Anorectal Surgery – Dr. Sirwan Hama

Anorectal Surgery – Dr. Sirwan Hama
Injuries
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Rectum or anal canal may be injured in a number of ways, all uncommon:
Falling in a sitting posture onto pointed object: → rectal impalement
Penetrating injury (including gunshots) to buttocks
Sexual assault or sexual activity involving anal penetration
Fetal head during childbirth, especially forceps-assisted
Diagnosis
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If rigidity or tenderness do early laparotomy
Water-soluble contrast enema or CT scan with rectal contrast to identify perforation
Prior to op put a urethral catheter, if any possibility of urethral injury (suggested by difficulty passing urine or
haematuria) do urethrogram to exclude injury, but better to do suprapubic cystostomy
Treatment: repair +/- defunctioning colostomy or Hartman’s procedure
Foreign bodies in the rectum
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Variety of foreign bodies
A turnip
A large soft rubber sex toy
A tumbler
If difficulty in removal → laparotomy
If considerable laceration of mucosa → temporary colostomy
PROLAPSE
Mucosal prolapse
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Mucous membrane and submucosa of rectum protrude outside the anus for approximately 1–4 cm
double layer of mucous membrane
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In infants
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Undeveloped sacral curve leads to direct downward course of rectum
Reduced resting anal tone causes diminished support to the mucosal lining of the anal
canal (Mann)
In children
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Often commences after an attack of diarrhoea or Loss of weight and consequent loss of fat in ischiorectal fossae
May also be associated with:
o fibrocystic disease
o neurological causes
o mal-development of pelvis
In adults
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Often associated with third-degree haemorrhoids
In female: a torn perineum & in male straining from urethral obstruction
both predispose to mucosal prolapse
In old age: atony of the sphincter mechanism leads to both mucosal and full-thickness prolapse but whether this
atony is the cause of the problem or secondary to it is unknown
Operation for fistula in ano may cause partial prolapse if a large portion of muscle has been divided
prolapse usually localized to the damaged quadrant & seldom progressive
Prolapsed mucous membrane: is pink
prolapsed internal haemorrhoids: is plum-colored and more pedunculated
Treatment
Infants and young children:
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Digital repositioning
o Parents taught to replace protrusion, and any underlying causes are addressed
Submucosal injections
o If digital repositioning fails after 6 weeks’ trial, do injections of 5% phenol in
almond oil under GA causes aseptic inflammation and the mucous membrane
becomes tethered to muscle coat
Surgery
o Occasionally surgery required, retrorectal space entered and rectum sutured to
sacrum
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In adults
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Local treatments
Mucosal prolapse:
o Submucosal injections of phenol in almond oil
o Application of rubber bands sometimes successful
o Excision of the prolapsed mucosa
Unilateral prolapse redundant mucosa excised
Circumferential prolapse: → endoluminal stapling technique
Full-thickness prolapse (synonym: procidentia):
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less common
Consists of all layers of rectal wall
Usually associated with a weak pelvic floor.
Prolapse is thought to commence as an intussusception of rectum, which descends to protrude outside anus
Starts with anterior wall of the rectum, where supporting tissues are weakest, especially in women
More than 4 cm and commonly as much as 10–15 cm in length
Between finger and thumb, the prolapse feels much thicker than a mucosal prolapse
a double thickness of the entire wall of the rectum
Any prolapse over 5 cm in length contains anteriorly between its layers a pouch of peritoneum
A large peritoneal pouch may contain small intestine, which returns to general peritoneal cavity with a
characteristic gurgle when prolapse reduced.
Anal sphincter characteristically patulous and gapes widely on straining to allow rectum to prolapse
Complete prolapse uncommon in children
In adults:
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occurs at any age, but more in elderly
Women: 6X > men
Commonly associated with prolapse of uterus
In Middle East and Asia: complete rectal prolapse not uncommon in young males
In about 50% of adults have fecal incontinence
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Differential diagnosis
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Ileocaecal intussusception protruding from anus → a child with abdominal pain, prolapse
In rectosigmoid intussusception in adult
a deep groove (5 cm or more) between the emerging protruding mass and the margin of the anus, into which
finger can be placed
Treatment
Surgery (perineal or abdominal)
Abdominal rectopexy:
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lower rate of recurrence
but, in elderly and very frail, a perineal operation is indicated
Abdominal procedure causes damage to pelvic autonomic nerves which leads to possible sexual dysfunction,
perineal approach is also usually preferred in young men.
Perineal approach:
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Used most commonly
Thiersch operation
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A steel wire or, more commonly, a silastic or nylon suture around anal
canal:
It is obsolete procedure now
o Suture would often break or cause chronic perineal sepsis, or both
o Anal stenosis may happens and causes severe functional problems
Delorme’s operation:
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Rectal mucosa removed circumferentially from prolapsed rectum over its length
Underlying muscle is then plicated with a series of sutures, when tied rectal muscle concertinaed towards anal
canal
Anal canal mucosa is then sutured circumferentially to rectal mucosa remaining at the tip of the prolapse
Prolapse reduced → a ring of muscle created above anal canal, which prevents recurrence
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Altemeier’s procedure
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Excision of prolapsed rectum and associated sigmoid colon from below with coloanal anastomosis
Abdominal approach
Principle of all:
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Replace and hold rectum in its proper position
Recommended in complete prolapse but otherwise in good health
Wells’ operation: Rectum is fixed firmly to sacrum by inserting a sheet of polypropylene mesh between them
Ripstein’s operation: Hitching up rectosigmoid junction by a Teflon sling to front of the sacrum
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Many surgeons:
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sutured rectopexy
sutures mobilized
rectum to sacrum
by just 4-6 interrupted
non-absorbable sutures
Recently done laparoscopically, reducing operative trauma & limiting
hospital stay
Abdominal rectopexy may ->severe constipation
Some surgeons:
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rectopexy + resection sigmoid colon resection rectopexy (Goldberg)
About 50% of adults with
complete rectal prolapse:
have incontinent
rectopexy cures only
about one third
Ulcerative proctocolitis
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Proctitis present in a high % of ulcerative colitis
Degree of severity of the rectal involvement may influence type of operative procedure
Proctitis due to Crohn’s disease
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Crohn’s occasionally affect rectum, although classically spared
Sigmoidoscopy:
o *inflammatory process tends to be patchy rather than confluent
o *there may be fissuring, ulceration and even a cobblestone appearance
Often associated with severe perineal disease characterised by fistulation
Skip lesions often present in the rest of the colon or small bowel, or both
Amoebic granuloma
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Presents as a soft mass, usually in rectosigmoid region
Frequently mistaken for a carcinoma
Sigmoidoscopy: an ulcerated surface, but less friable than a carcinoma.
A scraping should be taken, preferably with a small, sharp spoon on a long handle, for immediate microscopic
examination
A biopsy can also help
Encountered from time to time in a patient who has never visited an endemic area
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Tuberculous proctitis
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Nearly always associated with active pulmonary TB or TB ulceration of the anus
Submucous rectal abscesses burst and leave ulcers with an undermined edge
A hypertrophic type of TB proctitis occurs in association with TB peritonitis, or TB salpingitis
Requires biopsy for diagnosis
Gonococcal proctitis
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Occurs in both sexes as the result of:
o rectal coitus
o in female, from direct spread from vulva
Acute stage, the mucous membrane is hyperemic, and thick, pus can be expressed as the proctoscope
withdrawn
Early stages, diagnosis easily by bacteriological examination but, later, when infection mixed, more difficult
Systemic treatment so effective that local treatment unnecessary.
Lymphogranuloma venereum
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Modes of infection are similar to GC proctitis
but, in female, chlamydial infection spreading from cervix uteri via lymphatics to the pararectal lymph nodes
common
Proctological findings are similar to GC proctitis
Diagnosis should be suspected when the ing LNs greatly enlarged, although the enlargement may be subsiding
when proctitis commences.
Acquired immunodeficiency syndrome
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May present with a particularly florid type of proctitis
Unusual organisms such as cytomegalovirus (CMV), herpes simplex virus and organisms such as Cryptosporidium
often found.
‘Strawberry’ lesion of the rectosigmoid
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Spirochaeta vincenti and Bacillus fusiformis
Leading symptom diarrhoea, often scantily blood-stained.
Occasionally, diagnosis by demonstration of the specific organisms in the stools
More often, sigmoidoscopy required
Characteristic lesion is thickened, somewhat raised mucosa with superficial ulceration rectosigmoid area
Inflamed mucous membrane oozes blood at numerous pinpoints, resembles an over-ripe strawberry
A swab should be taken from lesion and examined for Vincent’s and fusiform organisms
Swabs from the gums and throat also advisable.
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Rectal bilharziasis
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Schistosoma mansoni, endemic in many tropical and subtropical countries, and particularly in delta of Nile
Stage 1: a cutaneous lesion develops at entrance site of cercariae (parasites of freshwater snails)
Stage 2: pyrexia, urticaria and a high eosinophilia
o Both these stages frequently overlooked
Stage 3 results from deposition of ova in rectum (much more rarely in bladder causing bilharzial dysentery
O/E: later stages, papillomas frequent
sessile or pedunculated, contain ova of trematode
Life cycle same as Schistosoma haematobium.
Untreated, rectum becomes festooned, and prolapse of diseased mucous membrane usual
Prone to develop multiple fistulae in ano
Treatment
o Primary treatment systemic
o When papillomas persist in spite of general treatment local destruction
Proctitis due to herbal enemas
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Well-known clinical entity in tropical Africa
An enema of a concoction of ginger, pepper and bark given by a witch doctor → a virulent proctitis → frequently
pelvic peritonitis
not infrequently, a complete gelatinous cast of the mucous membrane of the rectum extruded
Very large doses of morphine + streptomycin, often prevent a fatal outcome if started early (Bowesman)
Temporary colostomy is often advisable
Treatment
o Bed rest in extreme cases
o Stools should be kept soft
o Suppositories of 5-ASA often beneficial
o Infective causes: specific treatment
SOLITARY RECTAL ULCER
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More commonly diagnosed problem
Classically, an ulcer on the anterior wall
DD:
o *rectal ca
o *inflammatory bowel disease, particularly Crohn’s
Ulceration may heal, leaving a polypoid appearance
Causes:? persistent trauma by anal digitation
Recent proctographic studies:
Constipation → chr straining → ? a combination of internal intussusception or anterior rectal wall prolapse and
an increase in intrarectal pressure
Histological appearances confirm diagnosis (Morson) similar to appearances of biopsies from a full-thickness
overt rectal prolapse
Although benign & difficult to treat Symptomatic relief from bleeding and discharge may sometimes be achieved
by preventing internal prolapse by:
o biofeedback
o intrarectal stapling procedure
o abdominal rectopexy
o may require rectal excision
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BENIGN TUMOURS
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Most frequent site of polyps (and cancers) in GIT: rectum + sigmoid colon
Adenomatous polyps of the colon and rectum potential to become malignant
Risk increases if > 1 cm in diameter
Removal of all polyps
o to exclude (or confirm) carcinoma
o to prevent local recurrence
best by endoscopic hot biopsy or snare polypectomy techniques
If one or more rectal polyps are discovered on sigmoidoscopic examination → must colonoscopy as further
polyps frequently found in colon and treatment may changed
No rectal polyp should be removed until possibility of a proximal ca ruled out, otherwise may → local
implantation of cancer cells in the distally situated rectal wound.
The rectum shares substantially the same spectrum of polyps as the colon.
Polyps relevant to the rectum
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Juvenile polyp
Bright-red glistening pedunculated sphere (‘cherry tumour’)
infants and children
Occasionally persists into adult life
Can cause bleeding, or pain if it prolapses during defecation
Often separates itself, but can be removed easily with forceps or a snare
A solitary juvenile polyp: virtually no tendency to mg change
Treated if causing symptoms
A unique histological structure of large mucus-filled spaces covered by a smooth surface of thin rectal cuboidal
epithelium
The rare autosomal dominantly inherited syndrome juvenile polyposis has an increased risk of ca
Characterised by multiple juvenile polyps and a positive family history
Hyperplastic polyps
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Small, pinkish, sessile polyps
2–4 mm in diameter
frequently multiple
Harmless
Inflammatory pseudopolyps
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Edematous islands of mucosa
Usually associated with colitis in UK, but most inflammatory diseases (including tropical diseases) can cause
them
More likely to cause radiological difficulty
Sigmoidoscopic appearances: usually obvious signs of inflammatory cause
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Villous adenomas
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Characteristic frond-like appearance
May be very large, occasionally fill the entire rectum
Enhanced tendency to become malignant sometimes be detected by palpation
with finger
Any hard area should be assumed malignant and biopsied
Rarely profuse mucous discharge rich in K causes dangerous electrolyte and
fluid losses
If ca change excluded:
o *submucosal resection endoscopically
o *surgically per anum
o *sleeve resection from above
o *Very occasionally rectal excision
o *A recent technique: transanal endoscopic microsurgery (TEM) (Buess): improved endoanal approach
for local removal of villous adenomas
Highly specialized technique
Familial adenomatous polyposis
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Autosomal dominantly inherited
multiple rectal and colonic polyps, around puberty
Diagnosis by colonoscopy and biopsy
Recently adenomatous polyposis coli (APC) gene isolated on chromosome 5 (Bodmer), so screening more
straightforward
Pre-malignant must → total colectomy
Often, the rectum preserved, but regular flexible endoscopy and polypectmy before ca change
Alternatively restorative proctocolectomy with pouch–anus anastomosis if proctectomy required rectum is
replaced by a ‘pouch’ of folded ileum
A pan-proctocolectomy with permanent ileostomy necessary in some instances, especially if follow-up
impractical
Treatment
o Colonoscopic polypectomy in most adenomas large lesions, especially the sessile → transanal excision or
even excision of rectum
o Follow-up required: frequency depends on number, size and histological type of adenomas
Benign lymphoma
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Circumscribed movable nodule, firm but not hard
greyish-white to pink in colour
Essentially submucosal
Rare neoplasm
Occurs at all ages and in both sexes,
No definite capsule
Complete local excision curative.
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Endometrioma
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Rare
May be misdiagnosed as ca
o constricting lesion of the rectosigmoid
o tumour invading rectum from rectovaginal septum → a very tender submucous elevation of the rectal
wall
Age usually 20-40 ys
Less often at menopause
Dysmenorrhoea and rectal bleeding (especially if at menses)
Sigmoidoscopy: endometriosis at rectosigmoid junction: usually stricture, but mucous membrane intact
Hormonal manipulation first line of therapy but sometimes total abdominal hysterectomy & bilateral
salpingoophorectomy
Haemangioma
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Uncommon cause of serious hemorrhage
When localized in lower part of the rectum or anal canal: can be excised
If diffuse, or lying in the upper part of the rectum
o Symptoms simulate ulcerative colitis, and diagnosis often missed for a long period
o Mistaken to be ca
Selective angiography and embolisation may help
Sometimes excision of rectum
Gastrointestinal stromal tumour
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Smooth muscle tumours of rectum
Rare
likely to metastasize if:
*mitotic rate is high
*variation in nuclear number, size and shape, hyperchromasia and frequent bizarre cells
should be classified as mg GIT stromal tumours (formerly leiomyosarcomas)
Uncertainty in behaviour: so whenever possible radical excision.
CARCINOMAS
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Colorectal ca s: 2nd most common mg
West: about 18 000 pat.s dying/y in UK
Rectum is the most frequent site
Origin
All colorectal ca s from adenomas in a stepwise progression
Adenoma → accumulation of genetic abnormalities → increasing dysplasia
Adenoma–carcinoma seqcauence; (Vogelstein)
About 5%: → more than one carcinoma
Usually presents as an ulcer, but polypoid and infiltrating types also common
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Types of carcinoma spread
Local spread
Circumferentially rather than in longitudinal
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A period of 6Ms: ¼ circumference involved
18M-2ys required for complete encirclement
Muscular coat penetrated then into surrounding mesorectum, but initially limited by
the mesorectal fascia
Anterior penetration:
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male: prostate, seminal vesicles or bladder male
female: vagina or uterus invaded
either sex: penetration laterally invades ureter
Posterior penetration:
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may invade sacrum & sacral plexus
Downward spread: > few cms rare
Lymphatic spread
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Above the peritoneal reflection: occurs almost exclusively in an upward direction
Below that level: still upwards, but if lies within field of middle rectal artery, primary lateral spread along the
lymphatics that accompany it not infrequent
Downward spread: is exceptional, with drainage along subcutaneous lymphatics to groins being confined to the
LNs draining perianal rosette and epithelium lining the distal 1–2 cm of anal
canal
Metastasis at a higher level than main trunk of sup rectal artery occurs only
late
A radical operation should ensure that high-lying LNs removed by ligating inf
mesartery at a high level
Atypical and widespread lymphatic permeation can occur in highly
undifferentiated cas
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Venous spread
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Principal sites liver (34%), lungs (22%) and adrenals (11%)
Remaining 33%: many other locations including brain
Peritoneal dissemination
May follow penetration of peritoneal coat by a high-lying rectal carcinoma
Stages of progression:
Dukes classification (Dukes’ staging):
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A: limited to rectal wall (15%): prognosis excellent
B: extended to extrarectal tissues, but no metastasis to regional LNs (35%): prognosis reasonable
C: secondary deposits in LNs (50%) subdivided into:
o C1: local pararectal LNs alone involved
o C2: LNs accompanying supplying BVs involved up to the point of division
D: often included, not described by Dukes, widespread metastases: usually hepatic
Other staging systems:
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(Astler–Coller, TNM) to improve prognostic accuracy
But optimum classification: tumour–node–metastasis (TNM) classification now recognized internationally
TNM staging
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T: extent of local spread, 4 grades:
o T1: invasion through muscularis mucosae, but not into muscularis propria
o T2: invasion into but not through muscularis propria;
o T3: invasion through muscularis propria, but not through serosa (on surfaces covered by peritoneum) or
mesorectal fascia
o T4: invasion through serosa or mesorectal fascia
N:
o N0: no LN involvement;
o N1: 1–3 involved LNs
o N2: 4 or more involved LNs
M: presence of distant metastases
o M0: no distant metastases
o M1: distant metastases
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Histological grading
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Great majority of cases columnar-celled adenoca
More nearly cells approach normal shape and arrangement less malignant the tumour
Greater % of cells undifferentiated more malignant the tumour
Low grade = well-differentiated 11% prognosis good
Average grade 64% prognosis fair;
High grade = anaplastic tumors 25% prognosis poor
Poor prognostic features:
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vascular and perineural invasion
presence of an infiltrating (rather than pushing) margin
Primary mucoid ca:
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a small number of cases mucus lies within cells, displacing the nucleus to periphery, like the seal of a signet ring
A rapidly growing bulky growth, metastasizes very early
Prognosis of which is very poor
Clinical features
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Can occur early in life
But age of presentation usually above 55 years, when incidence rises rapidly
Often early symptoms are so insignificant that does not seek advice for 6Ms or more
Diagnosis often delayed in younger patients as these symptoms are attributed to benign causes
Initial rectal exam and a low threshold for investigating persistent symptoms essential
Bleeding
Earliest and most common symptom
Nothing characteristic about time at which occurs, nor color or amount of blood distinctive:
often bleeding slight in amount and at the end of defecation, or noticed because stained underclothing
More often than not, bleeding in every respect simulates that of internal hemorrhoids (hemorrhoids and
carcinoma sometimes coexist).
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Sense of incomplete defecation:
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Bowels open, but sensation that more faeces to be passed (tenesmus, a distressing straining to empty bowels
without resultant evacuation)
o a very important early symptom
o almost invariably in tumors of lower half
o May endeavour to empty rectum several times a day (spurious diarrhea) often with passage of flatus
and a little blood-stained mucus (‘bloody slime’)
Alteration in bowel habit
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Next most frequent symptom patient may find it necessary to start taking an aperient or to supplement usual
dose
A patient who has to get up early in order to defecate, or one who passes blood and mucus in addition to feces
(‘early-morning bloody diarrhea’) usually found in ca of rectum
Annular carcinoma rectosigmoid junction occasionally suffers from increasing constipation
Growth in ampulla of rectum who has early-morning diarrhea (Bruce).
Pain
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A late symptom
But colicky pain may accompany advanced tumors of rectosigmoid: → some degree of intestinal obstruction
If a deep carcinomatous ulcer of rectum erodes prostate or bladder may cause severe pain
Backache, or sciatica: in ca invades the sacral plexus
Weight loss suggestive of hepatic metastases
Diagnosis and assessment of rectal cancer
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All patients with suspected rectal cancer should undergo:
Digital rectal examination
Sigmoidoscopy and biopsy
Colonoscopy if possible (or CT colonography or barium enema)
All patients with proven rectal cancer require staging by:
Imaging of the liver and chest, preferably by CT
Local pelvic imaging by magnetic resonance imaging and/or endoluminal ultrasound
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Surgery for rectal cancer
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Surgery is the mainstay of curative therapy
The primary resection consists of rectal excision with total mesorectal excision (TME)
Most cases can be treated by anterior resection with colorectal anastomosis being achieved with a circular
stapling gun
A smaller group of low, extensive tumours require an abdominoperineal excision with a permanent colostomy
Preoperative radiotherapy can reduce local recurrence
Adjuvant chemotherapy can improve survival in node-positive disease
Liver resection in carefully selected patients offers the best chance of cure for single or well-localised liver
metastases
Pilonidal sinus
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In natal cleft overlying coccyx one or more, usually non-infected, midline openings, which communicate with a
fibrous track lined by granulation tissue and containing hair lying loosely within the lumen
A common affliction amongst military, ‘jeep disease’
Aetiology and pathology
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Acquired disease
Evidence of acquired theory:
o Interdigital pilonidal sinus an occupational disease of hairdressers the hair within the interdigital cleft or
clefts being the customers’
Pilonidal sinuses of the axilla and umbilicus
The age incidence: (82% between 20 - 29 y) at variance with age of onset of congenital lesions.
Hair follicles never demonstrated in walls of sinus
Hairs projecting from sinus dead hairs, with their pointed ends directed towards blind end of sinus
Mostly affects men, in particular hairy men
Recurrence common, even though adequate excision of track done
How does it occur:
o Combination of buttock friction and shearing forces leads the shed hair or broken hairs which have
collected there to drill through midline skin then chronic infection
From this primary sinus, secondary tracks may spread laterally, which may emerge at skin as granulation tissuelined, discharging openings
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Clinical features
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Much more frequently in men than women
Usually after puberty and before 4th decade
Characteristically seen in dark-haired individuals rather than softer blond hair (Oldham)
Intermittent pain, swelling and discharge at the base of the spine but little constitutional symptoms
Often a history of repeated abscesses that burst spontaneously or incised, usually away from the midline
Primary sinus may have one or many openings, all strictly in the midline between the level of sacrococcygeal
joint and tip of coccyx
Conservative treatment
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Natural history usually one of regression, symptoms relatively minor
Simple cleaning out of tracks and removal of all hair, with regular shaving of the area and strict hygiene, may be
recommended
Surgical treatment of chronic pilonidal disease:
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Excision of the sinus with leaving the wound opened for secondary intention healing
Excision with primary closure
Treatment of an acute exacerbation (abscess):
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rest, baths, local antiseptic dressings and a broad-spectrum AB. If failed do drainage and curettage of
granulation tissue and hair
Recurrent pilonidal sinus, Three possibilities:
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part of sinus complex overlooked at the primary op
new hairs enter skin or scar
persistence of a midline wound caused by shearing forces and scarring
ANAL FISSURE
(synonym: fissure-in-ano) a longitudinal split in anoderm of the distal anal canal extends from anal verge proximally
towards, but not beyond dentate line
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Aetiology
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The cause why posterior midline so frequently affected is not completely understood
Classically, acute anal fissures from trauma caused by:
o strained evacuation of a hard stool
o less commonly, from repeated passage of diarrhoea
Location in posterior midline perhaps relates to
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exaggerated shearing forces acting at that site at defecation, combined with a less elastic anoderm endowed
withan increased density of longitudinal muscle extensions in that region of anal circumference
Anterior anal fissure much more common in women and may arise following vaginal delivery
Perpetuation and chronicity may result from:
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Repeated trauma
Hypertonicity (contraction)of anal muscles
And vascular insufficiency because posterior commisure less well perfused than the remainder of anal
circumference
Clinical features
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Exquisitely sensitive anoderm, defaecation → severe anal pain
o Usually resolves spontaneously after a variable time only
o To recur at next evacuation
Passage of fresh blood, normally noticed on tissue after wiping
Chronic fissures:
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characterized hypertrophied anal papilla internally and a sentinel tag externally (both consequent upon
attempts at healing and breakdown), between which lies slightly indurated anal ulcer overlying fibres of internal
sphincter.
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When chronic:
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itching secondary to irritation from:
o sentinel tag
o discharge from ulcer
o discharge from an associated intersphincteric fistula, which has arisen through infection penetrating via
fissure base.
Although most sufferers young adults, but can affect any age, from infants to the elderly
Men and women equally.
Anterior fissures: 10% in women but only 1% in men
Fissures neither post nor ant or with atypical features:
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??? specific aetiology, Exam under GA & biopsy to exclude:
o Crohn’s disease
o TB
o Sexually transmitted or HIV-related ulcers like :syphilis, Chlamydia, chancroid, lymphogranuloma
venereum, HSV, cytomegalovirus, Kaposi’s sarcoma, B-cell lymphoma) and squamous cell ca
Treatment
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Confirm diagnosis in clinic or under GA
Exclusion of secondary causes of anal ulceration
conservative management → healing of almost all acute and majority of chronic fissures:
o Nonormalization of bowel habits, passage of stool less traumatic:
o Addition of fibre to diet to bulk up stool
o stool softeners
o adequate water intake
o Warm baths and topical local anaesthetic agents → relieve pain
o Anal dilators usually low compliance and consequently little effect
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Conservative management:
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Topical pharmacological agents to relax int sphincter
Most commonly nitric oxide donors (Scholefield):
o reduce spasm
o relieves pain increases vascular perfusion promotes healing:
o glyceryl trinitrate (GTN) 0.2% applied 4X/day to anal margin (although this may cause headaches)
o diltiazem 2% applied twice daily.
Operative measures
•
•
•
Historically, under regional or GA forceful manual (four- or eight-digit) sphincter dilatation to reduce sphincter
tone has risk of incontinence so it is unpopular
More conservative controlled stretching still can be practiced in young men with very high sphincter tone
Posterior division of exposed fibers of int sph in fissure base: → healing, but prolonged healing, as well as passive
anal leakage thought mainly due to keyhole gutter deformity. however may be indicated if an associated
intersphincteric fistula
Lateral anal sphincterotomy (Notaras)
•
•
•
Internal sphincter divided away from fissure itself – usually either in right or left lateral positions
Early complications: haemorrhage, haematoma, bruising, perianal abscess and fistula
Low recurrence rates
Most important complication: incontinence of a variable nature and severity, up to 30% of patients, particularly women:
•
•
because they have weaker, shorter sphincter complexes
may already have been masked sphincter damage caused by childbirth
Proctalgia fugax
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•
•
•
•
•
•
•
•
Attacks of severe pain arising in rectum, recurring at irregular intervals and apparently unrelated to organic
disease
Pain described as cramp-like, often occurs in bed at night, usually lasts only for a few minutes and disappears
spontaneously
May follow straining at stool, sudden explosive bowel action or ejaculation
More commonly in patients suffering from anxiety or undue stress, and also said to afflict young doctors
Pain may be unbearable – possibly caused by segmental cramp in pubococcygeus muscle
unpleasant and incurable but fortunately harmless and gradually subsides
A more chronic form called ‘levator syndrome’ and can be associated with severe constipation
Biofeedback techniques used to help
Previously some surgeons severing puborectalis muscle, but may incontinence and should never be carried out.
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HAEMORRHOIDS
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Prevalence of haemorrhoids by proctoscopically far outweighs prevalence of symptoms, i. e not all the patients
have symptoms
The term should only be used when patients have symptoms referable to them. Occasionally PHT causes rectal
varices, should not be confused with haemorrhoids as the consequences may be disastrous
Internal hds (Greek: haima = blood, rhoos = flowing; synonym: piles, Latin: pila = a ball) are symptomatic anal
cushions and characteristically lie in 3, 7 and 11 o’clock in lithotomy position
Hds may be observed between main pile masses of internal hds: they are secondary hemorroids
On the right side we have two primary hemorroids at 3 and 7 o’clock, because the right superior rectal artery is
divided into anterior and posterior branches
External hds relate to venous channels of inf hdal plexus deep in skin surrounding anal
verge and are not true hds. They are usually only recognized as a result of a
complication, most typically a painful solitary acute thrombosis
External hds associated with internal hds (‘interoexternal piles’) result from
progression of the latter to involve both hdal plexuses best thought of as being
external extensions of internal hds
Secondary internal hds:
•
•
•
As a result of a specific condition, although mechanisms involved may be same as of primary internal hds
Most important cause, relatively uncommon: carcinoma of anorectum
May other causes, which may be categorized as follows:
o Local: e. g. anorectal deformity, hypotonic anal sphincter
o Abdominal: e. g.ascites;
o Pelvic: e.g. gravid uterus, uterine neoplasm (fibroid, ca of the uterus or cervix), ovarian neoplasm,
bladder ca
o Neurological: e.g. paraplegia, multiple sclerosis.
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Primary hemorroids:
•
•
•
•
Man’s upright posture (we know little about haemorrhoidal problems in
animals)
Lack of valves in the portal venous system
Raised abdominal pressure
portal venous pressure in portal hypertention as a cause of hemorroid ???
Other vascular causes:
•
Some haemorrhoids thought to be haemangiomatous or to result from changes in erectile tissue that forms part
of continence mechanism, such as hyperplasia of ‘corpus cavernosum recti’.
Infection (as a caues):????
•
Repeated infection of anal lining, secondary to trauma at defaecation weakening and erosion of walls of veins of
submucosa
Diet and stool consistency:
•
•
•
•
•
Role of constipation in development of hds
Much of management attempts to ‘normalize’ bowel habits
A fiber-deficient diet → a prolonged gut transit time → passage of smaller, harder stools that require more
straining to expel
Hard fecal mass in rectum could obstruct venous return:
Sometimes diarrheal disorder is a cause of hemorroid
Anal hypertonia:
•
A significant proportion of patients who suffer haemorrhoidal symptoms in whom the anal canal relatively
patulous, and there is mucosal prolapse, which is associated with perineal descent and pudendal neuropathy
Ageing
•
Supporting structures show a higher proportion of collagen than muscle fibres which are fragmented and
disorganized
Haemorrhoids: clinical features
•
•
•
•
Haemorrhoids or piles are symptomatic anal cushions
They are more common when intra-abdominal pressure is raised, e.g. in obesity, constipation and pregnancy
Classically, they occur in the 3, 7 and 11 o’clock positions with the patient in the lithotomy position
Symptoms of haemorrhoids:
o bright-red, painless bleeding
o mucus discharge
o prolapse
o pain only on prolapse
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Clinical features
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•
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Bleeding:
o Principal and earliest symptom
o Characteristically separate from the motion and either on paper on wiping or as a fresh splash in the pan
o Very rarely, bleeding may → anaemia
Pain not commonly associated with bleeding & if present → possibility of another diagnosis
However, pain may result from congestion of pile masses below a hypertonic sphincter
Piles + bleeding alone: first-degree hds
May true ‘piles’, lumps, appear at anal orifice during defaecation & return spontaneously afterwards (seconddegree hds)
Piles that have to be replaced manually: third-degree haemorrhoids
Piles that lie permanently outside : fourth-degree haemorrhoids
In addition to pain and prolapse, patients may complain of:
o Anal irritation by mucus secretion from the caudally displaced rectal mucosa
o Minor leakage through a now imperfect anal seal
o Difficulties in cleaning after defecation because of the irregularity of the anal verge.
Complications of haemorrhoids
•
•
•
•
•
Strangulation and thrombosis
Ulceration
Gangrene
Portal pyaemia
Fibrosis
Profuse haemorrhage: not rare, mainly occurs externally but it may continue internally after the bleeding hd has
retracted or has been returned; rectum is found to contain blood
Treatment of complications:
Strangulation, thrombosis and gangrene:
•
•
•
•
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•
immediate surgery can be justified in many patients*postoperative stenosis by some surgeons; so they advise
carrying out haemorrhoidectomy only if necessary
Conservative treatment:
Besides adequate pain relief
Bed rest with frequent hot baths
Warm or cold saline compresses with firm pressure usually cause the pile mass to shrink considerably in 3–4
days
An anal dilatation technique has in the past been used as an alternative treatment to surgery for painful
‘strangulated’ hds However, because of risk of incontinence this is no longer advised
23 | P a g e
Severe haemorrhage:
•
•
Usually bleeding diathesis, or use of anticoagulants
Exclude these causes then:
o a local compress containing adrenaline solution
o an injection of morphine
o blood transfusion if necessary
o after adequate blood replacement, ligation and excision of the piles may be required.
Management of hemorroid (in general):
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•
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•
First priority: exclusion of other causes of rectal bleeding, especially colorectal ca
In the absence of a specific predisposing cause:
o attempts to normalize bowel and defecatory habits
o only evacuating when the natural desire to do so arises
o adopting a defecatory position to minimize straining
stool softeners and bulking agents to ease the defecatory act
Various proprietary creams from a collapsible tube fitted with a nozzle, at night and before defecation
Suppositories are also useful.
1st & 2nd degree piles:
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•
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if not improved by conservative measures → injection sclerotherapy (Mitchell)
Submucosal injection of 5% phenol in arachis oil or almond oil to submucosa at apex of each pile pedicle
Aim to create fibrosis → causes obliteration of the vascular channels and hitch up anorectal mucosa
patient reassessed after 8 weeks; if necessary, injections repeated
If superficially injected may cause:
o *superficial ulceration
o *rarely serious septic sequelae However
If too deeply injected may cause
o *pelvic sepsis
o *prostatitis
o *impotence
o *rectovaginal fistula
More bulky piles: → banding but associated with more discomfort
Barron’s bander: to slip tight elastic bands onto the base of pedicle of each haemorrhoid → ischaemic necrosis
of the piles and later → slough off
Within 10 days:
•
•
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•
May be associated with bleeding
Three piles may be treated at one session
May be repeated after several weeks if necessary
Cryotherapy (Lloyd Williams) and infrared photocoagulation (Leicester) not often used nowadays
24 | P a g e
Operation
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Indications:
o third- and fourth-degree hds
o second-degree hds, not been cured by non-operative treatments;
o fibrosed hds
o intero-external hds when the external hd well defined.
If any doubt about diagnosis of hds, examination under anaesthesia and, if indicated, biopsy necessary
Other strong indication for surgery is hdal bleeding sufficient to cause anaemia
Relative indications: to improve symptoms, but not without risk:
o Elderly multiparous women with hypotonic sphincters who are just continent before
haemorrhoidectomy may find that the procedure results in frank incontinence, a far worse condition
than that for which they originally sought help.
Open technique: Milligan-Morgan operation
Closed technique:
Stapled hemorrhoidectomy
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Postoperative care
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Patient discharged within a day or two of the operation
IN USA: day-case
Take two warm baths each day
A bulk laxative 2X/day + appropriate analgesia
Dry dressings are applied as necessary, a sterile sanitary towel usually being ideal
Patient seen again 3–4 weeks after discharge and a rectal examination is performed
If there evidence of stenosis: encouraged to use a dilator
Postoperative complications:
Early complications:
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Pain: may require opiate analgesia
Retention of urine: especially in men, rarely catheterization
Reactionary haemorrhage: much more common than secondary haemorrhage, may be mainly or entirely
concealed but, evident on examining the rectum
If persistent after adequate analgesia → operating theatre and bleeding point secured by careful diathermy or
under-running with a ligature
Should a definite bleeding point not be found anal canal and rectum packed
Late postoperative complications:
•
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•
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•
Secondary haemorrhage: uncommon about seventh or eighth day after operation.
Usually controlled by morphine but, if severe bleeding controlled under anesthesia
Anal stricture: must be prevented at all costs
Detected by rectal exam postoperatively
It may be necessary to dilate under GA then daily use of dilator
Anal fissures and submucous abscesses
•
Incontinence, especially if inadvertent damage to underlying internal sphincter Although uncommon but
obviously a very serious problem that is difficult to treat
External haemorrhoids
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A thrombosed external haemorrhoid relates anatomically to veins of superficial or external haemorrhoidal
plexus & commonly termed a perianal haematoma
Presents as a sudden onset
olive-shaped, painful, blue subcutaneous swelling at anal margin. Usually consequent upon straining at stool,
coughing or lifting a heavy weight
Usually situated in a lateral region of the anal margin
If presents within the first 48 hours the clot may be evacuated under local anaesthesia
Untreated may resolve, suppurate, fibrose and give rise to a cutaneous tag, burst and the clot extrude, or
continue bleeding
Majority, resolution, or fibrosis occurs
Has been called ‘a 5-day, painful, self-curing lesion’ (Milligan).
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ANORECTAL ABSCESSES
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Acute sepsis in region of the anus is common
A fundamental distinction whether :
??? by chance (simple boil, skin appendage infection)
??? as a consequence of the presence of the anorectum, specifically the anal glands
Men > women
But infections with skin-type organisms (and thus unrelated to fistula) are evenly distributed between male &
female
The cryptoglandular theory of intersphincteric anal gland infection (Parks):
pus travels along the path of least resistance: may spread
o *caudally → perianal abscess
o *laterally across the external sphincter → ischiorectal abscess
o *rarely, superiorly above anorectal junction → supralevator intermuscular or pararectal abscess
(depending on its relation to the longitudinal muscle)
o *circumferentially in any of the three planes: intersphincteric/intermuscular, ischiorectal or pararectal
supralevator
Sepsis unrelated to anal gland infection may occur same or at other sites including:
1.
2.
3.
4.
5.
6.
Pelvirectal supralevator abscess
Submucous abscess
Isciorectal abscess
marginal abscess
Perianal abscess
Intersphincteric abscess.
Presentation
perianal abscess:
•
•
•
confined by the terminal extensions of longitudinal muscle
usually a short (2–3 day) history of increasingly severe, well-localized pain and a palpable tender lump at the
anal margin
O/E: an indurated hot tender perianal swelling
ischiorectal abscess:
•
usually present later, with less well localized symptoms but more constitutional upset and fever
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Summary:
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•
•
•
•
Usually produces a painful, throbbing swelling in the anal region. The patient often has swinging pyrexia
Subdivided according to anatomical site into perianal, ischiorectal, submucous and pelvirectal
Underlying conditions include fistula-in-ano (most common), Crohn’s disesase, diabetes, immunosuppression
Treatment is drainage of pus in first instance, together with appropriate antibiotics
Always look for a potential underlying problem
FISTULA-IN-ANO
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•
A fistula-in-ano, or anal fistula:
a chronic abnormal communication, usually lined to some degree by granulation tissue, which runs outwards
from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock
(or rarely, in women, to the vagina)
May associate with specific conditions, like Crohn’s disease, TB, lymphogranuloma venereum, actinomycosis,
rectal duplication, foreign body and malignancy (which may also very rarely arise within a longstanding fistula),
and suspicion should be aroused if clinical findings unusual
However, majority: non-specific, idiopathic or cryptoglandular
Intersphincteric anal gland infection is the cause
Presentation
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•
•
•
•
non-specific anal fistulae more common in men than women, cause unknown
overall incidence about 9/ 100 000/ year in western Europe, and
most commonly affects 3rd, 4th, & 5th decades usually intermittent purulent discharge (which may be bloody)
and pain (which increases until temporary relief occurs when pus discharges)
often, but not invariably, a previous episode of acute anorectal sepsis that settled (incompletely) spontaneously
or with antibiotics, or which was surgically drained
passage of flatus or feces through external opening: suggestive of a rectal rather than an anal internal opening
[
Park’s classification of anal fistula:
1. inter-shincteric
2. transsphincteric
3. suprasphincteric
4. extrasphincteric
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Classification
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High fistula: indicating a high risk of incontinence if laid open
Low fistula: risk of incontinence lower but still some risk to function
‘simple’:
‘complex’:
o by the level at which primary track crosses sphincters
o presence of secondary extensions or
difficulties faced in treatment
Vast majority of fistulae intersphincteric or trans-sphincteric
Goodsall’s rule:
•
•
To indicate the likely position of internal opening according to position of external opening(s), helpful but not
infallible
site of internal opening may be felt as:
o a point of induration
o or seen as an enlarged papilla
o Probing in an awake patient is painful, and can be dangerous
o Full examination under anaesthesia before surgical intervention is
necessary .
Fistulectomy:
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Fistulotomy: excision of the fistula
Setons: Uses of loose setons
o For long-term palliation to avoid septic and painful exacerbations by establishing effective drainage
most often in Crohn’s disease
those with problematic fistulae not wishing to countenance the possibility of incontinence.
Cutting setons: to achieve the high fistula w/o cutting sphincter m s
Chemical cautery using an Ayurvedic method, known in India as Kshara sutra, in which a specially prepared
seton thread burns through enclosed tissue
Advancement flaps
Glues
ANAL INTRAEPITHELIAL NEOPLASIA (AIN)
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Virally induced dysplasia of the perianal or intra-anal epidermis
Incidence unknown
Detected with increasing frequency in anoreceptive intercourse and HIV are prevalent. Patients often
asymptomatic
Diagnosis often a histological surprise, although increasing numbers in high-risk groups are picked up on anal
cytology.
Classified according to degree of dysplasia on biopsy into AIN I, AIN II and AIN III, according to lack of keratocyte
maturation and extension of the proliferative zone from the lower third (AIN I) to full thickness of epithelium
(AIN III), in same manner as cervical or vulval dysplasia
Natural history is uncertain but progression from AIN II to AIN III to invasive carcinoma has been observed,
notably in immunocompromised patients.
The term Bowen’s disease should probably be avoided
Presentation
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•
AIN is often subclinical but is found in up to 30% of patients with anal warts
Suspicious areas are raised, scaly, white, erythematous, pigmented, or fissured
Diagnosis and management
•
•
•
•
•
A high index of suspicion and targeted biopsy yields diagnosis
Multiple (mapping) biopsies give an indication of extent and overall severity of the disease
AIN II and III should be regularly monitored clinically and, if necessary, by repeat biopsy to exclude invasive
disease.
Focal disease: may be excised.
More widespread disease: wide local excision and closure of the resultant defect by flap or skin graft, with or
without covering colostomy (especially if there is intra-anal disease) Topical imiquimod or oral retinoids has
some effect on the progression of dysplasia
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MALIGNANT TUMOURS
Malignant lesions of the anus and anal canal
•
•
•
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•
Anal malignancy rare
< 2% of all large bowel cancers
Those arising below dentate line usually squamous
whereas those above the dentate line, variously termed basaloid, cloacogenic or transitional
Collectively known as epidermoid carcinomas, to distinguish them from those of nonsquamous cell origin
(adenocarcinoma, melanoma, lymphoma, sarcoma).
Squamous cell carcinoma
•
•
•
•
•
•
Although rare
Incidence (SCC) rising, with a direct association with HPV infection, AIN and immunosuppression
High-risk groups:
o those infected with HPV (especially subtypes 16, 18, 31 or 33)
o those with HIV infection, recipients of organ transplants (renal transplant patients have a 100-fold
increased risk)
o those with a past history of cancers at ‘sexually accessible’ sites (usually genital)
Most common symptoms Pain and bleeding thus often initially misdiagnosed as a benign condition
High level of suspicion and adequate examination
Less common: mass, pruritus or discharge Advanced tumors may cause faecal incontinence by invasion of the
sphincters and, in women, anterior extension may result in anovaginal fistulation
O/E: anal margin tumors look like malignant ulcers
•
•
•
•
may be associated HPV lesions
Anal canal tumors are palpable as irregular indurated tender ulceration
Sphincter involvement may be evident.
Lymphatic spread: to inguinal LNs
Management
Historically:
•
•
early anal margin tumors: local excision
anal canal tumours: abdominoperineal (AP) excision of rectum
Nowadays:
•
primary treatment: chemoradiotherapy [combined modality therapy (CMT); Nigro] usually including a
combination of 5-fluorouracil (5-FU) with mitomycin C or cisplatin
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Role of surgeon:
•
•
•
•
initial diagnosis: biopsy
small marginal tumors: still best local excision
radical surgery if persistent or recurrent disease following CMT
defunctioning stoma in pat.s treated before & if disease regression is associated with radionecrosis,
incontinence or fistula.
Other anal malignancies
Adenocarcinomata within the anal canal:
•
•
•
•
•
usually extensions of distal rectal cancers
Rarely, adenocarcinoma may arise from anal glandular epithelium
develop within a longstanding (usually complex) anal fistula
Treatment as for low rectal cancers [i.e. abdominoperineal excision of rectum (APER) with or without previous
radiotherapy or chemoradiotherapy]
Prognosis is less good.
Malignant melanoma:
•
•
•
•
•
Melanocytes can be found in the transitional zone of the anal canal
Very rare
Usually presents as a bluish-black soft mass that may mimic a thrombosed external pile, although it may be
amelanotic
Prognosis, irrespective of treatment, is extremely poor
Perianal Paget’s disease is exceedingly rare
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