结扎速血管闭合系统在痔切除术中的应用

为探讨结扎速血管闭合系统（Ligasure）在痔切除术中的使用方法,并与传统手术（Milligan—Morgan术）对比进行疗效分析。将58例Ⅲ、Ⅳ期混合痔患者随机分成两组,观察组29例患者在骶麻下用Ligasure实施痔切除术,对照组29例采用传统手术（MilliganMorgan术）,观察两组手术时间、术后恢复时间、术后疼痛和并发症情况。结果显示,两组手术时间、术后恢复时间、术后使用止痛药次数、肛门狭窄及肛门失禁例数均有显著性差异（P〈0．05）。结果表明,Ligasure用于痔切除术具有疗效可靠,手术时间短,患者术后疼痛轻,并发症少等优点。     

Radiofrequency ablation and plication--a new technique for prolapsing hemorrhoidal disease

BACKGROUND: The author describes a modified procedure of ablation with a radiofrequency device and plication of the hemorrhoidal mass for prolapsing hemorrhoids. The study is aimed at ascertaining if this procedure provides any advantages over the conventional hemorrhoid surgery. MATERIALS AND METHODS: Two different studies are included. The first study describes 600 serial patients with prolapsing hemorrhoids treated with this technique over a period of 18 months. An Ellman radiofrequency generator was used for the ablation of the hemorrhoids. The operative technique and postoperative outcome is reported. The second study compares this technique with standard Milligan-Morgan hemorrhoidectomy in a randomized trial of 100 patients. RESULTS: With this new procedure, the post-defecation pain and pain at rest were within tolerable limits (pain scores 1 to 4 on visual analog scale). Post-defecation bleeding was present in 60% of the patients. Pruritus and perianal thrombosis were complained by few others. No patient encountered any incontinence, prolapse, or stenosis. The comparative study showed definite advantages of this modified technique over Milligan-Morgan hemorrhoidectomy. CONCLUSION: The procedure of radiofrequency ablation and plication of hemorrhoids restricts the hospital stay to only a few hours and provides rapid physical recovery. It does seem to be a better alternative to the conventional surgical procedures in terms of postoperative pain, return to work, and complications.     

PPH术与传统外剥内扎术治疗痔的临床疗效对比

【摘要】 目的 探讨吻合器痔上粘膜环形切除术(PPH)和传统外剥内扎术(Milligan-Morgan术,MM)在治疗痔疮的效果。方法 回顾性分析我科从2009年1月到2012年6月期间的152例痔疮病人的临床资料,其中82例行PPH手术(PPH组),70例行MM术(MM组)。比较两组的疗效及手术时间、术后住院时间、住院费用、术中出血、术后并发症的差别。 结果 两组患者术后原有症状均得到了有效控制。PPH手术较MM术手术时间、术后住院时间明显缩短,术中术后出血发生率明显减低,但住院费用较高,以上差异均有统计学意义。治愈率、术后尿潴留及术后肛门坠胀感两组相比无显著性差异。结论 与外剥内扎术相比,PPH术具有疗效较好、创伤小,术后恢复快。     

Milligam-Morgan hemorrhoidectomy and stapled mucoprolapsectomy. Clinical comparison of the results

The aim of this retrospective study was to assess the results of treatment for hemorrhoids by Milligan-Morgan hemorrhoidectomy and by stapled mucoprolapsectomy in terms of operative time, postoperative pain, lenght of hospital stay, incidence of early and late complications, time to return to work and to normal social activities and patient satisfaction. Between January 2002 and December 2003, a total of 65 patients with hemorrhoids (35 men and 30 women with a mean age of 46.9 years) underwent surgical treatment: 41 patients underwent conventional hemorrhoidectomy and 24 patients stapled mucoprolapsectomy. All patients were contacted by phone or were reviewed in the outpatient clinic with a mean follow-up of 2 months (range 8-31). The Authors emphasize that it is difficult to make an objective comparison between hemorrhoidectomy and stapled mucoprolapsectomy because the two procedures are completely different in terms of rationale and technique; however, stapled circumferential mucosectomy in their experience causes less postoperative pain and bleeding and can be considered a valid therapeutic option for third- and fourth-degree disease.     

Randomized controlled trial of bipolar diathermy vs ultrasonic scalpel for closed hemorrhoidectomy

AIM:To compare hemorrhoidectomy with a bipolar electrothermal device or hemorrhoidectomy using an ultrasonically activated scalpel.METHODS:Sixty patients with grade Ⅲ or Ⅳ hemorrhoids were prospectively randomized to undergo closed hemorrhoidectomy assisted by bipolar diathermy(group 1) or hemorrhoidectomy with the ultrasonic scalpel(group 2).Operative data were recorded,and patients were followed at 1,3,and 6 wk to evaluate complications.Independent assessors were assigned to obtain postoperative pain scores,oral analgesic requirement and satisfaction scores.RESULTS:Reduced intraoperative blood loss median 0.9 mL(95% CI:0.8-3.7) vs 4.6 mL(95% CI:3.8-7.0),P = 0.001 and a short operating time median 16(95% CI:14.6-18.2) min vs 31(95% CI:28.1-35.3) min,P < 0.0001 was observed in group 1 compared with group 2.There was a trend towards lower postoperative pain scores on day 1 group 1 median 2(95% CI:1.8-3.5) vs group 2 median 3(95% CI:2.6-4.2),P = 0.135.Reduced oral analgesic requirement during postoperative 24 h after operation median 1(95% CI:0.4-0.9) tablet vs 1(95% CI:0.9-1.3) tablet,P = 0.006 was observed in group 1 compared with group 2.There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.CONCLUSION:Bipolar diathermy hemorrhoidectomy is quick and bloodless and,although as painful as closed hemorrhoidectomy with the ultrasonic scalpel,is associated with a reduced analgesic requirement immediately after operation.     

Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy

BACKGROUND: The new technique of circular stapler for the treatment of hemorrhoids has shown early promise in terms of minimal or no postoperative pain, early discharge from hospital, and quick return to work. This study was designed to compare stapled technique with the well-accepted conventional Milligan Morgan hemorrhoidectomy. METHODS: After fulfilling the selection criteria, 84 patients were randomly allocated to the stapled (n = 42) or open group (n = 42). All patients were operated on under spinal anesthesia. The 2 techniques were evaluated with respect to the operative time, pain scores, complications, day of discharge, return to work, and level of satisfaction. RESULTS: The mean age of patients was 46.02 years (SD, 12.33) in the stapled group and 48.64 years (14.57) in the open group. Grade III or IV hemorrhoids were more common in men (ie, 80.9% and 85.7% in the stapled and open group, respectively). The mean operative time was shorter in the stapled group 24.28 minutes (4.25) versus 45.21 minutes (5.36) in the Milligan-Morgan group (P < .001). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group. Mean hospital stay was 1.24 days (0.62) and 2.76 days (1.01) (P < .001) in the stapled and open group, respectively. The patients in the stapled group returned to work or routine activities earlier (ie, within 8.12 days [2.48]) as compared with 17.62 (5.59) in the open group. Only 88.1% of patients were satisfied by the open method compared with 97.6% after the stapled technique. The median follow-up period was 11 months with a maximum follow-up of 19 months (range 2-19 months). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective day-care procedure for the treatment of grade III and grade IV hemorrhoids. It ensures lesser postoperative pain, early discharge, less time off work, complications similar to the open technique, and in the end a more satisfied patient with no perianal wound. However, more such randomized trials are essential to deny any long-term complication.     

Major complications in thyroid surgery: utility of bipolar vessel sealing (Ligasure Precise)

In the present study the Authors tried and assess the advantages of the standard sutureless thyroidectomy performed by the Ligasure Vessel Sealing System, thanks to the use of the dedicated Precise handle. The Authors compared the efficacy of haemostasis and the economical impact of the device, in terms of drug administration and costs. The Authors comparatively analyzed 120 total extracapsular thyroidectomies (TET) performed by the standard operative technique (Group A, control) and 70 TET achieved by the "sutureless technique" (Group B, case). There was a statistically significant decrease of transient postoperative hypocalcemia (5.71% vs 7.5%) and also of mean operative time (about 20 minutes) in patients of the group B. Non significant decrease of other kind of complications (postoperative hemorrhage, transient and permanent inferior laryngeal palsy, stupor of the superior laryngeal nerve, seromas) were also observed. The use of the Ligasure Precise resulted easy, safe and efficient in the Authors' experience. It allowed the decrease of postoperative haemorrhages and mean operative time.     

吻合器痔上黏膜环切钉合术加外痔切除术治疗混合痔的疗效分析

目的研究吻合器痔上黏膜环切钉合术（PPH）加外痔切除术治疗Ⅲ、Ⅳ度混合痔的临床疗效。方法将112例混合痔患者随机分成PPH1组34例、PPH2组36例、剥扎组42例，PPH1组采用单纯PPH术，PPH2组采用PPH加外痔切除术，剥扎组采用外剥内扎术治疗。观察和比较3组患者术后24h疼痛程度及术后排便疼痛指数、出血、伤口水肿、尿潴留、肛门坠胀、肛门控便能力、手术时间、住院时间和费用等指标；肛肠测压仪检测手术前后3组患者肛管动力学变化指标；随访0．5。1年并记录痔复发或发生血栓外痔情况。结果PPHl组术后24h疼痛指数低于另外2组（P〈0．05）：3组患者在出血、肛门坠胀、肛门控便能力方面差异无统计学意义（P〉0．05）。在术后排便疼痛、伤口水肿、手术时间、住院时间方面，PPHl组和PPH2组优于剥扎组（P〈0．05）：在术后尿潴留、费用方面剥扎组处于优势（P〈0．05）。手术前后剥扎组肛管静息压变化值小于另外2组（P〈0．05），手术前后3组患者直肠感觉阈和直肠耐受量变化值差异无统计学意义（P〉0．05）。随访半年至1年，PPH1组无复发患者，有3例发生血栓外痔；PPH2组无复发患者；剥扎组复发2例，发生血栓外痔1例。结论PPH加外痔切除术是治疗混合痔的安全有效术式，适合外痔严重的混合痔。     

Stapled and Open Hemorrhoidectomy: Randomized Controlled Trial of Early Results

Abstract The aim of the study was to compare the early results in 52 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Seventy-four patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (37 patients) or open (37 patients) hemorrhoidectomy. Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique. Postoperative pain was assessed by means of a visual analogue scale (V.A.S.). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and a 17.5 (10 to 27)-month median telephone follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (median 25 [range 15 to 49] minutes versus 30 [range 20 to 44] minutes, p = 0.041). Median (range) V.A.S. scores in the stapled group were significantly lower (V.A.S. score after 4 hours: 4 [2 to 6] versus 5 [2 to 8], p = 0.001; V.A.S. score after 24 hours: 3 [1 to 6] versus 5 [3 to 7], p = 0.000; V.A.S. score after first defecation: 5 [3 to 8] versus 7 [3 to 9], p = 0.000). Resumption of pain-free defecation was significantly faster in the stapled group (10 [6 to 14] days vs 12 [9 to 19] days, p = 0.001). At follow-up 4 weeks and 6 months postoperatively the median (range) symptom severity score was similar in both groups (1 [0 to 2] versus 0 [0 to 3], p = 0.150 and 0 [0 to 2] versus 0 [0 to 2], p = 0.731). At long-term follow-up occasional pain was present in 6/37 (16.2) patients in the stapled group and 7/37 (18.9%) in the Milligan-Morgan group (p = 1.000); episodes of bleeding were reported by 8/37 (21.6%) patients in the stapled group and 5/37 (13.5%) patients in the Milligan-Morgan group (p = 0.542). No problems related to continence and defecation were reported in either group. Patients were satisfied with the operation in 33/37 (89.2%) cases in the stapled group and 31/37 (83.8%) cases in the Milligan-Morgan group (p = 0.735). Hemorrhoidectomy with a circular staple device is easy to perform and achieves better results than the Milligan-Morgan technique in terms of postoperative pain and recovery. Comparable results are obtained at long-term follow-up.     

Plantago ovata (Laxomucil) after hemorrhoidectomy

The aim of this prospective randomized study is to describe the effects of laxative plantago ovata after open hemorrhoidectomy (Milligan-Morgan). Sixty patients divided into 2 equal groups were included in this study. The first group was treated postoperatively with 2 sachets of bulk agent Laxomucil (3.26 g plantago ovata), twice daily, for a period of twenty days, while the control group was treated with glycerin oil. The p.ovata group patients had a statistically significant shorter postoperative length of hospital stay (2.9 v.s. 4.1 days). Pain after stool was statistically significant more tolerable in the p.ovata group. In conclusion, the application of bulk agent plantago ovata after hemorrhoidectomy shortens the mean postoperative hospital stay, expedites digestive function recovery and lessens the pain after stool.