吻合器痔上黏膜环切钉合术与经肛门吻合器直肠切除术治疗Ⅳ度混合痔的临床对比研究

Procedure for prolapse and hemorrhoids versus stapled transanal rectal resection in the treatment of grade IV hemorrhoids

目的研究对比吻合器痔上黏膜环切钉合术(PPH)与经肛门吻合器直肠切除术(STARR)治疗Ⅳ度混合痔的疗效及安全性。方法采用回顾性队列研究方法。分析2015年1月至2016年12月期间,在北京大学人民医院胃肠外科确诊并首次接受手术治疗的Ⅳ度混合痔患者病例资料。排除合并其他肛肠疾病、急诊手术、有炎性肠病、肿瘤或其他外科手术禁忌证、以及临床病例资料不全者后,共263例Ⅳ度混合痔患者被纳入本研究,其中接受PPH手术治疗129例(PPH组),接受STARR手术治疗134例(STARR组)。PPH组于齿状线上方约4 cm处2-0滑线螺旋式缝合直肠黏膜一圈,置入PPH吻合器,收紧荷包,持续牵引下旋紧、激发吻合器,切除脱垂黏膜及黏膜下层;STARR组于直肠前壁黏膜缝合3~5针,保护直肠后壁黏膜,插入PPH吻合器,将缝线自吻合器两侧孔勾出并保持牵引,根据疾病情况适当牵引缝线,旋紧、激发吻合器,切除直肠前壁黏膜,剪开吻合口两端钉合连接处,同法切除直肠后壁黏膜。对比两组患者的短期效果、手术安全性及预后情况。结果PPH组男性67例(51.9%),STARR组男性57例(42.5%),两组中位年龄分别为51.0(22.0,80.0)岁和49.0(24.0,74.0)岁,两组基线资料比较,差异均无统计学意义(均P>0.05)。两组术中出血、住院天数、术后镇痛药物使用、术后出血、术后感染等情况比较,差异均无统计学意义(均P>0.05)。STARR组手术时间和住院费用均高于PPH组[(44.0±19.3)min比(26.3±8.5)min,t=9.701,P=0.001;(11047±473)元比(7674±309)元,t=32.826,P=0.001],差异均有统计学意义。STARR组术后发生1例直肠阴道瘘。全组中位随访40(33,52)个月,PPH组和STARR组分别有108例和114例完成随访,期间STARR组未出现复发,PPH组4例(3.7%)复发;STARR组3年疾病复发率为0,PPH组3年疾病复发率为4.2%,差异具有统计学意义(P=0.042)。结论STARR手术治疗Ⅳ度痔可改善预后,但应注意防范严重临床并发症的发生。

Objective To compare the efficacy and safety of two procedures in the treatment of hemorrhoid:the procedure for prolapse and hemorrhoids(PPH)and stapled transanal rectal resection(STARR).Methods A retrospective cohort research was conducted.Clinical data of 263 patients undergoing the first elective surgery for grade IV hemorrhoids by the same team of surgeons at our department from January 2015 to December 2016 were analyzed retrospectively,while those had other anorectal diseases,emergency surgery,inflammatory bowel disease,tumor and incomplete clinical data were excluded.PPH was performed in 129 patients and STARR was performed in 134 patients.PPH procedure:a circular purse 2-0 string suture was made at 4 cm above the dentate line;in accordance with the standard protocol,the PPH circular stapling devicewas introduced;the suture was closed,and a pull-through followed;the traction was continued;the stapler was fired;the prolapsed mucosa and submucosa were removed.STARR procedure:3-5 needles were sutured in the anterior rectal mucosa,protecting the posterior wall mucosa;with the help of a finger the PPH stapler was inserted into the vaginal lumen;the sutures were hooked from both sides of the stapler to maintain traction;according to the disease condition,the suturewas tightened appropriately;stapler was screwed and activated;the anterior wall mucosa was removed;the joint of the both ends of anastomosis was cut;the posterior wall mucosa was removed as well.The short-term efficacy,surgical safety and prognosis of the two groups were compared.Results There were 67 males(51.9%)in the PPH group and 57(42.5%)males in the STARR group.The median age of the two groups was 51.0(22.0,80.0)years and 49.0(24.0,74.0)years,respectively.There were no significant differences in the baseline data between the two groups(all P>0.05).No significant differences in the intraoperative bleeding,length of hospital stay,postoperative analgesic drug use,postoperative bleeding,postoperative infection,etc.were found between two groups(all P>0.05).As compared to PPH group,STAAR group had longer operation time and higher hospitalization cost with significant differences[(44.0±19.3)minutes vs.(26.3±8.5)minutes,t=9.701,P=0.001;(11047±473)yuan vs.(7674±309)yuan,t=32.826,P=0.001].One case in STAAR group developed rectovaginal fistula.The median follow-up period of the whole group was 40(33,52)months.A total of 108 cases in STARR group and 114 cases in PPH group completed the follow-up.The 3-year disease-relapse rate was 0 in STARR group and 4.2%in PPH group(P=0.042).Conclusion STARR procedure can improve the prognosis in the treatment of grade IV hemorrhoid,but attention should be paid to the development of complications.