Perianal diseases are one of the most common human diseases, which seriously affect people’s health and even life. In recent years, with the application of advanced science and technology at home and abroad, the medical profession has conducted detailed studies on the anatomy, physiology and pathology of the anus and corrected some traditional misconceptions, such as: the pathogenesis of hemorrhoids – the doctrine of inferior displacement of the anal cushion; the doctrine of anterior rectal distention – the doctrine of prolapse of the rectal mucosa, etc. Hemorrhoids Hemorrhoids are one of the common and frequent clinical diseases, and there are still debates about the causes of hemorrhoids. In the late 1990s, Longol et al. reaffirmed the “anal cushion theory” and conducted a more in-depth study. He proposed that hemorrhoids are not a disease, but a normal anatomical structure of the human body, and that asymptomatic hemorrhoids do not need to be treated and symptomatic hemorrhoids do not need to be cured. He developed a new method of treating hemorrhoids using anastomosis – procedure for prolaps and hemorrhoids (PPH). This has brought about a ‘revolution’ in the understanding and treatment of hemorrhoids. I. Overview Hemorrhoids are one of the most common human diseases, and their incidence is reported differently at home and abroad. The incidence of hemorrhoids has long been known as “nine hemorrhoids in ten men” and “ten hemorrhoids in ten women” in our folklore, and the incidence of hemorrhoids is considered to be very high. But in reality it is not high, in 1977 the national census of 155 units of 57,427 people, the incidence of hemorrhoids accounted for 51.44%. Foreign reports range from 22% to 47%, with some reports as high as 80%. The symptoms of hemorrhoids are pain, bleeding and prolapse outside the anus, so traditionally hemorrhoids are considered to be varicose veins, and the Greek word “Haemorrhoids” or “Pila” means bleeding and masses. But in recent years, with the development of medical science, people have used advanced scientific methods to study hemorrhoids in more depth and detail, and the concept of hemorrhoids has changed, considering hemorrhoids to be “vascular anal cushions” that are part of the normal anatomy of the human body, and hemorrhoids themselves are not a disease, but only when there is bleeding, pain, or prolapse for some reason. It is only when the symptoms of bleeding, pain and prolapse occur for some reason that they are called diseases. The anal cushions (Anal Cushions), also known as the Haemorrhoidal zone, and the rectal spongiosa (Corpus covernosum recti), are the anatomical and physiological basis for the modern concept of hemorrhoids. When the anal cushion is stimulated by some undesirable factors, the sympathetic nerve is stimulated and the secretion of amines increases, causing capillary spasm, tissue ischemia and hypoxia, releasing histamine, capillary dilatation, blood stagnation, tissue edema, and serious localized necrosis and erosion and bleeding can occur. Normally the anal pad is fixed by the Treits and Park muscles, which are medial to the internal sphincter. Congenital and genetic factors Treits muscle dysplasia and any cause of increased intra-abdominal pressure make Treits muscle overstretch, fracture, capillary regulation within the anal cushion is impaired leading to anal cushion downward migration and hemorrhoid prolapse. 2, genetic theory Investigation found that patients with hemorrhoids often have a family history, but no definitive genetic evidence has been found. The incidence in developed countries is higher than in developing countries, which may be related to food structure, defecation habits and environmental factors. The hemorrhoids are located above the dentate line and are covered by the rectal mucosa, and are commonly found in the left middle, right front and right back, which is also known as the anal cushion. It can be bleeding, painful and prolapsed when it occurs. 2.External hemorrhoids are located below the dentate line and covered by the skin, commonly have thrombosed external hemorrhoids, the main symptom is pain. 3.Other Located near the dentate line, the surface is covered by skin mucosal junction tissue and has the characteristics of both internal and external hemorrhoids. Some people think it is actually hemorrhoids with an external component (hemorroids with an external component). The staging of hemorrhoids The staging method of the Chinese Medical Association’s Anorectal Group. Stage I No obvious clinical symptoms Sometimes bleeding during defecation Anal cushion hypertrophy and congestion can be seen under the anoscope. Stage II Anal cushion prolapses during defecation, and at the end of defecation the cushion retracts on its own with blood in the stool, or more serious blood in the stool. Stage III Anal cushion prolapses during defecation and must be retracted by hand at the end of defecation. Stage IV The hemorrhoids are prolapsed for a long time and cannot be retracted. Most of them are circular hemorrhoids or mixed hemorrhoids, and the anal cushion is mostly fibrotic, with blood in the stool, but less serious blood in the stool. V. Clinical symptoms 1. Blood in stool Internal hemorrhoids and mixed hemorrhoids commonly have painless blood in stool in early stage, bright red color, mostly blood in stool or on paper, sometimes there can be anal drip or jet bleeding, blood in stool can stop on its own after several days. Mostly bleeding after drinking alcohol or eating irritating food. 2.Prolapsed hemorrhoids usually occur in the more advanced stages, mostly during the stool, after the stool back on its own, and then develop into the need to return by hand, and finally completely unable to return or even embedded. The patient is often in great pain, which seriously affects the work. 3, pain Early bleeding internal hemorrhoids are often not painful, and only when inflammation, necrosis or impaction occurs will there be pain. Pain is the main symptom of external hemorrhoid thrombosis, which mostly occurs when the patient exerts himself, after drinking, the patient is in pain and cannot walk. 4.Itching Late stage patients have prolonged prolapse of hemorrhoid mass, anal relaxation, discharge, itching and discomfort around the anus, and even rash. Differential diagnosis According to the clinical symptoms of internal hemorrhoids and the necessary anal examination, the diagnosis is not difficult, but it must be distinguished from the following diseases: 1, rectal cancer The most common clinical misdiagnosis of rectal cancer as hemorrhoids is mainly due to the diagnosis based on symptoms only, without careful rectal diagnosis and anoscopy, which is also the main reason for delaying the timely treatment of patients. 2.Prolapsed rectal polyps Low-positioned rectal polyps with tips prolapsed outside the anus are often misdiagnosed as internal hemorrhoids, and the polyps have tips that are round and active. 3, rectal prolapse Rectal prolapse is circular, the surface mucosa is smooth, rectal finger examination can be found often with anal sphincter relaxation, circular internal hemorrhoid prolapse is generally plum petal-shaped, sphincter is not relaxed. Seven, the principle of treatment 1, one, two internal hemorrhoids are usually clinically asymptomatic, so there is no need to treat, if there is bleeding, can take internal conservative treatment. 2.For prolapsed hemorrhoids of stage 3 or 4 or severe hemorrhoids with serious bleeding, surgical treatment is required. 3.For embedded hemorrhoids, if they are more than 48 hours old and have inflammation, conservative treatment such as anti-inflammation, pain relief and rejection should be performed first, and then surgery should be performed after the inflammation has improved. Eight, surgical methods (a), there are many kinds of traditional surgical methods injection method, electrocoagulation method, ligation method and so on and some foreign physicians named Buie method, Fansler method, Milligan-Morgan, Parks method. And the principle of all these methods is one purpose: to remove or surgically excise the hypertrophied, prolapsed, bleeding hemorrhoid nucleus. The result did cure some patients, but at a cost. The integrity of the human anal cushion is severely damaged, causing some irreversible complications such as: anal stenosis, fecal incontinence, recurrence of symptoms, etc. In addition, the long operation time and postoperative pain also bring great pain to patients. (b), rectal mucosal circumferential anal cushion suspension (PPH) PPH was proposed by Longo in 1998, also known as Longo technique, in fact, in 1990 Allegra has proposed the use of anastomosis to remove circumferential hemorrhoids. 1997 pescation reported the clinical use of anastomosis for rectal mucosal prolapse. longo on this basis to carry out improvements, further elaborating on the mechanism of prolapsed hemorrhoids, and collaborating with Johnson & Johnson to form the current PPH procedure. The PPH procedure is performed by circumferential resection of the rectal mucosa about 3M above the dentate line above the hemorrhoid using an anastomosis clutch about 3-4M above the dentate line and completes the anastomosis at the same time, thus restoring the subluxated anal cushion to its normal physiological position, improving the self-control function of the anus, reducing the internal pressure of the anal canal, and eliminating the symptoms of prolapsed hemorrhoids; it does not destroy the anal cushion tissue, preserves the ability of the rectum to recognize the intestinal contents, and does not cause the anal stricture, incontinence, or bowel control dysfunction that occur with traditional surgery. The anastomosis is 1.5-2M above the dentate line, where there are few sensory nerves, and no obvious anal pain and discomfort will occur after the operation. 1.Surgical evaluation of PPH: (1) Short operation time, the average operation time is 10 minutes or less after successful anesthesia. (2) Less bleeding, usually no or little bleeding as long as the operation is done correctly. (3)Light postoperative pain, because the anastomosis is above the tooth line, there are few body sensory nerves and no damage to the anal cushion, the postoperative pain is light and generally no or little painkillers are used. (4) Short hospitalization time, most patients can move freely and eat normally 24 hours after surgery, and the average hospitalization time is less than 72 hours. In China, there are reports of outpatient surgery under local anesthesia, and patients can go home after surgery. The patient can return to work in one week. (5) Less recurrence, PPH surgery is based on restoring the subluxation of the anal cushion and cutting off the common blood of the inferior rectal artery, after which the hypertrophic anal cushion is rapidly retracted, swelling is reduced and hemostasis is stopped. Although it has been carried out for a short period of time, 5 years abroad and 3 years in China with a larger number of cases followed up, its recurrence rate (<1%) is much lower than that of traditional surgical methods. Our hospital has used PPH to treat more than 300 cases of severe hemorrhoids since June 2000, and there are no recurrence cases yet. (6) PPH has not been carried out for a long time, and its long-term efficacy is not known now. In addition, the cost of PPH anastomosis is relatively high, which increases the treatment cost of patients and also prevents PPH technology from being carried out faster and more widely. 2. Indications and contraindications of PPH (1) Indications for PPH: III-IV degree prolapsed circumferential hemorrhoids, severely bleeding II degree hemorrhoids, rectal mucosal prolapse, early embedded internal hemorrhoids (within 48h). (2) Contraindications of PPH: Those who cannot move the whole anal cushion smoothly and narrow anal canal due to rectal and anal canal fibrosis, external anal hemorrhoids and anal incontinence. 3. Complications of PPH and its prevention and treatment (1) Pain, Italian scholar Ravo reported 1107 patients of PPH surgery in 12 anorectal treatment centers, 5% of patients had severe pain. (1) The purse-string suture is too deep so that muscle is mixed with the resected tissue. (ii) The anastomosis was close to the tooth line causing somatosensory neuropathic pain. â‘¢Postoperative anastomotic edema pain. â‘£Pain after excision of external hemorrhoid skin. (2) Thrombosis, the incidence of which is reported by Ravo as 2.3%, usually improves with conservative treatment. (3) Urinary retention, which has been reported to occur in 50% of patients after PPH, the cause of which is still unknown and may be caused by various factors such as anesthesia, and generally recovers on its own in the short term. (4) Other complications, such as anastomotic dehiscence, rectovaginal fistula and rectal wall hematoma. As long as the operation is careful, it usually does not occur. 4, PPH treatment of severe hemorrhoids at home and abroad Since Longo invented PPH technology to treat severe hemorrhoids in 1998, PPH surgery has been widely carried out in Europe and the United States, and now the developed countries abroad have basically replaced the traditional hemorrhoid surgery method with PPH technology, which has become the gold standard for the treatment of severe hemorrhoids. at the end of 2003, there were a total of 250,000 cases worldwide, including 200,000 cases in Europe. in early 2006, domestic has In early 2006, about 30,000 cases of PPH surgery were reported in China.