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Benign Anorectal Disease
L Yuko Shimotake SUNY – Downstate Department of Surgery
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Outline
• Anorectal anatomy • Hemorrhoids • Abscess • Fistula • Anal Fissure • Rectal Prolapse
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Anorectal Anatomy • rectum 12-15cm • dentate line - transition point
between rectal columnar cells and anal squamous cells
• anal canal - dentate line to anal verge
• internal and external sphincters
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Anorectal Anatomy • blood supply
• IMA → superior rectal artery • IIA → middle rectal artery • IIA → pudendal artery → inferior
rectal artery • venous drainage
• superior rectal veins → IMV into portal system
• middle and inferior rectal veins → pudendal vein → IIV
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Hemorrhoids
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Hemorrhoids
• cushions • left lateral • right anterior • right posterior
• valsalva → engorgement of hemorrhoids → occlusion of anal canal
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Hemorrhoids
• maintains continence • allows for dilation of anoderm without
tearing • discriminate between solid, liquid, gas
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Hemorrhoids
• cushions • left lateral • right anterior • right posterior
• valsalva → engorgement of hemorrhoids → occlusion of anal canal to maintain continence
• allows for dilation of anoderm without tearing
• discriminate between solid, liquid, gas
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Hemorrhoids • straining/constipation → OVER-
engorgement and bleeding • age - decreased collagen
content
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Hemorrhoids • internal
• proximal to dentate line • insensate • bleeding or prolapse
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Hemorrhoids • internal
• proximal to dentate line • insensate • bleeding or prolapse
• external • distal to dentate line • sensate • painful
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Hemorrhoids • internal
• proximal to dentate line • insensate • bleeding or prolapse
• external • distal to dentate line • sensate • painful
• combined - cross dentate line
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External Hemorrhoids • acute thrombosis
• rupture of external hemorrhoidal plexus
vein → tense hematoma
• pain increases or remains constant x 2-3 days then subsides as clot reabsorbs or overlying skin necrosis
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External Hemorrhoids • if within 72h → EXCISION of hemorrhoid
• if after 72h → sitz bath, stool softeners,
topical anesthetics
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Internal Hemorrhoids
• classification • grade I - bleeding and prolapse
into anal canal • grade II - spontaneous
reduction • grade III - manual reduction • grade IV - irreducible
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• grades III-IV, gangrenous → operative management
• uncomplicated grades II-III → fixation procedure
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• rubber band ligation • infrared coagulation • sclerotherapy
• grades III-IV, gangrenous → operative management
• uncomplicated grades II-III → fixation procedure
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• grades III-IV, gangrenous → operative management • closed hemorrhoidectomy • open hemorrhoidectomy
• uncomplicated grades II-III → fixation procedure
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• grades III-IV, gangrenous → operative management
• uncomplicated grades II-III → fixation procedure • stapled hemorrhoidopexy • suture hemorrhoidopexy
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• rubber band ligation • infrared coagulation • sclerotherapy
• grades III-IV, gangrenous → operative management • closed hemorrhoidectomy • open hemorrhoidectomy
• uncomplicated grades II-III → fixation procedure • stapled hemorrhoidopexy • suture hemorrhoidopexy
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• rubber band ligation • infrared coagulation • sclerotherapy
• 80-100% effective
• superior to sclerotherapy with respect to prolapse, bleeding and recurrence
• should treat each complex individually - 2 per session
• complications • severe pain • external hemorrhoid thrombosis • bleeding 3-7d after procedure requiring
intervention • pelvic sepsis - pain, fever, difficulty
urinating → EUA, debridement of necrotic tissue, IV antibiotics
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• rubber band ligation • infrared coagulation • sclerotherapy
• tungsten-halogen light coagulation
• less painful and less risk of hemorrhage than banding
• less effective
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Internal Hemorrhoids - treatment • grades I-III → non-operative management
• rubber band ligation • infrared coagulation • sclerotherapy
• acutely bleeding grades I-II
• can treat all hemorrhoids at once, but may require multiple treatments
• complications - prostatic abscess, ED, pylephlebitis, sloughing ulcer, stricture
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Internal Hemorrhoids - treatment • grades III-IV, gangrenous → operative management
• closed hemorrhoidectomy • open hemorrhoidectomy
• diamond-shaped incision • identify internal sphincter muscle • suture ligated with with 2-0 absorbable
suture • Gelfoam packing, pain control, sitz bath,
stool softeners
• complications - wound infection, fistula, stricture, 90% success rate
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Internal Hemorrhoids - treatment • grades III-IV, gangrenous → operative management
• closed hemorrhoidectomy • open hemorrhoidectomy - leave anoderm open, Europe
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Internal Hemorrhoids - treatment • uncomplicated grades II-III → fixation procedure
• stapled hemorrhoidopexy • suture hemorrhoidopexy • purse-string suture placement
• 2cm proximal to the apex of hemorrhoid • 4cm above the dentate line then tightened • circular stapler and inspect for doughnut in
tissue • avoid injury to vagina!
• maintains the vascular cushions • less painful • better wound healing
• high recurrence rate
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Internal Hemorrhoids - treatment • uncomplicated grades II-III → fixation procedure
• stapled hemorrhoidopexy • suture hemorrhoidopexy
• horizontal sutures above dentate line and at apex of hemorrhoid
• excision of rectal mucosa between • tie and allow adherence
• no special instruments required
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Hemorrhoids – special cases • pregnancy
• constipation, lax sphincter, increased blood volume, straining, uterine pressure
• often resolve spontaneously after delivery
• conservative management • can intervene in acutely thromboses
hemorrhoids if necessary
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Hemorrhoids – special cases • pregnancy
• IBD
• avoid surgical management due to risk of non healing
• high risk of major incontinence • 90% heal within 2 months with NOM
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Hemorrhoids – special cases • pregnancy
• IBD
• immunocompromised
• must rule out infectious etiology via endoscopy, biopsy, cultures
• safe if well-controlled disease but surgery should be avoided unless absolutely necessary
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Hemorrhoids – special cases • pregnancy
• IBD
• immunocompromised
• portal hypertension
• same rate of hemorrhoids in patients with portal hypertension
• anorectal varices can be ligated, staple anopexy, TIPS, mesocaval shunt, mesorenal shunt
• avoid hemorrhoidectomy
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Abscess
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Abscess - causes
• cryptoglandular - blockage of anal crypts → infection of gland → suppuration → 40-60% go on to have fistula
• crohn’s disease • trauma • pelvic sepsis - diverticuliits,
appendicitis • atypical infections - TB
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Abscess - types
• perianal • intermuscular • intersphincteric • submucosal • supralevator • ischiorectal
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Abscess - types
• perianal • intermuscular • intersphincteric • submucosal • supralevator • ischiorectal - horseshoe -
deep postanal space to either or both sides
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Abscess – presentation and evaluation
• anal pain • tenderness • erythema • swelling • systemic symptoms - fever, tachycardia, leukocytosis
• consider CT scan if concern for horseshoe abscess, supralevator
abscess, or necrotizing soft tissue infection
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Abscess - treatment
• incision and drainage
• consider packing or mushroom catheter if large
• consider OR if large or complicated • antibiotics for DM, erythema or
necrotizing infection
• horseshoe - do not unroof, but perform radial counter incisions with connecting penroses
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Fistula
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Fistula
• 40-60% abscess • “chronic abscess”
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Fistula - types
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Fistula – Goodsall’s rule
• posterior → posterior midline internal opening via curved tract
• anterior → radial tract anterior
opening
• exception - 3cm from anal verge anteriorly → posterior midline internal openings
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Fistula – clinical presentation
• pain • purulent/bloody drainage • external opening
• if change in bowel function, multiple external fistula opening, internal opening other than dentate line, or multiple internal openings, then consider IBD, malignancy, HIV
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Fistula – evaluation
• anoscopy versus EUA • probe all openings with care to avoid iatrogenic fistulization • hydrogen peroxide, endoanal US, fistulography, MRI
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Fistula – goals of management
• complete drainage of abscess • maintain sphincter function • allow for healing of the fistula • removal of internal opening
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Fistula – treatment
• cutting • primary fistulotomy
• sphincter-sparing • seton placement • endorectal or dermal advancement flap • fibrin sealant • anal fistula plug • ligation of interphincteris fustal tract (LIFT)
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Fistula – primary fistulotomy
• superficial, intersphincteric fistulas or low transsphincteric fistulas involving less than 1/3 external sphincter muscle
• unroof and marsulialize
• C/I - women with anterior fistula,
immmunocompromised patients, IBD to avoid incontinence
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Fistula – seton
• high transphincteric fistulas, suprasphincteric fistula, anterior fistula, immunocompromised, IBD
• drainage - via braided suture or vessel loop
• cutting seton - high risk of incontinence
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Fistula – fibrin
• fibrin seal • coagulation seal • low morbidity • no risk of incontinence • 14-40% success rate
• fibrin plug • porcine submucosal plug • 43-87% success rate
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Fistula – LIFT
• ligation of intersphincteric fistula tract
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Fistula – advancement flap
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Fistulas
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Anal Fissure
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Anal fissure
• exquisitely painful ulcer or mucosal tear
• constipation 3x likelihood
• passage of hard stool, trauma
• increased resting tone
(decreased vascular supply)
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Anal fissure - presentation
• 90% posterior midline
• female 25% anterior midline - lateral blood supply
• atypical location or refractory
fissures - must biopsy to r/o infection, granuloma, cancer
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Anal Fissure - types
• acute • <6 week • superficial • flat edges • painful • non-pruritic
• chronic • >6 weeks • deep • sentinel pile and raised edges • less painful • pruritic
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Anal Fissure – operative management
• goal • relief of spasm of internal anal sphincter
• complications of surgery • bleeding • infection • fecal incontinence - cochrane review that quality of life is still higher with
incontinence compared to with fissure
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Anal Fissure – non-operative management
• nitroglycerine ointment • nitric oxide dimer locally releases nitric oxide → binds cGMP → smooth muscle
relaxation • SE - headaches
• CCB
• smooth muscle relaxation • effective as nitroglycerine with less side effects
• phosphodiesterase inhibitor
• cGMP degradation → smooth muscle relaxation
• botulinum toxin injection • acetylcholine release prevention → inhibits striated muscle contraction of external
sphincter and internal sphincter; as effective as nitro with less side effects
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Anal Fissure – operative management
• open sphincterotomy • closed sphincterotomy
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Anal Fissure – treatment
• acute → sitz bath, dietary fiber, stool softeners x 6 weeks
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Anal Fissure – treatment
• acute → sitz bath, dietary fiber, stool softeners x 6 weeks • refractory → add CCB, botox, nitroglycerine ointment
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Anal Fissure – treatment
• acute → sitz bath, dietary fiber, stool softeners x 6 weeks • refractory → add CCB, botox, nitroglycerine ointment • chronic or recurrent → surgery
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Rectal Prolapse
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Rectal Prolapse
• epidemiology • 90% females • >50yo s/p vaginal childbirth • psychiatric patients • nursing home patients • young men 20-40yo
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Rectal Prolapse • full thickness
• all layers of bowel wall • circular mucosal fold
appearance • partial thickness
• mucosa only • radial folding
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Rectal Prolapse – symptoms and evaluation
• rectal bleeding with defection • mucoid discharge • sensation of incomplete
evacuation • tenesmus
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Rectal Prolapse – symptoms and evaluation
• rectal bleeding with defection • mucoid discharge • sensation of incomplete
evacuation • tenesmus
• exam • protruding rectum on valsalva • patulous anus • diminished resting tone and squeeze
pressures on DRE • colonoscopy - r/o other pathology • manometry - assess sphincter
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Rectal Prolapse – surgical approach
• perineal approach • transabdominal approach
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Rectal Prolapse – surgical approach
• perineal approach • local anesthesia • less pain • earlier return of bowel
function • quicker tolerance of regular
diet and ambulation
• higher recurrence rate
• transabdominal approach • general anesthesia • more pain • longer hospitalization
• definitive treatment
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Rectal Prolapse – perineal approach • delorme’s procedure aka
mucosal sleeve resection • altemeier’s procedure aka
perineal rectosigmoidectomy
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Rectal Prolapse – perineal approach • delorme’s procedure aka
mucosal sleeve resection • excision of mucosa and
submucosal layers • complications
• urinary retention • bleeding • leak • stricture • diarrhea • recurrence - 6-26%
• altemeier’s procedure aka perineal rectosigmoidectomy
![Page 71: Benign Anorectal Disease Anorectal Disease.pdfAnal Fissure . everyone has hemorrhoids. Anal fissure • exquisitely painful ulcer or mucosal tear • constipation 3x likelihood •](https://reader033.vdocuments.net/reader033/viewer/2022043000/5f750aab915fed0fe17aa4ee/html5/thumbnails/71.jpg)
Rectal Prolapse – perineal approach • delorme’s procedure aka
mucosal sleeve resection • excision of mucosa and
submucosal layers • complications
• urinary retention • bleeding • leak • stricture • diarrhea • recurrence - 6-26%
• altemeier’s procedure aka perineal rectosigmoidectomy • full-thickness excision and
removal of redundant colon • complications
• bleeding • dehiscence • recurrence - if
inadequate resection
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Rectal Prolapse – delorme’s procedure
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Rectal Prolapse – altemeier’s procedure
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Rectal Prolapse - transabdominal approach
• abdominal rectopexy and sigmoidectomy • complete mobilization of rectum to levator complex • elevation of rectum and fixation to pre-sacral fascia
• recurrence 0-9%
• complications
• LBO • SBO • leak • bleeding
• abdominal rectopexy alone • worse constipation
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Summary • Hemorrhoids
• Internal - hemorrhoidectomy versus NOM • External - excision versus NOM • Past medical history
• Abscess • incision and drain
• Fistula • spare the sphincter
• Fissure • relax the sphincter
• Rectal Prolapse • perineal - high recurrence • transabdominal - higher complication rate
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Thank you
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