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Proctology in Primary Care

Proctology in Primary Care. Jamshed Shabbir MBBS,MMedSci,FRCSGlasg(Gen.Surg), FRCS Consultant Colorectal and General Surgeon BRI. Fistula in Ano:. 1:10,000 Fourth decade 90% are Cryptoglandular Crohn’s Disease TB HIV Diverticular disease Cancer. Anatomy and Classification:.

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Proctology in Primary Care

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  1. Proctology in Primary Care Jamshed Shabbir MBBS,MMedSci,FRCSGlasg(Gen.Surg), FRCS Consultant Colorectal and General Surgeon BRI

  2. Fistula in Ano: • 1:10,000 • Fourth decade • 90% are Cryptoglandular • Crohn’s Disease • TB • HIV • Diverticular disease • Cancer

  3. Anatomy and Classification:

  4. Clinical Assesment: • History • Physical examination • DRE • Palpation-lubricated finger • Culture Swabs

  5. Investigations: • Endoanal US • Can alter management in 40% of case at surgery (Colorectal Disease 2002;4:118-22) • MRI • 94% accuracy • 97% specificity and 100% sensitivity (BJS 1996;83:1396-8)

  6. Principals of Management: • Eliminate the fistula • Prevent recurrence • Preserve anal sphincter function

  7. Treatment: • Acute Sepsis • Incision and drainage • Subsequent fistula in ano 26-66% • Low fistulae can be laid open if an experienced surgeon is available • High / complex fistula with acute sepsis • drain sepsis and refer to a colorectal surgeon • Seton insertion in experienced hands (Int J Colorectal Dis 2003)

  8. Fistulotomy-Laying Open • Low fistula in ano can be laid open with healing by secondary intention • Recurrence 0-26% • Missed 2nd tracks • Furtehr sepsis • Horseshoe fistulae (Frontiers in colorectal surgery)

  9. Seton: • Loose Seton • Drain sepsis • Stimulate fibrosis • Assist decision making re subsequent fistulotomy • Short term success rate between 44-86% (Ann R CollSurgEng Oct 2013)

  10. Cutting Seton • Advancement Flaps • Ligation of Intersphincteric Fistula Tract (LIFT) • Fibrin Sealant

  11. Fistula Pulg • Healing rate of upto 50% • Recurrence rate of upto 56% (Colorectal Disease Feb 2014) • FIAT Trial • Fistula plug v surgeon’s choice

  12. Haemorrhoids: • One of the most common conditions in general surgical practice • 3 out of 5 people in the western world affected by this condition • Prevalence in the UK of 36.4% • 50% of those aged over 50 are affected

  13. Physiology • Artero-venous anastomoses within the submucosa are thought to contribute to increase the anal cushions volume, sealing the anal canal (mechanical plug) • The anal cushions contribute approximately 15%–20% of the resting anal pressure • Stieve 1928; Widmer 1955, Selzner 1962; Thomson 1975; Gibbons et al. 1986, Lestar et al. 1989; Selzner 1992

  14. Treatment • Different therapeutic option with different indications according to the stage • Non surgical • Office Based Procedures • Surgical • Surgery is the most effective treatment for the most advanced stages

  15. Surgical options • No gold standard • Conventional Haemorrhoidectomy (SH) • Transanal Haemorrhoidal Dearterialisation (THD) • Stapled Haemorrhoidopexy (SH) or PPH

  16. Haemorrhoidectomy

  17. Conventional HaemorrhoidectomyAdvantages • Effective • Technically “easy” to perform • Economical

  18. Conventional Haemorrhoidectomy Disadvantages • Significant postoperative pain • Risk of complications • Can impair continence mechanism

  19. Stapled Haemorrhoidopexy

  20. Stapled HaemorrhoidopexyPossible advantages • Cures or improves symptoms without removing the haemorrhoidal cushions • Anatomical and functional restoration of the anal canal • Easy and quick to perform • Less post-operative pain and quicker return to normal activities • No need for nursing care

  21. Transanal Haemorrhoidal Dearterialisation Advantages • Easy to perform • Safe • Minimal or no postoperative pain • Day case procedure • General or Local anaesthesia

  22. Haemorrhoids: blood supply Superior rectal artery: 6 (4-8) terminal branches

  23. THD

  24. The HubBLe Trial • 370 patients entered the trial • At 1 year post procedure, 30% of the HAL group had evidence of recurrence compared with 49% after RBL [(OR) = 2.23, 95% confidence interval (CI) 1.42 to 3.51; p = 0.0005]. • Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year (9% HAL and 29% RBL) • In the base-case analysis, the difference in mean total costs was £1027 higher for HAL

  25. eTHoS Trial • 777 patients were randomised (389 to receive stapled haemorrhoidopexy and 388 to receive traditional excisional surgery • Recurrence rate 14% in Haemorrhoidectomy group v 32% in stapled group at 12 months • The difference was maintained at 24 months • QoL score were better in Haemorrhoidectomy v Stapled

  26. Acute Fissure • Analgesia • Diet

  27. Chronic Fissure • >6 week history • Wider and deeper than acute fissure (IASfibres) • Midline • Skin tag

  28. Perianal Haematoma

  29. Thrombosed Haemorrhoids

  30. Pilonidal Sinus Disease

  31. AIN and Anal Cancer • Accounts for 4% of all large bowel cancers • Incidence 1.7/100000 • Risk Factors • HPV • Anal warts • Smoking • Receptive Anal Intercourse • HIV/Immunocompromised status

  32. AIN • Anal Intra-epithelial Neoplasia (AIN) is a risk factor for anal cancer • AIN is graded based on whether the involvement is only • of the outer third of skin (AIN1), • or the outer two thirds of skin (AIN2) • or the entire thickness of skin (AIN3) • Patients may present with • pruritus or anal discharge. • Suspicious lesions may be raised, scaly, white plaques, erythematous,pigmented, fissured, or eczematous

  33. AIN-Anal Intraepithelial Neoplasia

  34. CT Colonography • Adenomas –Carcinoma sequence is well proven • Cancer risk increases with size of polyp • <1% for polyp less than 1cm • 10% for polyp size between 1-2 cm • >20% for polyp size above 2cm

  35. CT Colonoscopy • CTC has sensitivity of 93-100% for polyps >10mm • CTC has sensitivity of 70-80% for polyps between 6-9 mm • Extracolonic findings

  36. Terminology of DD • Diverticulosis. It is the presence of colonic diverticula; these may or may not be symptomatic or complicated • Diverticular disease. It is defined as clinically significant and symptomatic diverticulosis; this may be from true diverticulitis or from other less well-understood manifestations (e.g. visceral hypersensitivity in the absence of verifiable inflammation)

  37. Terminology Contd • Symptomatic Uncomplicated Diverticular Disease (SUDD). It is the presence of persistent abdominal symptoms attributed to diverticula in the absence of macroscopically overt colitis or diverticulitis • Diverticulitis. It describes macroscopic inflammation of diverticula with related acute or chronic complications Uncomplicated. CT may show colonic wall thickening with fat stranding Complicated. Complicating features of abscess, peritonitis, obstruction, fistulas

  38. SCAD Segmental colitis associated with diverticulosis (SCAD). It is a unique form of inflammation that occurs in areas of diverticulosis. Endoscopic and histological characteristics show features suggestive of inflammatory bowel disease (IBD)

  39. Diverticulitis

  40. Medical Treatment • SUDD • Fibre • Mesalazine • Probiotics

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