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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_636_Библиотеки_им_академика_М_И_Перельмана.pdf
172
-anal neoplasm
Anterior
Posterior
-Crohn’s
-Tuberculosis
-HIV
-Leukemia
-anal neoplasm
Fig. 13.1 Chronic ssure with external sentinel tag,
internal hypertrophied papilla, and thickened internal anal
sphincter muscle
K. C. Lu and D. O. Herzig
Fig. 13.3 Atypical ssure with skin changes, broad base,
and lateral location. (Courtesy of Sam Atallah, MD)
Typical
-Crohn’s
-Tuberculosis
AtypicalAtypical
-HIV
-Leukemia
Fig. 13.2 Acute ssure with clear edges and no signs of
chronicity of sphincter hypertrophy. (Courtesy of Richard
P.Billingham, MD)
– Atypical ssures
• Can occur anywhere in the anal canal
(Fig.13.3)
• Tend to be associated with other diseases, including malignancy, Crohn’s
disease, human immunodeciency virus
(HIV) infection, syphilis, and tuberculosis (Fig.13.4)
Typical
Fig. 13.4 Type of ssure by location
Pathogenesis
• The exact etiology remains uncertain.
• Typically occur after the passage of a large,
hard stool or anal trauma.
• Fissures can occur in the absence of any
trauma or constipation.
• Theories:
– Mechanical theory – the anorectal angle
creates the greatest stress posteriorly.
– Sphincter hypertonicity– it is documented
by manometry in multiple studies,
undetermined if the cause of the disease or
an effect.
– Ischemia – the posterior midline is rela-
tively ischemic by both arteriographic
studies and laser Doppler.
13 Anal Fissure
173
Non-operative Treatment
Healing Rates in Acute Anal Fissure
• Safe, few side effects, and should usually be
the rst step in therapy
• Up to 90% with acute anal ssure when prescribed 10g of unprocessed bran twice daily
and use of a warm sitz bath for 15min twice
daily and after bowel movements
Healing Rates in Chronic Anal Fissure
• Spontaneous healing rates are likely to be seen
in only a minority of patients.
• Cochrane Review of the non-operative treatment of chronic anal ssure (over 70 randomized trials): healing rate in the combined
placebo group was 35.5%.
• Because internal anal sphincter hypertonicity
is related to anal ssure, initial non-operative
treatment is targeted to alleviate internal anal
sphincter activity through two topical agents,
nitroglycerin and diltiazem, and one injectable
agent, botulinum toxin A.
• Most common side effect of topical GTN
treatment is headache (27–50%).
• A second potential drawback is tachyphylaxis,
which does not respond to escalations in dose
or frequency.
• In 2011, the FDA approved Rectiv: 0.4%
nitroglycerin applied endoanally bid for
6–8weeks. At 24-week follow-up, there was a
77% healing rate.
Calcium Channel Blockers
• Both diltiazem and nifedipine have been
described either orally or topically to cause
relaxation of the smooth muscle of the internal
anal sphincter.
– Oral and topical nifedipine have been
shown to lower mean resting anal pressure.
Diltiazem has been shown to decrease
mean resting anal pressure, although the
effect is greater with topical diltiazem.
• Multiple small trials suggest healing rates
equivalent to GTN with fewer side effects.
• Neither diltiazem nor nifedipine are FDAapproved for the treatment of anal ssure.
There is no topical formulation available in
the United States, so a compounding pharmacy is needed.
Topical
Nitroglycerin
• Nitric oxide is the neurotransmitter mediating
relaxation of the internal anal sphincter.
• Topical application of 0.2% glyceryl trinitrate
(GTN) ointment relaxes the anal sphincter by
manometric studies.
• A landmark randomized trial was reported in
1997 that showed a healing rate of 68% with
GTN treatment, compared with 8% in the placebo group (15).
• Cochrane analysis of 18 trials, however,
showed a healing rate of 48.9% with GTN
treatment, compared to 35.5% in the placebo
or control group.
• With longer-term follow-up, recurrence varied
from 51% to 67%.
Botulinum Toxin Type A
• Botulinum toxins are a family of neuroparalytics synthesized by Clostridium botulinum.
• They inhibit the release of acetylcholine at the
neuromuscular junction.
• They have also been used off-label in other
disorders, including chronic anal ssures.
There is no uniformly recommended dose or
site of injection.
• Botulinum toxin type A is supplied as a powder in 100-unit single-patient use vials.
Relaxation of the muscle occurs within days
and lasts for 2–4months.
• This has the theoretical advantage of allowing
ssure healing while avoiding permanent
fecal incontinence.
• Various methods of injection, including injection into the internal or external sphincter, at
174
K. C. Lu and D. O. Herzig
single or multiple sites, and in various doses,
have been described.
• Comparative trials
– Botulinum toxin injections vs. placebo,
botulinum toxin A injection superior to
nitroglycerin ointment
• Healing rate: 73% after nitroglycerine,
13% with placebo (p=0.003).
– Botulinum toxin injection vs. lateral inter-
nal sphincterotomy
• 92.5% for the lateral internal sphincterotomy, 45% botulinum toxin.
• Meta-analysis of seven randomized
controlled trials; the healing and recurrence rates were worse with botulinum
toxin compared to LIAS.
• There is limited data regarding the long-term
effectiveness of botulinum toxin.
Operative Treatment
Anal Dilation
groove, and the distal internal anal sphincter is divided under direct vision (Fig.13.6).
– Division was originally described to the
dentate line, but recent reports describe a
more conservative approach, either with
division of the muscle to the ssure apex or
with division just until the band of hypertrophied muscle is released.
Outcomes Between Closed and Open Anal Sphincterotomy
Cochrane Review: no difference in either persistence of ssure or incontinence with the two
techniques
Postoperative endoanal ultrasounds showed
that open sphincterotomy is associated with a
signicantly higher proportion of complete
sphincterotomies.
Extent of Sphincterotomy
• Dilation is not more effective than sphincterotomy and has a higher rate of incontinence
• Balloon dilation is a more standardized and
objective method of anal stretch, with lower
incontinence rates.
Anal Sphincterotomy (Technique)
• Posterior internal sphincterotomy at the site of
the ssure led to a posterior midline “gutter”
or “keyhole” deformity, leading to fecal soiling in 30–40% of patients.
• Lateral sphincterotomy laterally eliminated this
problem and has become the main surgical intervention for failure of medical management.
• The variations currently include open vs.
closed technique and conservative vs. traditional sphincterotomy.
– Closed technique is performed by inserting
the scalpel blade in the intersphincteric
groove and then turning it medially to break
the bers of the internal sphincter (Fig.13.5).
– Open technique is done through a radial
incision overlying the intersphincteric
• Controversial topic: excessive division
increases the risk of incontinence, yet inadequate division increases the risk of persistence
or recurrence.
• Lateral internal sphincterotomy to the dentate
line vs. to the apex of the ssure:
– Mentes etal. prospectively randomized 76
patients with chronic anal ssure.
• Treatment failure was zero in the traditional group and 13% in the conservative group after 1year of follow-up.
• No statistically signicant difference in
the postoperative incontinence scores.
– Elsebae etal. prospectively randomized 92
patients.
• Treatment failure was 0 in the traditional group and 4% in the conservative
group (p=NS).
• Persistent incontinence was 4% in the
traditional group and 0% in the conservative group (p=NS).
• Magdy etal. randomized 150 patients to traditional sphincterotomy, V-Y advancement ap,
or conservative sphincterotomy + V-Y advancement ap.
ab
13 Anal Fissure
c
175
Fig. 13.5 Closed lateral sphincterotomy. (a) Location of
the intersphincteric groove. (b) Insertion of the knife
blade in the intersphincteric plane. (c) Lateral to medial
– The healing rates were 84% in the tradi-
tional group and 94% in the conservative
division/advancement ap group.
– The incontinence rates were 14% vs. 2%,
respectively.
division of the internal anal sphincter (inset: medial to lateral division of the muscle)
Fissurectomy
The hallmark of chronic ssure is the triad of a
hypertrophied internal sphincter, a hypertrophied
anal papilla, and an external sentinel tag.
176
K. C. Lu and D. O. Herzig
ab
c
Fig. 13.6 Open lateral internal sphincterotomy. (a) Radial skin incision distal to the dentate line exposing the inter-
sphincteric groove. (b) Elevation and division of the internal sphincter. (c) Primary wound closure
Results of Sphincterotomy
72% of patients can avoid operative treatment,
and 97% of patients can be healed.
• A myriad of additional nonrandomized reports
are available, describing a wide range of
results from lateral internal sphincterotomy.
• While most reports cite low rates of treatment
• The low rate of sphincterotomy comes at the
price of increased recurrences before complete healing and a longer time spent in
treatment.
failure, the incontinence rate is widely variable and is as high as 30–40%.
• The disease, however, is largely measured by the
Fissures Without Anal Hypertonicity
subjective experience of the patient, who is ultimately the best judge of which treatment is worth
pursuing and which risks are worth taking.
• With multiple options available to patients,
the ultimate time to healing is prolonged, but
• A subset of patients with ssure will not demonstrate hypertonicity.
• Giordano et al.: simple cutaneous advancement ap in 51 patients over a 6-year period
13 Anal Fissure
177
for all patients, regardless of anal tone, 98%
treatment success rate.
• Nyam et al.: island advancement ap in 21
patients with ssures and below-normal anal
pressure resulted in complete healing and no
incontinence in all patients.
• While this technique may be useful for all
patients with refractory ssures, it holds
particular promise in addressing the ssure
in the setting of a hypotonic anus. Video
13.1 demonstrates the technique of an anal
ap.
Crohn’s Disease
• Fissures are commonly seen in people with
Crohn’s disease, affecting approximately 30%
of patients.
• Tend to be in more atypical locations, deeper,
and associated with other pathology, especially stula.
• Some authors have reported acceptable outcomes from interventions in these patients, but
caution should be the rule, and sphincter salvage is prudent.
• Appropriate medical management of the disease may lead to resolution of the anorectal
disorders in 50% or more of these cases.
Human Immunodeficiency Virus
• HIV-related anal disease includes both typical
ssures and anorectal ulcers, which can appear
as deep, broad-based, or cavitating lesions.
• Small studies have reported successful treatment of typical ssures, and the medical treatment of HIV continues to improve.
• Concerns about delayed wound healing and
increased infectious complications, however,
remain.
Conclusions
• A suggested treatment algorithm is provided
in Fig.13.7.
178
Anal fissure (with hypertonic anal sphincter)
K. C. Lu and D. O. Herzig
Lateral/atypical
Biopsy and/or Culture Determine Length of Symptoms
< 6 weeks, Acute> 6 weeks, Chronic
Increased fiber
Increased water
Laxatives
Topical lidocaine
Note:
•Hypotonic anal sphincter:often needs a
dermal advancement flap
•Crohn’s disease: Discuss in
multidisciplinary conference
Posterior/anterior midline (typical)
Medical therapy bid for 8 weeks:
Topical nitroglycerin 0.2% (compounded)-0.4 %
(commerciallyavailable)
Failure
or
Topical diltiazem 2% (compounded)
or
Topical nifedipine 0.3% / lidocaine (compounded)
Invasive Options
1) Botulinum toxin injection into internal anal sphincter
(marginal fecal continence)
or
2) Lateral internal anal sphincterotomy (closed vs open)
(> 90% healing rate, but risk of fecal incontinence)
Failure
Fig. 13.7 Treatment algorithm for anal ssure
Anorectal Abscess andFistula
BradleyR.Davis andKevinR.Kasten
14
Key Concepts
• Successful management of anorectal abscesses
requires an in-depth knowledge of pelvic oor
anatomy and potential spaces through which
sepsis can spread.
• The spaces occupying the anus and their anatomic landmarks will dene the nomenclature
of abscesses– perianal, perirectal, supralevator, and postanal space.
• Drainage of most abscesses can be performed
in the ofce without drains or setons. If a stula is encountered, it should only be addressed
if the anatomy in relationship to the sphincters
is clearly identied.
• Necrotizing soft tissue infections are lifethreatening emergencies that require aggressive surgical debridement and management of
the offending anal gland.
• Fistulas will complicate a signicant proportion of perirectal abscesses and are classied
based on their relationship with the anal
sphincter complex.
• Physical examination is often the only modality needed to determine the stula track and
selection of treatment, and preoperative imaging (MRI, US) is typically unnecessary except
B. R. Davis (*) . K. R. Kasten
Department of Surgery, Section of Colorectal
Surgery, Atrium Health, Carolinas Medical Center,
Charlotte, NC, USA
e-mail: bradley.davis@uc.edu
for patients with multiple external openings,
when the internal opening cannot be identied
or for recurrent cases.
• Goodsall’s rule, while being helpful, is accurate in about 60% of cases and is more accurate for posterior stulas.
• Fistulotomy is the most successful of the surgical treatments but is also associated with the
highest rates of continence disturbances– several non-cutting techniques have been
described– all of which have limitations and
varying degrees of success.
Introduction andEpidemiology
• Delay in diagnosis, mismanagement of the
disease, or failure to recognize the diagnoses
can result in multiple procedures, increased
cost, and protracted suffering.
• Although the true incidence and prevalence is
elusive, the incidence of abscess is reportedly
between 0.4% and 5% of patients undergoing
operative management, yielding between
68,000 and 96,000 cases of anorectal abscess
each year in the United States.
• Patients are males at a 3:1 ratio.
• Mean age of 40years (range 20–60years).
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_14
179
180
a
b
B. R. Davis and K. R. Kasten
Pathophysiology
• As a consequence of these extensions, select
anorectal spaces are at risk for transmission of
Anatomy
bacteria with subsequent formation of abscess.
• The perianal space (Fig.14.1a) lies immedi-
• Between the columns of Morgagni, which
number between 6 and 14, are unevenly distributed anal crypts whereby anal ducts empty.
• Importantly, ducts may extend into the internal
sphincter, the intersphincteric space, or through
the internal sphincter into the external sphincter.
Fig. 14.1 Anorectal
spaces: (a), coronal
section; (b), sagittal
section. Vasilevsky
CA.Anorectal abscess
and stula-in-ano. ((168)
© 1997 David Beck,
MD, with permission)
Supralevator
ately around the anal verge, with medial
extension to the dentate line and lateral extension to the subcutaneous fat of the buttocks.
The ischiorectal/ischioanal fossa is a pyramidal-shaped potential space between the
perineum and levator ani (Fig.14.1b).
Intersphincteric
Ischioanal
Perianal
Submucosal
Retrorectal
Supralevator
Deep
Postanal
Superficial
Postanal
Supral
Perianal
14 Anorectal Abscess andFistula
181
• Above the anococcygeal ligament and below
the levator ani, these fossae are continuous
with the deep posterior anal space.
• Above the levator ani, between the pelvic wall
and rectum, lies the supralevator space.
– Because this space is superiorly bordered
by the peritoneum, abscesses may form
from intersphincteric sources that track
superiorly or abdominal sources that track
from the peritoneal cavity.
Etiology
• Anal crypts are considered the primary source
for development of perianal abscesses.
• The cryptoglandular theory hypothesized that
obstruction of a crypt by foreign body or perianal debris led to abscess formation due to
stasis within the ducts.
• Predisposing factors include liquid stool
entering the anal duct, trauma, tobacco abuse,
and cystic dilation of the duct resulting in poor
emptying.
• The remaining 10% are the result of specic
disorders such as inammatory bowel disease (IBD), trauma, and malignancy
(Table14.1).
Classication
• Each anorectal abscess is classied based
upon the potential space it inhabits (Fig.14.2).
• Perianal and ischiorectal abscesses are the most
common, accounting for over 80% of all
diagnoses.
Table 14.1 Etiology of anorectal abscess
Nonspecic
Cryptoglandular
Specic
Inammatory bowel disease
Crohn’s disease
Ulcerative colitis
Infection
Tuberculosis
Actinomycosis
Lymphogranuloma venereum
Trauma
Impalement
Foreign body
Surgery
Episiotomy
Hemorrhoidectomy
Prostatectomy
Malignancy
Carcinoma
Leukemia
Lymphoma
Radiation
Fig. 14.2 Classication
of anorectal abscesses.
((169) © 1997 David
Beck, MD, with
permission)
evator
Inter-
sphincteric
Ischioanal