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Minor anorectal conditions

Minor anorectal conditions. Dr. Simon Ng Associate Professor Division of Colorectal Surgery The Chinese University of Hong Kong. Intensive Surgery Course for Medical Year 5 (2006/2007). Levator ani. Rectum. Puborectalis. Dentate line. Anal canal. Internal sphincter. External sphincter.

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Minor anorectal conditions

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  1. Minor anorectal conditions Dr. Simon Ng Associate Professor Division of Colorectal Surgery The Chinese University of Hong Kong Intensive Surgery Course for Medical Year 5 (2006/2007)

  2. Levator ani Rectum Puborectalis Dentate line Anal canal Internal sphincter External sphincter Anal/rectal anatomy

  3. Dentate line Anal canal

  4. Symptoms • Rectal bleeding • Anal lump • Anal pain • Pruritis ani • Perianal discharge

  5. Colorectal clinic Digital rectal examination Rigid sigmoidoscopy Proctoscopy Evaluation 

  6. Role of colonoscopy in minor anorectal conditions • Diagnostic • Differential diagnoses for rectal bleeding • Underlying causes for FIA • Therapeutic • Endoscopic ligation and fixation of haemorrhoids • APC for radiation proctitis

  7. Anal fissure

  8. Anal fissures A tear in the anal canal extending from just below the dentate line to the anal verge

  9. A superficial split of the anoderm Acute anal fissure 80% heals within 3 weeks If fails to heal within 6 weeks  chronic anal fissure

  10. Chronic anal fissure Features of chronicity: a distal sentinel tag, a proximal hypertrophied anal papilla, fibrotic edges, exposed internal sphincter fibres

  11. Acute and chronic anal fissure Crohn’s disease Syphilis Tuberculosis Leukaemia Cancer HIV Crohn’s disease Syphilis Tuberculosis Leukaemia Cancer HIV Acute and chronic anal fissure >90% in the posterior midline

  12. Pain Failure of healing Sphincter spasm Sphincterotomy Surgical Chemical Ischaemia Vicious cycle

  13. Chemical sphincterotomy • Pharmacological agents that act on the anal sphincter to induce relaxation • Topical nitrates (0.2% glyceryl trinitrate ointment) Headache • Topical calcium channel blocker Headache • Botulinum toxin injection Transient flatus incontinence

  14. BOTOX Botulinum toxin injection Causes paralysis of internal sphincter by inhibiting presynaptic release of ACh from NMJ

  15. Closed Open Lateral sphincterotomy

  16. Open sphincterotomy Chronic anal fissure at 6 o’clock Incision made at 3 o’clock Open lateral sphincterotomy Healing rate >90% Variable degree of minor incontinence

  17. V-Y anoplasty/advancement flap

  18. Favours surgery Treatment efficacy: meta-analysis • Surgery is more effective than medical therapy (GTN, Btx) in curing chronic anal fissure • Medical therapy for acute or chronic anal fissure is only marginally better than placebo Nelson R. Dis Colon Rectum 2004; 47: 422-31.

  19. Haemorrhoids

  20.   “Piles of defeat” Napoleon at Waterloo

  21. St. Fiacre’s stone St. Fiacre’s Curse

  22. “十個男人十個痔”

  23. “十個女人九個痔”

  24. Straining Aging Hormonal Vascular cushion theory

  25. First degree Fourth degree Goligher’s classification • First degree Bleeding without prolapse • Second degree Prolapse with spontaneous reduction • Third degree Prolapse with manual reduction • Fourth degree Irreducible prolapse

  26. Thrombosed haemorrhoids Pain++++

  27. Medical treatments High fibre diet Topical medications Oral medications (micronized purified flavonoid fraction) Office treatments Injection sclerotherapy Rubber band ligation Thermal methods (infrared coagulation, laser, cryotherapy) Treatment

  28. Gabriel’s needle 5% phenol in almond oil Injection sclerotherapy

  29. Injection sclerotherapy Submucosal injection above the anal cushions 2 cm above dentate line  fibrosis  fixation of haemorrhoids

  30. Rubber band ligation

  31. Rubber band ligation Apply the band  ischaemic necrosis  fixation of mucosa by fibrosis

  32. Infrared coagulation Infrared coagulation  protein necrosis

  33. Haemorrhoidectomy • Most effective and long-term cure • <5% recurrence rate • Several techniques have been described, but none has been shown to be the best

  34. Haemorrhoidectomy should be reserved for … • Patients who are refractory to office procedure • Patients who are unable to tolerate office procedure • Patients with large external haemorrhoids • Patients with fourth degree haemorrhoids • Patients with thrombosed haemorrhoids

  35. Ligation Excision Clover-leaf Milligan-Morgan open technique (UK)

  36. Ferguson closed technique (USA)

  37. Complications • Early Urinary retention (within 24 – 48 hours) Reactionary haemorrhage • Intermediate Faecal impaction Secondary haemorrhage (7 – 16 days) • Late Anal stenosis: too much skin/mucosa removed Incontinence: damage to anal sphincters Recurrence

  38. Comparison of treatment modalities: meta-analysis • Haemorrhoidectomy was better than RBL in treatment response, but complications were greater as was pain • RBL was better than sclerotherapy in treatment response, with no difference in complication rate • Patients treated with RBL were less likely to require further therapy than those treated with sclerotherapy, although pain was greater after RBL MacRae HM and McLeod RS. Dis Colon Rectum 1995; 38: 687-94.

  39. Ligasure Harmonic scalpel Bipolar scissors Alternative energy sources Multiple comparison studies have been done, but no consensus exists identifying superiority of one technique over another

  40. PPH • Procedure for Prolapsed Haemorrhoids • Not really haemorrhoidectomy • Better described as haemorrhoidopexy • Reduction and fixation of the prolapse • Same principle as sclerotherapy and rubber band ligation

  41. PPH - 03 Haemorrhoid circular stapler (HCS 33 mm) Suture threader Circular anal dilator Purse-string suture anoscope

  42. Stapled haemorrhoidopexy • New technique • Originated in Italy by Dr. Antonio Longo in 1993 • Fully developed and released in 1997 • More than 100,000 operations have been done

  43. Stapled haemorrhoidopexy Column of mucosa and submucosa excised with the circular stapler Resulting scar will fix the mucosa and prevent prolapse

  44. Stapled haemorrhoidopexy

  45. Stapled haemorrhoidopexy Before After

  46. Information from available publications • Definite short term advantages • Less postoperative pain • Shorter hospital stay • Earlier return to normal activities • Comparable complication rates • Feasible as a day-case procedure vs. traditional haemorrhoidectomy

  47. Insufficient information • Long term recurrence rate • Management of recurrence after PPH • Application in acute setting • Persistent anal pain/faecal urgency in some patients

  48. Endoscopic ligation and fixation

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