Anal fissure, fistula and rectal prolapse
Northern Region SpR teaching programme Mr J French Mr P Hainsworth 08.10.04
Anal Fissure
Introduction
1
– Split in skin of distal anal canal – Male = female – Post defaecation pain, bleeding – Location usually posterior midline
Differential diagnosis: TB, IBD, HIV, Syphilis Acute vs chronic
BJS 1996: 83 (10) 1335-1344
Anal Fissure
Introduction
2
– Split in skin of distal anal canal – Male = female – Post defaecation pain, bleeding – Location usually posterior midline
Differential diagnosis: TB, IBD, HIV, Syphilis, malignancy Acute vs chronic
BJS 1996: 83 (10) 1335-1344
Anal Fissure
3
Physiological and pharmacological control of internal anal sphincter
– IAS partial contraction. – Relaxation to rectal distension (rectosphincteric reflex)
Sympathetic innervation, 5th lumber via hypogastric
Contraction; alpha-adrenoreceptors
Relaxation; beta-adrenoreceptors
Anal Fissure
4
Physiological and pharmacological control of internal anal sphincter
– IAS partial contraction. – Relaxation to rectal distension (rectosphincteric reflex)
Sympathetic innervation, 5th lumber via hypogastric
Contraction; alpha-adrenoreceptors
Relaxation; beta-adrenoreceptors
Acetylcholine via muscarinic EFS; NANC Nitric oxide
Anal Fissure
Pathogenesis
– Traditionally
– Passage of hard stool – Varicose veins, childbirth – Spasm –
not related to pain
5
– Current theories
– Ischaemia of post midline Post-mortem angiography paucity of inferior rectal artery at post commisure Doppler flowmetry anodernal bloodflow negatively correlated with resting anal pressure
Anal Fissure
Treatment
– Non-surgical
Dietary Local anaestheitc Local hydorcortisone Anal dilators Local Nitrates (e.g. Glycerly trinitrate) Calcium channel blockers (e.g.nifedipine, diltiazem) Botulinum toxin
Contraction; alpha-adrenoreceptors
6
Relaxation; beta-adrenoreceptors
Acetylcholine via muscarinic EFS; NANC Nitric oxide Cochrane database of systemic reviews. 2004, Vol2
Anal Fissure
Treatment
– Surgical
Anal dilatation Sphincterotomy
– – – – – – Local vs general Posterior vs lateral Open vs subcutaneous Length of sphincterotomy Advancement flaps Complications
Incontinence 10-15% minor 0-5% major
7
Cochrane database of systemic reviews. 2004, Vol2
Anal Fissure
Anal fissure Acute GTN Resolution Failure Repeat GTN Resolution Treat as chronic Resolution Rule out other causes
8
Chronic
Lateral Sphincterotomy Failure
Anal physiology Sphincter visualisation Repeat Sphincterotomy
Anorectal sepsis and Fistula
Introduction
– Anorectal sepsis one of commonest surgical emergencies – Recurrence common. 80% associated with formation of fistula-in-ano – AETIOLOGY/PATHOGENESIS
10-12 anal glands (intersphincteric) draining into crypts of morgagni Reasons for cryptoglandular tissue unknown (Crohns, UC, TB, hidradenitis, fissure, malignancy) Gland infection – intersphincteric abscess – expansion and tracking – Perianal, ischiorectal, supralevator, circumfrential
1
Anorectal sepsis and Fistula
Classification
5%
2
35%
60%
Anorectal sepsis and Fistula
Clinical presentation/evaluation
– Abscess: Pain,swelling,fever
Perianal: Tender anal verge, fluctuanat mass,erythema Ischiorectal: Larger, less dramatic cutaneous findings Intersphincteric/supralevator: Severe rectal pain
3
Evaluation Often difficult beside EUA Black spot – widespread necrotising infection
Anorectal sepsis and Fistula
Treatment
– Adequate incision and drainage
4
Elliptical, saucerisation Drains usually not necessary, packing counterproductive No antibiotics (Diabetes, RHD, immunosuprression, extensive cellulits, prosthetic device) Horseshoe: Drains encircling skins bridges Supralevator: MRI/CT to determine source of sepsis
Anorectal sepsis and Fistula
Supralevator abscesses
5
Anorectal sepsis and Fistula
Classification
6
Anorectal sepsis and Fistula
Clinical presentation/evaluation
– – – – – Abscess (37-50% patients) Intermittent bloody/purulent discharge (↓pain) Pain with defecation External opening seen / internal difficult H202 Goodsalls rule
7
Anorectal sepsis and Fistula
Goodsalls rule
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>3cm Complicated cephalad extension
Straight tracks Radial opening
Transverse Line
Curved tracks Opening post midline
Anorectal sepsis and Fistula
Clinical presentation/evaluation
– – – – – – – – Abscess (37-50% patients) Intermittent bloody/purulent discharge (↓pain) Pain with defecation External opening seen / internal difficult H202 Goodsalls rule Fistulography unreliable Transanal ultrasound MRI
9
Anorectal sepsis and Fistula
Treatment
– – – – –
10
Aim: eliminate fistula, prevent recurrence, preserve sphincter Identification of primary opening and limiting muscle division Intersphincteric / transphincteric: Laying open Proximal to dentate line: seton Extrasphincteric: Lower portion divided, rectal opening closed.
May need temporary colostomy
Fibrin Glue? Long, narrow but enthusiasm fading.
Rectal prolapse
Introduction
– Intersusseption of the rectum – Categorised: Internal/Occult, External, Mucosal – 5th decade, 80-90% women
1
Causes
– No single common theory
Classic anatomical features Progression from intersusseption Perineal descent
Rectal prolapse
Moschcowitz
– –
1912
2
Redundant sigmoid colon (A), deep pouch of Douglas (B), loss of sacral attachments (C) Acute recto-sigmoid junction (D) – straining – sliding hernia (sigmoid / small bowel) through weakened pelvic floor (F).
D A C E
B
F
Rectal prolapse
3
Progression from intersusseption
Originally thought rectal prolapse endpoint of a spectrum Longterm follow-up of patients with interssuseption, only 2-3% prolapse
Rectal prolapse
Perineal descent
– Injury to pudendal nerves
4
Support: association between neurogenic faecal incontinence and rectal prolapse. Detract: Normal innervation and prolapse. Incontinence improves after surgery for prolapse.
Rectal prolapse
Presentation
5
– Protrusion, discharge, straining+constipation, incomplete evacuation. Incontinence, bleeding +ulceration.
Examination
– – – – – – – – Differentiate from mucosal prolapse PR: anal sphincter for defects / strength. ?Rectocoele Rigid sigmoidoscopy Colonoscopy / Barium: concurrent disease Shapes study: colonic inertia Defecating proctogram: outlet obstruction Rectal manometry/USS/Pudendal nerve motor latency: Inconitinence Proctography/Cystography/small bowel contrast: additional pelvic support disorders suspected.
Rectal prolapse
Operative repair
6
– Considerations: Degree of prolapse, associated disorders comorbidity, presenting symptoms. – Goals of surgery
Resection / plication of redundant bowel. Fixation of rectum to sacrum Improving symptoms of faecal incontinence and constipation.
– Categorised
Perineal or abdominal.
Rectal prolapse
Operation Perineal Thiersch Loop Resection Abdominal Resection + rectopexy
6
Laparoscopic Rectopexy
Delorme repair
Altmeier Procedure
Sigmoid resection
Frykman repair
Sutured rectopexy
Ripstein Procedure Ivalon Sponge