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242
Fig. 12.9 Diamond (rhomboid) ap
V. L. Tsikitis and S. Marecik
Fig. 12.10 House ap
ap into the anal canal. Clinical improvement or healing of
the stenosis was reported in more than 90% of patients
(Fig.12.10) [83–85].
U Flap (Island Flap Anoplasty)
This technique was developed by Pearl etal. and can also be
used in the treatment of ectropion as well as distal stula in
ano [86]. The U ap provides a wide-base island ap that can
cover a large area of anodermal defect, similar to the previously described techniques. The important difference, however, is that the donor site in this technique is not closed but
is left open for secondary healing. Initially, wet to dry gauze
application is required to allow the area to granulate. Dry
gauze can then be used to allow the wound to epithelialize.
Of 25 patients treated with this aps (20 for anal stenosis and
5 for mucosal ectropion), 16 reported excellent and 7 reported
good results [86].
Rotational S Flap
This technique is used most often to cover larger
defects resulting from the excision of perianal Paget’s
or Bowen’s disease. The rotational S flap (S-plasty) can
also be used to effectively move a significant amount of
perianal skin into the anus in order to cover a large defect
after circumferential excision of the stenotic scar in the
distal anal canal. In this technique, two full-thickness,
well-vascularized cutaneous flaps with an appropriate
amount of underlying subcutaneous tissue (sometimes as
fascio-cutaneous flaps) are created by the S-shape incision and centered around the anal opening. The flaps
are subsequently advanced, rotated into the distal anus
along the incision, and sutured to the non- strictured rectal mucosa, as well as to the corresponding edges of the
defect (Fig.12.11) [87, 88].
Technical Aspects
Reconstructive ap procedures are performed after mechanical bowel preparation. A complete bowel preparation may be
difcult to accomplish in patients with anal stenosis.
Frequently, a prolonged 1–2-day bowel preparation is
required in addition to a roughage-free diet for several days
prior to the procedure. If the patient is found to have a large
amount of liquid stool in the colon immediately before the
procedure, an ad hoc colonoscopic washout and aspiration
can be performed.
The mechanical bowel preparation can be supplemented
with oral antibiotic administration. This is in line with current recommendations for proctectomy cases, since the anas-
Defect
ab
cd
Stricture excision
12 Anal Fissure andAnal Stenosis
243
Mucosa
Fig. 12.11 Rotational ap (a) scar excision, (b) internal sphincterotomy, (c) ap creation, (d) ap xation in place
tomosis (suture line) is created in the ap cases. Perioperative
antibiotics are given. In cases with large amount of contamination, a low-concentration chlorhexidine solution jet irrigation can be used (Irrisept®). The choice of post procedure
antibiotics (IV, oral, or none) is dependent upon the complexity of the case, bowel preparation, and surgeon
preference.
Most of the ap procedures are performed with the patient
in the prone jackknife position, with the exception of posterior rectal advancement aps. The buttocks are initially taped
apart and the Lone-Star retractor can be useful. Low wattage
cautery and sharp knife dissection are used.
In the current era of effective hemostasis, hemostatic epinephrine solution injection is primarily reserved for cases of
stubborn bleeding from the scar tissue. Alternatively,
epinephrine- soaked gauze application can be utilized.
Additionally, injection of epinephrine into the ap can lead
to ischemia of its terminal parts, whereas injection into the
dissected tissues can disturb the surgical planes or even
decrease the effective space in an already tight anal canal.
244
V. L. Tsikitis and S. Marecik
Excision of the scar requires precision and should avoid
thermal injury to the underlying healthy tissues. Frequently a
thin layer of the scar can be inltrated with saline or epinephrine solution and removed sharply.
It is important that the minimal amount of absorbable suture
material is used, typically 2-0 Vicryl for strength and 3-0 Vicryl
or Chromic for tissue approximation. Occasionally, a few nonabsorbable strength sutures can be placed. Care should be taken
to avoid dead space formation underneath the aps.
In selected cases, the ap reconstruction can be protected
using a diverting ostomy, most often created with laparoscopic assistance at the end of the procedure. Tenuous repairs
with poor bowel preparation and negative predictive healing
factors can be the determinants for prophylactic diversion.
Flap Aftercare
The majority of ap procedures are performed on an outpatient basis. Patients are instructed to not sit directly on the
repair site. Showering or rinsing with water is recommended,
particularly when soiling with stool occurs. The wounds
should then be covered with dry dressings to prevent tissue
maceration. Wet to dry dressings are suggested for the open
wounds.
Close follow-up is necessary to observe for any ap ischemia, suture line breakdown, granulomas, or wound dehiscence. Localized dehiscence is not uncommon but can be
effectively monitored and treated in the ofce setting and by
thorough wound care. Not healed wound dehiscence can
lead to chronic ssures, especially when associated with ap
ischemia. Patients should be seen in the ofce within 5days
from surgery in order to check on wound healing and to reinforce the aftercare instructions.
Postoperative bowel rest can be benecial and is frequently used by surgeons for complex and repeat repairs.
Pharmacological bowel rest with antimotility and narcotic
agents can be used; however, the consequences of subsequent stool buildup, fecal impaction, and its effect on the
healing wound should be carefully weighed. Today, an available option is total or peripheral parenteral nutrition (TPN or
PPN), which can often be administered in the home setting
via the PICC line or Medline®, respectively. This route of
nutrition can be effectively combined with a liquid diet high
in fat and protein to provide sufcient nutrition during the
rst 1–2weeks of healing. The cost of this approach is more
favorable compared to the option of protective diverting
ostomy (author’s observation).
Alternatively, patients can be restarted on a soft high-ber
diet with an appropriate amount of water to bulk up the stools
and prevent constipation (similar to the bowel regimen for
the ssure patients). Local antibiotic ointments (e.g., triple
antibiotic ointment) can be used for topical application.
Postoperative pain control can be provided by intraoperative injection of liposomal bupivacaine (e.g., Exparel®) as
well as oral analgesia (e.g., nonsteroidal anti-inammatory
drugs (NSAIDs), acetaminophen, Lyrica®). Stool softeners
are recommended during opioid analgesia. Diarrhea should
be prevented, since liquid stool appears to be more detrimental to ap repairs than bulky or rm stool.
A successful ap procedure rarely requires further dilation maneuvers. However, if recurrent stricture formation is
identied, dilations should be performed.
Choosing theRight Procedure
The ideal procedure should be simple, effective, and free
from serious morbidity and should restore the anal function
for a good long-term outcome. Unfortunately, there is no
one-ts-all solution. The choice of procedure should also
depend on the surgeon’s comfort level. The involvement of
the scar tissue needs to be determined. Repair of the stenosed
anoderm will fail if the concomitant internal sphincter brosis is not addressed. Conversely, the lateral internal sphincterotomy will not be successful if the problem of the
concomitant anodermal stenosis is not corrected [63].
Not every stenosis needs correction. Patients with asymptomatic stenosis found during digital rectal exam should only
be instructed about dietary modications and the potential
need for dilations should symptoms occur. The possibility of
underlying malignancy must also be excluded.
The simplest form of anoplasty involves longitudinal incision of the involved tissue with transverse closure of the
resulting diamond-shape defect in a Heineke-Mikulicz
fashion. This approach can be utilized for stenosis at different levels in the anal canal and performed more than once
around the circumference. It is reserved for small areas of
stenosis, has a high chance for restenosis, and may require
additional dilations [69]. For proximal and mid-anal stenosis, rectal advancement aps should be considered.
Mid and distal anastomosis can be successfully treated
with Y-V aps; however, the tip of the ap can be at risk for
ischemia if signicant tension is applied. If the Y-V ap cannot reach into the desired location without excessive tension;
it can be converted into the diamond island ap [69].
Insufcient release of the stenosis with one diamond ap can
be addressed by a repeated procedure on the contralateral
site.
For scenarios that require advancement of a larger amount
of tissue in both transverse and longitudinal aspects, the V-Y,
house, and U ap (island ap anoplasty) are more appropriate. They can also be performed bilaterally. Circumferential
excision of the distal anoderm is best addressed by the rotational S-plasty or larger skin aps, based on the named vascular pedicles [79, 87–89].
12 Anal Fissure andAnal Stenosis
245
It is extremely difcult to comparatively interpret the
results of many case series involving various reconstructive
procedures. The only randomized study by Farid compared
the house ap, rhomboid ap, and Y-V anoplasty in anal stenosis patients. The average operative times were the longest
in the house ap group (62min) and the shortest in the Y-V
anoplasty (35min). The anal caliber at 1year was the largest
in the house ap group, together with the highest quality of
life score and a signicant improvement of symptoms
(p < 0.05) [83]. Helpful summaries of the ap procedures
with their respected outcomes have been presented by
Brisinda and Shawki [48, 54].
Few complications have been reported with most of these
techniques. They can include infection, ap failure, recurrence of the stenosis, fecal incontinence, and impaction [54].
In cases where no satisfactory results can be obtained using
the abovementioned procedures, a diverting colostomy
remains the last resort option.
Anal Stenosis inCrohn’s Disease
Anal stenosis in Crohn’s disease is common and does not
frequently manifest itself clinically due to the liquid nature
of stools in this patient population. The stricturing, stulizing, and ssuring nature of the disease, with subsequent
healing attempts, can lead to the possibility of anal stenosis
at any level of the anal canal and frequently involves the anorectal junction. Poor wound healing, constant inammation,
and scar tissue formation pose a signicant challenge for the
possibility of surgical correction.
In a study of 224 patients with anorectal complications
of Crohn’s disease, 65 patients presented with anal stenosis, and 4 patients went on to develop anal stenosis during
the study [67]. Most of these patients specically indicated
that anal stenosis was their only complaint, and only a
small number of patients from this group required absolutely no surgical intervention. Another 16 patients underwent mechanical dilatation, and 17 patients ultimately
underwent proctectomy or diverting stoma within a mean
follow-up of 19 months. In another study of 44 patients
with anal stenosis secondary to Crohn’s disease, 75%
underwent mechanical dilatation and 43% eventually
required proctectomy [66]. Brochard reported successful
healing in Crohn’s-related anorectal stricture in 59% over
the course of 8.9years [90].
These results highlight the signicant risk of loss of bowel
continence in patients with Crohn’s disease and anal stenosis. Some authors have suggested that manual anal dilatation
may result in further scarring and progressive stenosis or
incontinence and should thus be avoided in patients with
Crohn’s disease [51, 61, 68].
Prevention
Avoidance of several crucial mistakes during hemorrhoidectomy, which is the procedure responsible for 90% of all stenosis cases, should decrease the chance of this complication
occurring. In particular, overzealous removal of all abnormal
hemorrhoidal tissue should be avoided, and the mucocutaneous bridges of viable tissue should be preserved (>1 cm
strips). Some of the remaining abnormal hemorrhoidal tissue
can be incorporated into the closure suture line, thus eliminating the need to remove it altogether.
Other devascularization techniques (suture ligation, supplemental rubber band ligation) can also be used to address the
remaining engorged hemorrhoidal tissue. Three-quadrant
hemorrhoidectomy can often be replaced by two-quadrant
excision, with the addition of limited resection or rubber banding of the third remaining hemorrhoidal pedicle. Often, the
remaining smallest third pedicle is so devascularized after the
two other columns are removed that no resection is needed.
Techniques of vascular plexus resection with preservation of
the anoderm or hemorrhoidopexy can also be utilized.
Finally, treatment of acute grade IV hemorrhoidal disease
should be done with caution, since the majority of the anoderm is abnormally swollen at the time of the resection and
will return to normal after the acute process is resolved.
Injection of a local anesthetic before the resection of the
hemorrhoid or a skin tag articially “inates” the tissues. In
the end, this can result in excessive resection. In many cases,
the rectal mucosa can be anchored to the internal sphincter at
the level of the dentate line, or even more distally, thereby
avoiding the need to close each wound in the vertical fashion. Similarly, some of the remaining anoderm of the anal
verge can be anchored into the sphincter in order to prevent
its outward retraction.
Resection of the hemorrhoidal tissue in the anterior or
posterior midline can lead to poor wound healing, ssure formation, and anal stenosis and thus should be avoided if possible. Care should be taken to minimize the thermal injury to
the non-resected tissues in the anal canal.
Anal Stenosis, Conclusions
Anal stenosis is a rare but serious problem, which every
colorectal surgeon will encounter. Prevention of this complication is crucial among any surgeon who is addressing the
anorectal pathology. Appropriately performed hemorrhoidectomy should minimize the risk of anal stenosis.
Conservative management is reserved for mild stenosis
cases. Several surgical options for moderate and severe stenosis include sphincterotomy, stricturotomy or stricturectomy, and appropriate ap anoplasty.
246
V. L. Tsikitis and S. Marecik
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Cryptoglandular Abscess andFistula
EricK.Johnson andGretaBernier
13
Key Concepts
• Anorectal abscess should be treated with surgical drainage, not antibiotic therapy.
• At least one-third of cryptoglandular abscesses will progress to stula.
• Anal stula in the typical patient should be evaluated with
examination under anesthesia. Subsequent management
will be dictated by anatomic ndings in the operating
room.
• Priorities of management are control of sepsis, maintenance of continence, and cure without recurrence, generally in that order.
• While there are many new and emerging methods of treatment, the surgeon should be critical of the published literature and base their informed consent discussion on
their observed results over time. Most studies would indicate that at least 12months of follow-up is required to
determine success.
Introduction
Anorectal abscess and stula-in-ano are commonly encountered in a colorectal surgery clinic. It is imperative for the
surgeon to fully understand the pathophysiology of this disease process, the anatomy of the anal canal and pelvis with
respect to cryptoglandular abscess and stula, and how to
appropriately individualize care for each patient.
As stated by Dr. Herand Abcarian, “It is difcult if not
impossible to accurately assess the incidence of anorectal
abscesses because they often drain spontaneously or are
incised and drained in a physician’s ofce, emergency room
or surgicenter” [1]. Similarly, our estimates do not account
for those treated with antibiotics alone in the primary care
setting. This is further complicated by the misdiagnosis of
many common anorectal pathologies as “hemorrhoids,” both
by patients and referring physicians.
The incidence of anorectal abscess is documented as 8.6–
20 patients per 100,000 people, with males being more
affected than females at an incidence of 2.4–3:1 and presentation at a mean age of 40years [2–4]. The most common
etiology is cryptoglandular, accounting for 90% of anorectal
abscesses, although both abscess and stula can arise from a
multitude of etiologies, including Crohn’s disease, obstetric
injury, ssure, and infectious etiologies such as tuberculosis,
sarcoid, and HIV.These etiologies are outside the scope of
this chapter but will be discussed in further detail in subsequent chapters.
Cryptoglandular Pathophysiology
Cryptoglandular abscess and stula-in-ano arise from glands
at the dentate line, nestled between the anal papilla and the
columns of Morgagni. These glands extend into the submucosal space, internal sphincter, intersphincteric space, and
external sphincter to varying degrees. When bacteria and
debris become inspissated in these glands, an infection
develops, and this will track along the course of the gland or
follow to the path of least resistance from its origin (Fig.13.1)
[5, 6]. This theory was described and popularized by
Eisenhammer in the 1950s [5].
E. K. Johnson (*)
Department of Colon and Rectal Surgery, Cleveland Clinic,
Cleveland, OH, USA
G. Bernier
UW Medicine– Valley Medical Center, Department of Surgery,
Renton, WA, USA
© Springer Nature Switzerland AG 2022
S. R. Steele et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, https://doi.org/10.1007/978-3-030-66049-9_13
Cryptoglandular Abscess
As described above, anorectal abscesses occur in multiple
spaces in the pelvis and are so classied by these locations:
perianal, ischiorectal, intersphincteric, and supralevator
249
250
E. K. Johnson and G. Bernier
toms such as a ssure, thrombosed hemorrhoid, sexually
transmitted infection, or malignancy. Supralevator abscesses
may arise from cephalad extension of a cryptoglandular origin but, however, are more commonly associated with an
intraabdominal process such as diverticular disease, malignancy, or Crohn’s disease. Perianal and ischiorectal abscesses
represent the majority of anorectal abscess, 65–80% [7, 8].
Ramanujam et al. further described the incidence of each
subtype of anorectal abscess in their evaluation of 1023
patients presenting over a 5.5-year period. In their series,
perianal abscesses accounted for 42.7% of anorectal
abscesses, ischiorectal for 22.7%, intersphincteric for 21.4%,
and supralevator for 7.3%.
Diagnosis
Fig. 13.1 Image depicting the anal canal with surrounding muscula-
ture and crypt glands in cross section coursing through the internal anal
sphincter. (Reprinted with permission, The Cleveland Clinic Center for
Medical Art & Photography © 2009–2020. All Rights Reserved)
Fig. 13.2 Cross-sectional image showing abscess formation in the different potential spaces. (Reprinted with permission, The Cleveland
Clinic Center for Medical Art & Photography © 2009–2020. All Rights
Reserved)
(Fig. 13.2). Another classication, horseshoe abscess,
describes an abscess that courses posteriorly through the
deep postanal space to involve the bilateral ischiorectal
spaces.
Both perianal abscesses and ischiorectal abscesses typically present with perianal pain, swelling, and uctuance,
with possible spontaneous drainage of purulent uid.
Intersphincteric abscesses typically do not have any external
manifestations but rather present as intense anal pain, such
that the patient will often not tolerate a digital rectal exam,
without any other clear pathology to account for these symp-
History and physical examination are generally sufcient to
diagnose perianal and ischiorectal abscesses. Imaging
adjuncts, such as CT scan, MRI, stulogram, and endoanal
ultrasound, are not indicated for the patient with classic
uncomplicated presentation, without diagnostic dilemma or
comorbidity, and a uctuant area is appreciated on examination [3, 9]. Imaging may be benecial in the workup of those
with an unclear diagnosis, such as those with isolated intersphincteric abscess or those that have other complicating
factors, such as history of malignancy, radiation, Crohn’s
disease, prior anorectal operations, or trauma, or those with
concern for complex abscesses such as horseshoe or supralevator extension. Imaging adjuncts may also be useful in
select cases for management of associated stula-in-ano, as
discussed later in this chapter.
Treatment
The primary treatment for anorectal abscess is expeditious
incision and drainage. Perianal and ischiorectal abscesses
should be drained through the skin overlying the area of
uctuance. If the abscess cavity is large, the incision should
be made over the area of the cavity that is closest to the anal
verge. With this technique, if the patient develops a resultant stula-in-ano, the tract will not be unnecessarily long.
This consideration is important, as approximately one-third
of acute anorectal abscesses persist as a stula-in-ano [8,
10, 11].
Intersphincteric abscesses and supralevator abscesses
require special considerations both for effective drainage and
to avoid iatrogenic injury. Intersphincteric abscesses typically require internal drainage at the dentate line via sphincterotomy if there is no external area of uctuance.
The route of drainage is of particular importance for
supralevator abscesses. Those that arise from an intraabdom-
Inter
Submucosal space
ic space
13 Cryptoglandular Abscess andFistula
Fig. 13.3 Image showing
different potential spaces for
abscess formation, with
emphasis on appropriate
drainage route for
supralevator abscess.
(Reprinted with permission,
The Cleveland Clinic Center
for Medical Art &
Photography © 2009–2020.
All Rights Reserved)
251
Ischiorectal space
External sphincter
nal sphincter
Perianal space
inal source should be drained either transabdominally using
interventional radiology assistance or transrectally, while
those arising from cephalad extension of a cryptoglandular
source via the intersphincteric space should be drained transrectally. Those that arise from a cephalad extension of an
ischiorectal abscess should be drained transcutaneously.
These principles are important in order to avoid iatrogenic
creation of a suprasphincteric stula (Fig.13.3).
Another special case is drainage of the horseshoe abscess.
As stated previously, these typically arise from extension of
an ischiorectal abscess via the deep postanal space. In order
to adequately drain these abscesses, there must be both bilateral transcutaneous ischiorectal drainage and posterior drainage via division of the anococcygeal ligament to access the
deep postanal space. Other examples of a horseshoe abscess
include those arising from a perianal abscess extending
through the supercial postanal space, those extending
through the anterior perianal space, or a supralevator
abscesses coursing through the posterior supralevator space
(Fig.13.4).
Acute Fistula Management
By denition, 100% of anorectal abscesses of cryptoglandular etiology will have a path from the dentate line to the
drained abscess cavity. At the time of acute abscess presentation, 30–70% of patients will have an identiable tract [8,
12–14]; however, this tract is not mature and will only
become a stula tract in ~30–35% of patients. There is also a
Supralevator space
Intrasphincter
risk of creating a false passage while attempting to identify a
stula tract in the setting of acute inammation. If a tract is
identied, some advocate for primary stulotomy at the time
of abscess drainage to reduce recurrent abscess or need for
second operation were a stula to develop. And while some
have shown a decrease in both abscess recurrence and stula
formation with primary stulotomy [12], this approach
results in occasionally unnecessary sphincter division in
patients who would not have ultimately developed a chronic
stula. In addition, inammation from the concomitant
abscess will make it more difcult to discern the degree of
muscle involvement, precluding appropriate surgical judgment, thereby potentially increasing the risk of incontinence
[12, 15]. Given this controversy and potential risks, it is not
generally recommended to denitively manage this tract at
the time of abscess drainage.
Incision and drainage in the clinic instead of the operating
room is preferred as it expedites the time to control of sepsis.
In order to perform this procedure in clinic, the provider
must have an adequate setup with anesthetic, instruments,
patient positioning, and an amenable patient. In many cases,
patients will tolerate in ofce drainage. This can be facilitated by injecting a wheal of anesthetic at the intended site of
drainage, decompressing the cavity through the wheal with a
larger needle prior to injecting additional anesthetic, and
then completing drainage via a small incision. Complex perianal abscesses, such as those that are deep/nonpalpable,
those that are associated with tissue necrosis, and those inpatients who are intolerant of a bedside procedure, are better
managed in the operating room.