吻合器痔固定术在德国的应用与发展

Stapled Haemorrhoidopexy in Germany

德国于1998年引进吻合器痔固定术(stapled haemorrhoidopexy,SH)。与传统手术如痔切除术(excisional haemorrhoidectomy,EH)或肛门成形术相比,SH具有出血量少、手术时间短、疼痛轻、患者能较快重返工作岗位等优点,以上优点加上吻合器痔上黏膜环切钉合术(procedure for prolapse and haemorrhoids,PPH)及其标准化操作流程的建立,使其得以被快速接受并在全国推广。对于外科医师而言,SH是一种全新术式,因此需要经历一定的学习曲线。在初期,吻合器被用于Ⅱ~Ⅳ度痔的治疗,但到了1999年末,由于术后脱垂复发率较高,人们意识到SH并不适用于Ⅳ度痔的治疗。大多数患者在SH术后数日便无明显疼痛感并可以重返工作岗位,但也有少数患者在SH术后出现剧烈疼痛,甚至会持续相当长的时间。外科医师开始面临一些在传统痔手术后不会出现的严重并发症,这引发了人们对SH的重新评价,尤其是能量设备被应用于EH之后。一项随机对照试验显示,SH相对于EH的优势(疼痛轻、患者能较快重返工作岗位)在随访过程中逐渐消退,且SH的治疗成本高于EH。目前,SH在痔病(haemorrhoidal disease,HD)的手术治疗方案中仍有一席之地,但手术的适应证已有所限制,并且外科医师需与患者充分讨论各种术式的利弊。鉴于此,该术式开展得不如20年前那样普遍就毫不意外了。

In Germany stapled haemorrhoidopexy(SH)was introduced in 1998.Compared to the traditional procedures like ex⁃cisional haemorrhoidectomy(EH)or anoplasty,SH had several advantages:less blood loss,shorter operation time,less pain,less time off work,etc.These advantages and the introduction of Procedure for Prolapse and Haemorrhoids(PPH)with its standard⁃ized procedural steps led to a rapid acceptance leading to a nationwide spread of the procedure.Because it was a completely new procedure for surgeons,there was a learning curve to be taken.In the beginning the stapling device was used in haemor⁃rhoids ranging from 2nd to 4th degree.At the end of 1999,however,it was known that 4th degree haemorrhoids were not suitable for SH,because of a high rate of recurrent prolapse.Most patients were pain free after a couple of days and went back to work again accordingly,however a small number of patients had severe pain after SH,some of them for a long period of time.Sur⁃geons were confronted with severe complications that were usually not encountered after traditional haemorrhoidal surgery.This led to a re-appraisal of the SH procedure,especially after the introduction of energy-driven devices for EH.In addition,a ran⁃domised controlled trial showed that the advantage of SH(less pain and shorter period off-work)compared to EH declined dur⁃ing follow up and the costs of SH were higher than that of EH.Today SH still has its place in surgery of haemorrhoidal dis⁃ease(HD),but the indication for the procedure has been limited and should be critically discussed with the patient.In this re⁃spect,it is not surprising that the procedure is not performed as often as 20 years ago.