An approach to haemorrhoids

OBJECTIVE: Many patients with haemorrhoids are investigated because of the fear of missing colorectal cancer (CRC). The aim of this study was to determine whether a primarily clinical approach regarding the need for investigation was safe and did not miss patients with CRC. PATIENTS AND METHODS: Data was collected prospectively on 589 consecutive patients with the principle diagnosis of haemorrhoids at first clinic visit. All had clinical assessment including rigid sigmoidoscopy and were treated by phenol injection or banding. They were categorized for (1) no review unless symptoms persisted -'One Stop SOS' (2) outpatient review or (3) investigation. To check for the development of CRC they were contacted by postal questionnaire or telephone interview with a minimum of one year from diagnosis and treatment. All 589 patients were cross-referenced with the Pathology database and the Hospital Information Services System. RESULTS: Four hundred and sixty-nine (80%) answered the questionnaire; 352 patients (60% of the total group) fell in the 'one stop SOS' outpatient category; 95 (16%) patients were followed up to review response to treatment for large haemorrhoids; 105 (18%) were investigated with barium enema (12%), flexible sigmoidoscopy (4%), colonoscopy (1%) and miscellaneous (1%); 37 (6%) patients were either given a haemorrhoidectomy date or referred on with a different diagnosis. No patients selected for 'one-stop' treatment developed CRC. Five (0.8%) patients were diagnosed with CRC after appropriate investigation was instituted for suspicious symptoms. One patient with distal transverse colon cancer had a delayed diagnosis as she was investigated initially by flexible sigmoidoscopy. CONCLUSION: Most patients with the primary diagnosis of symptomatic haemorrhoids do not need investigation.     

Patient satisfaction and symptom relief after anal dilatation

Anal dilatation is used as a simple method of treatment and has been used for both anal fissure and haemorrhoids. This study examined longer-term results among a cohort of 162 patients, 132 of whom responded to a detailed questionnaire, an 82% response (66 patients were male; age range 17–75 years, median 42 years). Follow-up ranged from 16 months to 36 months (median 27 months) after anal dilatation (68 patients for fissure, 32 for haemorrhoids, and 32 for both). In the early months after dilatation, 83% had symptomatic improvement and 76% remained improved. Five (7%) patients with fissure and 11 with haemorrhoids (17%) required further hospital treatment, while 10% and 17%, respectively, had received further treatment from their general practitioners (GPs). Seventy-one percent said they would have a further anal dilation if symptoms recurred. There was no difference in results obtained by surgeons of different seniority. Complications – bleeding (29%) and difficulty controlling flatus (15%) or faeces (8%) – resolved in all cases. The results of anal dilatation for fissure are generally satisfactory in the longer term, with a trend toward better symptom relief in patients with fissure compared with those with haemorrhoids. We do not recommend anal dilatation as the sole treatment of patients with haemorrhoids, but it may be a useful adjunct to other treatments such as banding or sclerotherapy. Morbidity was generally acceptable and the majority of our patients would be prepared to have this procedure again if their symptoms were to return. Accepted: 14 September 1998     

Continence disorders after anal surgery—a relevant problem?

Subject  Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure. Methods  The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula. Results  Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0–50%, lateral sphincterotomy 0–45%, haemorrhoidal surgery 0–28%, lay open technique of anal fistula 0–64% and plastic repair of fistula 0–43%. Results vary considerably depending on what definition of “incontinence” was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum. Conclusions  Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.     

Surgical treatment of haemorrhoids with the use of the circular stapler and open haemorrhoidectomy. A comparative study

The surgical treatment of haemorrhoids with the use of a circular stapler is a novel method. A comparative retrospective study of two groups of patients treated surgically for third- and fourth-degree haemorrhoids was conducted. Fifty patients (group A) underwent a surgical intervention with the circular stapler in the rectal mucosa 4 cm above the dentate line. In another group of 50 patients (group B), the standard open haemorrhoidectomy (Milligan-Morgan) was carried out. The new method (group A) compared with the standard haemorrhoidectomy (group B) was found to be less time consuming (mean time, 10±2 minutes vs. 35±5 minutes, p<0.001). The majority of patients (28) in group A experienced mild pain (VAS, 3–5) while pain for the majority of patients in group B was 5–7 on the VAS scale (p<0.01). The duration of postoperative hospitalisation was 1±1 days for the patients of group A and 5±2 days for the patients of group B (p<0.05). The early postoperative bleeding rate was 6% in group A and 12% in group B (p<0.01). None of the patients of group A developed incontinence and 6 (12%) patients in group B developed mild liquid incontinence during the first postoperative month. During the period of follow-up (12 months to 3 years, median length 18 months in outpatient visits), no patient in either group developed recurrence of haemorrhoids or rectal prolapse. In conclusion, the surgical treatment of haemorrhoids with the circular stapler seems to be an efficient alternative to the standard open haemorrhoidectomy when this is indicated. Received: 28 April 2000 / Accepted in revised form: 18 October 2000     

超选择性直肠上动脉栓塞术在直肠出血中的应用

背景与目的 内痔是引起直肠出血的常见原因,当出血严重影响患者生活质量或危及生命时,由于存在手术禁忌无法进行外科手术或患者不愿接受外科手术,通过导管超选择性直肠上动脉（SRA）造影可快速、准确地定位出血部位,并可同期予以栓塞,实现快速止血目的。相比于传统的外科手术止血,血管腔内介入止血具有微创、并发症少、术后恢复快等特点,但国内对于超选择SRA栓塞术在内痔导致的直肠出血中的临床应用报道较少,其止血效果及安全性还存在争论。本研究旨在评价超选择性SRA栓塞术治疗内痔为原因的直肠出血的安全性及有效性,并就该方法相关的技术要点及注意事项做一探讨,以期为临床提供参考。方法 回顾性分析滨州医学院附属医院2016年12月—2021年10月接受超选择性SRA栓塞治疗的直肠出血患者的临床资料,观察SRA栓塞术后3~7 d（初期止血率）及术后1~12个月的止血效果（临床成功率）、术后并发症。结果 共50例成功实施超选择性SRA栓塞治疗的直肠出血患者,按照纳入和排除标准,共有29例内痔出血患者进入最终研究,其中Ⅱ度内痔11例,Ⅲ度内痔18例;男17例,女12例;平均年龄（51.8±12.2）岁。所有患者介入术中均使用金属弹簧圈（直径2~3 mm）联合明胶海绵颗粒（直径350~560 μm）或PVA颗粒（直径300~500 μm）行栓塞治疗,技术成功率100%。27例患者术后3~7 d出血症状消失,初期止血率为82.8%（24/29）,术后1个月临床成功率为86.2%（25/29）。3例患者在随访6个月时便血复发,术后6个月临床成功率为75.9%（22/29）,其中2例行髂内动脉分支栓塞后症状消失,1例选择保守治疗。所有患者得到随访,随访时间（10.7±2.5）个月,1例患者因术后里急后重感明显,术后1周行肠镜检查可见直肠小片状浅表黏膜溃疡,予以保守治疗;2例患者出现穿刺部位血肿,保守治疗后血肿消失,其余患者无介入栓塞相关的感染、肠穿孔、大出血等严重并发症发生。结论 超选择性SRA栓塞在治疗以Ⅱ~Ⅲ度内痔为原因的直肠出血中是一种相对安全、低风险的手术方法,短期止血效果肯定,具有较好的临床应用价值,值得推荐使用。     

吻合器痔上黏膜钉合术与传统痔手术的护理对照研究

目的探讨吻合器痔上黏膜钉合术(PPH术)与传统痔手术治疗重度痔疮的护理方法,以提高护理工作效率和质量。方法对PPH术(PPH组)和传统痔切除术(对照组)的心理护理、术前指导、术中配合、术后护理、手术时间、术后疼痛、平均住院天数和恢复工作时间等方面作统计学处理和对照研究。结果 PPH组患者手术时间为9．5±0．8 min,对照组为41±1．5 min,差别有统计学意义(P<0．05)。PPH组患者住院天数2．3±1．2 d,对照组 11．8±2．6 d,两组比较有统计学差异(P<0．05)。结论 PPH术治疗重度痔疮与传统方法相比,具有创伤小、恢复快、住院时间短、恢复工作早、无复发等优点,提高了护理工作效率,是保证护理质量的关键。     

Carotid Endarterectomy for the Symptomatic Patient: Thinking Beyond “Stenosis > 70%”

Purpose: To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM).

Methods: In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months.

Results: Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P < 0.0001). Healing time was shorter after PPH (P < 0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P < 0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM.

Conclusions: Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haem-orrhoidal disease, needing further surgery.     

快速康复外科护理新路径在痔疮患者围手术期的应用研究

目的：探讨快速康复外科护理新路径在痔疮患者围手术期的应用。方法：将2013年－2014年我科室收治的200例痔疮手术患者随机分为观察组与对照组,每组各100例患者,对观察组痔疮患者采用快速康复护理新路径进行护理,对照组采用传统常规护理方案进行护理,对两组护理方式的康复结果进行对比。结果：两组患者在愈合时间、首次排便时间、健康教育知晓率、患者满意度、术后并发症发生率等方面的差异具有统计学意义（ P ＜0．05）。结论：快速康复外科护理新路径在痔疮患者围手术期的应用可缩短伤口愈合时间、减少术后并发症,有利于患者康复,具有良好的社会效益。