Holzheimer René G
University Halle-Wittenberg, Germany.
Eur J Med Res. 2004 Jan 26;9(1):18-36.
Hemorrhoids are a common cause of perianal complaints and affect 1-10 million people in North-America and with similar incidence in Europe. Symptomatic hemorrhoids are associated with nutrition, inherited predisposition, retention of feces with or without chronic abuse of laxatives or diarrhea. Increased pressure and shearing force in the anal canal may lead to severe changes in topography with detachment of the hemorrhoids from the internal sphincter and fibromuscular network resulting in bleeding, itching, pain and disordered anorectal function, even incontinence. The significance of hemorrhoids for anal continence (corpus cavernosum) is recognized. In most instances, hemorrhoids are treated conservatively; the surgeon is contacted when conservative measures have failed or complications, e.g., thrombosis, have occurred. 4 degrees prolapsed internal hemorrhoids are the main indication for hemorrhoidectomy: high (Parks) or low (Milligan-Morgan) ligation with excision, closed hemorrhoidectomy (Ferguson) or stapler hemorrhoidectomy. Thrombosed external hemorrhoids are primary treated by incision and secondary by excision. Complications after operative treatment of external thrombosed hemorrhoids are rare. After standard hemorrhoidectomy for internal hemorrhoids approximately 10% may have a complicated follow-up (bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, incontinence); there may be concomitant disease, e.g., perianal cryptoglandular infection, causing complex fistula/abscess, which is associated with an increased risk (30-80%) for complications, e.g., incontinence. Other treatment options, e.g., sphincterotomy, anal stretch, have been accused to cause more complications, e.g., incontinence in 30-50% of cases. However, incontinence is a complex phenomenon; it is evident that an isolated single injury is normally not a sufficient cause, e.g., injury of the internal sphincter. The majority of patients may present with prior obstetric injury, perianal infection or Crohn's disease and other comorbidity. Therefore all systemic and regional disorders, causing incontinence, should be excluded before starting manometric, neurophysiological and sonographic investigations. Variation and overlap in test results, patient-, instrument- or operator-dependent factors ask for cautious interpretation. There is vast evidence that the demonstration of muscle fibers in hemorrhoidectomy specimens is a normal feature. In conclusion, standard hemorrhoidectomy with proper indication is a safe procedure. If complications occur, it is in the interest of the patient and surgeon to perform a thorough investigation.
痔疮是引起肛周不适的常见原因，在北美有100万至1000万人受其影响，欧洲的发病率与之相似。有症状的痔疮与营养、遗传易感性、有无长期滥用泻药或腹泻导致的粪便潴留有关。肛管内压力和剪切力增加可能导致形态发生严重改变，痔疮从内括约肌和纤维肌肉网络分离，从而导致出血、瘙痒、疼痛和肛门直肠功能紊乱，甚至失禁。痔疮对肛门节制（海绵体）的意义已得到认可。在大多数情况下，痔疮采用保守治疗；当保守治疗失败或出现并发症（如血栓形成）时，才联系外科医生。4度脱垂内痔是痔切除术的主要指征：高位（帕克斯）或低位（米利根-摩根）结扎加切除、闭合式痔切除术（弗格森）或吻合器痔切除术。血栓性外痔主要通过切开治疗，其次是切除。血栓性外痔手术治疗后的并发症很少见。内痔标准痔切除术后约10%的患者可能有复杂的后续情况（出血、肛裂、肛瘘、脓肿、狭窄、尿潴留、便污、失禁）；可能存在合并症，如肛周隐窝腺感染，导致复杂的肛瘘/脓肿，这会增加并发症（如失禁）的风险（30% - 80%）。其他治疗选择，如括约肌切开术、肛门扩张术，被指责会引起更多并发症，如30% - 50%的病例出现失禁。然而，失禁是一个复杂的现象；显然，单一孤立的损伤通常不足以导致失禁，例如内括约肌损伤。大多数患者可能有既往产科损伤、肛周感染或克罗恩病等合并症。因此，在开始测压、神经生理学和超声检查之前，应排除所有导致失禁的全身性和局部性疾病。检查结果的变异和重叠、患者、仪器或操作者相关因素要求谨慎解读。有大量证据表明，痔切除标本中出现肌纤维是一种正常特征。总之，有适当指征的标准痔切除术是一种安全的手术。如果发生并发症，对患者和外科医生来说，进行全面调查是有益的。
