PPH术中采用双荷包缝合治疗重度痔的近、远期疗效评价

Short-and long-term effectiveness of double purse-string suturefor procedure for prolapse and hemorrhoids in treating severe hemorrhoids

目的探讨吻合器痔上黏膜环切术(PPH)中采用双荷包缝合治疗重度痔的近期及远期疗效。方法回顾性分析2013年9月至2019年9月北京协和医院基本外科收治的103例重度痔患者的临床资料,所有患者均接受PPH治疗且在术中均采取双荷包缝合方法。分析患者手术相关情况和治疗效果,并比较Ⅲ度、Ⅳ度痔患者手术情况、治疗效果、住院期间近期并发症,术后肛门功能、出院后复发及其他远期并发症情况、再手术情况的差异。结果103例患者中Ⅲ度痔36例(35%),Ⅳ度痔67例(65%);Ⅲ度痔患者男性16名,女性20名,平均年龄(38.9±9.8)岁;67名Ⅳ度痔患者男性33名,女性34名,平均年龄(41.2±11.9)岁,两组患者年龄、性别比例差异均无统计学意义(均P>0.05)。手术时间18~32 min,平均(24.4±7.7)min;术中出血量10~20 mL,平均(11.7±1.8)mL;痔上黏膜切除宽度2.3~4.2 cm,平均(3.3±0.4)cm。Ⅲ度、Ⅳ度痔患者手术时间、术中出血量、痔上黏膜切除宽度、黏膜切除均匀程度、术后住院时间、术后出血发生率及术后疼痛持续时间比较差异均无统计学意义(均P>0.05);103例患者总体治疗有效率为79.6%(82/103),Ⅲ度患者总体有效率高于Ⅳ度患者,差异有统计学意义(91.7%vs.73.1%,P=0.026)。患者出院后接受随访,总体术后肛门功能Wexner评分0~9分,平均(1.1±0.8)分;迟发性肛门出血3例(2.9%);肛门狭窄2例(1.9%);脱垂复发13例(Ⅲ度痔3例,Ⅳ度痔10例);再手术13例(Ⅲ度痔2例,Ⅳ度痔11例)。Ⅳ度患者术后Wexner评分高于Ⅲ度患者,差异有统计学意义(P<0.05),余并发症情况比较差异均无统计学意义(均P>0.05)。结论PPH术治疗重度痔时采取双荷包缝合近期效果佳,远期复发脱垂率及再手术率仍较高。痔严重程度可能为影响远期疗效的危险因素之一。相较于Ⅲ度痔患者,PPH治疗Ⅳ度痔患者时远期肛门功能较差。

Objectives To investigate the short-and long-term effectiveness of double purse-string suture for procedure for pro⁃lapse and hemorrhoids(PPH)in treating severe hemorrhoids.Methods We retrospectively analyzed 103 patients with severe hem⁃orrhoids treated at the Department of General Surgery,Peking Union Medical College Hospital,between September 2013 and Sep⁃tember 2019.All patients received double purse-string suture for PPH.We compared the followings between patients with gradeⅢand gradeⅣhemorrhoids:surgical parameters,effectiveness,short-term complications during hospitalization,postoperative anal function,recurrence after discharge,long-term complications and re-surgery.Results Thirty-six(35%)patients,including 16 men and 20 women,had gradeⅢhemorrhoids and a mean(SD)age of 38.9(9.8)years.Sixty-seven(65%)patients,includ⁃ing 33 men and 34 women,had gradeⅣhemorrhoids and a mean(SD)age of 41.2(11.9)years.There were no significant dif⁃ferences between the two groups in age and gender(P>0.05).The duration of surgery ranged from 18 to 32 minutes with a mean(SD)of 24.4(7.7)minutes.Intraoperative blood loss ranged from 10 to 20 mL with a mean(SD)of 11.7(1.8)mL.The ex⁃cision width of hemorrhoid mucosa were 2.3~4.2 cm,the mean(SD)width of hemorrhoid mucosal resection was 3.3(0.4)cm.Pa⁃tients with gradeⅢandⅣhemorrhoids did not differ significantly in the duration of surgery,intraoperative blood loss,the width of hemorrhoid mucosal resection,uniformity of mucosal resection,duration of postoperative hospitalization,the incidence of postoperative bleeding and duration of postoperative pain(P>0.05).Overall effectiveness was 79.6%(82/103)with significantly higher effectiveness in patients with gradeⅢthan those with gradeⅣhemorrhoids(91.7%vs.73.1%,P=0.026).Patients were fol⁃lowed-up after discharge.Wexner anal function score ranged from 0 to 9 with a mean(SD)of 1.1(0.8).There were three late anal bleeding(2.9%),two anal stricture(1.9%),13 recurrences of prolapse(3 patients with gradeⅢand 10 patients with gradeⅣhemorrhoids).13 patients with reoperation(2 patients with gradeⅢ,11 patients with gradeⅣhemorrhoids).Patients with gradeⅣhemorrhoids had significantly higher Wexner scores than those with gradeⅢhemorrhoids(P<0.05).The incidence of other complications did not differ between the two groups(P>0.05).Conclusion Double purse-string suture for PPH has favor⁃able short-term effectiveness for severe hemorrhoids but still has a relatively high risk of long-term recurrence and re-surgery.The severity of hemorrhoids negatively impacts long-term prognosis.Compared with gradeⅢhemorrhoids,gradeⅣhemorrhoids treated by PPH has a poorer long-term anal function.