吻合器痔上黏膜环切术荷包缝合的体会

Experience in the Operation Details to Reduce the Complications of PPH

目的探讨吻合器痔上黏膜环切术（procedure for prolapse and hemorrhoids,PPH）操作中距齿状线荷包缝合高度的个性化选择以及荷包缝合深度以减少手术并发症。方法回顾性分析2007年10月-2015年8月在我科行PPH术的356例患者临床资料,Ⅱ期内痔56例,Ⅲ、Ⅳ期内痔以及混合痔300例。选择荷包缝合的高度及深度,观察吻合口出血及术后并发症的发生情况。结果Ⅱ期内痔56例患者中：荷包距齿状线2.5-4 cm的16例,术后疼痛者4例（25%）;荷包距齿状线4-6 cm的40例患者,术后均无疼痛发生。所有病人术后一月随访无悬吊不佳情况。Ⅲ、Ⅳ期内痔以及混合痔的300例患者中：荷包距齿状线2.5-4 cm的238例,术后疼痛者18例（7.6%）,术后悬吊不佳者6例（2.5%）;荷包距齿状线4-6 cm的62例,术后无疼痛发生,术后悬吊不佳者22例（35.5%）。356例患者术中发现吻合口有活动性出血30例（8.4%）,其中有20例切除的粘膜环不完整,予以跨吻合口＂8＂字缝合后好转。早期术后吻合口狭窄者4例（1.1%）,术中检查切除的粘膜环均带肌纤维。结论 PPH术中Ⅱ期出血为主的内痔应选择荷包高度距齿状线上4-6 cm以减少术后疼痛;以肿物脱出为主的Ⅲ、Ⅳ期内痔以及混合痔应选择荷包高度距齿状线2.5-4 cm以减少悬吊效果不佳的发生。荷包缝合深度应至黏膜下层,可明显减少吻合口狭窄及出血的发生。

Objective To assess the experience in the operation details to reduce the complications of procedure for prolapsed and hemorrhoids（ PPH）. Methods The clinical data of 356 hemorrhoid cases performed PPH in our hospital from October 2007 to August 2015 were analyzed retrospectively,including 56 of stageⅡ and 300 of stage Ⅲ / Ⅳ or mixed hemorrhoids. During the PPH,the height and depth of pouch suture were chosen by individual conditions and postoperative complications as anastomotic stoma bleeding were observed. Results In the 56 cases withⅡ period of hemorrhoids： The distance from pouch line to dentate line was 2. 5 to 4 cm in 16 cases,with the postoperative pain rate of 25%（ 4 /16）; Pouch apart to dentate line was4 to 6 cm in 40 patients,there were no postoperative pain. Poor suspension was not found during the one month follow-up after the surgery. In the 300 cases with Ⅲ / Ⅳ period hemorrhoids or mixed hemorrhoids： The distance from pouch line to the dentate line was 2. 5 to 4 cm in 238 cases,with postoperative pain rate of 7. 6%（ 18 /238） and postoperative poor suspension rate of 2. 5%（ 6 /238）; Pouch apart from the dentate line was 4to 6 cm in 62 cases,with postoperative poor suspension rate of 35. 5%（ 22 /238）. Among 356 cases,there were 30 cases（ 8. 4%） took place active anastomotic bleeding,including 20 cases with incomplete resection of mucosa ring and improved by ＂ 8＂ suture cross anastomosis. 4 cases（ 1. 1%） of postoperative anastomotic stenosis were found muscle fibers in the removal mucosa ring. Conclusions The pouch height from the dentate line was chosen 4 to 6 cm for the stage Ⅱ hemorrhoid patients with the major symptom of bleeding to decrease the post-operative pain,and was 2. 5 to 4 cm for stage Ⅲ / Ⅳ or mixed hemorrhoid cases to improved the suspension result. The depth of pouch suture should be to the submucosa,it can reduce the incidence of anastomotic stenosis and bleeding.