Shen K, Wang C, Gao Z D, Jiang K W, Wang Y L, Ye Y J
Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2019 Dec 25;22(12):1165-1169. doi: 10.3760/cma.j.issn.1671-0274.2019.12.012.
To compare the efficacy and safety of two procedures in the treatment of hemorrhoid: the procedure for prolapse and hemorrhoids (PPH) and stapled transanal rectal resection (STARR). A retrospective cohort research was conducted. Clinical data of 263 patients undergoing the first elective surgery for grade IV hemorrhoids by the same team of surgeons at our department from January 2015 to December 2016 were analyzed retrospectively, while those had other anorectal diseases, emergency surgery, inflammatory bowel disease, tumor and incomplete clinical data were excluded. PPH was performed in 129 patients and STARR was performed in 134 patients. PPH procedure: a circular purse 2-0 string suture was made at 4 cm above the dentate line; in accordance with the standard protocol, the PPH circular stapling devicewas introduced; the suture was closed, and a pull-through followed; the traction was continued; the stapler was fired; the prolapsed mucosa and submucosa were removed. STARR procedure: 3-5 needles were sutured in the anterior rectal mucosa, protecting the posterior wall mucosa; with the help of a finger the PPH stapler was inserted into the vaginal lumen; the sutures were hooked from both sides of the stapler to maintain traction; according to the disease condition, the suturewas tightened appropriately; stapler was screwed and activated; the anterior wall mucosa was removed; the joint of the both ends of anastomosis was cut; the posterior wall mucosa was removed as well. The short-term efficacy, surgical safety and prognosis of the two groups were compared. There were 67 males (51.9%) in the PPH group and 57 (42.5%) males in the STARR group. The median age of the two groups was 51.0 (22.0, 80.0) years and 49.0 (24.0, 74.0) years, respectively. There were no significant differences in the baseline data between the two groups (all >0.05). No significant differences in the intraoperative bleeding, length of hospital stay, postoperative analgesic drug use, postoperative bleeding, postoperative infection, etc. were found between two groups (all >0.05). As compared to PPH group, STAAR group had longer operation time and higher hospitalization cost with significant differences [(44.0±19.3) minutes vs. (26.3±8.5) minutes, =9.701, =0.001; (11 047±473) yuan vs. (7674±309) yuan, =32.826, =0.001]. One case in STAAR group developed rectovaginal fistula. The median follow-up period of the whole group was 40 (33, 52) months. A total of 108 cases in STARR group and 114 cases in PPH group completed the follow-up. The 3-year disease-relapse rate was 0 in STARR group and 4.2% in PPH group (=0.042). STARR procedure can improve the prognosis in the treatment of grade IV hemorrhoid, but attention should be paid to the development of complications.
吻合器痔上黏膜环切术（PPH）和经肛门吻合器直肠切除术（STARR）。进行一项回顾性队列研究。回顾性分析2015年1月至2016年12月在我科由同一组外科医生为263例IV度痔疮患者实施首次择期手术的临床资料，排除患有其他肛肠疾病、急诊手术、炎症性肠病、肿瘤及临床资料不全者。129例行PPH手术，134例行STARR手术。PPH手术步骤：在齿状线上方4cm处做2-0环形荷包缝合；按照标准操作流程，置入PPH环形吻合器；收紧缝线，随后进行拖出；持续牵引；击发吻合器；切除脱垂的黏膜和黏膜下层。STARR手术步骤：在前直肠黏膜缝合3-5针，保护后壁黏膜；在手指辅助下将PPH吻合器插入阴道腔；从吻合器两侧钩住缝线以维持牵引；根据病情适当收紧缝线；旋紧并启动吻合器；切除前壁黏膜；切除吻合两端的连接处；同时切除后壁黏膜。比较两组的短期疗效、手术安全性和预后。PPH组有67例男性（51.9%），STARR组有57例男性（42.5%）。两组的中位年龄分别为51.0（22.0，80.0）岁和49.0（24.0，74.0）岁。两组基线数据无显著差异（均>0.05）。两组术中出血、住院时间、术后镇痛药使用、术后出血、术后感染等方面均无显著差异（均>0.05）。与PPH组相比，STARR组手术时间更长，住院费用更高，差异有统计学意义[（44.0±19.3）分钟对（26.3±8.5）分钟，t=9.701，P=0.001；（11047±473）元对（7674±309）元，t=32.826，P=0.001]。STARR组有1例发生直肠阴道瘘。全组中位随访时间为40（33，52）个月。STARR组108例和PPH组114例完成随访。STARR组3年疾病复发率为0，PPH组为4.2%（P=0.042）。STARR手术可改善IV度痔疮的治疗预后，但应注意并发症的发生。
