​Both pictures and texts, teach you how to treat "hemorrhoids" under endoscopy (3)

It is only for medical professionals to read for reference.
Transparent cap assists in endoscopic sclerotherapy.

The first two articles respectively introduced the anatomy of hemorrhoids, the pathophysiology of formation, classification, grading, and the anatomical position of the dentate line, the concept of mother hemorrhoids, and the performance of hemorrhoids in the active stage under endoscopy.
In this article, we focus on the transparent cap assisted endoscopy.
Cap-assisted endooscopic sclerotherapy (CAES).

CAES is an innovation of traditional sclerotherapy.
A transparent cap is placed on the front of the colonoscope to assist in the treatment of internal hemorrhoids, a new minimally invasive method [1].

Compared with the traditional anal sclerosing agent treatment endoscope as a soft lens, it has its unique advantages.
First, the light source of the endoscope is brighter and the field of view is clearer, and it is easier to observe the lesion.
Secondly, it can be used for direct vision sclerotherapy or flipped under the mirror.
Operation, 360° no dead angle, more flexible and convenient operation.

The principle of endoscopic sclerotherapy The principle of endoscopic sclerotherapy is guided by the theory of "anal cushion", with the goal of eliminating symptoms rather than eliminating hemorrhoids.

On the basis of not destroying the physiological function of the mucosal tube and anal cushion, the injection of sclerosing agent into the hemorrhoid area (abnormally expanded venous mass) under the endoscope causes irreversible vascular endothelial cell damage, causing aseptic inflammatory effects, formation of thrombus, and finally It is transformed into a fibrous cord and occludes the branch blood vessels of the superior rectal vein, resulting in hardening and atrophy of hemorrhoids, which can prevent bleeding and prolapse [2].

For patients with external hemorrhoids, due to the occlusion of the branch vessels of the superior rectal vein, the backflow of portal vein blood through the communicating vein is blocked, the external hemorrhoids are further reduced, and the symptoms of external hemorrhoids can be relieved.

Indications 1.
Applicable to hemorrhoids in stage I, II and part of stage III (with symptoms such as bleeding and prolapse); 2.
Hemorrhoids in stage I-III are ineffective in diet and drug treatment; 3.
Recurrence after internal hemorrhoid surgery, but not after repeated anal surgery Surgery again; 4.
Fear of surgery, unwilling to receive surgical treatment; 5.
Old age, high blood pressure, diabetes and serious systemic diseases, can not tolerate surgery; 6.
Exclude perianal disease, colorectal cancer, inflammatory Diseases such as bowel disease (IBD).

Contraindications 1.
External hemorrhoids, severe mixed hemorrhoids and hemorrhoids in stage IV; 2.
Hemorrhoids in stage 1-III are accompanied by complications such as incarceration, thrombosis, ulcer, erosion, infection, and anal fistula; 3.
Severe heart, brain, lung, liver , Renal failure cannot tolerate the treatment of internal hemorrhoids; 4.
Perianal infectious diseases, IBD, anal fistula, etc.
; 5.
Combined physical symptoms, mental disorders, pregnant women; 6.
Immune deficiency and susceptibility to infection; 7.
Sclerosing agent allergy.

Patient preparation 1.
Preoperative diet education prepare a diet with less residue according to the intestinal tract; 2.
Concept education: inform patients that asymptomatic internal hemorrhoids do not require treatment.
Internal hemorrhoid treatment aims to eliminate and reduce the symptoms of hemorrhoids rather than changing the size of hemorrhoids and establish the psychological expectations of patients ; 3.
Preoperative talk (methods of operation, possible complications and treatments when complications occur, etc.
); 4.
Mental preparation.

Preoperative preparation 1.
Preoperative related examinations, such as blood routine, coagulation function, biochemistry, electrocardiogram, etc.
; 2.
It is recommended to complete the colonoscopy before treatment to exclude other colon diseases; 3.
Choose the treatment method according to the symptoms of internal hemorrhoids and the experience of the surgeon ( Reverse mirror/sequential mirror); 4.
Treatment plan for special circumstances such as complications during the operation; 5.
Anesthesia assessment.

Equipment and medicine preparation 1.
Endoscope: It is recommended to use colonoscopy for the front endoscope, and for the inverted endoscope, it is recommended to choose an endoscope with a good angle to facilitate the treatment of the inverted endoscope; 2.
Transparent cap and injection needle (25g 4mm injection needle is recommended for the front endoscope treatment 2.
Longer injection needles can be appropriately selected under the inverted lens); 3.
Polycinnamyl alcohol injection and methylene blue. Operation steps Before doing colonoscopy, install a transparent cap on the front end of the colonoscope, complete the colonoscopy.
Retract the mirror to the anus to determine the position of the internal hemorrhoids (focus on the position of the mother hemorrhoids), fully infuse the air to expose the field of view, and clarify the position of the dentate line.
Or determine the injection point at the base of the hemorrhoids through an inverted lens.
Prepare a syringe to prepare 10ml lauric alcohol + 0.
2ml methylene blue and prepare for injection.
The injection point is above the dentate line, and the injection needle is pierced at 30°-40° under direct vision.
(It is easy to penetrate into the muscular layer of the intestinal wall if it is too deep, and if it is too shallow, it will cause pain due to necrosis of the superficial mucosa.
) Just inject the needle with a sense of loss, and inject 0.
5-2ml of cinnamyl alcohol at each injection point, so as to slowly withdraw while injecting.
The needle expands to the injection area and the color turns dark blue to form a hardened post.
After the injection, the needle or the needle sheath is left in place for 10-20 seconds to avoid bleeding at the injection site.

According to the severity and size of hemorrhoids, the dosage of sclerosing agent and the number of injection points can be flexibly controlled.
Generally, 4-5 injection points are selected, and the total amount is controlled within 10-20ml.

After the treatment, the excess gas in the intestine is absorbed and an anal digital examination is performed to promote the even dispersion of the sclerosing agent under the mucosa.

Figure 1: Treatment under the orthoscope Figure 2: Treatment under the inverted microscope [3] Intraoperative details 1.
Wear a transparent cap and adjust it to the best position to fully expose the field of vision and determine the bleeding site.

At the same time, you can observe the needle ejection process and the needle ejection point of the sclerosing injection to reduce the occurrence of complications.
At the same time, you need to pay attention to the appropriate length.
Too short will affect the field of vision, and too long will affect the operating space.

2.
During the operation, there may be a situation where the anus is not tightly sealed and leaks, and the visual field cannot be fully exposed, which affects the observation.
At this time, the assistant can help to squeeze the buttocks to prevent the leak.

3.
Beginners are advised to choose a 4mm short needle to avoid injection into the muscle layer.
After the injection needle penetrates into the mucosa, it can be moved left and right to determine whether it has penetrated the muscle layer.
The skilled person can use a 10mm long needle for injection (used for orthoscopic surgery).
Retreat while injecting, it is more accurate to inject the sclerosing agent into the hemorrhoids to form a hardened pile instead of a hardened ball (the purpose of sclerotherapy is to eliminate the symptoms and at the same time it should be done on the levator anal cushion.
The formation of hardened piles is more effective Lifting the anal cushion).

4.
The injection dose is generally controlled within 2ml.
During stage I, hemorrhoids can be injected at 2-3 points; during stage II-III, hemorrhoids can be injected at 3-5 points, all of which can stop bleeding. 5.
The injection sequence is recommended to be performed in a clockwise direction, so as not to mix up the injection site.

6.
After treatment, be sure to inhale the excess gas in the intestines, so as not to cause the patient to feel bloated and want to defecate.

7.
Avoid fast and large injections to avoid serious complications such as refractory ulcers.
Try not to intensively arrange injections to avoid anal stenosis.

After postoperative care, stay in bed on the day after the operation, avoid standing upright, and reduce pressure on the injection site.

Drink water and fast for 4 hours.
During three days, the diet should be light, digestible, nutritious, and avoid spicy and other irritating foods; avoid strenuous exercise within a week, maintain good habits, and rest more; keep bowel movements smooth and avoid exertion Stool, excessive squatting and defecation and weight-bearing walking, especially for patients with constipation, take lactulose for 72 hours after surgery, 3 times a day, 10ml once for 3-5 days, ordinary patients can also take 1-2 days, and keep it Clean the anus, gently scrub the anus with warm water every time after defecation.
Generally, antibiotics and hemostatic drugs are not used after the operation.
If necessary, hemorrhoid cream or hemorrhoid suppository is used locally to promote recovery.

The advantages of foam sclerosing agent The transparent cap assists the use of sclerosing agent in endoscopic sclerotherapy, Professor Xu Leiming, from Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, innovatively proposed foam sclerosing agent.

The specific advantages of foam hardener are as follows: (1) High adhesion, increasing the contact area between the drug and the blood vessel wall, and the drug stays on the blood vessel wall for a longer time; (2) Good compactness, draining blood, reducing the dilution effect, and promoting blood vessels The occurrence of spasm increases the effect of sclerosis; (3) Ultrasound visibility, contrast before and after injection of sclerosis, using a small probe to check the blood flow of internal hemorrhoids can make it easy to control the drug injection and observe the effect; (4) The selective effect of endothelium makes The risk of tissue damage when overflowing outside the blood vessel is minimized; (5) White foam indications can be seen during the operation, which is not easy to bleed after the operation; (6) The dosage can be significantly reduced, thereby reducing the side effects; (7) The production is simple and safe, Temporary configuration, suitable for medical institutions at all levels.

The configuration method uses a 20ml syringe, selects the mixing ratio of 1% lauric alcohol and gas to 1:4 to prepare a standard foam hardener.

Original solution 4ml: 16ml of air (1:4), connected by a three-way valve, fast push back and forth 15-20 times, use the vortex principle to formulate foam hardener, the foam hardener will liquefy after staying for a period of time, and it can be formed by repeated pushing foam.

Figure 3: The amount of injection during the specific operation of the foam hardener preparation process depends on the color of the mucosa at the injection site and the color of the mucous membrane is off-white.
There is no need to add methylene blue.
The insufficient injection site can be injected under the inverted microscope first, and then injected under the front microscope; after the injection is finished Digital anal examination promotes the even diffusion of sclerosing agent under the mucosa.

Prolapse should be repaid immediately after injection to avoid acute hemorrhoid incarceration.

Figure 4 Treatment of postoperative complications 1.
Abdominal distension: Fully inhale after treatment, and postoperative anal canal exhaust.

2.
Pain: Consider the possibility of being too close to the dentate line, or during the period of anal canal inflammation (such as erosion, ulcer, anal fissure, etc.
).
Sit bath or anti-inflammatory symptomatic ointment can be given.
The anus is slightly painful, generally not Need to be dealt with, and those with obvious pain will be given analgesics after other problems have been ruled out.

3.
Ulcer: Considering that the injection is too deep, the dose is too large, and the injection site is inaccurate during the operation, try to choose the needle above 5mm of the dentate line, and use methylene blue as a tracer.
Fasting or less scum diet can be given.
Metronid Azole enema or oral antibiotics such as levofloxacin.

4.
Local or systemic fever: Consider giving metronidazole enema or oral antibiotic treatment due to inflammation.

5.
Low intestinal obstruction: clean the anus with enema and exhaust, if it is severe, the anal canal can be exhausted.
6.
Discomfort after defecation and change in stool frequency: consider the sensitive period of local skin and mucous membranes after surgery, mostly do not need treatment, and can relieve itself after a few weeks .

In this article, we introduced the related issues of transparent cap-assisted endoscopic sclerotherapy.
The next article will continue to introduce endoscopic apron ligation.
Please continue to pay attention. Reference materials: [1] Zhang Ting, Long Chuyan, Zhang Faming, etc.
Prospective study of transparent membrane assisted endoscopic sclerotherapy for hemorrhoids[J].
Chinese Journal of Digestive Endoscopy, 2017, 10 (34) 516- 518[2]Jagielska I,Kazdepka-Zieminska A,Kaczorowska A,et al.
Evaluation of cerbetocin and oxytoein efficacy in prevention of postpartum hemorrhage in women after cesarean section[J}.
Ginekol POl,2015,86(9):689- 693 [3] Zang Fengli, Sun Jianguo, Xu Keda Clinical observation of transparent cap assisted sclerotherapy for internal hemorrhoid hemorrhage under soft endoscopy.
Chinese Journal of Digestive Endoscopy, August 07, 2020, Issue 3