Bassi R, Bergami G
Divisione di Chirurgia Generale, USSL n. 24, Crema, Cremona.
Minerva Chir. 1997 Apr;52(4):387-91.
The operations to treat hemorrhoids of III and IV degree are numerous but classifiable into two groups: "closed" techniques such as Ferguson, Parks and Khubchandani, and "open" techniques such as Arnous-Parnaud of the most famous Milligan-Morgan. Recently the Anglo-Saxon school was proposed a technical variant to Milligan-Morgan operation: it involves diathermy excision without peduncle ligature. This technique partly because of the coagulation of the pain receptor, partly because of the absence of "at risk" sutures in septic ground would involve a reduction in the postoperative pain. We have developed the following study to have a global valuation of these methodologies.
From November 1993, 135 patients with haemorrhoids of III and IV degree have been recruited and grouped in 3 random groups: the patients of the I group have been subjected to closed hemorrhoidectomy (Ferguson and is variant according to Khubchandani), the patients of the II group have been subjected to the Milligan-Morgan operation and those the III group of the diathermy hemorrhoidectomy. All the patients have had the same kind of preoperative preparation and the same kind of analgesic during the post-operative course. Before the operation all the patients were given a questionnaire including a scale of the pain on which the administrations of analgesic were also noted.
A faster canalization and a minor postoperative pain were found in the patients of the II and III group and among them a minor use of analgesics in those subjected to diathermy-hemorrhoidectomy. No statistical difference occurred in postoperative haemorrhage into Milligan-Morgan and diathermy hemorrhoidectomy without peduncle ligature (2.2%).
All the methods we have considered have turned out to be effective for the clinical and anatomical recovery. However, in our experience, the open techniques involve in a significant reduction of the postoperative pain and those made with diathermy permit a minor use of analgesics in comparison with those made a conventional scissor excision. Finally the peduncle ligature doesn't influence postoperative haemorrhage.
治疗III度和IV度痔疮的手术方法众多，但可分为两组：“闭合”技术，如弗格森术、帕克斯术和胡布钱达尼术；以及“开放”技术，如最著名的米利根-摩根术式中的阿诺-帕尔诺术式。最近，盎格鲁-撒克逊学派提出了一种米利根-摩根手术的技术变体：即无蒂结扎的透热切除术。该技术部分由于疼痛感受器的凝固，部分由于在感染区域没有“有风险”的缝线，将减少术后疼痛。我们开展了以下研究以对这些方法进行全面评估。
从1993年11月起，招募了135例III度和IV度痔疮患者，并随机分为3组：I组患者接受闭合痔切除术（弗格森术及其根据胡布钱达尼的变体），II组患者接受米利根-摩根手术，III组患者接受透热痔切除术。所有患者术前准备相同，术后过程中使用相同类型的镇痛药。手术前，所有患者都收到一份问卷，其中包括疼痛量表，同时记录镇痛药的使用情况。
II组和III组患者的肛管引流更快，术后疼痛更轻，其中接受透热痔切除术的患者使用镇痛药更少。米利根-摩根手术与无蒂结扎的透热痔切除术在术后出血方面无统计学差异（2.2%）。
我们所考虑的所有方法在临床和解剖恢复方面均有效。然而，根据我们的经验，开放技术能显著减轻术后疼痛，与传统剪刀切除术相比，透热技术使用的镇痛药更少。最后，蒂部结扎不影响术后出血。
