local submucosal tenderness on anal fingerprinting on the 3rd postoperative day, and the symptoms disappeared on the 7th postoperative day after application of antimicrobial drugs. The rest of the patients did not have fever and blood abnormalities. 31 patients, none of them had anal dysfunction such as difficulty in defecation or abnormal urination. V. DISCUSSION 1. About the mechanism of ultrasound Doppler-guided hemorrhoidal artery ligation, the mechanism of DG-HAL has the following aspects: (1) After ligating the arterial vessels, the blood entering the internal hemorrhoids is blocked. Since the venous return is not impaired, the inflow/outflow ratio will be simultaneously reduced. As a result, the hemorrhoid will shrink, while bleeding and pain will disappear. (2) As tension is reduced, connective tissue will also regenerate, thus promoting shrinkage of the hemorrhoids. (3) After ligation, chronic inflammation is induced locally, resulting in tissue fibrosis, fixation of mucosal and submucosal adhesions, disappearance of hemorrhoidal atrophy, and ultimately a significant reduction in hemorrhoidal prolapse. This whole process supports the theory of “high tension hemorrhoidal cushion” [1-2]. (4) After ligation, the rectal mucosa and the superior hemorrhoidal artery may be directly sutured and fixed in the muscle layer, preventing the anal cushion from moving downward, and suspending and resetting the prolapsed anal cushion. Because of the high site of ligation and the preservation of most of the anal cushion tissue, the postoperative reaction was significantly reduced. In 1975, Thomson put forward the theory of anal cushion displacement and gradually recognized. For the surgical treatment of hemorrhoids, the understanding also tends to agree. Asymptomatic hemorrhoids do not need treatment, symptomatic hemorrhoids treatment aims to eliminate or alleviate the symptoms, mainly to correct the pathophysiological changes, rather than the root cause of pathological changes in the anal cushion. It was with the concept of painlessness and minimally invasiveness that Japanese scholar MorinagaK et al. first reported on hemorrhoidal artery ligation using a proctoscope with an ultrasound Doppler probe (Moricorn) combined with ultrasound Doppler flowmetry in 1995, concluding that hemorrhoidal artery ligation using the Moricorn was simple, safe, and highly effective. [4] 2. Regarding the indications for DG-HAL, many researchers have concluded that the best indication for hemorrhoidal artery ligation is internal hemorrhoids of degree II-III or mixed hemorrhoids, which are predominantly internal hemorrhoids of degree II-III, in a follow-up study of hemorrhoidal patients with degree I-IV hemorrhoidal disease [5-8] LienertM and UlrichB concluded that non-extruding hemorrhoids are the most suitable for hemorrhoidal artery ligation, and the most effective for non-extruding hemorrhoids. The most ideal indication for hemorrhoidal artery ligation [9], we believe that any degree of internal hemorrhoids with bleeding symptoms is an indication for hemorrhoidal artery ligation, and acute bleeding from other causes in the anorectal area can sometimes be treated with DG-HAL as a good adjunct. For prolapsed hemorrhoids DG-HAL procedure has a certain suspensory effect, but its long-term effect has to be further studied. In the data of this group, 19 patients had prolapse symptoms, and we greatly improved the degree of prolapse by adding the suspension method at the same time of treatment with DG-HAL procedure. 3. Evaluation of DG-HAL surgery The data in this group showed that DG-HAL surgery has the advantages of easy surgical operation, exact hemostatic effect, recent suspension effect, and few intraoperative and postoperative complications, and this surgery has minimal damage to the patient and can be performed under local anesthesia or even without anesthesia, which further reduces the possible negative reactions and shortens the time of postoperative surgery. This further reduces the possible negative reactions and shortens the healing time, and its postoperative complications are significantly reduced compared with the traditional ligation therapy. We counted 230 cases of third-degree internal hemorrhoids and mixed hemorrhoids treated with traditional external ligation from January to December 2013 in our department, the incidence of anal pain was 46%, the incidence of urinary retention was 6%, the incidence of anal edema was 16.8%, and the average hospitalization time was 8 days, whereas the incidence of anal pain in the DG-HAL procedure used in our group was only 2%; there was no case of anal edema and no case of anal edema, and no case of anal edema and no case of anal edema. 1 case of anal edema and urinary retention. Hemorrhoidal artery ligation is an extension of traditional ligation therapy and an upgrade of traditional ligation therapy, with more accurate localization of the hemorrhoidal artery and more direct blockage of blood flow. The precise efficacy of hemorrhoidal artery ligation, as well as its shorter hospital stay, lower complication rate, and less postoperative pain, make it more suitable as a quick-treatment surgical procedure, and, at the same time, meets the requirements of the least invasive surgical procedure.