Zindel Joel, Inglin Roman, Brügger Lukas
Klinik für Viszerale Chirurgie und Medizin, Inselspital, Bern Universitätsspital, Universität Bern.
Ther Umsch. 2014 Dec;71(12):737-51. doi: 10.1024/0040-5930/a000620.
Up to one third of the general population suffers from symptoms caused by hemorrhoids. Conservative treatment comes first unless the patient presents with an acute hemorrhoidal prolapse or a thrombosis. A fiber enriched diet is the primary treatment option, recommended in the perioperative period as well as a long-term prophylaxis. A timely limited application of topical ointments or suppositories and/or flavonoids are further treatment options. When symptoms persist interventional procedures for grade I-II hemorrhoids, and surgery for grade III-IV hemorrhoids should be considered. Rubber band ligation is the interventional treatment of choice. A comparable efficacy using sclerosing or infrared therapy has not yet been demonstrated. We therefore do not recommend these treatment options for the cure of hemorrhoids. Self-treatment by anal insertion of bougies is of lowrisk and may be successful, particularly in the setting of an elevated sphincter pressure. Anal dilation, sphincterotomy, cryosurgery, bipolar diathermy, galvanic electrotherapy, and heat therapy should be regarded as obsolete given the poor or missing data reported for these methods. For a long time, the classic excisional hemorrhoidectomy was considered to be the gold standard as far as surgical procedures are concerned. Primary closure (Ferguson) seems to be superior compared to the "open" version (Milligan Morgan) with respect to postoperative pain and wound healing. The more recently proposed stapled hemorrhoidopexy (Longo) is particularly advisable for circular hemorrhoids. Compared to excisional hemorrhoidectomy the Longo-operation is associated with reduced postoperative pain, shorter operation time and hospital stay as well as a faster recovery, with the disadvantage though of a higher recurrence rate. Data from Hemorrhoidal Artery Ligation (HAL)-, if appropriate in combination with a Recto-Anal Repair (HAL/RAR)-, demonstrates a similar trend towards a better tolerance of the procedure at the expense of a higher recurrence rate. These relatively "new" procedures equally qualify for the treatment of grade III and IV hemorrhoids, and, in the case of stapled hemorrhoidopexy, may even be employed in the emergency situation of an acute anal prolapse. While under certain circumstances different treatment options are equivalent, there is a clear specificity with respect to the application of those procedures in other situations. The respective pros and cons need to be discussed separately with every patient. According to their own requirements a treatment strategy has to be defined according to their individual requirements.
高达三分之一的普通人群患有痔疮引起的症状。除非患者出现急性痔脱垂或血栓形成，否则首先采用保守治疗。富含纤维的饮食是主要治疗选择，在围手术期以及长期预防中均有推荐。及时有限地应用局部软膏或栓剂和/或类黄酮是进一步的治疗选择。当症状持续时，应考虑对I-II度痔疮进行介入治疗，对III-IV度痔疮进行手术治疗。橡皮圈套扎术是首选的介入治疗方法。硬化疗法或红外线疗法的疗效尚未得到证实。因此，我们不推荐这些治疗方法来治愈痔疮。通过肛门插入探条进行自我治疗风险较低，可能会成功，尤其是在括约肌压力升高的情况下。鉴于这些方法报道的数据不佳或缺乏，肛门扩张术、括约肌切开术、冷冻手术、双极透热疗法、直流电疗法和热疗法应被视为过时的方法。长期以来，经典的痔切除术在外科手术方面被认为是金标准。在术后疼痛和伤口愈合方面，一期缝合（弗格森术式）似乎比“开放”术式（米利根-摩根术式）更具优势。最近提出的吻合器痔上黏膜环切术（龙氏术式）特别适用于环状痔。与痔切除术相比，龙氏手术术后疼痛减轻、手术时间和住院时间缩短、恢复更快，不过缺点是复发率较高。痔动脉结扎术（HAL）的数据，如果适当地与直肠-肛门修复术（HAL/RAR）联合使用，显示出类似的趋势，即手术耐受性更好，但复发率较高。这些相对“新”的手术同样适用于III度和IV度痔疮的治疗，对于吻合器痔上黏膜环切术，甚至可用于急性肛门脱垂的紧急情况。虽然在某些情况下不同的治疗选择是等效的，但在其他情况下这些手术的应用存在明显的特异性。需要分别与每位患者讨论各自的优缺点。必须根据患者自身的要求制定治疗策略。
