Sept.


4,
2012

ANORECTAL
SURGERY


 Dr.
Omar
Ocampo





Outline
 thrombosis.
Prolapse,
bleeding,
and
thrombosis
are
the

• Hemorrhoids

o Sypmtoms

common
problems
encountered
in
haemorrhoids.

o Types
 

o Classification
and
Symptoms
 1. INTERNAL
hemorrhoids
above
the
dentate
line

o Treatment
 o Bleeding

o Hemorrhoids
during
pregnancy

o Hemorrhoids
in
Portal
Hypertension

o Prolapse

• Anal
Fissure
 o Thrombosis
(rare)

o Symptom
 

o Classification
 2. EXTERNAL
hemorrhoids
below
the
dentate
line

o Treatment

• Anorectal
Abscess
 o Thrombosis
which
may
cause
severe
pain
(anoderm)

o Types
 

o Diagnosis

o Treatment

• PERIANAL
SEPSIS
IN
THE
IMMUNOCOMPROMISED

• NECROTIZING
SOFT
TISSUE
INFECTION
OF
THE
PERINEUM

• FISTULA
IN
ANO

• STENOSIS/STRICTURE

• ANAL
SPHINCTER
INJURY



Hemorrhoids

• Cushions
of
submucosal
tissue
containing
venules,

arterioles,
and
smooth
muscle
fibers

• Has
three
hemorrhoidal
cushions

o Left
lateral

o Right
posterior
 

o Right
anterior
 Figure
2.
Hemorrhoids


 

Types
of
Hemorrhoids



External
Hemorrhoids

• Located
distal
to
the
dentate
line

• Covered
with
anoderm

• Thrombosis
may
cause
significant
pain

• Adequate
local
anesthesia



Skin
Tag

• Redundant
fibrotic
skin
at
the
anal
verge

• Persisting
as
the
residua
of
a
thrombosed
external

hemorrhoids


 • Itching
and
difficulty
with
hygiene

Figure
1.
Right
hemorrhoidal
cushions
can
also
be
lateral
(right



anterolateral,
right
posterolateral).
There
are
also
minor

Both
External
haemorrhoids
and
skin
tags
may
require
surgery

cushions
that
may
become
asymptomatic.

if
large
and
symptomatic.
Non‐symptomatic
hemorrhoids
don’t



need
surgery.

o Part
of
the
continence
mechanism



o Aid
in
complete
closure
of
anal
canal
at
rest

Internal
Hemorrhoids

o Treatment
is
ONLY
indicated
if
it
becomes

• Located
proximal
to
the
dentate
line

symptomatic

• Covered
by
insensate
anorectal
mucosa
(no
pain)





Symptoms

First‐Degree
Hemorrhoids

• Excessive
straining

‐ Bulge
into
the
anal
canal
and
may
prolapse
beyond
the

• Increased
abdominal
pressure

• Hard
stools
 PROLAPSE
 dentate
line
on
straining



• BLEEDING
 Increased
venous
 Second‐Degree
hemorrhoids

• THROMBOSIS
 engorgement
of
the
 ‐ Prolapse
through
the
anus
but
reduce
spontaneously


 hemorrhoidal
plexus



Due
to
excessive
straining,
increased
abdominal
pressure
or

Third‐Degree
Hemorrhoids

hard
stools
there
is
increase
in
venous
engorgement
of
the

‐ Prolapse
through
the
anal
canal
and
require
manual

hemorrhoidal
plexus
leading
to
prolapse,
bleeding
and

reduction.

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
1
of
12

Fourth
degree
hemorrhoids
 Rubber
Band
Ligation

‐ Prolapse
but
cannot
be
reduced
and
are
at
risk
for
 • Mucosa
located
1
to
2
cm
proximal
to
the
dentate
line
is

strangulation

 grasped
and
pulled
into
a
rubber
band
applier,
causing


 scarring
and
preventing
further
bleeding
or
prolapse

Mixed
Hemorrhoids
 

• Mixed
internal
and
external
hemorrhoids
and
have
the

characteristics
of
both.

• Hemorrhoidectomy
for
large
and
symptomatic

• [Schwartz]
can
also
be
called
combination
of
internal
and
external

haemorrhoids,
where
characteristics
of
both
are
present.



Classification
and
Symptoms

External

o Perianal
sweeling

o Thrombosis

 Pain
 

Figure
4.
Rubber
Band
Ligation

 Increased
swelling


 

• Ligate
only
1‐2
quadrants
per
visit.
The
next
quadrant

Internal

should
be
ligated
3
weeks
after.

o First
degree

• If
you
ligate
3
or
more
quadrants
in
a
visit,
the
patient
will

 Bleeding

o Second
degree
 complain
pain
and
discomfort.



 Bleeding

Complications

 Prolapse
spontaneous
reduction

• Severe
pain
if
banded
distal
to
the
dentate
line

o Third
degree

• Urinary
retention
(1%)
is
moe
likely
if
inadvertently

 Prolapse
requires
manual
reduction

 Itch
 included
a
portion
of
the
internal
sphincter

• Infection
–
severe
pain,
fever
and
urinary
retention
(early

 Bleeding

signs);


o Fourth
degree

o Treatment:
EUA
(Examination
Under
Anesthesia),

 Prolapse
not
reducible

 Bleeding
 debridement,
drainage,
antibiotics
(BS)

• Bleeding
–
7
to
10
days
post
RBL
(pedicle
necroses
and

 Thrombosis
(rarely)

sloughs);
usually
self‐limited



o Treatment:
If
persistent
–
EUA,
suture
ligation
of
the

Treatment

pedicle

• Depends
on
the
signs
and
symptoms





st nd Infrared
Photocoagulation

Bleeding
(1 
and
2 
degree)

• Office
procedure

o Initial
–
dietary
fiber,
stool
softeners,
increased
fluid
 st nd
• Small
1 
degree
and
2 
degree

intake,
avoidance
of
straining
(medical
therapy)

• Applied
to
apex
of
each
hemorrhoid
to
coagulate
the

o Usually
bleeding
hemorrhoids
may
last
3‐5
days
or
1

week
which
stops
spontaneously
but
if
not,
it
is
 underlying
plexus

• 3
quadrants
during
the
same
visit

persistent
bleeding.





nd rd
Persistent
Bleeding
(1st,
2 
and
3 
degree)
 Sclerotherapy

o Rubber
band
ligation
 • Office
procedure
(injected
into
the
submucosa)

st nd rd

 • 1 
degree,
2 
degree,
and
small
3 
degree

nd rd
Prolapse
(2 
and
3 
degree)
 • Sclerosing
solution
(1‐3
mL)
phenol
in
olive
oil,
sodium

o Rubber
band
ligation
 morrhuate,
quinine
urea


 • Same
as
sclerotherapy
in
venous
problems






Figure
3.
Prolapse
 


 Figure
5.
Sclerotherapy


 


 

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
2
of
12

 Excision
of
External
Thrombosed
Hemorrhoids
  For
large,
bleeding
internal
haemorrhoids

• Intense
pain
for
the
first
24
to
72
hours
after
thrombosis
  Ineffective
in
management
of
external
or
large

(perform
elliptical
excision
immediately)
 mixed
hemorrhoids

• But
after
72
hours,
the
clot
begins
to
resorb,
and
pain
 o THD

resolved
spontaneously
(excision
unnecessary)
  Morinaga
introduced
a
new
technique
called

• Sitz
bath/analgesics
–
medical
treatment
performed
 hemorrhoidal
artery
ligation
(HAL)

beyond
third
day
(72hrs)if
no
excision
made
  Sohn
called
it
Transanal
hemorrhoidal


 Dearterialization
(THD)

 Doppler
to
locate
vessels
helps
accurately
ligate

the
vessel

 Vessel
ligation
results
in
decongestion
of
piles

 Decreased
blood
flow
allows
shrinkage
of
piles

and
reduction
of
prolapse
with
reduction
in

bleeding






Figure
6.
External
Thrombosed
Hemorrhoids



Operative
Hemorrhoidectomy

• Elective

• Decreasing
blood
flow
to
the
hemorrhoidal
plexuses

• Excising
redundant
anoderm
and
mucosa





Figure
8.
Hemorrhoidopexy



Whitehead’s
Hemorrhoidectomy
for
Very
Large
Prolapse

o Circumferential
excision
of
hemorrhoidal
cushions

above
the
dentate
line

o Ectropion
–
Whitehead’s
deformity





Figure
7.
Operative
Hemorrhoidectomy
 Efficacy:
Stapled
hemorrhoidopexy
vs.
Conventional

1. Excisional
 Hemorrhoidectomy

o Open
–
Milligan
Morgan
(heals
by
secondary
 
 PPH
 Conventional

intention)
 Pain
 ↓
 ↑

o Closed
–
Parks/Ferguson
 Wound
healing
 ↑
 ↓


 Wound
discharge
 ↓
 ↑

Widened
hemorrhoidectomy
is
performed
for
severe
cases
 Return
to
work
 Faster
 Equivocal

(cauliflower
haemorrhoids)
but
usual
complication
is
ectropion.
 Overall
satisfaction
 better
 Equivocal


 

2. Energy
Source
 Complications
of
Hemorrhoidectomy

o None
(scissors)
 • Post‐operative
Pain

o Diathermy
 o Oral
narcotics
(usually)
–
NSAIDS

o Harmonic
scalpel
 o Muscle
relaxants

o Ligasure
 o Topical
analgesics


 o Warm
sitz
baths
(comfort
measure)

3. Hemorrhoidopexy
 

o PPH
[Procedure
for
Prolapse
and
Hemorrhoids]
 • Urinary
Retention

 Renamed
(from
stapled
hemorrhoidectomy)
now
 o Occurs
in
10
to
50%

called
Stapled
Hemorrhoidoplexy
 o Minimized
by
limiting
peri‐op
IV
fluids
and
providing

 Fixes
the
redundant
mucosa
above
the
dentate
 adequate
analgesia

line
 o Initial
management:
warm
compress
over
the
bladder

 Removes
a
short
circumferential
segment
of
 o Straight
catheter
or
Indwelling
foley
catheter
if
still

rectal
mucosa
proximal
to
the
dentate
line
using
 not
resolved

a
circular
stapler
 

 Effectively
ligates
the
venules
feeding
the
 • Fecal
Impaction

hemorrhoidal
plexus
and
fixes
redundant
 o Decreased
by
pre‐op
enemas/bowel
prep,
post‐op

mucosa
higher
in
the
anal
canal
 laxatives,
and
adequate
pain
control

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
3
of
12

• Massive
Bleeding
 • Treatment

o One
of
the
most
common
experienced
problems
 o Lowering
portal
venous
pressure

o Immediate:
inadequate
ligation
of
the
pedicle
24‐ o Suture
ligation
may
be
necessary
if
massive
bleeding

38hrs
after
ligation.
The
patient
is
sent
immediately
to
 persists
(rarely)

the
operating
room.
 o Surgical
hemorrhoidectomy
should
be
avoided
in

 Kasalanan
ng
surgeon
why
this
occurs
 these
patients
because
of
the
risk
of
massive,

o Treatment:
emergency
suture
ligation

 difficult‐to‐control
variceal
bleeding

o Delayed:
7‐10
days
after
the
where
the
vascular
 

mucosa
over
the
pedicles
 [Schwartz]


 Rectal
Varices

• In
Schwartz
this
is
placed
under
types
of
hemorrhoids

• Infection

• May
result
from
portal
hypertension

o Uncommon
 • Despite
the
anastomoses
between
portal
venous
system
(middle
and

o Necrotizing
soft
tissue
infection
can
occur
with
 upper
hemorrhoidal
plexuses)
and
systemic
venous
system
(inferior

devastating
consequences
 rectal
 plexuses),
 hemorrhoidal
 disease
 are
 no
 more
 common
 in

o Treatment:
EUA,
drainage
of
abscess
and/or
 patients
with
portal
hypertension
than
in
normal
population.

debridement,
antibiotics
 • May
cause
significant
hemmorhage


 • Best
 treated
 with
 lowering
 portal
 venous
 pressure;
 avoid
 surgical

hemorrhoidectomy
 due
 to
 risk
 of
 massive,
 difficult‐to‐control

variceal
bleeding.



Anal
Fissure

• Tear
in
the
anoderm
distal
to
the
dentate
line

• Related
to
trauma
from
either
the
passage
of
hard
stool
or

prolonged
diarrhea

• Ask
for
history
of
hemorrhoidal
problem

• Cycle
contributes
to
development
of
a
poorly
healing


 wound
that
becomes
a
CHRONIC
ANAL
FISSURE

Figure
9.
Infection
 



• Long‐term
Sequalae

o Incontinence

 Transient
incontinence
to
flatus
(short
lived)

 The
most
feared
complication
(probably)

 Permanent
incontinence
is
technical
if
the

patient
cuts
off
the
sphincter

o Anal
stenosis

 Scarring
after
extensive
resection
of
perianal
skin

o Ectropion



Hemorrhoids
During
Pregnancy

• Should
only
be
offered
for
acutely
thrombosed
and

prolapsed
hemorrhoidal
disease
(local
anesthesia
in
the
 

Figure
10

left
anterolateral
position
to
rotate
the
uterus
off
the
IVC)





Location
of
Chronic
Anal
Fissure

Postpartum
Hemorrhoids

• Posterior
midline
–
85
to
90%

• Note:
in
Schwartz
this
is
under
types
of
hemorrhoids

• Anterior
midline
–
10
to
15%

• Straining
during
labor

• Off
midline
–
<1%
(lateral
location
think
of
other
problems)

o Edema

o Crohn’s
disease

o Thrombosis

o HIV

o Strangulation

o Syphilis

• Hemorrhoidectomy

o TB

o Majority
that
intensify
during
delivery
usually
resolve

o Leukemia

o Do
not
perform
right
after
delivery
even
if
the
patient



is
still
in
anesthesia,
wait
for
few
weeks
because
it

Characteristic
Symptoms

usually
resolves

• Tearing
pain
with
defecation



• Hematochezia
(blood
on
the
toilet
paper)

Portal
Hypertension
in
Relation
to
Hemorrhoids

• Sensation
of
intense
and
painful
anal
spasm
for
several

• Portal
hypertension
was
long
thought
to
increase
the
risk

hours
after
BM

of
hemorrhoidal
bleeding
because
of
the
anastomoses

• Too
tender
too
tolerate
DRE,
anoscopy,
or
proctoscopy
–

between
the
portal
venous
system
(middle
and
upper

Do
not
perform
digital
rectal
exam
immediately


hemorrhoidal
plexuses)
and
the
systemic
venous
system



(inferior
rectal
plexuses)



• Incidence:
normal
population
=
patients
with
portal
HPN



• Rectal
varices
may
cause
haemorrhage
in
these
patients



Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
4
of
12

 Classifications
of
Anal
Fissure
 • Recurrence
in
less
than
10%

• Acute
fissure
 • May
be
performed
close
or
open
with
the
same
principle
of

o Superficial
tear
of
the
distal
anoderm
 hemorrhoidectomy.
Open
heals
through
second
intention.


o Almost
always
heals
with
medical
management
 


 [Schwartz]

The
aim
of
this
procedure
is
to
decrease
spasm
of
the
internal
sphincter

• Chronic
fissure

by
 dividing
 a
 portion
 of
 the
 muscle.
 Risk
 of
 incontinence
 (usually
 to

o Ulceration
and
heaped‐up
edges
with
the
white
fibers
 flatus)
ranges
from
5
to
15%.

of
the
IAS
visible
at
the
base
of
the
ulcer
 

o External
skin
tag
 

o Hypertrophied
anal
papilla

o May
require
surgery



[Schwartz]

A
 lateral
 location
 of
 a
 chronic
 anal
 fissure
 may
 be
 evidence
 of
 an

underlying
 disease
 such
 as
 Crohn's
 disease,
 human
 immunodeficiency

virus,
syphilis,
tuberculosis,
or
leukemia.



Treatment



st
1 
Line
Therapy:
Medical
Management

• Bulk
agents

• Stool
softeners

• Warm
sitz
bath

• Analgesic
creams

• 2%
Lidocaine
jelly/analgesic
creams
 

• 0.2%
nitroglycerin
ointment
–
improve
blood
flow;
side
 Figure
12.
Open
Lateral
Internal
Sphincterotomy
for
Fissure
in
Ano
effect
(headaches)
 

• Oral
and
topical
Ca
channel
blockers
(Diltiazem
and

Nifedipine)

o Temporary
use



Botox
Injection

• Temporary
 myscle
 paralysis
 by
 preventing
 acetylcholine

release
from
presynaptic
nerve
terminals

• Healing
appears
to
be
equivalent
to
medical
therapies






Figure
13.
Closed
Lateral
Internal
Sphincterotomy
for
Fissure
in
Ano


Anorectal
Abscess

• Majority
from
cryptoglandular
infection
found
in
the

intersphincteric
plane



Spaces


 • Perianal
Space

Figure
11.
Botox
Injection
 o Surrounds
the
anus
and
laterally
becomes
continuous


 with
the
fat
of
the
buttocks

[Schwartz]
 

Injection
 of
 botulinum
 toxin
 has
 been
 proposed
 as
 an
 alternative
 to

surgical
 sphincterotomy
 for
 chronic
 fissure.
 Although
 there
 is
 limited

experience
 with
 this
 approach,
 results
 appear
 to
 be
 superior
 to
 other

medical
 therapy,
 and
 complications
 such
 as
 incontinence
 are
 rare.

However,
 healing
 is
 slower
 than
 after
 sphincterotomy
 and
 recurrence

may
be
more
common.




Left
Lateral
Internal
Sphincterotomy

• Recommended
for
fissures
that
failed
medical
therapy

• Decrease
spasm
of
the
IAS
by
dividing
30%
of
the
fibers
 

laterally

 Figure
14

• Healing
rate:
95%
(with
immediate
pain
relief)
 

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
5
of
12

• Interspheric
Space
 TYPES

o Separates
the
internal
and
external
anal
sphincters.
It
 

is
continuous
with
the
perianal
space
distally
and
 Perianal
Abscess

extends
cephalad
into
the
rectal
wall
 • Most
common
manifestation


 • Painful
swelling
at
the
anal
verge

• Ischiorectal
Fossa
 • Spread
through
the
external
sphincter
below
the
level
of
the

o Lateral
and
posterior
to
the
anus
 puborectalis
produces
an
ischiorectal
abscess.

o Contains
the
inferior
rectal
vessels
and
lymphatics
 

o Connected
posteriorly
by
the
deep
postanal
space






Figure
17


 

Figure
15
 Perianal
Abscess

Ischiorectal
Abscess


 • May
become
extremely
large
and
not
visible
in
the

• Deep
Postanal
Space
 perianal
region

o The
two
ischiorectal
spaces
connect
posteriorly
above
the
 • DRE:
painful
swelling
laterally
at
the
ischiorectal
fossa

anococcygeal
ligament
but
below
the
levator
ani
muscle,
 

forming
the
deep
postanal
space

Intersphincteric
Abscess



• Supralevator
spaces

 • Intersphincteric
space

o Lie
above
the
levator
ani
on
either
side
of
the
rectum
 • Notoriously
difficult
to
diagnose
often
requiring
EUA

and
communicate
posteriorly
 


 Pelvic/Supralevator
Abscess

Anatomy
of
these
spaces
influences
the
location
and
spread
of
 • Uncommon

cryptoglandular
infection
 • Upward
extension
of
an
intersphincteric/ischiorecctal

abscess

• Downward
extension
of
an
intraperitoneal
abscess



Diagnosis

• Severe
anal
pain
(most
common
presenting
complaint)‐

walking,
coughing,
or
straining
can
aggravate
the
pain

• A
palpable
mass
may
be
detected
by
inspection
of
the

perianal
area
or
DRE

• Occasionally:
fever,
urinary
retention,
life‐threatening

sepsis



Perianal

PE
alone

Ischiorectal



Complex

CT/MRI

Atypical
Presentations

(such
as
supralevator
or
extralevator
abscess)





 

Figure
16.
Anatomy
of
Perianorectal
Apaces.
(A)
Anterior
View
and
(B)
 Figure
18

Lateral
View
 


 


 

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
6
of
12

[Schwartz]
 Intersphincteric
Abscess

The
diagnosis
of
a
perianal
or
ischiorectal
abscess
can
usually
be
made
 • Difficult
to
diagnose
(little
swelling
and
few
perianal
signs)

with
physical
exam
alone
(either
in
the
office
or
in
the
operating
room).
 • Pain
is
deep
and
“up
inside”
the
anal
area,
usually

However,
 complex
 or
 atypical
 presentations
 may
 require
 imaging

exacerbated
by
cough/sneeze

studies
such
as
CT
or
MRI
to
fully
delineate
the
anatomy
of
the
abscess.


• Intense
pain
that
precludes
DRE



• Diagnosis:
high
index
of
suspicion
requiring
EUA

Treatment

• EUA
–
drained
through
a
limited,
posterior
internal

• Drainage
and
debridement
as
soon
as
diagnosed

sphincterotomy

(antibiotics
alone
are
ineffective)



• If
the
diagnosis
is
in
question,

Supralevator
Abscess

o EUA
(most
expeditious
way
to
both
confirm
and
treat)

• Due
to
upward
extension
of
an
intersphincteric
abscess
–

o Note:
delayed
or
inadequare
treatment
may

drained
through
the
rectum

occasionally
cause
extensive
and
life
threatening

• If
drained
through
the
ischiorectal
fossa
–
complicated

abscess
with
massive
tissue
necrosis
and
septicaemia

suprasphincteric
fistula

• Antibiotics

• Due
to
intra‐abdominal
disease
–
treat
the
primary
cause

o Extensive
overlying
cellulitis

• Abscess
may
be
drained
via
the
most
direct
route:

o Immunocompromised

transabdominal

rectal

ischorectal
fossa

o DM
 

o Valvular
heart
disease
 [Schwartz]

o Drainage
may
be
enough
but
it
is
still
better
to
give
 • Uncommon
and
because
of
its
proximity
to
the
peritoneal
cavity,

antibiotics
 this
can
mimic
intra‐abdominal
conditions.


 • Digital
rectal
examination
may
reveal
an
indurated,
bulging
mass

Perianal
Abscess
 above
the
anorectal
ring.

• Most
can
be
drained
under
local
anethesia
 • If
a
supralevator
abscess
arises
from
the
upward
extension
of
an

ischiorectal
abscess,
it
should
be
drained
through
the
ischiorectal

• Cruciate
incision
(dog
ears
excised
to
prevent
premature

fossa.
 Drainage
 of
 this
 type
 of
 abscess
 through
 the
 rectum
 may

closure)
 result
in
an
extrasphincteric
fistula.



Perianal
Sepsis
in
the
Immunocompromised

[Schwartz]


• Because
 of
 leukopenia,
 these
 patients
 may
 develop
 serious

perianal
 infection
 without
 any
 of
 the
 cardinal
 signs
 of

inflammation.


• While
 broad‐spectrum
 antibiotics
 may
 cure
 some
 of
 these

patients,
 an
 exam
 under
 anesthesia
 should
 not
 be
 delayed

because
 of
 neutropenia.
 An
 increase
 in
 pain
 or
 fever,
 and/or

clinical
deterioration
mandates
an
exam
under
anesthesia.


• Any
 indurated
 area
 should
 be
 incised
 and
 drained,
 biopsied
 to

exclude
a
leukemic
infiltrate,
and
cultured
to
aid
in
the
selection

of
antimicrobial
agents.




 Necrotizing
Soft
Tissue
Infection
of
the
Perineum

Figure
19.
Technique
of
Drainage
of
Perianal
Abscess

 • Lethal
condition

Ischiorectal
Abscess
 • Polymicrobial
and
synergistic

• May
form
horseshoe
abscess
 • Secondary
to
undrained/inadequately
drained

• Simple
abscess:
ipsilateral
drainage
 cryptoglandular
abscess
or
urogenital
infection

• Horseshoe
abscess:
modified
Hanley
technique
requiring
 • Increased
risk:
immunocompromised/diabetic

opening
of
the
deep
postanal
space
and
often
require
 

counterincisions
over
one
or
both
ischiorectal
spaces






Figure
21



Factors

• Delay
in
the
diagnosis
and
treatment
(primary
factor)

• Virulence
of
the
organism
involved

• Metastatic
infections

• Diabetes


 • Blood
dyscrasia,
heart
disease,
CRF

Figure
20.
Drainage
of
Horseshoe
Abscess:
The
deep
postanal
space
is
 • Undrained
abscess/fistula

entered,
incising
the
anococcygeal
ligament
–
counter
drainage

• Obesity
and
smoking

incisions
are
made
for
each
limb
of
the
ischiorectal
space



Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
7
of
12

 Physical
Examination
 • The
fistula
usually
originates
in
the
infected
crypt
(internal

• Necrotic
skin
 opening)
and
tract
to
the
site
of
prior
drainage
(external

• Bullae
 opening)

• Crepitus
 • Other
causes
(complex,
recurrent,
nonhealing
should
raise

• Signs
of
systemic
toxicity
(hypotension,
tachycardia)
 the
suspicion)

• Hemodynamic
instability
 o Trauma


 o Crohn’s
disease

A
high
index
of
suspicion
is
necessary
because
perineal
signs
of
 o Malignancy

severe
infection
may
be
minimal
and
prompt
surgical
 o Radiation

intervention
can
be
lifesaving.
 o Other
infections
(TB,
actinomycosis,
chlamydia)


 • Palpation
rule
=
more
accurate

Types
 

• Type
I:
skin,
subcutaneous
tissue,
fascia
or
muscle

• Type
II:
preperitoneal/retroperitoneal
space
involvement

CT
scan
–
best
diagnostic
procedure



Treatment

• Radical
debridement
–
mainstay
(multiple
operations
may

be
necessary)

• Aggressive
resuscitation

• Broad
spectrum
antibiotics
 

• Colostomy
 Figure
23

o Temporary
‐
Diverticulostomy
 

o For
patient
with
wound
difficult
to
treat
 • Salmon‐Goodsall’s
rule
‐
guide
in
determining
the
location
of

o Sphincter
resection
extensive
 the
internal
opening

o Difficult
wound
management
–
due
to
stool
 • Categorized
based
upon
the
relationship
to
the
anal

contamination
 sphincter
complex


 • Persistent
drainage
will
not
heal
without
surgery

Mortality
 • Majority
(80%)
will
heal
in
single
surgery
but
the
20%
will

• >50%
 require
multiple
operation
depending
on
the
type
of
fistula.

• 3x
higher
in
diabetics,
elderly,
delayed
treatment
 Can
be
depressing
to
the
patient
because
series
of
surgery


 are
done
after
6
months
to
1
year.

[Medscape]
 

Fournier’s
Gangrene
 Types

o Defined
as
a
polymicrobial
necrotizing
fasciitis
of
the



perineal,
perianal,
or
genital
areas

o Disease
is
not
limited
to
young
people
or
to
males,
and
a
 Intersphincteric

cause
is
now
usually
identified
 • Tracks
through
the
distal
IAS
and
intersphincteric
space
to


 an
external
opening
near
the
anal
verge

Fistula
in
Ano
 

• Majority
are
secondary
to
cryptoglandular
abscess
(50%

cured,
50%
FIA)

o The
course
of
the
fistula
can
be
predicted
by
the

anatomy
of
the
previous
abscess






Figure
24



Transsphincteric

• Secondary
to
ischiorectal
abscess
and
extends
through

both
the
IAS
and
EAS



Low
transsphincteric:
30%
of
external
sphincter
is
involved

High
transsphincteric:
>30%
and
treatment
is
different






Figure
22.
Fistula
in
Ano




Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
8
of
12

 Intersphincteric

• Fistulotomy

o Opening
the
fistulous
tract
(unroof)

o Curettage

o Marsupialization

o Healing
by
secondary
intention

• Fistulectomy
(?)
the
outcome
is
the
same
as
fistulotomy

but
with
longer
wound
healing
and
high
rate
of
sphincter



Figure
25
 damage


 

Suprasphincteric
 Transsphincteric

• Originates
in
the
intersphincteric
plane
and
tracks
up
and
 • Low
transphincteric
(<30%)

around
the
entire
EAS

 o Fistulotomy/sphincterotomy


 o Fistulomoty
‐
Best
treatment

o LIFT
(Ligation
of
Intersphincteric
Fistula
Tract)
since
this

procedure
is
not
found
in
our
book,
sir
will
not
ask
about
this.

 Step
1:
identify
the
internal
opening
by
the

injection
of
water
or
probing
through
the

external
opening

• High
transphincteric
(>30%)

o Seton
placement
–
best
treatment

 Drain
placed
through
a
fistula
to
maintain

drainage
and/or
induce
fibrosis

 Cutting
–
consist
of
a
suture
or
a
rubber
band
that
is

placed
through
the
fistula
and
intermittently
tightened


 in
the
office. OR
draining
–
a
noncutting
seton
which

Figure
26
 is
a
soft
plastic
drain,
often
a
vessel
loop,
placed
in
the


 fistula
to
maintain
drainage

Extrasphincteric
 o LIFT

• Originates
in
the
rectal
wall
and
tracks
around
both
 o Advancement
flap

sphincters
to
exit
laterally,
usually
in
the
ischiorectal
fossa
 

• Rare
 Suprasphincteric

• Seton
placement



Extrasphincteric

• Depends
upon
both
the
anatomy
of
fistula
and
its
etiology

–
difficult
to
treat

• In
general,
the
portion
of
the
fistula
outside
the
sphincter

should
be
opened
and
drained
as
well
as
the
primary
tract

at
the
level
of
the
dentate
line

• Multiple
procedures/liberal
use
of
drains
and
setons

• Failure
to
heal

colostomy




 [Schwartz]

Figure
27
 Higher
 fistulas
 may
 be
 treated
 by
 an
 endorectal
 advancement
 flap.


 Fibrin
glue
has
also
been
used
to
treat
persistent
fistulas
with
variable

results.

Investigations



• Endoscopy
(anoscopy,
Flex
sig,
Colo)

Seton
Placement

• Fistulography

• CT
Scan
 May
be
a
suture
or
vessel
loop,
usually
a
drain
placed
in
the

Establish
the
relationship
of
 fistula
to
drain.
Patient
should
have
regular
post‐operative

• Endoanal
UTZ

the
primary
tract
to
anal
 follow
to
monitor
persistence
of
the
disease
or
recurrence
of
the

• MRI


sphincters
 problem







[Schwartz]

Treatment
 Seton
 placement
 –.
 It
 is
 a
 drain
 placed
 through
 a
 fistula
 to
 maintain

• Goal
of
treatment:
eradication
of
sepsis
without
sacrificing
 drainage
and/or
induce
fibrosis

continence
 • Cutting
 seton
 ‐
 consist
 of
 a
 suture
 or
 a
 rubber
 band
 that
 is

• Incontinence
(20
to
50%)
 placed
 through
 the
 fistula
 and
 intermittently
 tightened
 in

• Recurrence/persistence
(up
to
20%)
 the
 office.
 Tightening
 the
 seton
 results
 in
 fibrosis
 and

o Injection
of
H2O2/diluted
methylene
blue
to
detect
the
 gradual
division
of
the
sphincter,
thus
eliminating
the
fistula

while
maintaining
continuity
of
the
sphincter.

tract
of
fistula

• Draining
 seton/
 noncutting
 seton
 is
 a
 soft
 plastic
 drain

o Avoid
creating
artificial
internal
opening
thus
often
 (often
 a
 vessel
 loop)
 placed
 in
 the
 fistula
 to
 maintain

converting
simple
into
a
complex
FIA
 drainage.

o Regular
post‐operative
follow‐up
 


Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
9
of
12

 Stenosis/Stricture
 • Severe:
Cannot
insert
little
finger
unless
forceful
dilatation

• Narrowing
of
the
anus
 or
a
small
Hill‐Ferguson
retractor

o Scarring
 

o Contracture
 Treatment


 • Conservative
treatment

Etiology
 o Bowel
habit
training

• Post‐anorectal
surgery
(most
common
cause
–
 o Bulk
forming

hemorrhoidectomy)
 o Dilatation

• Trauma
  Forceful
dilatation
should
be
condemned

• Radiation
  For
mild
to
moderate
strictures.
Poor
risk

• Anorectal
malformation
 patients,
Crohn’s
dsease,
pelvic
irradiation

• Treatment
of
haemorrhoid
by
caustic
agent
application
or
  Post
stricture
repair
(6
to
8
weeks)

injection
 






Figure
28.
Trauma





Figure
31






Figure
29.
Anorectal
Malformation



Post
hemorrhoidectomy
 
 87.7%

Anorectal
operation
(Crohn’s)
 3.3%

Excision
villous
tumor
 
 1.4%

Others
 
 
 
 2.8%
 


 Figure
32



• Surgical
options

o Stricture
release

o Sphincterotomy

o Stricturoplasty

o anoplasty



Anal
Sphincter
Injury

• Obstetric
trauma
during
vaginal
delivery
(most
common)

th
o Laceration
that
extends
into
the
rectum
(4 
degree)


 o Infection
of
episiotomy

Figure
30.
Overzealous
Post‐hemorrhoidectomy
 o Prolonged
labor


 o Midline
episiotomy

Classification
 • Hemorrhoidectomy

Based
on
severity:
 • Sphincterotomy

• Mild:
tightness
by
well
lubricated
index
finger
or
a
medium
 • Anorectal
abscess/FIA
sugery

Hill‐Ferguson
retractor
 • Trauma

• Moderate:
forceful
dilatation
for
index
finger
or
a
medium
 

Hill‐Ferguson
retractor
 

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
10
of
12

 Diagnostics
 • Obstetrical
injury:
a
preventable
tragedy

• Anal
manometry
 • Complicated
diverticulitis
may
cause
a
colovaginal
fistula.
Crohn's

• EMG
 disease
can
cause
rectovaginal
fistulas
at
all
levels,
as
well
as

colovaginal
and
enterovaginal
fistulas.[Schwartz]

• Endoanal
ultrasound


 

Treatment
 Diagnosis

• Mild
Incontinence
±
Sphincter
Defect
 • Passage
of
flatus/stool
in
the
vagina

VAGINITIS

o May
respond
to
dietary
changes
and/or
biofeedback
 • Large
fistula:
obvious
in
anoscopic/vaginal
examination

• Severe
Incontinence
 • Smaller
fistula
may
be
difficult
to
locate

o Wrap‐around
sphincteroplasty

 • Barium
enema
or
vaginogram


 • Endorecctal
ultrasound

• With
the
patient
in
the
prone
position,
installation
of

methylene
blue
into
the
rectum
while
a
tampon
is
in
the

vagina
may
confirm
the
presence
of
a
small
fistula.



Treatment

• Depending
on
size,
location,
etiology,
and
condition
of
the

surrounding
tissues

• It
is
prudent
to
wait
for
3
to
6
months
before
embarking

upon
surgical
repair
because
up
to
50%
of
RVF
by

obstetrical
injury
heal
spontaneously

• Abscess
should
be
drained

• cryptoglandular
abscess
–
drainage
of
the
abscess
may
allow

spontaneous
closure
[Schwartz]


 • ENDORECTAL
ADVANCEMENT
FLAP
±
overlapping

Figure
33
 sphincteroplasty
(fecal
diversion
rarely
required)


 o Best
for
low
and
middle
RVF

• Significant
loss
of
sphincter
muscle
 o The
principle
of
this
procedure
is
based
upon
the

o Gracilis
muscle
transposition
±
electrostimulation
 advancement
of
healthy
mucosa,
submucosa,
and
circular

o Artificial
anal
sphincter
 muscle
over
the
rectal
opening
(the
high
pressure
side
of
the

o Sacral
nerve
stimulation
(intact
sphincter)
 fistula)
to
promote
healing
[Schwartz]

o OVERLAPPING
SPHINCTEROPLASTY
–
should
be
performed

o The
results
are
variable
and
majority
of
the
results
are

concurrenytly
If
a
sphincter
injury
is
present
[Schwartz]

not
good

• TRANSABDOMINAL
APPROACH
(resection
–
anastomosis)



o High
RVF

• Intractable
incontinence

o Colovaginal
fistula/enterovaginal
fistula

o End
stoma
 o The
diseased
tissue,
which
caused
the
fistula
(upper
rectum,


 sigmoid
colon,
or
small
bowel),
is
resected
and
the
hole
in

Penetrating/Blunt
Trauma
 the
vagina
closed.
[Schwartz]

• Definitive
repair
is
often
deferred
until
other
injuries
have
 o Healthy
tissue,
such
as
omentum
or
muscle,
is
frequently

been
repaired
and
the
patient’s
clinical
condition
is
stable
 interposed
between
the
bowel
anastomosis
and
the
vagina

• Isolated
sphincter
injuries
–
primary
repair
 to
prevent
recurrence.[Schwartz]

• Rectal
+
sphincter
injury
–
fecal
diversion,
distal
rectal
 • RVF
secondary
to
Crohn’s:

washout,
drain
placement
 o Adequate
drainage
of
perianal
sepsis


 o Nutritional
support

Rectovaginal
Fistula
 o Advancement
flap
if
rectum
is
spared

A
 rectovaginal
 fistula
 is
 a
 connection
 between
 the
 vagina
 and
 the
 o Not
amenable
to
advancement
flap
because

rectum
or
anal
canal
proximal
to
the
dentate
line.
Rectovaginal
fistulas
 of
damage
to
the
surrounding
rectal
and
vaginal

are
 classified
 as
 low
 (rectal
 opening
 close
 to
 the
 dentate
 line
 and
 tissues

vaginal
 opening
 in
 the
 fourchette),
 middle
 (vaginal
 opening
 between
 o Mid
and
high
are
occasionally
successfully

the
 fourchette
 and
 cervix),
 or
 high
 (vaginal
 opening
 near
 the
 cervix).
 repaired
via
a
transabdominal
approach

[Schwartz]
 (interposition
of
healthy
tissue
)‐
healthy


 tissue
(omentum,
muscle,
or
nonradiated
bowel)

Classification
 is
interposed
between
the
damaged
rectum
and

LOW
 Rectal
opening
close
 Obstetric
injuries
 vagina.

to
the
dentate
line
 Trauma
(foreign
body)
 • RVF
secondary
to
malignancy

Vaginal
opening
in
 o Resection
of
tumor

the
fourchette
 • Because
differentiating
radiation
damage
from
malignancy

can
be
extremely
difficult,
all
fistulas
resulting
from
radiation

MIDDLE
 
 Severe
obstetric
injury
 should
be
biopsied
to
rule
out
cancer.[Schwartz]

AR/LAR
 

(stapled/handsewn)
 

Radiation
injury
 

Undrained
abscess
 

extension
 

HIGH
 Vaginal
opening
near
 Operative/radiation
 

the
cervix
 injury
 

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
11
of
12

 Anogenital
Warts
(Condyloma
Acuminata)
 Recurrence

• Prevalence:
 • 25
to
67%
within
3
months

o US:
1%
sexually
active
adult;
most
commonly
 • Reactivated
or
reinfection

diagnosed
STDs
 • Immunocompressed
more
(66%
vs
27%)

o Thailand:
most
commonly
diagnosed
STDs
 • Shoreter
recurrence
time
in
immunocompromised
(6.8
vs

• Human
Papilloma
Virus
 15
months)

o There
are
approximately
30
serotypes
of
HPV
[Schwartz]
 • CD4
less:
more
recurrence

o HPV
16
and
18
predispose
to
malignancy
and
flat
 • SURVEILLANCE!
–
IMPORTANT!

dysplasia
in
skin
unaffected
by
warts
 

o HPV
6
and
11
commonly
cause
warts,
no
malignant
 Sexually
Transmitted
Diseases

degeneration
.

 • Bacterial

o Associated
with
AIN
(anal
intraepithelial
neoplasia)
 o Proctitis:
 N.
 gonnorhea,
 C.
 trachomatis,
 T.
 pallidum

and
SCC
 (syphilis),
 H.
 ducreyi
 (chancroid),
 Donovanian
 (granuloma

o Occur
in
the
perianal
area
or
in
the
squamous
 inguinale)

epithelium
of
the
anal
canal
 o Diarrhea:
Campylobacter,
Shigella,
others


 • Parasitic

LOW
RISK
 6,
11
 Genital
wart
 o Entamoeba
histolytica,
Giardia
lamblia

INTERMEDIATE
 31,
33,
45,
51,
 Squamous
 • Viral

o HSV:
cause
extremely
painful
proctitis

RISK
 52,
56,
58,
59
 intraepithelial

o HPV:
 cause
 condyloma
 acuminate
 (anogenital
 warts),
 and

neoplasia
 intraepithelial
 neoplasia,
 SCC.
 HPV
 serotype
 16
 and
 18

HIGH
RISK
 16,
18
 Cervical
dysplasia
 appear
 to
 predispose
 to
 malignancy
 and
 often
 cause
 flat

and
anogenital
 dysplasia
in
skin
unaffected
by
warts.HPV
serotypes
6
and
11

cancer
 often
 cause
 warts,
 but
 do
 not
 appear
 to
 cause
 malignant


 degenerations.
Treatment
of
anal
condyloma
include
topical

Natural
History
 application
 of
 bichloroaceticacid
 or
 podophyllin
 (small

warts),
Imiquimod
(Aldara)
and
surgical
excision/fulguration

• Transmission
via
contact
and
minor
abrasion
 (larger
or
more
extensive
warts)

• Infected
to
basal
keratinocyte



• Viral
genome
+
host
DNA

Pilonidal
Disease

• Incubation
period:
3
weeks
to
8
months

• Cyst
or
infection

• Clinical
manifestation
is
WART
 • Hair‐containing
sinus
or
abscess
occurring
in
the
intergluteal
cleft

• Increase
in
number
and
size
 • Ingrown
hair
may
become
infected
and
preset
acutely
as
abscess


 in
the
sacrococcygeal
region

Eradication
 • Treatment:
incision
and
drainage
for
abscess
as
soon
a
sdiagnosis

• These
lesions
are
difficult
to
treat
 is
made

• Both
conservative
and
surgical
approaches
are
beset
by
 • Definitive
surgical
treatment
includes:

o Unroofing
 the
 tract,
 curetting
 the
 base,
 and
 marsupializing

very
high
recurrence
rate

the
wound


 o Small
lateral
incision
and
pit
incison

Treatment
 o Flap
 closure,
 Z‐plasty,
 advancement
 flap,
 or
 rotational
 flap

• Depends
on
the
location
and
extent
of
disease
 (extensive
and/or
recurrent
pilonidal
disease)


• Topical
(bichloracetic
acid/podophyllin)
 

o 60
to
80%
response
rates
 Hidradenitis
Suppurativa

o Recurrence
and
reinfection
are
common
 • Infection
of
the
cutaneous
apocrine
sweat
glands

• Imiquimod
(Aldara)
–
immunomodulator
 • Mimic
 complex
 anal
 fistula
 disease,
 but
 stops
 at
 anal
 verge

• agent
is
highly
effective
in
treating
condyloma
located
on
 because
there
are
no
apocrine
glands
in
the
anal
canal

the
perianal
skin
and
distal
anal
canal
 • Treatment:
 incision
 and
 drainage
 of
 acute
 abscesses
 and

• For
larger
and
numerous
warts
 unroofing
and
debridement
of
all
chronically
inflamed
fistula

o Excision
and/or
fulguration
(sent
for
pathologic
exam
 END

to
rule
out
dysplasia/malignancy
 

1.
The
pathological
difference
between
the
internal
hemorrhoids
and

• HPV
vaccine

external
hemorrhoids
is
due
to
one
of
the
following:


 a.
The
internal
hemorrhoids
are
located
above
the
dentate
line.

Goals
of
Treatment
 b.
The
internal
hemorrhoids
are
insensate
due
to
its
location

• Eradicate
all
lesions
 above
the
dentate
line.

• Less
pain
 c.
The
lining
epithelium
of
the
internal
hemorrhoids
is
columnar

• Minimal
sessions
 epithelium.
*
0.5

• No
scarring
 d.
The
internal
hemorrhoids
have
painless
bleeding.



• Offer
HPV
immunity

2.
The
area
that
is
responsible
for
sampling
response
is



a.
Above
the
dentate
line
*
0.33

Indications
for
Treatment
 b.
Dentate
line

• Patient’s
desire
 c.
Anorectal
junction

• Symptoms:
pain,
bleeding,
itching
or
burning
 d.
Anal
verge

• Disabling
or
disfiguring
lesions

• Large
numbers
or
sizes

• Patient’s
desire
to
prevent
spreading
to
partner

• Immunocompromised

Ardales|Austria|Avanceña|Azucenas|Cusi
 
 Page
12
of
12