PPH联合部分肛门内括约肌切断术应用于重度混合痔并直肠肛管静息压高压患者的疗效观察

Observation on effect of PPH combined with partial internal anal sphincterotomy in treatment of severe mixed hemorrhoids complicated with high rectal and anal canal resting pressure

目的观察吻合器痔上黏膜环切术(PPH)联合部分肛门内括约肌切断术应用于重度混合痔并直肠肛管静息压高压患者的疗效。方法选取2016年1月至2018年6月于中山大学附属东华医院拟接受手术治疗的Ⅲ~Ⅳ度混合痔患者进行前瞻性研究,其中高压患者(>70 mm Hg,1 mm Hg=0.133 kPa)100例,低压患者(≤70mm Hg)100例,再将直肠肛管静息压高压或低压患者按随机数字表法分为试验组及对照组(每组50例),对照组仅行PPH术,试验组行PPH联合部分肛门内括约肌切断术,观察各组患者治疗效果及围术期指标,采用视觉模拟评分(VAS)法评估手术前后的疼痛情况,观察各组并发症发生及症状复发情况,并分析影响PPH联合部分肛门内括约肌切断术治疗效果的因素。结果无论是直肠肛管静息压高压或低压患者,虽然试验组的手术时间均分别长于对照组(t=8.996, P<0.001;t=8.927,P<0.001),但是与对照组相比,试验组的总有效率均更高(χ~2=7.294,P=0.007;χ~2=6.775,P=0.009)、住院时间均分别明显缩短(t=11.922,P<0.001;t=11.442,P<0.001)、住院费用明显减少(t=2.226,P=0.028;t=2.562,P=0.012)、术后24 h和72 h时的VAS评分均分别明显降低(24 h:t=12.659,P<0.001;t=12.191,P<0.001;72 h:t=9.920,P<0.001;t=9.901,P<0.001)、总并发症发生率均更低(χ~2=7.484,P=0.006;χ~2=11.416,P=0.001),而且随访0.5~2年,试验组和对照组的症状总复发率比较差异均无统计学意义(χ~2=1.042,P=0.307;χ~2=0.211,P=0.646)。多因素分析结果显示,病程及内痔分度为影响重度混合痔并直肠肛管静息压高压患者治疗显效率的独立影响因素(χ~2=7.417、P=0.009;χ~2=4.286、P=0.017)。结论 PPH联合部分肛门内括约肌切断术治疗重度混合痔并直肠肛管静息压高压患者疗效较好,能促使患者快速恢复、减轻术后疼痛,尤其对病程较长及内痔分度较严重患者应加以重视。

Objective To observe the effect of procedure for prolapse and hemorrhoids(PPH)combined with partial internal anal sphincterotomy(Abbreviated as combined therapy)in the treatment of severe mixed hemorrhoids complicated with high rectal and anal canal resting pressure.Methods From January 2016 to June 2018,the patients with gradeⅢ–Ⅳmixed hemorrhoids who underwent surgical treatment in this hospital were selected for the prospective study,including 100 patients with high pressure(>70 mm Hg,1 mm Hg=0.133 kPa)and 100 patients with low pressure(≤70 mm Hg),then which were divided into an experimental group and a control group according to the random number table method(with 50 cases in each group).The patients in the control group underwent the PPH and in the experimental group underwent the combined therapy.The therapeutic effect and perioperative indicators were observed in each group,Visual Analogue Scale(VAS)was used to evaluate the degree of pain before and after the operation,the incidence of complications and the recurrence rate of symptoms were observed,the factors influencing the therapeutic effect of combined therapy were analyzed.Results Whether for the patients with high or low rectal and anal canal resting pressure,although the operation time of the experimental group was significantly longer than that of the control group(t=8.996,P<0.001;t=8.927,P<0.001),the total effective rate was higher(χ2=7.294,P=0.007;χ2=6.775,P=0.009),the length of stay in hospital was shorter(t=11.922,P<0.001;t=11.442,P<0.001),the hospital expenses decreased significantly(t=2.226,P=0.028;t=2.562,P=0.012),the VAS score at 24 h and 72 h after operation were lower(24 h:t=12.659,P<0.001;t=12.191,P<0.001;72 h:t=9.920,P<0.001;t=9.901,P<0.001),the incidence of postoperative complications was lower(χ2=7.484,P=0.006;χ2=11.416,P=0.001)in the experimental group as compared with the control group;there was no significant difference between the two groups(χ2=1.042,P=0.307;χ2=0.211,P=0.646).The course of disease and the grade of internal hemorrhoids were the independent factors influencing the marked efficiency of combined therapy(χ2=7.417,P=0.009;χ2=4.286,P=0.017).Conclusions Combined therapy is effective in treatment of severe mixed hemorrhoids complicated with high rectal and anal canal resting pressure,it could accelerate recovery of patients and relieve pain.It should be paid attention to patients with long course of disease and severe degree of internal hemorrhoids.