Sonographic appearance of anal cushions of hemorrhoids.

AIM: To evaluate the diagnostic value of different sonographic methods in hemorrhoids. METHODS: Forty-two healthy volunteers and sixty-two patients with grades I-IV hemorrhoids received two different sonographic examinations from January 2013 to January 2016 at the First and Second Hospitals of Xinjiang Medical University in a prospective way. We analyzed the ultrasonographic findings of these participants and evaluated the outcomes. Resected grades III and IV hemorrhoid tissues were pathologically examined. The concordance of ultrasonographic results with pathology results was assessed with the Cohen's kappa coefficient. RESULTS: All healthy volunteers and all patients had no particular complications related to sonography. There were no statistically significant differences between the participants regarding age (P = 0.5919), gender (P = 0.4183), and persistent symptoms (P > 0.8692). All healthy control participants had no special findings. However, 30 patients with hemorrhoids showed blood signals around the dentate line on ultrasonography. When grades I and II hemorrhoids were analyzed, there were no significant differences between transrectal ultrasound (TRUS), transperianal ultrasound (TPUS), and transvaginal ultrasound (TVUS) (P > 0.05). Grades III and IV hemorrhoids revealed blood flow with different directions which could be observed as a "mosaic pattern". In patients with grades III and IV hemorrhoids, the number of patients with "mosaic pattern" as revealed by TRUS, TPUS and TVUS was 22, 12, and 4, respectively. Patients with grades III and IV disease presented with a pathologically abnormal cushion which usually appeared as a "mosaic pattern" in TPUS and an arteriovenous fistula in pathology. Subepithelial vessels of resected grades III and IV hemorrhoid tissues were manifested by obvious structural impairment and retrograde and ruptured changes of internal elastic lamina. Some parts of the Trietz's muscle showed hypertrophy and distortion. Arteriovenous fistulas and venous dilatation were obvious in the anal cushion of hemorhoidal tissues. After pathological results with arteriovenous fistulas were taken as the standard reference, we evaluated the compatibility between the two methods according to the Cohen's kappa co-efficiency calculation. The compatibility (Cohein kappa co-efficiency value) between "mosaic pattern" in the TPUS and arteriovenous fistula in pathology was very good (ĸ = 0.8939). When compared between different groups, TRUS presented the advantage that the mosaic pattern could be confirmed in more patients, especially for group A. There was a statistical difference when comparing group A with group B or C (P < 0.05 for both). There were obvious statistical differences between group A and group B with regard to the vessel diameter and blood flow velocity measured by TRUS (P < 0.05). CONCLUSION: Patients with grades III and IV hemorrhoids present with a pathologically abnormal cushion which usually appears as a "mosaic pattern" in sonography, which is in accord with an arteriovenous fistula in pathology. There are clearly different hemorrhoid structures shown by sonography. "Mosaic pattern" may be a parameter for surgical indication of grades III and IV hemorrhoids.

Anal cushion lifting method is a novel radical management strategy for hemorrhoids that does not involve excision or cause postoperative anal complications.

AIM: To describe the anal cushion lifting (ACL) method with preliminary clinical results. METHODS: Between January to September 2007, 127 patients who received ACL method for hemorrhoid was investigated with informed consent. In this study, three surgeons who specialized in anorectal surgery performed the procedures. Patients with grade two or more severe hemorrhoids according to Goligher's classification were considered to be indicated for surgery. The patients were given the choice to undergo either the ACL method or the ligation and excision method. ACL method is an original technique for managing hemorrhoids without excision. After dissecting the anal cushion from the internal sphincter muscle, the anal cushion was lifted to oral side and ligated at the proper position. Clinical characteristics and outcomes of patients were recorded including complications after surgery. RESULTS: A total of 127 patients were enrolled. Their median age was 42 (19-84) years, and 74.8% were female. In addition, more than 99% of the patients had grade 3 or worse hemorrhoids. The median follow-up period was 26 (0-88) mo, and the median operative time was 15 (4-30) min. After surgery, analgesics were used for a median period of three days (0-21). Pain control was achieved using extra-oral analgesic drugs, although some patients required intravenous injections of analgesic drugs. The median duration of the patients' postoperative hospital stay was 7 (2-13) d. A total of 10 complications (7.9%) occurred. Bleeding was observed in one patient and was successfully controlled with manual compression. Urinary retention occurred in 6 patients, but it disappeared spontaneously in all cases. Recurrent hemorrhoids developed in 3 patients after 36, 47, and 61 mo, respectively. No anal stenosis or persistent anal pain occurred. CONCLUSION: We consider that the ACL method might be better than all other current methods for managing hemorrhoids.

Anal cushion suspensory and external hemorrhoid airfoil-shaped suture in treatment of ring-ship mixed hemorrhoid / 中国医师进修杂志

Objective To discuss the clinical effects of anal cushion suspensory and external hemorrhoid airfoil-shaped suture in treatment of ring-ship mixed hemorrhoid,improve the level of the surgical treatment of ring-ship mixed hemorrhoid.Methods One hundred and twenty patients with ring-ship mixed hemorrhoid were divided into treatment group (60 cases treated by anal cushion suspensory and external hemorrhoid airfoil-shaped suture) and control group (60 cases treated by Milligan-Morgan operation) according to the operation method.The postoperative pain,hospitalization time,wound healing time,postoperative complications,etc were observed and compared.Results The cure rate was 100.0％ (60/60) in treatment group and 70.0％ (42/60) in control group,and there was significant difference between two groups (P ＜ 0.05).The hospitalization time,wound healing time was (8.58 ± 0.89),(14.00 ± 0.72) d in treatment group,(10.20 ± 0.30),(19.00 ± 0.21) d in control group,and there was significant difference between two groups (P ＜ 0.05).The incidence of postoperative complications and the degree of postoperative pain in treatment group was lower than that in control group,and there was significant difference between two groups (P ＜ 0.05).Conclusion Anal cushion suspensory and external hemorrhoid airfoil-shaped suture in treatment of ring-ship mixed hemorrhoid has advantage of shorter wound healing time,less postoperative pain,less postoperative complications.

Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection for circumferential mixed hemorrhoids.

AIM: To identify a more effective treatment protocol for circumferential mixed hemorrhoids. METHODS: A total of 192 patients with circumferential mixed hemorrhoids were randomized into the treatment group, where they underwent Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection, or the control group, where traditional external dissection and internal ligation were performed. Postoperative recovery and complications were monitored. RESULTS: The time to wound healing was 12.96 ± 2.25 d in the treatment group shorter than 19.58 ± 2.71 d in the control group. Slight pain rate was 58.3% in the treatment group higher than 22.9% in the control group; moderate pain rate was 33.3% in the treatment group lower than 56.3% in the control group severe pain rate was 8.4% in the treatment group lower than 20.8% in the control group. No edema rate was 70.8% in the treatment group higher than 43.8% in the control group; mild local edema rate was 26% in the treatment group lower than 39.6% in the control group obvious local edema was 3.03% in the treatment group lower than 16.7% in the control group. No stenosis rate was 85.4% in the treatment group higher than 63.5% in the control group; moderate stenosis rate was 14.6% in the treatment group Lower than 27.1% in the control group severe anal stenosis rate was 0% in the treatment group lower than 9.4% in the control group. CONCLUSION: Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection is the optimal treatment for circumferential mixed hemorrhoids and can be widely applied in clinical settings.

Effects of vagus nerve preservation and vagotomy on peptide YY and body weight after subtotal gastrectomy.

AIM: To investigate the relationship between the function of vagus nerve and peptide YY(3-36) and ghrelin levels after subtotal gastrectomy. METHODS: We enrolled a total of 16 patients who underwent subtotal gastrectomy due to gastric cancer. All surgeries were performed by a single skilled surgeon. We measured peptide YY(3-36), ghrelin, leptin, insulin, growth hormone levels, and body weight immediately before and one month after surgery. RESULTS: Vagus nerve preservation group showed less body weight loss and less increase of peptide YY(3-36) compared with vagotomy group (-5.56 ± 2.24 kg vs -7.85 ± 1.57 kg, P = 0.037 and 0.06 ± 0.08 ng/mL vs 0.19 ± 0.12 ng/mL, P = 0.021, respectively). Moreover, patients with body weight loss of less than 10% exhibited reduced elevation of peptide YY(3-36) level, typically less than 20% [6 (66.7%) vs 0 (0.0%), P = 0.011, odd ratio = 3.333, 95% confidence interval (1.293, 8.591)]. CONCLUSION: Vagus nerve preservation contributes to the maintenance of body weight after gastrectomy, and this phenomenon may be related to the suppressed activity of peptide YY(3-36).

Excisional hemorrhoidal surgery and its effect on anal continence.

AIM: To investigate the role of anal cushions in hemorrhoidectomy and its effect on anal continence of the patients. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Lift-up Submucosal Hemorrhoidectomy

PURPOSE: Hemorrhoidal tissues are normal anatomic structures present in every individual, and they act as cushions and are anchored to the internal anal sphincter by a connective tissue system. When the anchoring connective tissues undergo bears degenerative changes, the hemorrhoids not only bulge but also descend into the lumen of the anal canal. The veins also become distended. The previous hemorrhoidectomy methods (excision and ligation methods) tend to remove excessive amounts of hemorrhoidal tissues, possibly causing incontinence or stenosis. This study introduces a modified hemorrhoidectomy method. METHODS: A retrospective study was done with 650 patients (358 males, 292 females) who underwent hemorroidectomies from Jan. 1997 to Jan. 2000. Under saddle-block anesthesia, the patient was placed in a prone jack-knife position. After narrow incisions on the mucosa of the selected pile, a bilateral submucosal dissection was performed. The pedicle was ligated by transfixing sutures 2 or 3 times with 2-0 chromic catgut to lift up the mucosa. RESULTS: The mean operation time per hemorrhoidal pile was 12.7 minutes, and the mean hospital-stay was 4.3 days. Acute and delayed postoperative anal bleeding occurred in 7 (1.1%) and 3 (0.5%) patients, respectively. The symptoms of both subsided spontaneously. Ninety-three (93) patients (14.3%) reguired nelaton catheterization for voiding difficulty, and one patient (0.2%) showed mild anal stenosis. The most frequent complaint was skin-tag formation (148 cases, 22.8%). In 140 cases, the skin tag was removed under local anesthesia. CONCLUSIONS: It is desirable to keep the normal structure of the anal canal by removing as little of the cushions as possible. Our 'lift-up submucosal hemorrhoidectomy' shows good results and is an easy operative method when compared with Parks' original method.

Modified Anal Cushion Preserving Hemorrhoidectomy

PURPOSE: The ligation and excision method of hemorrhoids is a simple and rapid procedure, but it has a drawback of possible damage to the anal cushion. To solve this problem, we tried to preserve the anal cushion with superficial ligation and excision method of anorectal mucosa including removal of the hemorrhoidal tissues from the anal cushion after submucosal dissection. However, it was difficult to remove hemorrhoidal vessels with this procedure and it was time consuming. To minimize these problems, we originally tried a new cushion preserving procedure in 15 patients during 1 year. METHODS: R> After mobilization of the anorectal mucosa, hemorrhoidal tissues and anal cushion from the anal sphincter muscles, the anorectal mucosa was first dissected from the anal cushion, then the hemorrhoidal vessels were removed and the remaining anal cushion was reattached to the anal sphincter muscles. RESULTS: The results of this surgery have been satisfactory with only one postoperative bleeding and two anal skin tags. CONCLUSIONS: This method is simple and convenient for preservation of anal cushion with minimal complications when compared with the conventional method of anal cushion preservation.