There are many surgical methods for rectal prolapse, [1] [2] and there are about a hundred of them. The more treatment methods there are for a disease, the worse the outcome may be. The research and understanding of its mechanism are still accepted by most scholars as the “sliding hernia theory” [3] and the “intussusception theory” [4]. On this basis, numerous treatment modalities have been developed. From 1999 to May 2012, 30 cases of rectal prolapse with different surgical procedures were collected and followed up for 1-5 years in a retrospective analysis and comparative study.
1. information and methods.
1, 1 The cases in this group, male, 18 cases, female, 12 cases. The average age: 45,7 years old, the average duration of disease 10,5 years, including 5 cases of I degree prolapse, 20 cases of II degree prolapse, 5 cases of III degree prolapse.
1.2 Diagnostic criteria: In 1975, the National Conference on Proctology divided rectal prolapse into III degrees, I degree prolapse: the rectal mucosa prolapsed outside the anus 3-5 cm when defecating or increasing abdominal pressure, and the prolapsed part could be returned after defecation. II degree prolapse: the rectal mucosa prolapsed outside the anus 5-10 cm when defecating or increasing abdominal pressure, and the prolapsed part needed to be reset by manipulation after defecation. III degree prolapse: the rectal part of the anal canal and sigmoid colon can be prolapsed outside the anus for more than 10 cm when defecating, and it is difficult to reset by manipulation and has a barrel-like appearance.
1, 3 Treatment methods.
Preoperative preparation: 800,000 units of gentamicin and 0,4 grams of methotrexate two days before surgery, orally three times a day, preoperative fasting, clean enema, combined rigid and lumbar anesthesia, lithotomy position.
1,3,1 subrectal submucosal spot injection of anti-hemorrhoid spirit: use a 10 ml syringe to extract 1:1 mixture of anti-hemorrhoid spirit (i.e. 1 ml of anti-hemorrhoid spirit original solution mixed with 1 ml of injectable saline) and use a No. 5 skin test needle to perform submucosal spot injection under the prolapsed rectal mucosa from near to far, so that the entire rectal mucosa is blister-like change, after the injection is completed, evenly press the rectal mucosa and then slowly send it back to the anus. The amount of anti-hemorrhoid mixture should not exceed 100ml.
1, 3, 2 Antihemorrhoid Ling perianal injection: The index finger of the left hand is used as a guide in the anus, and the right hand holds a fine lumbar penetrating needle at the 3, 6, and 9 points of the truncus position, which is parallel to the anal canal into the needle, piercing above the anal levator muscle, about 7-8 cm, and injecting 30 ml, 40 ml, and 30 ml of 1:1 Antihemorrhoid Ling mixture into the rectum at one time, retreating the needle while injecting, so that the Antihemorrhoid Ling mixture is evenly distributed in the rectal anal canal around the rectal canal. The total amount of anti-hemorrhoid mixture should not exceed 100 ml.
1.3.3 Rectal mucosal column suture: The prolapsed rectal mucosa is clamped longitudinally with curved forceps and sutured through with No.7 silk thread “8”, 3 columns are sutured in one plane, staggered from near to far until 1 cm on the dentate line. all sutures are completed and slowly sent into the anus.
1,3,4 Anal tightening: a longitudinal incision of 0,5cm is made at the front and back anal edges with a sharp knife, the finger enters the anal canal for guidance, the posterior incision to the anterior incision and then the anterior incision to the posterior incision are sutured with a tension-reducing suture, the No.2 absorbable thread is looped under the perianal skin, the ends of the absorbable thread are tightened until the anus is shrunken by one and a half fingers, then the knot is buried under the skin and the anterior and posterior incisions are sutured with a fine silk thread. .
1.3.5 External anal sphincter folding operation: the skin was incised subcutaneously for 3 cm in a radial pattern 1 cm from the anal margin directly behind the anus, and the flap was freed to expose the external anal sphincter, and 3 stitches were folded transversely with No.2 absorbable thread until the anus could accommodate one and a half fingers, and the incision was closed with fine silk sutures, and the stitches were removed in 7 days.
1, 3, 6 rectal mucosal stripping suture: drag the prolapsed rectum out of the anus intact, start from 1, 5 cm from the dentate line to remove the rectal mucosa in a circular manner from far to near to the highest point of rectal prolapse, complete stripping after electrocoagulation to stop bleeding. Absorbable thread interrupted nodal longitudinal full-layer suture of rectal mucosa, and after the completion of suture check no bleeding sent back to the anus.
1, 3, 7 Efficacy criteria: clinically cured: no intestinal prolapse during defecation and increased abdominal pressure, and no set in the rectum by finger diagnosis. Effective: no intestinal tube prolapse during defecation and increase of abdominal pressure, and finger diagnosis of rectum with ligature. Ineffective: no significant improvement of symptoms, still need to return by hand.
2.Results
The surgical methods were grouped into four groups: ① subrectal submucosal dot injection of elimination hemorrhoids + perianal injection of elimination hemorrhoids + anal tightening in 3 cases, and there were 1 effective case and 2 ineffective cases. The effective rate was 33.3%. (2) 5 cases of perianal injection of hemorrhoids + rectal mucosal column suture + anal tightening, 2 cases were clinically cured, 1 case was effective, and 2 cases were ineffective. The effectiveness rate was 60%. (3) The nine cases of perianal injection + rectal mucosal column suture + external anal sphincter folding, four cases were clinically cured, two cases were effective, and three cases were ineffective. The efficiency was 66.6%. In 13 cases, 10 cases were clinically cured, 2 cases were effective, and 1 case was ineffective. The effectiveness rate was 92.3%. One invalid patient recurred 2 months after the operation due to premature weight-bearing work.
The efficiency of peri-anal injection + rectal mucosal debridement and suturing was significantly higher than that of the previous three groups. The difference between the four groups with different surgical methods was statistically significant by x2 test, P<0,05.
3. Discussion
The etiology of rectal prolapse is still unclear, mainly the sliding hernia theory proposed by moschcowite, and the intestinal overlap theory proposed by broden and snellman, and the treatment of rectal prolapse is mainly surgery. The cause of this disease in adult patients is mostly deepening of the douglas depression and relaxation of the pelvic floor muscles, forming a sliding hernia or intussusception of the pelvic floor. The prolapsed intestine accumulates in the rectum, resulting in cystic dilatation of the rectum, and the puborectal muscle and external sphincter are stretched for a long time, making the rectal angle of the anal canal larger and the anal canal looser. The rectum prolapses repeatedly for a long time, which also makes the anal canal loose and weak, and the anal canal 〖案毓芏災背Φ闹С肿眉缚酰纸徊郊又赝汛梗纬啥裥匝贰T诠庾賀庾钗惴惴褂玫Neon quality sweet strangulation of the Tokyo Tokyo backtank acylshus some harmonious chaff kind of backν笔褂萌斯げ牧霞庸膛璧住U庵质质 sweet strangulation pepper shallow S行В whacking the real diaphragm to stop the brine capsule Jia solitary kind of cheek while cheeking (5) Yan vortex constipation. The choice of a procedure that ensures surgical results and avoids the use of artificial materials during surgery to reduce the possibility of infection and maintain rectal compliance has caused many scholars to think.
Subrectal submucosal spot injections of eliminating hemorrhoids provide only partial relief of intussusception. Anal tightening and external anal sphincter folding only serve to “tighten the pocket” and do not resolve pelvic floor sliding hernias or intussusception, so the postoperative efficiency is low.
The main point of high efficiency after rectal mucosal debridement and suture + perianal injection is that the rectal mucosa of the anal canal is excised, and the folded rectal wall after full suture plays the role of strengthening the function of the anal sphincter to restore the normal structure of the pelvic floor and reconstruct the douglas depression. Advantages 1. Direct resection of prolapsed intestinal mucosa solves intussusception, and the folded rectal wall strengthens the function of anal sphincter and solves pelvic floor sliding. The efficacy is precise and the recurrence rate is low.2. The intestinal canal is dragged out of the anus for surgery, and the anatomy is clear and easy to operate.3. Anesthesia does not need to be too deep and is suitable for all types of patients.4. No open transplantation of artificial patches is required, reducing the chance of infection [5] and other complications.
The pharmacological study now shows that the following four effects of eliminating hemorrhoids: (1) can cause a sterile inflammatory reaction, on the basis of chronic inflammation to produce tissue fibrosis, so that the mucosa and submucosa and muscle layer adhesion fixed; (2) to make the ligament tissue outside the relaxed anal canal mucosa to produce fiber adhesion fixed; (3) to promote vasoconstriction to form arteriovenous thrombosis and occlusion of blood vessels function. Combined with the theory of Chinese medicine that “acid is the mainstay of collection” and “color is the mainstay of astringency”, the perianal injection of hemorrhoid elimination can cause sterile inflammation outside the rectal wall, produce tissue fibrosis, form adhesions and fixation of ligaments outside the rectal wall, and further reduce the possibility of pelvic floor slippage and intussusception. .