Hemorrhoids

Hemorrhoids - dilating of cavernous little bodies of a rectum though till 60th years there was an opinion, that at this disease is possible a lesion of rectal arteries.

This extremely widespread disease (more than 10 % of all adult population suffer a hemorrhoids). These patients compound 15-28 % from the general number of proctologic patients. Men are ill in 3-4 times more often women. Age of sick 30-50 years.

Distinguish the outside hemorrhoidal ganglions immediately located under a skin at a fundament (varices haemorrhoidales subcutanaee), formed of the inferior veniplex (v. Haemorrhoidales inferior) and the intrinsic hemorrhoidal ganglions formed of the top veniplex, settling down in a submucosal layer of a rectum.

Questions of an etiopathogenesis of a hemorrhoids practically began to be shined after researches Stelzaer (1979) which has shown, that in a submucosal layer of the proctal canal, along branches of the top proctal artery, bunches of cavernous bodies (are available in norm, are pawned on 3-8 weeks of embryonic development), disturbance of outflow of blood from which leads to their hyperplasia and actually to formation of hemorrhoidal ganglion at 3-7-11 o'clock settle down. Other factors in hemorrhoids development are: congenital functional insufficiency of a copulative tissue, disturbance of nervous control of a tonus of a venous side, rising of pressure owing to constipations, a continuous duty in position both sitting, and standing, serious physical work, pregnancy; important value give to abuse by alcohol, a spicy food therefore arterial inflow to cavernous bodies of a rectum strengthens.

The specified cavernous bodies settle down between proctal arteries and veins, are supplied with an arterial blood and differ from usual veins of a submucosal layer rectum an abundance of arteriovenous anastomosises. From here characteristic for a hemorrhoids of abjection of scarlet blood from rectum.

Studying an angioarchitecture of distal part rectum, presence of cavernous bodies at all humans, irrespective of age is established. Thus, the hemorrhoids is polygenic monopathogenetic disease with a primary lesion of system of rectal glomerular structures and proctal veins. Approximately at 40 % of patients the combination of an outside and intrinsic hemorrhoids - the admixed hemorrhoids is observed.

The outside hemorrhoids compounds 10 % among other types of a hemorrhoids.

Clinic and diagnostics

In the beginning unpleasant sensations (foreign body). These phenomena strengthen at diet disturbance, disorders of function of an intestine. Then there are bleedings (at the moment of a defecation or after it), a pain (arises at apposition of an inflammation, a clottage, infringement, fundament fractures), an itch (owing to a skin maceration at mucous abjections from an intestine, that can lead to an eczema).

The following stage - abaissement:

1. I STAGE: ganglions prolapse from the proctal canal only at a defecation and then are independently set
2. II STAGE: abaissement of ganglions at a defecation and physical exercises, independently are not set (arm)
3. III STAGE: abaissement of ganglions at an insignificant load, independently is not set

Treatment

I STAGE - conservative at not complicated forms (clysters, purgatives, sclerosing therapy).

Contraindications: infectious diseases, inflammatory diseases in the field of the proctal canal.

Alcohol-novocainic admixture, an admixture of Acidum carbolicum with Novocainum and sunflower-seed oil.

Surgical treatment at II - III stages.

The modern concept of a pathogenesis has allowed all establishments to consider pathogenetic as the most proved operation hemorrhoidectomy. Recognizing that in overwhelming majority of cases patients with a hemorrhoids have three basic bunches of hemorrhoidal ganglions (3-7-11 hours) and that outside ganglions (fimbrias) have the same localisation, they have suggested to exsect these three ganglions outside - inside the uniform block, dressing the establishments of ganglion a silk ligature and abandoning wounds the open. The given intervention the most radical also has the least number of relapses. Meanwhile after this operation there is a big number of complications: a pyesis of wounds of the proctal canal and perianal range, acute a paraproctitis, a strong painful syndrome, bleedings, rasping vicious hands of the proctal canal, an anus stricture.

Proceeding from the above described complications two paravariations of the given intervention are offered:

• A hemorrhoidectomy with sewing of two phlegmskinned wound edges to a bottom. Thus there is a part of not taken in surface of the wound which healing descends a second intention. The given operation is shown at patients with an inflammation of the mucosa covering hemorrhoidal ganglions or with the circumscribed region of a necrosis.

  Technics of operation: a divulsion of the proctal canal do not effect. Crush clamps on ganglions do not impose. Edges of the proctal canal plant in parties Alice plugs. The Bottom edge of the thrombosed intrinsic ganglion (7 hours), grasp Alice plugs and cautiously tighten outside. The leg of ganglion located some above a dentate line in which palpatory define a pulsing of a trailer branch of the top proctal artery is Thus clearly visible. On mucous legs in region do a nyxis by an abrupt round needle and a ligature from the chromeplated catgut spend in a submucosal layer under the establishment of a leg of ganglion, pricking out a needle on an inverse lateral surface of a leg of ganglion, stretch a ligature and in the same foramen do again a needle nyxis, spend her anatropicly in a submucosal layer and tap through a pristine foramen of a puncture. Thus a ligature spend in a submucosal layer round all vascular bundle of a leg of ganglion. After that the intestines deduced in a lumen tighten the ligature extremities and fasten in three ganglions. After cutting off of strands ligature the ganglion is dipped in a submucosal layer. A ligation of vascular bundles in legs of ganglions at 3-7-11 o'clock carry out at different levels.

  The space 0,3 see more distally from the location ligate the vascular leg, two semioval cuts dissect a mucosa, a dermal part of the anal canal and the perianal skin, covering ganglion. Dissect from two parties mucous and a skin separate to the ganglion establishment then ganglion cut from the establishment to ligate a vascular leg outside inside. separate from ganglion slizisto-dermal edges of a wound file from two parties to a bottom of a bed of remote ganglion rare nodal catgut seams in chessboard order. Thus in the centre the bed remains to the traumatic surface open a narrow stria in width no more than 0,2 see Similarly delete ganglions on 3 and 11 hours. Operation finish introduction in a lumen of the canal of the turunda impregnated with ointment.

• The hemorrhoidectomy with a sealing of wounds tightly is applied, when the phenomena of a necrosis and an inflammation mucous, covering ganglions, no.

  The technics is similar previous except for the closing stage - a sealing of operational wounds. Thus a sealing effect tightly nodulose catgut seams with seizure last bottoms of a wound. Operation finish applying of a bandage with 50 ° alcohol on anus range.

  Both new procedures allow to execute a hemorrhoidectomy and when there is no full conformity in a locating of intrinsic and outside ganglions. Thus on one of two new methods first of all it is necessary to remove intrinsic, then outside ganglions.

Advantage of new procedure over applied earlier:

• The ligation at different levels excludes a ligature sliding, its becoming infected - preventive maintenance of bleedings
• In addition frames the best conditions for faster healing of wounds

Authors develop new paravariation of a hemorrhoidectomy at which in the proctal canal the linear wounds taken in by a thin catgut and protected from a becoming infected by the special device from the polymerous Membranula are formed. They also have refused a distention of a proctal constrictor and in the presence of a sphincter spastic stricture consider expedient performance of a lateral hypodermic intrinsic sphincterotomy.

New procedures

For the purpose of excising of hemorrhoidal ganglions last years began to apply often cryosurgical equipment. Together with it there are complications (entering of liquid contents from a fundament, an ulcer of the proctal canal, a stricture of an anus, a proctorrhagia, an emiction delay) which confine indications to application of the given mean.

Many surgeons have received good results after a hemorrhoidectomy with application of a laser scalpel. However, excising of hemorrhoidal ganglions by means of laser beams is bound to presence of special equipment and the prepared shots that complicates its application.

Surgical treatment of a hemorrhoids at elderly patients with concomitant diseases sometimes is fraught with a failure. In this connection the procedure of a dressing of intrinsic hemorrhoidal ganglions by means of the special devices, for the first time offered Blaisdell is applied. Barron has improved the instrument and has changed a silk ligature small, with outside diameter 5 mm, the latex ring, having the soft, gradual squeezing an effect leading to an ischemia and a necrosis of the dressed ganglion. The displacement (of crude oil) the stump ring teared away ganglion protects it from occurrence of a bleeding both in early, and in more serotinal season. Small traumatic procedures it is caused by speed of applying by means of the device of the latex ring through an anoscope on a leg of the ganglion which is settling down above a dentate line where the mucosa is insensitive.

Mediate place between conservative and surgical methods occupy an injection mean of treatment.

There is an opinion, that it is effective at sick of a hemorrhoids without abaissement of intrinsic ganglions and in the absence of inflammatory processes in the field of an anus.

Summarising, it is possible to tell, that now the basic method of treatment of a hemorrhoids is the surgical mean, and the most adequate operation - hemorrhoidectomy in modern paravariations.