痔核上方直肠壁组织形态学研究

目的 探讨痔核上方直肠黏膜下组织中是否存在病理改变及其形态特征和临床意义.方法 利用特殊染色和免疫组织化学染色技术(Elivision两步法),对比研究21例Ⅲ～Ⅳ度内痔患者的痔上黏膜环切术标本(包括痔上远和近端)直肠黏膜下组织中平滑肌和Ⅲ型胶原纤维,并以7例(非痔)直肠上段癌患者肛垫上方组织作为对照,观察其形态改变特征.结果 肛垫(痔核)上方直肠黏膜肌层和血管壁平滑肌纤维断裂、松散、走行紊乱,其近端直肠壁平滑肌改变与更远端直肠壁组织以及非痔患者相对正常肛垫上方组织比较具有统计学意义(P<0.05).痔核上方直肠黏膜下组织中Ⅲ型胶原纤维增生,并取代平滑肌纤维.结论 痔的病理改变范围超过了肛垫自身,痔核上方的直肠黏膜下组织中平滑肌松散、断裂及被增生的Ⅲ型胶原纤维增生所取代.     

痔组织弹性纤维退变和血管生成的机制及其意义

目的研究痔组织弹性纤维的病理变化及微血管密度(MVD)和血管生成相关蛋白的表达与痔形成的关系。方法利用免疫组织化学染色技术(SP法),对比研究24例Ⅲ度痔患者的正常肛垫和痔两种组织内弹性纤维和MVD的变化,并检测一氧化氮合酶(NOS)的3种亚型、血管内皮生长因子(VEGF)和金属基质蛋白酶(MMP)2、MMP9在两种组织中表达的差异。结果痔组织存在显著的新生血管形成,痔组织与相对正常肛垫组织间的MVD计数、VEGF、MMP9表达差异存在统计学意义(P<0.05)。痔组织中iNOS明显增高,但与正常肛垫组织比较,不具备统计学意义;痔组织弹性纤维出现断裂、扭曲、变形、玻璃样变等异常,而正常肛垫组织中弹性纤维形态较规则、密集,断裂和变形少见。结论新生血管形成可能是痔的发病机制之一;MMP9对肛垫纤维支持结构的直接降解作用可能是痔形成和加重的一个重要机制;痔组织中iNOS表达增高还提示炎症因素和一氧化氮可能参与了痔的病理过程。     

痔上黏膜及黏膜下组织分点结扎消痔灵注射治疗Ⅱ、Ⅲ期痔临床观察

痔是人类常见的一种疾病，痔的现代概念是肛垫病理性肥大向下移位及肛周皮下血管丛血流淤滞形成的团块。肛垫由血管、平滑肌（Treitz肌）弹力纤维和结缔组织所构成。Treitz肌过度断裂即可导致痔脱垂的产生，根据痔的形成理论，我院2003年4月至2004年2月对Ⅱ、Ⅲ期内痔、混合痔采用痔上黏膜及黏膜下组织分点位结扎，结扎点下注射1：1消痔灵，结果疗效满意，报告如下。     

痔处理方法的选择

痔是常见病、多发病。自“肛垫”这一概念提出以后，痔的处理方法的选择发生了很大变化。肛管齿状线以上有1．5～2．0cm环状紫红色的“肛垫”，其黏膜下富有纤维结缔组织、纤维肌性组织、Treitz肌和动、静脉吻合。这些结构随年龄增长而发生退行性变化，诸如出现断裂、扭曲和疏松结缔组织及弹性纤维减少，尤其是30岁以后渐趋明显，而老年人的这些改变更加明显，常导致“肛垫”下移。如因慢性腹泻、便秘等刺激肛管壁，引起肛门内、外括约肌收缩、痉挛，肛管压力升高，使“肛垫”中的静脉血回流受阻，“肛垫”肥大。     

肛垫悬吊术治疗痔的进展

近10～20年来,通过不断探索,人们对痔有了新的认识。1975年Thomson根据其研究结果首次提出肛垫学说。它是由黏膜下层的血管平滑肌和弹力纤维组成,其功能是协同肛门括约肌保证肛管的正常闭合,精细地辨别气、水及粪便。1994年,Lord等进一步提出内痔发生的肛垫下移学说,即由于固定肛垫的悬韧带Treitz和Park韧带退化、肥厚、损伤或断裂,导致肛垫的脱垂。现代外科学认为肛垫是指直肠下端的唇状肉赘,位于自齿状线上1．5cm的直肠柱区的一环形海绵状组织带,是诱发排便感觉中心。对肛垫的全新认识直接导致痔概念的改变,即内痔是肛垫（肛管血管垫）的支持结构、     

PPH术后并发症的研究进展

Longo1997年提出吻合器痔上黏膜环形切除钉合术(procedure for prolapse and hemorrhoids,PPH)概念.2000年6月,姚礼庆教授完成国内首例PPH手术.基于痔的现代概念:当黏膜下层的血管因调节障碍发生淤血或肛垫的支撑组织Parks韧带和Treitzs肌发生断裂时,肛垫下移,肛垫即为痔.PPH是通过环形切除齿状线上方直肠黏膜,使肛垫上移,阻断痔血供,控制出血症状及使残留部分痔术后萎缩,以达到治愈痔的目的.     

环状痔脱出伴直肠黏膜内脱垂的外科治疗

目的：采用肛垫部分切除加直肠黏膜纵行缝合术治疗环状痔脱出伴直肠黏膜内脱垂。方法：于痔右前、右后、及左侧环状母痔处将松弛的黏膜即肛垫部分切除，同时将在切除肛垫处痔上缘齿线上1cm处纵行缝合直肠黏膜5cm以上，使组织缩短悬吊内脱垂的黏膜及痔，以取代松弛断裂的Trietz肌。结果：本组患者术后痔脱出症状减轻甚至消失，同时直肠黏膜内脱垂引起的便秘症状明显改善。结论：脱垂痔与直肠黏膜内脱垂往往同时存在，处理痔的同时一并处理内脱垂的直肠黏膜引起的便秘症状，合理解决了痔病——便秘——加重痔病这一恶行循环。     

肛垫注射治疗小儿直肠黏膜脱垂32例临床观察

目的:观察小儿直肠黏膜脱垂的病因和肛垫注射治疗的效果.方法:肛用1∶1消痔灵-维生素B1药液对32例直肠黏膜脱垂患儿作3、7、11点黏膜下注射.结果:全部病例均一次注射后治愈,随访1个月至6个月未见复发,亦无其它并发症.结论:小儿直肠黏膜脱垂主要是因为肛垫的支持组织Treitz肌的发育异常、断裂或缺陷、黏膜和肌层结合松散所致,肛垫注射治疗快速有效,无并发症.     

铜离子电化学治疗技术园地有奖征文

铜离子电化学疗法是建立在肛垫学说上的能够保护肛垫的治疗方法 ,其操作简单 ,对患者创伤小 (每次治疗仅 2个针孔 ) ,不会破坏肛垫组织 ,符合现代医学的微创理论。治疗时仅是通过微电流将铜离子导入痔核中 ,改变局部酸碱平衡 ,造成局部酸中毒 ,同时 ,导入组织中的铜离子与相应组织成分结合 ,形成络合物 ,最终血管内膜细胞发生改变 ,形成微血栓 ,并促发以浆细胞及淋巴细胞浸润为主的无菌性炎症 ,进而血管逐渐闭塞 ,组织机化 ,最终形成周围组织纤维化 ,从而消除黏膜下层血管出血性病变并制止痔的脱出。该疗法已经写入由中华医学会外科学分会肛…     

铜离子电化学治疗技术园地有奖征文

铜离子电化学疗法是建立在肛垫学说上的能够保护肛垫的治疗方法 ,其操作简单 ,对患者创伤小 (每次治疗仅 2个针孔 ) ,不会破坏肛垫组织 ,符合现代医学的微创理论。治疗时仅是通过微电流将铜离子导入痔核中 ,改变局部酸碱平衡 ,造成局部酸中毒 ,同时 ,导入组织中的铜离子与相应组织成分结合 ,形成络合物 ,最终血管内膜细胞发生改变 ,形成微血栓 ,并促发以浆细胞及淋巴细胞浸润为主的无菌性炎症 ,进而血管逐渐闭塞 ,组织机化 ,最终形成周围组织纤维化 ,从而消除黏膜下层血管出血性病变并制止痔的脱出。该疗法已经写入由中华医学会外科学分会肛…     

Randomized controlled trial to assess the role of raised anal pressures in the pathogenesis of symptomatic early hemorrhoids

BACKGROUND: Increased maximum resting anal pressures (MRAP) have been found in patients with large prolapsed hemorrhoids undergoing hemorrhoidectomy, but their pathogenic role is controversial especially in view of the sphincteric damage that occurs with open and stapled procedures. This prospective randomized clinical trial was conducted to compare anal pressure changes in early symptomatic hemorrhoidal disease before and after successful treatment with band ligation or injection sclerotherapy, and to compare these pressures with those in normal asymptomatic controls. METHODS: 32 patients with symptomatic grade II hemorrhoids were randomized to treatment with either band ligation or injection sclerotherapy. Anal manometry was done before treatment and 8 weeks after completion of treatment, and compared with 20 normal age-matched controls. RESULTS: The pretreatment values in both study groups were similar to each other (69.38 cm H(2)O, 95% CI 58.67-80.08, vs. 67.75 cm H(2)O, 95% CI 56.86-78.64; p = 0.790), but were significantly higher (p = 0.0001 in both groups) than in the controls (45.25 cm H(2)O, 95% CI 38.36-52.14). After successful completion of treatment, there was a highly significant drop in the MRAP in both study groups (p = 0.0001 in group A, and p = 0.001 in group B) reaching normal values. CONCLUSIONS: Our study shows that even in early-stage hemorrhoids, the anal pressures are significantly raised, but after successful treatment with band ligation or injection sclerotherapy, these pressures return to normal, showing that they do not play a pathogenic role but are secondary to the congested hemorrhoidal cushions.     

Anatomy of the anal canal with attention to the clinical management of symptomatic hemorrhoids

Hemorrhoids are normal anatomic structures that aid in the maintenance of fecal continence. The name hemorrhoid includes structures proximal and distal to the anal canal. These structures can manifest a variety of conditions resulting in pruritus, pain, bleeding, and mucous discharge. The anatomy of the anal canal is reviewed with emphasis on structures and relationships that bear on the clinical management of symptomatic hemorrhoidal disease. A brief history of the knowledge of anal anatomy is presented. The relationship of the vascular cushions, the surrounding structures, and their innervation that allows our current management is reviewed in detail.     

Total circular hemorrhoidectomy

For the surgical treatment of hemorrhoids, the Whitehead-operation is considered bad because it leads to complications like anal stenosis, incontinence and mucous ectropion or prolapsus. Modifications suggested by A. Toupet help to avoid these inconveniencies. But it still requires excellent understanding and training in ano-rectal surgery. The Whitehead-operation, modified by A. Toupet, is indicated in the following cases total hemorrhoidal prolapsus, especially with thrombosis and mucous prolapsus.     

选择性痔上黏膜切除吻合术治疗内痔的临床研究

目的观察和评价选择性痔上黏膜切除吻合术(TST)治疗内痔的临床疗效。方法采用前瞻性、随机、对照的研究方法,将120例Ⅱ～Ⅳ度内痔患者随机分为TST组和PPH组,分别采用TST术和PPH术,比较观察两组患者的手术用时、术中出血量和术后便血、肿物脱出、肛门疼痛、尿潴留、肛门功能、吻合口狭窄等情况,并根据疗效评分标准进行评价。结果两组临床疗效比较,差异无统计学意义(P>0.05),两组手术时间比较,差异无统计学意义(P>0.05),但TST组在术中出血量、术后肛门疼痛、尿潴留、肛门功能、吻合口狭窄等方面明显优于PPH组(P<0.05)。结论 TST对Ⅱ～Ⅳ度内痔患者的治疗效果与PPH相似,且对肛门功能损伤小,术中出血少,术后疼痛轻,并发症少,能显著降低吻合口狭窄发生率。     

吻合器痔上粘膜环切术（PPH）并发症的防治

目的探讨吻合器痔上粘膜环切术（PPH）并发症的原因及防治策略。方法回顾性分析本院自2002年1月至2008年10月PPH治疗的90例重度痔病患者并发症发生情况。结果术后出血6例、尿潴留43例、肛门部疼痛17例、痔粘膜回缩不良2例,术后精细控便障碍1例,并发肛瘘1例;无吻合口感染、肛门狭窄、大便失禁、痔复发、直肠阴道瘘病例。结论PPH术具有疗效好,恢复快、疼痛少的优点,但PPH存在多种并发症。严格掌握手术适应症、加强围手术期处理．可减少并发症的发生。     

微创治疗环状混合痔疗效观察

为探索环状混合痔的做创手术治疗方法，将混合痔96例随机分为治疗组50例，对照组46例，分别采用小切口肛垫固托术与传统外剥内扎术进行临床对比观察。结果显示，手术时间、术中出血量、住院天数、疼痛分级、术后肛缘水肿例数各项指标，治疗组明显优于对照组（P〈0．01）。术后半年随访，两组痊愈、好转、复发率无显著性差异。结果表明，小切口肛垫固托术，内痔微创缝合，使肛垫复位、缩小，缝线及硬化剂的异物致炎刺激使痔组织与黏膜下层、肌层之间发生纤维化增生，瘢痕性粘连固化，闭塞、压迫肛垫内扩张变性的血脉网络，达到消除内痔病理状态的目的。外痔区微小切口减压，消除过多赘生外痔组织，外痔症状得到有效改善，临床疗效明显优于传统手术。     

Haemorrhoids are associated not with hypertrophy of the internal anal sphincter, but with hypertension of the anal cushions.

A combined manometric and ultrasonographic study of the internal anal sphincter was carried out in 20 patients with haemorrhoids and 20 age-matched normal controls. Mean(s.e.m.) basal anal pressure was significantly higher in patients than in controls, 62(4) versus 45(6) cmH2O (P less than 0.05), although there were no significant differences in mean maximum basal and squeeze pressures. During rectal distension 90 per cent of patients showed no reduction in anal pressure in the outermost anal channel, although the internal sphincter electromyogram was suppressed and the external sphincter electromyogram did not necessarily increase above baseline. The mean(s.e.m.) maximum residual pressure was significantly higher in patients, 70(6) versus 45(6) cmH2O (P less than 0.05). Direct pressure measurement in anal cushions exhibited abnormally high median pressure in patients compared with controls, 35 versus 10 cmH2O (P less than 0.001). Pressures recorded during coughing and straining were also significantly higher in patients than in controls (P less than 0.001). Ultrasonographic study of the anal canal revealed a clear image of the internal sphincter, the thickness of which could easily be measured. The mean(s.e.m.) thickness of the sphincter was not significantly different, 2.3(0.2) versus 2.1(0.1) mm, between patients with haemorrhoids and controls (P = 0.18). The absence of any significant differences in the internal sphincter thickness between normal subjects and patients with haemorrhoids suggests that the high anal pressure in patients with haemorrhoids is of vascular origin.     

超声多普勒引导下痔动脉结扎加内痔悬吊术治疗Ⅱ、Ⅲ期环状内痔的临床观察

为观察超声多普勒引导下痔动脉结扎加内痔悬吊术治疗Ⅱ、Ⅲ期环状内痔的疗效,对32例Ⅱ、Ⅲ期环状内痔脱垂伴出血的患者行超声多普勒引导下痔动脉结扎加内痔悬吊术,并进行临床观察。结果显示,本组32例患者术后随访1～5个月,患者痔脱垂和出血症状均消失,且术后无直肠血肿、创口出血及创口感染,无肛门、直肠狭窄,也无术后痔复发病例。结果表明,超声多普勒引导下痔动脉结扎加内痔悬吊术不失为治疗轻度环状内痔的一种好方法,具有微创、微痛及与PPH相比治疗成本低的优点。