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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 7-3 Use of a closed anoscope to demonstrate hemorrhoidal prolapse.
Poking the mucosa with a Q-tip tests its laxity on the underlying muscle
and, therefore, the suitability for elastic banding.
Before taking the scope out completely, the obturator is replaced, the
scope reinserted into the hilt and turned through 90 degrees. This
withdrawal procedure is repeated twice so that all four quadrants of the
anal canal are inspected.
Longer beveled anoscopes allow examination of more of the lower
rectum. If these scopes are used, the knee-chest position is preferred as it
allows the rectum to balloon open and provides superior views.
Rigid Proctoscopy
Rigid proctoscopy has largely been superseded by flexible
proctosigmoidoscopy as a way of examining the entire rectum.
The view provided is inferior to that from a flexible instrument, and
therapeutic or biopsy procedures are more difficult. It is a simple way of
checking the status of the rectal mucosa, in a patient being followed for
proctitis, or checking the site of a low rectal polyp excision to exclude
recurrence.
Rigid proctoscopy has been the most accurate way of defining the location
of a cancer within the anus, by distance from the anal verge and location
within the circumference.
The technique usually involves preparation with an enema. The patient
can be in knee-chest or left lateral position, and the appropriate-sized
proctoscope is inserted through the anus using the “Open Sesame”
technique.
Once its tip is above the pelvic floor, the scope is angled forward to allow
the tip to pass posteriorly into the rectal vault.
The insufflator is then used to inflate the rectum, and advancement can
occur under direct vision.
The scope is inserted to the top of the rectum and withdrawal is
systematic, using circular movement to examine the circumference of the
rectum.
Rigid biopsy and suction are available to improve the view and to sample
abnormal mucosa.
Flexible Sigmoidoscopy
Flexible sigmoidoscopy is indicated in the investigation of complaints
such as rectal bleeding, diarrhea, and urgency. It is also useful for the
follow-up of rectosigmoid lesions that have been treated locally, proctitis,
and an ileorectal anastomosis in patients with colitis or familial
adenomatous polyposis (FAP).
The aim is to examine at least the rectum and most of the sigmoid colon,
although the 60-cm scope can at times reach the mid-transverse colon.
The intent of the examination is to accomplish this without causing pain,
in a nonsedated patient, and so the examination must be as gentle as
possible and should stop if it is uncomfortable.
Preparation is with two-fleet enemas, ideally given just before the
examination. The patient signs a consent for the examination and is placed
in left lateral position.
A “timeout” safety check is carried out, and a digital rectal examination
precedes scope insertion.
As the tip of the scope traverses the anus, insufflation of air and water
facilitates its passage and allows inspection of the anal canal. The scope is
advanced out of the rectum into the sigmoid colon.
Attempts are made to straighten the angles by judicious torqueing, pulling
back, aspirating air, and applying abdominal pressure. If the sigmoid can
be straightened, the scope can usually be advanced to the splenic flexure.
Inspection of the mucosa occurs both on insertion and withdrawal. The
examination is aborted if the patient is suffering pain that cannot be
relieved by straightening the scope.
Diverticular disease is commonly seen in patients older than 60 years and
is sometimes accompanied by spasm, rigidity, and narrowing. Such
patients will not get a complete examination.
If a more thorough examination is called for, the patient should have a full
colonoscopy. If the extent of the sigmoidoscopy is suboptimal, a full
colonoscopy is indicated.
Pouchoscopy
Patients with an ileal J- or S-pouch constructed during surgery for
ulcerative colitis, Crohn colitis or FAP needs surveillance examinations at
regular intervals (q1 year for FAP and q2-3 years for colitis), and
diagnostic examinations of their pouch when there are symptoms.
The examination begins with one or two enemas, but because pouch stool
is often liquid, it can be attempted without a prep. One of the first
differences unique to pouchoscopy is the presence of a pouch-anal
anastomosis.
A stapled anastomosis (by far the more common) is easier to examine but
even that may be stenotic. A handsewn anastomosis is frequently stenotic
and rigid, or is accompanied by a tendency for seepage of stool and some
perianal and anal canal excoriation. This causes insertion of the scope to
be very painful. Lidocaine jelly is indicated.
The anus needs to be examined on insertion so that anal polyps or ulcers
can be seen, and this is achieved by slow insertion while instilling air and
water through the scope channel. Slow insertion allows the anus to relax
and the view improves (Fig. 7-4). This is done again on withdrawal. The
technique of pouchoscopy is relatively straightforward. Advance to the
junction of afferent and efferent limbs of the “J” (Fig. 7-5). Then progress
into the afferent limb. On withdrawal, check if there is an ATZ. Answer
the following questions:
Is the pouch straight? You should be able to see the “owl’s eye” of the
afferent/efferent limb junction from the bottom of the pouch (Fig. 7-6).
If you can’t, there may be a twist or a curve. This may impair emptying
of the pouch and cause more frequent defecation.
FIGURE 7-4 View of the anal canal via pouchoscopy.
FIGURE 7-5 Junction of afferent and efferent limbs.
FIGURE 7-6 Owl’s eye.
Is the pouch normal size? A huge pouch can mean chronically
obstructed defecation and multiple stools.
Is the afferent limb kinked? If you cannot intubate, it there may be an
afferent limb syndrome.
Are there shelves in the pouch? If so, there may be a rotational twist
incorporated into the pouch, with adverse effects on pouch emptying.
Is the mucosa normal? In patients with colitis, look out for pouchitis
with ulcerations, erythema, and granularity. Longitudinal ulcers may
suggest Crohn disease. In patients with FAP, look out for adenomas.
Isolated ulcers, especially on staple lines and at the confluence of
afferent and efferent limbs, are usually normal. They do not mean
Crohn or pouchitis.
Look at the ATZ … in colitis patients, is it inflamed? In FAP patients,
are there polyps? Polyps can be quite subtle.
Can you safely and comfortably retroflex the scope to get a good look
at the low pouch and upper anus? If so, do it.
If it is an S-pouch, how long is the efferent limb? Over 2 in (5 cm) is
particularly liable to cause difficult pouch emptying.
Routine biopsies of the pouch and ATZ are reasonable, especially when
follow-up exceeds 10 years, or when the indication for the colectomy
was neoplasia.
Scoping Stomas and Diverted Bowel
Ileostomies and colostomies can be scoped in the office with either rigid
or flexible scopes.
The usual indications for an ileostomy are to check for adenomas in
patients with FAP and to check for Crohn disease in patients with that
diagnosis.
The indications for a colostomy include checking the extent of ischemia in
a newly formed stoma, checking for strictures at or just below the fascia
level, or performing surveillance colonoscopy after neoplasia surgery.
Rigid Ileoscopy
A pediatric proctoscope is ideal for this procedure.
First, insert a Q-tip into the stoma and examine it. Blood on the tip
suggests inflammation … it is not normal.
Lube the proctoscope and rest the obturator tip on the opening of the
stoma. Let the weight of the scope rest on the stoma, and the stoma will
relax to admit the scope.
Once the scope is well in to the stoma, remove the obturator and use the
air insufflator. Once through the fascia, follow the lumen. Good suction is
necessary as the small bowel constantly produces stool.
Flexible Ileoscopy
A pediatric gastroscope is a good instrument to use and can also be useful
in patients with a strictured ileal pouch-anal anastomosis or in intubating a
continent ileostomy.
The technique involves using judicious air insufflation to follow the lumen
of the bowel. The bowel can be surprisingly tortuous, so insertion,
withdrawal, tip deflection, and torque are all important. Patience is
required in allowing bowel to contract and relax.
Colonoscopy through a Colostomy
This is similar to colonoscopy through the anus. One might think it will be
easy, but sometimes, the direction of the bowel proximal to the stoma can
be surprisingly tortuous, tracking down into the pelvis, or looping across
to the right side of the abdomen.
Parastomal hernias can make colonoscopy difficult.
Scoping Diverted Bowel
Diverted bowel tends to become inflamed due to the lack of short-chain
fatty acids in its lumen, stiff, fragile, and narrow.
Sometimes, other factors such as radiation and sepsis have impacted the
situation. Use narrow scopes (pediatric colonoscopy, ileoscope), be gentle,
and stop the inspection if there is serious patient discomfort.
The bowel can be hard to biopsy due to its stiffness and the loss of
suppleness of the mucosa.
Suggested Readings
Ashburn J, Church J. Open sesame revisited. Am J Gastroenterol. 2013;108(1):143. doi:
10.1038/ajg.2012.382.
Farmer KC, Church JM. Open sesame: tips for traversing the anal canal. Dis Colon Rectum.
1992;35(11):1092-1093.
Hurlstone DP, Saunders BP, Church JM. Endoscopic surveillance of the ileoanal pouch following
restorative proctocolectomy for familial adenomatous polyposis. Endoscopy. 2008;40(5):437-
442.
PART II
Anorectal Disease
Chapter 8
Hemorrhoidectomy
MASSARAT ZUTSHI
Perioperative Considerations
The mere presence of hemorrhoids is not an indication for
hemorrhoidectomy. Symptoms should be directly related to the
hemorrhoids.
Many patients with “hemorrhoids” are not hemorrhoids, and a thorough
evaluation for other anorectal pathology should be performed.
Excisional hemorrhoidectomy should be reserved for those patients with
external or grade III/IV hemorrhoids that have failed conservative
management.
Patients should be appropriately counseled as to the risk of pain, bleeding,
open wounds, recurrence, and resulting skin tags prior to
hemorrhoidectomy.
Anal stenosis following hemorrhoidectomy should be a rare occurrence
and is minimized by keeping >1 cm of anoderm between resected
columns.
Similarly, new incontinence following hemorrhoidectomy should be rare,
and all efforts to identify and preserve the sphincter should be done.
For appropriate patients, or those with more concerning symptoms, ensure
the colon has been evaluated with a colonoscope to rule out more proximal
pathology.
Sterile Instruments/Equipment
Betadine solution for skin preparation
Lighted Hill-Ferguson anal retractor
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