Objective.
To explore the value of clinical application of anastomotic suprahemorrhoidal mucosal loop hemorrhoidectomy (PPH) for the treatment of severe cricoid prolapsed internal hemorrhoids in order to promote its application in our city, fill the gap in our city and benefit patients. Methods: 100 patients with severe cricoid prolapsed internal hemorrhoids were selected for PPH surgical treatment, and the surgical results and complications were analyzed.
Results.
One hundred cases of severe cricoid prolapsed internal hemorrhoids were treated with PPH surgery, and the operation time ranged from 15 to 40 minutes, with an average of 23 minutes. Postoperative complications: 11 cases of postoperative pain, 1 case (1%) required pharmacological analgesia; 1 case (1%) of postoperative urinary retention; 1 case (1%) of postoperative hemorrhage; 3 cases (3%) of postoperative skin bridge edema and skin flap formation; 1 case (1%) of anastomotic stenosis; postoperative hospitalization time: 3-9 days, average 4.1 days. There were no recurrence cases from 3 months to 1 year of follow-up, all patients had no blood in the stool, and one patient with intractable constipation had anastomotic stenosis 1 month after surgery; 3 cases had skin flab formation.
Conclusion.
PPH surgery is safe and effective in treating severe cricoid prolapsed internal hemorrhoids, with little postoperative pain, few complications, and short time to resume daily work, combined with a large number of domestic reports of good long-term results and low recurrence rate, and can be the method of choice for the treatment of severe cricoid prolapsed internal hemorrhoids.
The incidence of hemorrhoids is high and there are “nine hemorrhoids in ten people”, especially severe cricoid prolapsed internal hemorrhoids, which seriously affects people’s normal life and brings inconvenience to people. The concept of hemorrhoids has changed with the deepening of anatomy, from varicose veins to anal cushion theory, and with the action of various etiologies, the normal anal cushion becomes congested, hypertrophied and shifts downward, forming hemorrhoids.
In 1998, Longo reported that the treatment of severe cricoid prolapsed internal hemorrhoids with a specially designed anastomosis is simple, less bleeding, effective, low postoperative recurrence rate and complications, and early return to normal life. The procedure was soon accepted by domestic and foreign anorectal surgeons and became the first choice for the treatment of severe circumferential prolapsed internal hemorrhoids.
The procedure is based on the new understanding that the inferior displacement of the anal cushion is the main reason for the formation of prolapsed internal hemorrhoids. By circumferentially removing the rectal mucosa and submucosal tissues above the internal hemorrhoids, on the one hand, the prolapsed anal cushion can be lifted upward, and on the other hand, because the hemorrhoid feeding artery located in the submucosa is cut off at the same time, the blood supply to the hemorrhoid is reduced and the hemorrhoid nucleus becomes smaller, so that the prolapsed internal hemorrhoids can be treated radically without removing the anal cushion.
1.Data and method
1.1 Clinical data The group of 100 cases, 46 men and 54 women; age 31-72 years old, average 46 years old; disease duration 2-30 years. There were 41 cases of hemorrhoid prolapse and 59 cases of hemorrhoid prolapse with blood in the stool. 6 patients were admitted to the hospital due to embedded hemorrhoid prolapse, 9 patients had received local sclerotherapy, and 13 patients had been treated with traditional external peel and ligation.
1.2 Treatment method Perfect preoperative preparation, epidural anesthesia, patient in bladder amputation position, routine disinfection and sterile towel, dilation to accommodate 3 fingers, use 3 non-invasive vascular forceps to clamp the anal edge, put in a transparent annular anal canal dilator (CAD33) and suture fixed, remove the internal peg, place the anal suture ligature (PAS33), about 3.5 cm on the dentate line with a No. 7 silk thread for submucosal load Suture the submucosa at about 3.5 cm on the dentate line with a No. 7 silk suture (for severe prolapse, another suture can be made above this suture at about 0.5-1.0 cm);
Remove the PAS33, open the hemorrhoidal anastomosis (HCS33) to its fullest extent, insert its head end through the CAD33 to the upper end of the purse-string suture, tighten the suture and tie it. The sutures are pulled out separately through the holes on both sides of the CAD33 with the accompanying strapwork, and the ligature is tugged appropriately to bring the prolapsed mucosa into the PSA33 trocar, and the PSA33 is tightened and struck (the vaginal wall must be inspected before striking in female patients) to complete the resection and anastomosis of the mucosa of the lower rectum. After the anastomosis is fired, it is kept closed for approximately 30 seconds to prevent bleeding.
Release the anastomosis, gently withdraw it, inspect the anastomosis, and stop the bleeding by adding sutures locally to the bleeding area. Remove the CAD33, place the PSA33 again, rotate and inspect the anal verge, and if there are residual external hemorrhoids, make a V-shaped excision. If individual internal hemorrhoids are severely prolapsed, additional ligation is done. After surgery, 2 hemorrhoid plugs were incorporated into the anus and the wound was bandaged. Intravenous rehydration on the day of surgery and antibiotics to prevent infection for 3 days; semi-liquid diet on the first postoperative day; 30ml of liquid paraffin by mouth to lubricate the stool was started on the second postoperative day via a general diet that night.
On the second postoperative day, we started to take a sitz bath with 1:5000 PP solution once or twice a day. On the third postoperative day, the stool is smooth and there is no discomfort such as pain or blood in the stool, and the patient can be discharged from the hospital. If any complications appeared, discharge after cure.
2.Results
The operative time ranged from 15 to 40 minutes, with an average of 23 minutes. Intraoperative bleeding was 0-150 ml, averaging 12 ml. 98 anastomoses in 100 patients were successful in one case, 2 cases had incomplete anastomoses and some anastomoses were split, which were closed with additional interrupted silk sutures. The excised intestinal wall tissues were circular, and the postoperative pathology showed mainly rectal mucosa and submucosal layer tissues, all of which were visible as part of the muscle layer tissues.
Postoperative complications: 11 cases of postoperative pain, 1 case (1%) required pharmacological analgesia; 1 case (1%) of postoperative urinary retention; 1 case (1%) of postoperative hemorrhage, which was healed by reoperation; 2 cases (2%) of postoperative blood in the stool, which was healed by symptomatic treatment; 3 cases (3%) of postoperative skin bridge edema and skin redundancy; 1 case (1%) of anastomotic stenosis; postoperative hospitalization time: 3-9 days, average 4.1 days. There was no recurrence from 3 months to 1 year of follow-up, and all patients had no blood in the stool. One patient with persistent constipation had anastomotic stenosis 1 month after surgery, which was cured by dilatation of anastomotic stenosis; 3 cases with superfluous skin formation were not treated.
3. Discussion
PPH is a treatment method that conforms to the nature of hemorrhoids, and uses circular excision and stapling of the lower rectal mucosa and submucosal tissue to treat prolapsed hemorrhoids in the anal canal and perianal area where sensory nerves are abundant. No incision is left, which reduces postoperative pain and shortens the course of treatment.
Main advantages of surgery.
(1) Cure and significant improvement of preoperative symptoms;
(2)The average time of surgery is short, 15-40 minutes, average 23 minutes;
(3) Short hospital stay, usually 3-5 days;
(4) Very little postoperative abdominal discomfort;
(5) Few serious postoperative complications;
(6) Quick recovery after surgery;
(7) No anal stricture;
(8) No recurrence.
Pain in the anal region is a common complication after PPH, mainly related to suture or clamp fixation of anal dilator in the perianal skin, and intraoperative anal dilation is also one of the causes of anal pain. There were only 11 cases among 100 patients in our group, and only 1 case required analgesic for anal pain after surgery.
Anal edge edema can also cause postoperative pain and residual connective tissue external hemorrhoids, mostly occurring on the second postoperative day, throughout the anal edge or half or at a local point, due to postoperative local circulation changes, venous and lymphatic reflux obstruction. It can be cured by symptomatic treatment.
Anastomotic stenosis occurs 1 month to 6 months after surgery, and the cause is not clear. It can be cured by regular anal dilation.
Intraoperative and postoperative bleeding is the most common and serious complication of PPH, which needs to be given sufficient attention. In our group of 100 patients, there were 32 cases of intraoperative anastomotic bleeding, 2 cases were caused by incomplete anastomosis and fracture of the anastomosis with large bleeding volume, about 100ml and 150ml respectively, which were cured by hemostasis and silk suture; 30 cases had less intraoperative bleeding volume, about 5~60ml, which were all in the hemorrhoidal vascular site. The reason for this was that the anastomotic nail was not in place, probably due to the quality of the instrument and/or the thicker local tissues resulting in incomplete nail closure; the remaining 68 cases had no or only a small amount of bleeding, with bleeding volume of about 0-5 ml.
One case of postoperative hemorrhage was the same patient as the one of urinary retention, an elderly male patient with severe intraoperative prolapse of the hemorrhoid nucleus at 11 points of the bladder truncation position, plus internal hemorrhoid ligation, and postoperative urinary retention resulting in struggle, causing the hemostatic ligature to fall off and induce hemorrhage, which was healed by emergency surgery. Two cases of postoperative hemorrhage in the stool occurred at 1 week after surgery, which was caused by intraoperative anastomotic hemorrhage that was stopped by suture ligation and hemorrhage from the ulcer formed at the suture ligation at 1 week, which was cured by symptomatic treatment with medication.
To prevent intraoperative and postoperative bleeding.
(1) Use a reliable quality anastomosis;
(2) The anastomosis should be positioned a certain distance away from the dentate line, the closer it is to the dentate line the greater the risk of bleeding;
(3) The purse-string suture should not be too deep to avoid pulling too much tissue to cause incomplete anastomosis;
(4) Intraoperative sutures to stop bleeding should not close too much tissue to avoid postoperative infection and ulcer bleeding;
(5) Prevent urinary retention after surgery, especially for elderly male patients, most of whom are combined with prostate hypertrophy and are prone to urinary retention, which should be actively prevented;
(6) Prevent constipation and keep the bowels unobstructed.
The principle of PPH treatment for hemorrhoids is to circumferentially remove the mucosa and submucosa of the rectum above the dentate line, so that the downwardly displaced anal cushion is suspended upward and its normal anatomical position is restored. PPH has many advantages: firstly, the operation is simple and the operation time is short. Secondly, the integrity of the anal cushion tissue is preserved, the fine control function is not affected after the operation, the postoperative pain is light, and there is no fecal incontinence, anal stenosis or perianal abscess formation.
Thirdly, the preoperative preparation is simple and no special care is needed after surgery. After performing PPH alone on cricoid mixed hemorrhoids, some patients still have obvious incomplete retraction of external hemorrhoids, re-prolapse of hemorrhoid nucleus, and with anal edge edema and formation of external hemorrhoid thrombus. The PPH alone can reduce the satisfaction of patients with stage III and IV mixed hemorrhoids and internal hemorrhoids with connective tissue external hemorrhoids, which have obvious external hemorrhoid skin tags, and often have residual external hemorrhoids after surgery.
Some people worry that adding external hemorrhoidectomy to PPH will aggravate postoperative pain and make PPH lose its advantages, so they do not advocate PPH but insist on using traditional external peeling and internal ligation, which artificially limits the development of PPH.
In recent years, in addition to PPH treatment for patients with severe annular prolapsed internal hemorrhoids, our department has also adopted PPH plus external hemorrhoidectomy for patients with mixed internal hemorrhoids stage III and IV with connective tissue external hemorrhoids. Although individual incisions are added, the trauma is not large and the recovery is still fast, and there is no significant increase in postoperative pain and the anal appearance is flat, which improves the satisfaction of most patients and also makes the indications for PPH treatment disease expanded.