A型肉毒杆菌毒素和硝酸甘油软膏在重度痔切除术后的应用比较

Application comparison of botulinum toxin-A and glyceryl trinitrate ointment after severe hemorrhoidectomy

目的比较A型肉毒杆菌毒素(BTX-A)和0.2%硝酸甘油软膏(GTN)在重度痔切除术后对患者疼痛及愈合的影响。方法选择2019年4月至2020年1月我院60例行痔切除术的Ⅲ、Ⅳ度混合痔患者,根据患者意愿分为BTX-A组(28例)和GTN组(32例)。使用视觉模拟量表(VAS)评分法分别在术后24 h及首次排便时进行疼痛评估,并统计术后1周镇痛药消耗总量;统计2组患者术后伤口愈合时间和头疼、失禁等不良反应;测量术前及术后1周肛管静息压和最大肛管收缩压,计算肛管静息压和最大肛管收缩压下降幅度,并于术后12周复查肛管压力。结果BTX-A组术后24 h最大静息痛、首次排便时疼痛VAS评分、镇痛药消耗总量均低/少于GTN组,差异具有统计学意义(P=0.000);BTX-A组愈合时间短于GTN组(P=0.002)。BTX-A组失禁Vaizey评分高于GTN组(P=0.016),但2组均表现为轻度的排气失禁,失禁症状在12周内消失。2组患者术前肛管静息压和最大肛管收缩压比较,差异无统计学意义(P>0.05);术后1周2组患者肛管静息压和最大肛管收缩压均显著下降(P<0.001),且BTX-A组降辐较GTN组大(P<0.05);术后12周肛管括约肌测压恢复。GTN组患者主要为轻度到中度头痛,与BTX-A组比较差异有统计学意义(P=0.007)。结论痔切除术后化学性括约肌切开不会对肛门自制造成永久损害,BTX-A可在短期内降低肛管压力,松弛括约肌,减轻肛管痉挛及术后疼痛,使切口愈合更快。

Objective To compare the effects of botulinum toxin-A(BTX-A)and 0.2%glyceryl trinitrate ointment(GTN)on the pain and healing after hemorrhoidectomy.Methods A total of 60 patients with gradeⅢandⅣof mixed hemorrhoid who received hemorrhoidectomy in our hospital from April 2019 to January 2020 were selected and divided into the BTX-A group(28 cases)and the GTN group(32 cases)according to patients’intention.Pain assessment was performed by using visual analogue scale(VAS)at 24 hours after surgery and at the first postoperative defecation,and the total consumption of analgesics in 1 week after surgery was calculated.The healing time of incision and adverse reactions such as headache and incontinence after surgery were recorded.The anal canal resting pressure and the maximum anal systolic pressure were measured before operaiton and 1 week after operation,their falling range were calculated,and the anal canal pressure was reviewed 12 weeks after operation.Results VAS scores of the maximum resting pain 24 hours after operation and the pain of first postoperative defecation,and the total consumption of analgesics in the BTX-A group were lower or less than those in the GTN group,the differences were statistically significant(P=0.000).In the BTX-A group,the healing time of incision was shorter than that in the GTN group(P=0.002).The incontinence Vaizey score in the BTX-A group was higher than that in the GTN group(P=0.016),but both two groups showed mild exhaust incontinence and the incontinence symptoms were all disappeared 12 weeks later.There was no significant difference in the anal canal resting pressure and the maximum anal systolic pressure before operation between the two groups(P>0.05),the anal canal resting pressure and the maximum anal systolic pressure of both groups were significantly decreased 1 week after operation(P<0.001),and the decrease of the BTX-A group was greater than that of the GTN group(P<0.05).The pressure of anal sphincter was restored 12 weeks after operation.Patients in the GTN group had mild to moderate headaches,and the difference was statistically significant when compared with the BTX-A group(P=0.007).Conclusion The chemical sphincterotomy after hemorrhoidectomy has no permanent damage to anal self-control,and BTX-A can reduce the anal pressure in a short term,relax the sphincter,relieve anal spasm and the pain,which can promote the incision healing.