Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou 310003, Zhejiang Province, China.
World J Gastroenterol. 2012 Aug 14;18(30):4059-63. doi: 10.3748/wjg.v18.i30.4059.
To investigate the role of anal cushions in hemorrhoidectomy and its effect on anal continence of the patients.
Seventy-six consecutive patients (33 men and 43 women) with a mean age of 44 years were included. They underwent Milligan-Morgan hemorrhoidectomy because of symptomatic third- and fourth-degree hemorrhoids and failure in conservative treatment for years. Wexner score was recorded and liquid continence test was performed for each patient before and two months after operation using the techniques described in our previous work. The speed-constant rectal lavage apparatus was prepared in our laboratory. The device could output a pulsed and speed-constant saline stream with a high pressure, which is capable of overcoming any rectal resistance change. The patients were divided into three groups, group A (< 900 mL), group B (900-1200 mL) and group C (> 1200 mL) according to the results of the preoperative liquid continence test.
All the patients completed the study. The average number of hemorrhoidal masses excised was 2.4. Most patients presented with hemorrhoidal symptoms for more than one year, including a mean duration of incontinence of 5.2 years. The most common symptoms before surgery were anal bleeding (n = 55), prolapsed lesion (n = 34), anal pain (n = 12) and constipation (n = 17). There were grade III hemorrhoids in 39 (51.3%) patients, and grade IV in 37 (48.7%) patients according to Goligher classification. Five patients had experienced hemorrhoid surgery at least once. Compared with postoperative results, the retained volume in the preoperative liquid continence test was higher in 40 patients, lower in 27 patients, and similar in the other 9 patients. The overall preoperative retained volume in the liquid continence test was 1130.61 ± 78.35 mL, and postoperative volume was slightly decreased (991.27 ± 42.77 mL), but there was no significant difference (P = 0.057). Difference was significant in the test value before and after hemorrhoidectomy in group A (858.24 ± 32.01 mL vs 574.18 ± 60.28 mL, P = 0.011), but no obvious difference was noted in group B or group C. There was no significant difference in Wexner score before and after operation (1.68 ± 0.13 vs 2.10 ± 0.17, P = 0.064). By further stratified analysis, there was significant difference before and 2 months after operation in group A (2.71 ± 0.30 vs 3.58 ± 0.40, P = 0.003). In contrast, there were no significant differences in group B or group C (1.89 ± 0.15 vs 2.11 ± 0.19, P = 0.179; 0.98 ± 0.11 vs 1.34 ± 0.19, P = 0.123).
There is no difference in the continence status of patients before and after Milligan-Morgan hemorrhoidectomy. However, patients with preoperative compromised continence may have further deterioration of their continence, hence Milligan-Morgan hemorrhoidectomy should be avoided in such patients.
探讨肛门垫在痔切除术（hemorrhoidectomy）中的作用及其对患者肛门节制功能的影响。
连续纳入 76 例（男 33 例，女 43 例）因症状性 3 度和 4 度痔和多年保守治疗失败而接受吻合器痔上黏膜环切术（PPH）治疗的患者。在手术前和手术后两个月，采用我们之前工作中描述的技术记录 Wexner 评分和液体节制测试。我们实验室准备了速度-常数直肠灌洗仪。该设备可以输出具有高压的脉冲和速度-常数盐水流，能够克服任何直肠阻力变化。根据术前液体节制测试的结果，将患者分为三组，A 组（<900mL）、B 组（900-1200mL）和 C 组（>1200mL）。
所有患者均完成了研究。切除的痔块平均为 2.4 个。大多数患者的痔症状持续超过 1 年，失禁时间平均为 5.2 年。术前最常见的症状是便血（n=55）、脱垂病变（n=34）、肛门疼痛（n=12）和便秘（n=17）。根据 Goligher 分类，39 例（51.3%）患者为 3 度痔，37 例（48.7%）患者为 4 度痔。5 例患者至少接受过一次痔切除术。与术后结果相比，术前液体节制测试中的保留量在 40 例患者中较高，在 27 例患者中较低，在其他 9 例患者中相似。术前液体节制测试中的总体保留量为 1130.61±78.35mL，术后量略有减少（991.27±42.77mL），但无统计学差异（P=0.057）。A 组患者在痔切除术前和术后的测试值差异有统计学意义（858.24±32.01mL 比 574.18±60.28mL，P=0.011），但 B 组或 C 组无明显差异。手术前后 Wexner 评分无统计学差异（1.68±0.13 比 2.10±0.17，P=0.064）。通过进一步分层分析，A 组患者在术前和术后 2 个月的评分差异有统计学意义（2.71±0.30 比 3.58±0.40，P=0.003）。相比之下，B 组或 C 组无显著差异（1.89±0.15 比 2.11±0.19，P=0.179；0.98±0.11 比 1.34±0.19，P=0.123）。
痔切除术前后患者的节制状态无差异。然而，术前有节制功能受损的患者可能会进一步恶化其节制功能，因此应避免对这些患者行痔切除术。
