Warung Bebas

Wednesday, 24 August 2011

Guillain Barre Syndrome Therapy and Treatment

In most patients can heal itself. treatment general is symptomatic. Although it is said that this disease can be cured itself, should be considered a long treatment time and number of disability ( sequelae ) high enough so that the treatment should still be given. The goal of therapy particular is to reduce disease severity and speed healing through the immune system ( immunotherapy ).

Most studies suggest that the use of steroid preparations is not has a value of / is not useful for therapy of GBS.

Plasmaparesis or plasma exchange aims to remove factors circulating autoantibodies. Plasmaparesis usage at GBS shows the results good, in the form of a more rapid clinical improvement, the use of the tools of breath fewer, and shorter treatment time. treatment is by replacing the 200-250 ml plasma / kg in 7-14 days. Plasmaparesis more beneficial when given during the initial symptom onset ( first week ).

Immunosuppressant treatment:
1. IV immunoglobulin
Treatment with gamma globulin is more profitable intervena compared plasmaparesis because of side effects / complications lighter. dose maintenance 0.4 g / kg weight / day for 3 days followed by dose maintenance 0.4 g / kg weight / day every 15 days until healed.
2. cytotoxic drugs
Sitotoxic drug delivery is recommended:
a. 6 mercaptopurin (6- MP )
b. azathioprine
c. cyclophosphamid
Side effects of these medications include: alopecia, vomiting, nausea and pain head.

Saturday, 13 August 2011

How To Diagnose and Prognose Guillain Barre Syndrome

After posting about the definition, etiology, and patofisiology, today Mbah Dukun Bagong, original shaman from Indonesia, will explain how to diagnose Guillain Barre Syndrome and how about prognosis. 

1.  Laboratory tests
Laboratory picture shows elevation of protein levels in the cerebrospinal fluid (> 0.5 mg%) without being followed by the elevation of the number of cells in the cerebrospinal fluid, this is called cytoalbuminic dissociation.  The elevation was started at 1-2 weeks of disease onset and reached its peak after 3-6 weeks.  The number of mononuclear cells was <10 cells/mm3.  However in a minority of patients found no elevation of protein levels in cerebrospinal fluid.  There is may increasing serum immunoglobulin.  Some patients, can occur with hyponatremia caused by SIADH (syndrome Inapproriate antidiuretic hormone).

 2.  Electrophysiological examination (EMG)
Electrodiagnostic manifestations that supports to diagnosis is the slowing speed of motor and sensory nerve delivery.  Retention of elongated distal motor speed slows down delivery of f-wave, indicating a slowdown in the proximal segments and nerve roots.  In addition to supporting the diagnosis of electrophysiological examination is also useful for determining the prognosis of the disease: if found potential denervation suggests that the longer the healing of disease and did not recover completely.

Commonly used diagnostic criteria are the criteria of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS), namely:
1.  The characteristics necessary for diagnosis:
The occurrence of progressive weakness Hyporeflexia
2.  The characteristics that strongly support the diagnosis of GBS:
a.  Clinical symptoms:
Diagnosis of GBS is clinically mainly enforced.  GBS is characterized by an acute paralysis / weakness of motor progresive rapidly (maximal within 4 weeks, 50% reached the peak in 2 weeks, 80% in 3 weeks, and 90% in 4 weeks), relatively symmetrical with loss of tendon reflexes  (areflexi or hipoflexia) and preceded by paresthesias of two or three weeks after suffering a fever accompanied by dissociation cytoalbumine on liquor and mild sensory disturbances and motor peripheral.  Symptoms of cranial nerves ± 50% occurred N VII parese and often bilateral.  Other brain nerves which supply can be affected especially the tongue and muscles of swallowing, sometimes <5% of cases, starting from the muscle ekstraocculer neuropathy or other brain nerves.  Recovery: starts 2-4 weeks after progression stops, can be elongated up to several months.  Autonomic dysfunction.  Tachycardia and arrhythmia, postural hypotension, hypertension, and vasomotor symptoms.  No fever at onset of neurological symptoms.
b.  The characteristics of cerebrospinal fluid abnormalities are strongly supporting the diagnosis:
Cerebrospinal fluid protein picture of the CSS.  Increased after 1 week of symptoms or an increase in LP serial number of cerebrospinal fluid mononuclear cells <10 cells / mm.
1) No increase in protein after 1 week of symptom CSS
2) The number of cells CSS: 11-50 MN/mm3
c.  EMG examination
Electrodiagnostic picture that supports the diagnosis: there is a slowdown in the speed of conductivity / nerve conduction block on EMG even in 80% of cases.  Usually the speed of carrying about 60% of normal.

1.  Asymmetric paralysis that persisted.
2.  Bladder and bowel disorders are settled.
3.  Bladder and bowel disturbances at onset.
4.  The number of mononuclear cells in cerebrospinal fluid> 50 cells mm3.
5.  There PMN leukocytes in the cerebrospinal fluid.
6.  Impaired sensibility demarcated.
7.  Poliomyelitis, botulism, hysteria or toxic neuropathies (eg due to lead poisoning / lead, itrofurantoin, dapsone, organophosphates), Diphtheric paralysis, miller-fisher syndrome, cranial sensory deficit, Pandisautonomia pure, Chronic demyyelinative acquired neuropathy, acute intermittent Porphyria.

Before the existence of artificial ventilation approximately 20% of patients died due to respiratory failure.  Today's death ranged from 2-10%, with cause of death due to respiratory failure, impaired autonomic function, pulmonary infection and pulmonary embolism.  Most patients (60-80%) recover completely within six months.  A small percentage (7-22%) healed within 12 months with mild motor abnormalities and atrophy of the small muscles in the arms and leg. 3-5% of patients relapse.

Guillain Barre Syndrome

Synonims for Guillain Barre Syndrome are : Idiopathic polyneuritis, acute febrile polyneuritis (polineuritis febrile), infective polyneuritis, Post Infectious polyneuritis (polineuritis acute post-infection), acute inflammatory demyelinating (acute toxic polineuritis), Polyradiculoneuropathy, Guillain Barre Strohl Syndrome, Landry Ascending paralysis, and Landry Guillain Barre Syndrome. 

GBS is a clinical syndrome characterized by acute paralysis that occurs is associated with the autoimmune process in which the target is the peripheral nerves, roots, and cranial nerves.
The etiology of GBS is still not yet known certainly.  The theory adopted today is an aberration immunobiologic, both primary immune response or immune mediated process.  Latent period between infection and symptoms polineuritis gives the notion that the abnormalities are likely caused by an allergic reaction in response to peripheral nerve.  In many cases, the infection was not previously found, except sometimes the peripheral nerves and ventral and dorsal spinal cord, there were also disturbances in the spinal cord and medulla oblongata.
Some conditions / diseases that precede and perhaps something to do with the occurrence of GBS, among others:
1.  Viral or bacterial infection
GBS often associated with acute non-specific infection.  Incidence of GBS cases associated with this infection approximately between 56% - 80%, ie 1 to 4 weeks before neurological symptoms occur such as upper respiratory tract or gastrointestinal infection.  Acute infections are associated with GBS:
a.  Viruses: CMV, EBV, HIV, varicella-zoster virus, Vaccinia / smallpox, influenza, Measles, Mumps, Rubella, hepatitis, Coxsackie, Echo.
b.  Bacteria: Campylobacter, Jejeni, Mycoplasma, Pneumonia, Typhoid, Borrelia B, paratyphoid, Brucellosis, Chlamydia, Legionella, Listeria.
2.  Vaccination
3.  Surgery, anesthesia
4.  Systemic diseases, such as malignancy, systemic lupus erythematosus, thyroiditis, and Addison's disease
5.  Pregnancy or the puerperium
6.  Endocrine Disorders

1.  Latent period
The time between infected or prodromal state that preceded it and the onset of neurological symptoms.  The length of this latent period ranged from one to 28 days, an average of 9 days.  In this latent period there has been no clinical symptoms that arise.
2.  Clinical Symptoms
a.  Paralysis
The main clinical manifestation is the paralysis of the muscles of the lower extremity motor neurone type of muscles of extremities, body and sometimes also the face.  In most patients, paralysis of both lower extremities begins later spread asenderen to the body, upper limbs and cranial nerves.  Sometimes it can also be subjected to all four limbs simultaneously, and then spread to the body and cranial nerves.  Paralysis of these muscles and is followed by a symmetrical or arefleksia hyporefleksia.  Usually the degree of paralysis of the muscles of the proximal portion is more severe than the distal, but it can also same, or distal parts more severe thanproximal part.
b.  Impaired sensibility
Paresthesias are usually more obvious on the distal extremities, the face can also be charged with distribution sircumoral.  Objective sensory deficit is usually minimal and often with the pattern of distribution such as socks and gloves.  Ekstroseptif sensibility more commonly affected than on proprioceptive sensibility.  Muscle pain often encountered after physical activity.
c.  Cranial nerve
Cranial nerve is most commonly affected is N. VII.  Paralysis of the facial muscles often begins on one side but then soon became bilateral.  All the cranial nerves may be subject except NI and N. VIII.  Diplopia can occur as a result of N. N. IV or III exposed.  When the N. IX and NX exposed will cause a disruption in the form of difficult swallowing, dysphonia and in severe cases cause respiratory failure due to n.  laryngeal paralysis.
d.  Impaired autonomic function
Impaired autonomic function is found in 25% of patients with GBS.  The disorder is a tachycardia or bradycardia less frequently, red face (facial flushing), fluctuating hypertension or hypotension, loss of sweating or episodic profuse diaphoresis.  Urinary retention or urinary incontinence is rarely encountered.  Autonomic disorders are rarely settled more than one or two weeks.
e.  Respiratory failure
Respiratory failure is a major complication that can be fatal if not treated properly.  Respiratory failure caused by paralysis of the diaphragm and the paralysis of respiratory muscles, which is found in 10-33 percent of patients.
f.  Papilledema
Sometimes found papilledema, the cause is not known with certainty.  Presumably because the elevation levels of protein in the muscles that cause blockage of fluid arachoidales villi that absorption of cerebrospinal fluid is reduced.

Myelinated axons conducts of nerve impulses faster than the unmyelinated axons.  Along the way the myelinated fibers interference occurs in the membranes (node Ranvier) where direct contact between the membrane of axons of cells with extracellular fluid.  Highly permeable membrane at the node, so that conduction be good.  Movement of ions into and out axons can occur rapidly only at the Ranvier nodes, so that impulses along nerve fibers bermielin can jump from one node to another node (conduction salsatori) with sufficiently strong.  In GBS, the myelin membranes that surround the axons lost.  Myelin membrane is quite susceptible to injury because many agents and conditions, including physical trauma, hypoxemia, toxic chemicals, vascular insufficiency, and immunological reactions.  Demyelination is a common response of neural networks against many adverse conditions.  Loss of myelin fibers in Guillain - Barre Syndrome makes salsatory conduction unlikely to occur, and the transmission of nerve impulses
canceled.  Mechanisms of how infections, vaccinations, trauma, or other factors that precipitate the occurrence of acute demyelination in GBS is still not known with certainty.  Many experts conclude that the nerve damage that occurs in this syndrome is through an immunologic mechanism (the process of antibody response against viruses or bacteria) that cause damage to the nervous edge to paralysis evidence that imunopatogenesis is the mechanism that causes peripheral nerve injury in this syndrome are :
1.  Obtainment of antibodies or cellular immune response (keen mediated immunity) against infectious agents on peripheral nerve.
2.  Presence of auto antibodies against peripheral nervous system
3.  Accumulation of antigen antibody complexes acquired from circulation in the blood vessels peripheral nerves causing peripheral nerve demyelination process.  Demyelination process of peripheral nerve in GBS is influenced by the response of cellular immunity and humoral immunity triggered by previous events, the most common viral infection.
Due to an infection or certain circumstances will arise that precedes GBS autoantibodies or cellular immunity against the network system peripheral nerves.  Meningococcal infections, viral infections, syphilis or trauma to the spinal cord, can lead to adhesion- arachnoid membrane attachment.  In tropical countries the cause is an infection of tuberculosis.  In certain places the attachment post-infection can ensnare ventral roots (dorsal root as well).  Because not all ventral roots exposed, but mostly on the cliquegroups , the root-root of the cervical and lumbosacral diinstrumensia are most commonly affected by the attachment of post-infection.  Therefore LMN paralysis most often found in the muscles of the limbs, the muscles around the shoulder and hip joints.  Paralysis of the arm with a sensory deficit on both legs or the muscles of the limbs.  Pathologically found myelin degeneration with edema that may or without cell infiltration.  Infiltration consisting of mononuclear cells.  These cells infiltrate mainly composed of small lymphocytes, medium and looks too, macrophages, and polymorphonuclear cells at the beginning of the disease.  After that comes the plasma cells and mast cells.  Segmental nerve fibers and axonal degeneration.  These lesions be limited to the proximal segments and spinal roots or spread along peripheral nerves.  Predilection for the spinal roots allegedly due to lack of effective permeability between the blood and nerves in the area.

Course of the disease
Natural history of GBS, the time scale and severity of paralysis varies between different patients with GBS.  The course of this disease consists of three phases, namely:
1.  Progressive phase
Starting from the onset of the disease, which during this phase of paralysis gain weight until it reaches a maximum.  This phase lasts a few from up to 4 weeks, rarely exceeding 8 weeks.
2.  Plateau phase
Paralysis has reached the maximum and settle.  This phase can be short for 2 days, most often for 3 weeks, but rarely more than 7 weeks.
3.  Phase reconvalesense
Characterized by the onset of extremity paralysis improvement that lasted for several months. Totally runs in time less than 6 months.

Saturday, 6 August 2011

Treatment and Therapy of Haemorrhoid (Ambeien)

Today Mbah Dukun Bagong the Original Indonesian Shaman has guest. She complaints about her anal. She feel comfort while sit and hurt when get pup. she telss that her faeces is bleeding. Whats wrong? Mbah Dukun will explain
1. Definition
2. Etiology
3 Classification
4 Therapy and Treatment

Haemorrhoid is enlarged veins or swelling and inflammation of the plexus hemorroidale veins, of rectum or anus region. Haemorrhoid is a submucosal swelling in the anal canal that contains a venous plexus, the small arteries, and the widened areolae tissue. Increased venous pressure caused by straining ( low-fiber diet ) or hemodynamic changes ( during pregnancy ) causes chronic dilatation of the submucosal venous plexus. Found at 3 o'clock position, 7, and 11 in the anal canal.

In addition Haemorrhoid also caused by:
1. Heredity
2. Pregnancy due to hormonal changes
3. chronic Obstipation ( constipation).
4. Disease which makes sufferers often push
5. The emphasis of venous blood return flow,
6. More sit position.
7. Chronic diarrhea.
8. stretching

Generally, divided into two haemorrhoids,  Haemorrhoid Internal and external:
1. Internal Haemorrhoids, swelling occurs in the rectum that can not be seen or touched, usually pink.
2. External Haemorrhoids, anal attacked, causing pain, soreness, and itching. If pushed out by the stool, constipation can lead to clotting ( thrombosis ), which makes the pile of blue - purple.

•    Grade 1 are small swellings on the inside lining of the back passage. They cannot be seen or felt from outside the anus. Grade 1 haemorrhoids are common. In some people they enlarge further to grade 2 or more.

•    Grade 2 are larger. They may be partly pushed out (prolapse) from the anus when you go to the toilet, but quickly spring back inside again.

•    Grade 3 hang out (prolapse) from the anus. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.
Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.

Haemorrhoid Treatment
1.  Non-surgical therapy
a.  Drug therapy (medical) / diet
Most people with Haemorrhoids grade I and grade II can be treated by simple local actions and diet advice.  Diet (food) should consist of high-fiber foods such as vegetables and fruits.  These foods make the blob contents of the colon, but soft, making it easier defecation and excessive straining reduces the necessity.  Rectal suppositories and ointments are known to have no significant effect except for the effects of anesthetic and astringent.
Prolapsed Internal Haemorrhoids with edema can usually be put back slowly followed by bed rest and local compress to reduce swelling.  Soak sitting with a warm liquid can also relieve pain
b.  Sclerotherapy
Sclerotherapy is the injection of chemical solutions that stimulate, for example 5% phenol from vegetable oil.  The injection is given into the submucosa in the loose areolar tissue beneath the internal Haemorrhoids with the intention of causing a sterile inflammation that later become fibrotic and scar.  Inoculation is done on the upper side of mucocutaneous line with a long needle through anoscope.  If the injection done at the right place, there is no pain.  Injection complications include infection, acute prostatitis if included prostate, and hypersensitivity reactions to drugs injection.Injection of sclerotic material with advice about food is an effective therapy for Haemorrhoids internal grades I and II, are not appropriate for more severe Haemorrhoids or prolapse.
c.  With rubber band ligation
Rubber band ligation is the most popular acts in America to treat Haemorrhoids, because without anesthesia, without sedation, and without hospitalization with a relatively low cost compared to surgery Haemorrhoidectomy techniques.  However, these measures are only effective at grade II and III.  This technique can actually be very meaningful solution for Haemorrhoid patients who do not want surgery but want therapy effectively.  In Indonesia, this tool has not been widely circulated, so the technique is still limited.
This technique is the simplicity only pair at the base of the Haemorrhoid rubber band which serves to clamp the blood vessels of Haemorrhoid.  In a few days and despite the Haemorrhoid will cured automatically and ruptured with faeces when defecation.  Usually after three to four days.  "there will be a scar which useful to prevent Haemorrhoids to recur.
Procedural in using this technique: First, patient with left lateral position, then, anoscope with obturator inserted into the anal canal and then pull the obturator to be able to see.  Anoscope used to look at the three locations Haemorrhoids.  Put two rubber bands on the ligator with filler cone.  Place the forceps into the ligator and insert them into the anoscope.  Clamp Haemorrhoid by forceps and then pull into the drum ligator.  Press the handle to release the second ligator rubber band to the bottom of Haemorrhoids.  Note the appearance of Haemorrhoids after the release of the instrument.  Haemorrhoid Ligator has length work seven inches.  At one time treatment only tied one Haemorrhoidal complex, whereas next ligation performed within the next 2-4 weeks.
The main complications of this ligation is the onset of pain caused mucocutaneous line exposeda.  To avoid this the bracelet is placed far enough from the mucocutaneous line.  Severe pain can be caused by infection.  Bleeding Haemorrhoids can occur when experiencing necrosis, usually after 70-10 days.
d.  Cryotherapy / surgical frozen
Haemorrhoids can also be frozen by low temperatures once using CO2 or NO2, resulting in necrosis and finally fibrosis.  If used carefully, and only given to the top of the Haemorrhoids in the rectum anus connection, then cryotherapy achieve results similar to those seen in ligation with rubber bands and no pain.  Cold induced through the sonde from the small engine
designed for this process.  This action is fast and easy to do in an office or clinic.  This therapy is not widely used because of the necrotic mucosa difficult specified extent.  Cryotherapy is more suitable for palliative therapy in rectal carcinoma ireponibel
e.  Haemorroidal artery ligation (HAL)
Use Doppler ultrasound method Haemorrhoidal Transproctoscopie Artery ligation (TDUHAL).  Implementation of this method is quite simple; patients underwent only the binding action of the arteries that leads to the swelling of Haemorrhoids.  Characteristic TDUHAL method is employed the tool of Doppler ultrasound and
supporting equipment.  In the sophisticated and expensive equipment have doppler transducer, such sensors are equipped loudspeakers.  With the help of this tool, doctors may hear the sound pulse so that it can know where the troubled artery.  In front of the doppler transducer, there is a small window and lights.  From this hole in the artery the doctor performs the binding problem earlier.  Approximate  fastening point 10 cm from the anus.  With the introduction of therapy in the form of sedation in order not anxious, this action only takes 15 minutes plus to recovery from sedation for about 30 minutes, handling the piles in this way is painless means.  Post-action is not required special care.  Patients do not need to be hospitalized.  Only be given antibiotics and analgesic, Haemorrhoids medicine (anusol), and laxatives to make soft of dirt.  By doing the binding of arteries, Haemorrhoidal blood supply is no longer received.  "In theory, two weeks after the binding, the blood vessels going to die," therefore, over time the lump will shrink, not lost.  The success rate of this method is about 80%.  TDUHAL best method to handle up to third-degree Haemorrhoids.  The more severe Haemorrhoid suffered by patients, the more binding performed.
f.  Infra Red coagulation (IRC) / Infra Red Coagulation
With the infrared rays generated by a tool called a photocuagulation, cauterized Haemorrhoids bulge resulting in tissue necrosis and ultimately fibrosis.  This method is best used on bleeding Haemorrhoids.
g.  Generator galvanized
Haemorrhoidal tissue damaged by direct electrical current from the battery chemistry.  This method is most effectively used on internal Haemorrhoids.
h.  Bipolar coagulation / bipolar diathermy
The principle remains the same with the other above the Haemorrhoid therapy that is causing tissue necrosis and finally fibrosis.  But used as a destroyer of the tissue of high-frequency electromagnetic radiation.  In therapy with bipolar diathermy, mucous membranes around the Haemorrhoidal heated by electromagnetic radiation frequency
height until eventually arise tissue damage.  This method is effective for internal bleeding Haemorrhoids.

2. Surgical Therapy
a. Haemorrhoidectomy
A surgery and the appointment hemoroidalis plexus and mucosal or without mucosa that is only done on the tissue which really excessive.  Indications: Patients with chronic complaints and grade III and IV Haemorrhoids, recurrent bleeding and anemia that doesn’t heal  with other  simple therapies, Haemorrhoids degrees IV with thrombus and severe pain.  Surgical therapy was chosen for patients who experience chronic complaints and in patients with degree III and IV hemorrhoids.  Surgical therapy can also be done with recurrent bleeding and anemia that can not be cured by other therapies are more modest.  Fourth-degree Haemorrhoidsufferers with thrombosis and severe pain can be helped immediately by haemoroidectomy.
The principle that must be considered in hemoroidektomi is excision which is only done on the tissue that actually redundant.  Excision anoderm economically performed on normal skin and does not interfere with the anal sphincter.  Excision of this tissue should be combined with the reconstruction of the tunica mucosa because of a deformity of the anal canal due to mucosal prolapse.  There are three surgical treatments available today that is conventional surgery (using a knife and scissors), laser surgery (laser beam as a cutting tool) and surgical staplers (using a tool with the working principle of a stapler).
Currently there are three commonly used surgical techniques are:
a.  Conventional Surgery
1.  Engineering Milligan - Morgan
This technique is used for Haemorrhoidbulge in three main places.  This technique was developed in England by Milligan and Morgan in 1973.  Hemorrhoidal mass base just above the linea mucocutaneous, hold  with hemostats and retracted from the rectum.  Then mounted transfiction catgut sutures proximal to the plexus hemoroidalis.  It is important to prevent the installation of suture through the internal sphincter muscle.  The second hemostat is placed distal to the external hemorrhoids.  An elliptical incision is made with a scalpel through the skin and the tunica mucosa around plexus hemoroidalis internus and externus, released from the underlying tissue.  Haemorrhoids excised totally.  When the dissection reached transfiction cat gut sutures then excised haemorrhoidal ekstrenal under the skin.
After securing hemostasis, the anal mucosa and skin was closed longitudinally with a simple tack.  Usually no more than three groups of Haemorrhoidare removed at one time.  Rectal stricture can be a complication of excision of the tunica mucosa of the rectum that is too much.  So it is better to take too little rather than taking too much tissue.
2.  Whitehead Engineering
Surgical technique used for Haemorrhoidthat this circular is to peel the entire Haemorrhoidby exempting from the submucosal and mucosal resection held a circular to the mucosal area.  Then try again mucosal continuity.
3.  Langenbeck technique
In Langenbeck technique, the internal Haemorrhoidradier clamped with clamps.  Perform tack under the clamp with cat gut chromic No. 2 / 0.  Then the excision of tissue above the clamps.  After the clamps removed and baste under the clamp jaws tied up.  This technique is used more often because of how easy and does not contain the risk of formation scar tissue causing stenosis secondary usual.
b.  Laser Surgery
In principle, this surgery same with conventional surgery, but only the tool uses a laser cutter.  When the laser cut, burned tissue vessels so not much bleeding, not a lot of injuries and with minimal pain.
In the laser surgery, pain decreased because of nerve pain seared participate.  In the anus, there are a lot of nerve.  In conventional surgery, when postoperative pain will be felt at all when cutting the tissue, nerve fibers nerve fibers did not open due to shrinking while the sheath to contract. While the laser surgery, nerve fibers and nerve sheath attached together, such as engraved so that nerve fibers do not open.
For haemoroidectomy, required laser power 12-14 watts.  Once the tissue is removed, the incision soaked antiseptic solution.  Within 4-6 weeks, the wound will dry up.  This procedure can be performed only by an outpatient basis.
c.  Surgical Stapler
This technique is also known by the name of the Procedure for Prolapse Haemorrhoid(PPH) or Haemorrhoids Circular Stapler.  This technique was introduced in 1993 by Italian physician named Longo so the technique is also often called the Longo technique.  In Indonesia, this tool was introduced in 1999.  Tools used in accordance with the principles of working stapler.  This tool forms like flashlights, consisting of a circle in front of and driving force behind it.  Basically hemorrhoidal tissue is naturally contained in the anal canal.  Its function is as a cushion during defecation.  Cooperation hemorrhoidal tissue and m.  sfinter ani to dilate and constrict ensure control of discharge and feces from the rectum.  PPH technique reduces the prolapse of hemorrhoidal tissue by pushing it upward
mucocutaneous line of hemorrhoidal tissue and restore it to its original anatomic position because hemorrhoidal tissue is still needed as a cushion during defecation, so it does not need to be removed all.
At first the prolapsed hemorrhoidal tissue is pushed upwards with a tool called a dilator, and then sewn to the tunica mucosa of the anal wall.  Then the stapler device is inserted into the dilator.  From stapler issued a bracelet of titanium inserted in the suture and implanted in the upper anal canal to strengthen the position of hemorrhoidal tissue.  Part of excess hemorrhoidal tissue into the stapler.  By turning the screw located at the tip of the tool, the tool will cut the excess tissue automatically.
Truncated hemorrhoidal tissue with the blood supply to tissues is interrupted so that the hemorrhoidal tissue to deflate by itself.  The advantage of this technique is to return to anatomical position, do not interfere with the function of the anus, no anal discharge, pain minimal because of the actions carried out sensitive parts, the action be quick about 20-45 minutes, patients recover more quickly so that the inpatients in the hospital getting shorter.
Although rare, the action has the risk of PPH:
1.  If too much tissue that go wasted, will result in damage to rectal wall.
2.  If m.  sfinter ani internus strechted, can cause dysfunction in both the short and long term.
3.  As with other techniques in surgery, pelvic infections have been reported.
4.  PPH may fail to Haemorrhoid which too large because it is difficult to gain entrance into the anal canal and even if they could get in, the tissue may be too thick to get into the stapler.

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