Suggested Reading

Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_837_Библиотеки_им_академика_М_И_Перельмана.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

38 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 1011 / 5011 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

A. Elias and R. G. Landmann

Table 10.1 Treatment comparison trials

Comparison trials Superior NTG vs Placebo

• Non-healing (OR 0.35)

• Headache (OR 4.5) NTG vs CCB (Diltiazem)

• Non-healing (OR 0.88)

• Adverse effects (OR 3.57)

• Headache (OR 6.9) NTG vs Sphincterotomy (LIS)

• Non-healing (OR 7.49)

• Incontinence (OR 0.51)

• Headache (OR 29) Diltiazem (CCB) vs Placebo

• Non-healing (OR 0.1)

• Adverse effects (OR 3.57)

• Headache (OR 6.9) CCB vs Sphincterotomy

• Non-healing (OR 60)

• Incontinence (OR 0.1)

• Headache (OR 13) Botox vs Placebo

• NON-healing (OR 0.29)

• Adverse effects (OR 1) Botox vs Sphincterotomy (LIS)

• NON-healing (OR 7.2)

• Incontinence (OR 0.11) Botox vs Botox + NTG

• NON-healing (OR 2.4)

• Incontinence (OR 0.3) Any surgery vs Medical Therapy

• NON-healing (OR 0.11)

NTG

CCB

LIS

CCB

LIS

Botox

LIS

Botox + NTG

Surgery

K. Topical options include compounded

nitrates/nitroglycerin (NTG), such as Rectiv® (Aptalis Pharma US, 0.4% topical nitroglycerin), and calcium channel blockers (CCB), such as nifedipine or diltiazem 2%. A 2012 Cochrane review demonstrated NTG to be marginally superior to placebo, with the principle side effect of headaches (30%). We recommend use of diltiazem, as it is both more effective and more tolerable than NTG and nifedipine (Table10.1). Generally, combinations with lidocaine are not necessary. Instruct the patient to apply a pea-to-toothpaste sized amount with a gloved nger to, but not inside, the anus four to six times daily for 6 weeks. Re-evaluate in 6weeks, and allow for continued healing if progressing appropriately.

L. Botox® (onabotulinumtoxinA, Allergan, Inc)

injections can be used to temporarily paralyze the internal anal sphincter by preventing release of acetylcholine from the presynaptic nerve terminals. Muscles begin to relax after several days, and the effect lasts up to 4months. In conjunction with CCB, this regimen has demonstrated excellent and durable healing rates. While studies have shown botox injections to be less efcacious than surgery, studies have also demonstrated fewer side effects and lower incidence of incontinence to stool (10–18% temporary incontinence to atus) (Table10.1). There is currently no standardized dosage or technique. A recent meta-analysis concluded lower doses may have lower rates of recurrence and incontinence, however, it was limited by weaknesses in the underlying evidence. We recommend choosing one side and injecting 100u/0.5cc NS into the internal sphincter/intersphincteric groove with a tuberculin syringe.

M. Surgery may be necessary for refractory s-

sures that fail medical management. Surgery should not be used for children or acute anal ssure. The most signicant risk of surgery is incontinence (9.8%) (Table 10.1). However, with specialized experience, this rate should be markedly less than 1–2%. For patients with anal hypertonicity, lateral internal sphincterotomy (LIS) is recommended, while a cutaneous advancement ap is recommended for patients with normal tonicity or a hypotonic anus. A combined approach may also be considered, as limited data shows the addition of an anocutaneous ap to botox injection or LIS may help decrease post-operative pain and expedite recovery. Sphincterotomy can be performed in an open fashion (our preference) or closed fashion. Generally the extent of internal sphincterotomy should be tailored to the length of the ssure or entire internal sphincter if a redo procedure is required. A tailored approach yields equivalent healing with a lower risk of incontinence compared to a traditional

10 Anal Conditions: Anal Fissure/Recurrent Anal Fissure

approach that extends to the dentate line. An alternative treatment option may be percutaneous posterior tibial nerve stimulation, which has shown promising results in a few small trials. More research, however, is needed, as sham stimulation (placebo) had equivalent effects.

Suggested Reading

Cheng CM, Chen JS, Patel RP.Unlabeled uses of botuli-

num toxins: a review, part 1. Am J Health Syst Pharm. 2006;63:145–52.

Eisenhammer S. The evaluation of the internal anal

sphincterotomy operation with special reference to anal ssure. Surg Gynecol Obstet. 1959;109:583–90.

Emile SH. Indications and technical aspects of internal

anal sphincterotomy: highlighting the controversies. Dis Colon Rectum. 2017;60:128–32.

Garcia-Granero E, Sanahuja A, Garcia-Botello SA, Faiz

O, Esclapez P, Espi A, etal. The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy. Color Dis. 2009;11:502–7.

Gibbons CP, Read NW.Anal hypertonia in ssures: cause

or effect? Br J Surg. 1986;73:443–5.

Giordano P, Gravante G, Grondona P, Ruggiero B, Porrett

T, Lunniss PJ. Simple cutaneous advancement ap anoplasty for resistant chronic anal ssure: a prospective study. World J Surg. 2009;33:1058–63.

Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G,

Albanese A.Botulinum toxin for chronic anal ssure. Lancet. 1994;344:1127–8.

Herzig DO, Lu KC. Anal ssure. Surg Clin North Am.

2010;90:33–44.

Herzig DO, Lu KC. Anal ssure. In: Steele SR, Hull

TL, Read TE, Saclaridea TJ, Senagore AJ, Whitlow CB, editors. The ASCRS textbook of colon and rec-

tal surgery. 3rd ed. New York, NY: Springer; 2016. p.205–14.

Hoexter B.Anal ssure. In: Fazio VW, Church J, Delaney

CP, editors. Current therapy in colon and rectal surgery. 2nd ed. Philadelphia, PA: Elsevier Mosby; 2005. p.19–22.

Keneck NJ, Gee AS, Durdey P. Treatment of resistant

anal ssure with advancement anoplasty. Color Dis. 2002;4:463–6.

Klosterhalfen B, Vogel P, Rixen H, Mittermayer

C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal ssure. Dis Colon Rectum. 1989;32:43–52.

Lin JX, Krishna S, Su’a B, Hill AG. Optimal dosing of

botulinum toxin for treatment of chronic anal ssure: a systematic review and meta-analysis. Dis Colon Rectum. 2016;59:886–94.

Mentes BB, Ege B, Leventoglu S, Oguz M, Karadag

A. Extent of lateral internal sphincterotomy: up to the dentate line or up to the ssure apex? Dis Colon Rectum. 2005;48:365–70.

Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana

T, Earl S.Operative procedures for ssure in ano. Cochrane Database Syst Rev. 2011;(11):CD002199.

Nelson RL, Thomas K, Morgan J, Jones A. Non surgical

therapy for anal ssure. Cochrane Database of Syst Rev. 2012;(2):CD003431.

Nothmann BJ, Schuster MM. Internal anal sphincter

derangement with anal ssures. Gastroenterology. 1974;67:216–20.

Perry GG. Fissure in ano—a complication of anusitis.

South Med J. 1962;55:955–7.

Ruiz-Tovar J, Llavero C. Percutaneous posterior tibial

nerve stimulation vs perianal application of glyceryl trinitrate ointment in the treatment of chronic anal ssure: a randomized clinical trial. Dis Colon Rectum.

Schouten WR, Briel JW, Auwerda JJ, De Graaf

EJ. Ischaemic nature of anal ssure. Br J Surg. 1996;83:63–5.

Stewart DB, Gaertner W, Glasgow S, Migaly J, Feingold D,

Steele SR.Clinical practice guideline for the management of anal ssures. Dis Colon Rectum. 2017;60:7–14.

Anal Conditions: Anal Stenosis andStricture

ShakM.Sidani andMaherA.Abbas

Refer to Algorithm in Fig. 11.1

A. Anal stenosis or stricture is a narrowing of

the anal canal, and can be a true anatomic stricture or a functional stenosis secondary to sphincter hypertonicity. A true anatomic anal stenosis results from the loss of pliability and elasticity of the anoderm which is replaced by noncompliant brosis and scarring.

B. Anatomic anal stenosis can be congenital or

acquired. Congenital causes include conditions such as anorectal malformations and Hirschsprung’s disease. Overzealous hemorrhoidectomy resulting in extensive loss of anoderm is one of the most common acquired etiologies. Other acquired causes include extensive excision or fulguration of anorectal lesions or tumors, stapled hemorrhoidectomy, low anastomoses such as coloanal and ileoanal anastomosis, trauma, inammatory bowel disease (IBD) particularly Crohn’s Disease, radiation therapy, chronic anorectal

S. M. Sidani (*) Department ofColon andRectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates e-mail: SidaniS@clevelandclinicabudhabi.ae

M. A. Abbas Al-Zahra Hospital - Dubai and King’s College Hospital, Dubai, United Arab Emirates

suppurative disease, chronic diarrhea, chronic laxative use, and venereal disease.

C. Up to 88% of anal stenosis cases can be caused

by hemorrhoidectomy, although only 1.5–4% of hemorrhoidectomies are complicated by a stricture. Classically, this complication, in association with mucosal ectropion, was seen more often after inappropriate modications of the Whitehead Hemorrhoidectomy. Sphincter damage and brosis may further worsen the stenosis. The prevention of post-hemorrhoidectomy anal stenosis centers on avoidance of sphincter damage and the preservation of anodermal and distal rectal mucosal bridges. If this is not possible, one must either compromise on the amount of tissue excised, or perform a primary anoplasty at the time of hemorrhoidectomy. The former option is preferable. These considerations are particularly important in the setting of an acute hemorrhoidal crisis. As a guide, one must be able to introduce a medium Hill-Ferguson anal retractor at the completion of the procedure to minimize the risk of stenosis.

D. Patients with anal stenosis present most com-

monly with difculty evacuating, constipation, painful bowel movements, bleeding, and narrow stool caliber. Fecal impaction may result in overow incontinence and diarrhea. Concomitant mucosal ectropion may cause seepage or wetness. Frequently, patients rely on stool softeners, laxatives,

https://doi.org/10.1007/978-3-319-65942-8_11

S. M. Sidani and M. A. Abbas

Fig. 11.1 Management algorithm for anal stenosis and stricture

11 Anal Conditions: Anal Stenosis andStricture

suppositories, enemas, or even digital assistance to facilitate evacuation. Symptomatology and degree of stenosis on exam may not correlate, and management strategy is generally based on the former. This is particularly relevant in the setting of Crohn’s Disease where patients may remain asymptomatic due to loose stools. A thorough history must be obtained to determine the etiology of the stenosis.

E. Inspection and digital examination easily

reveal the condition. Narrowing of the anus, scarring, and ssuring with discomfort during distraction of the buttocks can be noted. An involutional stricture secondary to chronic laxative abuse, particularly mineral oil, appears as a delicate, smooth, tight anal canal classically referred to as “parafn anus”. Mucosal ectropion appears as moist mucosa extending beyond the anal verge. An anal ssure may result in functional stenosis. Frequently, examination is not possible due to patient discomfort and an exam under anesthesia is warranted. This allows for distinguishing between functional and anatomic stenosis. A functional stenosis will diminish with anesthesia whereas anatomic stenoses will persist despite anesthesia due to brosis of the anal canal. The severity, level, and extent of the stenosis can be determined. Cultures and/or biopsies can be obtained as indicated should one suspect venereal disease, Crohn’s Disease, or neoplasia. If possible, endoscopic evaluation of the colon and rectum can be considered should there be concern for Crohn’s Disease. Preoperative anorectal physiology testing is unlikely to be tolerated, and is unlikely to affect management.

F. Classication of anal stenosis is based on the

level and degree of stenosis (Table 11.1). Furthermore, it can be circumferential, diffuse, or localized in the anal canal. Regarding severity, a stenosis is mild if it admits a welllubricated index nger or medium HillFerguson retractor, moderate if forceful dilatation is required to insert an index nger or medium Hill-Ferguson retractor, and severe if it does not admit the little nger or a

Table 11.1 Classication of anal stenosis

Severity

Mild: Tight anal canal that admits a well-

lubricated index nger or medium Hill-Ferguson retractor

Moderate: Forceful dilatation required to admit a

well-lubricated index nger or medium Hill-Ferguson retractor

Severe: Little nger or small Hill-Ferguson

retractor not admitted without forceful dilatation

Level

Low: At least 0.5cm distal to dentate line Middle: Within 0.5cm distal or proximal to

dentate line

High: At least 0.5cm proximal to dentate line

small Hill-Ferguson retractor without forceful dilatation. The level of stenosis is described in relation to the dentate line. Low stenosis involves the anal canal more than

0.5 cm distal to the dentate line. Mid-level stenosis occurs within 0.5cm distal or proximal to the dentate line. High stenosis extends more than 0.5cm superior to the dentate line. These criteria, along with the specic etiology, determine the management strategy for an individual patient.

G. Chronic transmural inammation or perianal

stulizing disease secondary to Crohn’s Disease may ultimately lead to anal stenosis. These strictures can vary in length and involvement of the anus and rectum, and commonly may lead to diversion with or without proctectomy. Biopsies should be considered due to the risk of adenocarcinoma in long-standing Crohn’s Disease.

H. Management depends on symptomatology

and etiology, as well as the severity, level, extent, and localization of the stenosis (Fig.

11.1). Asymptomatic patients usually do not

require treatment. Mild to moderate symptomatic stenoses are initially conservatively treated with stool softeners and bulking agents in an attempt to naturally and gradually dilate the anal canal by regular passage of stool. If conservative measures fail, dilatation can be considered. Initial dilatation frequently requires anesthesia, after which regular daily dilatation by the patient using

S. M. Sidani and M. A. Abbas

a b

Fig. 11.2 (a) Hegar dilators (Courtesy of Dr. Mustafa Sidani); (b) Plastic dilator used by the patient

plastic or metal dilators can be performed. Dilatation under anesthesia is performed gradually using a variety of well-lubricated dilators (Fig.11.2) or with the nger. It is the authors’ preference to dilate digitally as this approach allows a more controlled dilatation with less risk of proximal injury. After initial dilatation, patients are followed up frequently to ensure patient compliance and patency by digital exam. Infrequent follow-up after initial dilatation under anesthesia may require repeat dilatation under anesthesia should the stenosis recur. Stenoses secondary to Crohn’s Disease or radiation therapy are managed using this approach due to the risk of poor wound healing after more complex surgical options. Poor surrounding tissue health is unlikely to allow for successful anoplasty in these 2 groups of patients. Good results can be expected using this approach; however it carries the risk of incontinence, as well as sphincter damage and brosis with progressive stenosis. Concomitant proctitis secondary to Crohn’s Disease should be medically treated when possible prior to dilatation of anal stenosis to prevent infectious complications.

I. Moderate to severe anal stenosis that fails

nonoperative management, can be tackled by several options. Most options involve

incision or excision to release the nonpliable brotic scarring in the anal canal and replacement with a mobilized ap of compliant tissue from the anal skin or rectal mucosa. Adjacent tissue aps are categorized as advancement (sliding), island, or rotational aps. Advancement aps utilize rectal mucosa proximal to the stenosis or anal skin distally. Tissue is mobilized while maintaining vascular and tissue continuity with the original surrounding tissue, and advanced into the anal canal. Vascular supply is derived from submucosal or subdermal plexuses. Examples include the rectal mucosal advancement aps and Y-V anodermal ap. Island aps which include U-shaped, rectangular, diamond, and house ap are completely disconnected from the surrounding tissue and derive their vascular supply from the underlying subcutaneous tissue. Critical to the success of island aps is to include the subcutaneous tissue and avoid undermining of the ap to preserve the blood supply. Rotational aps such as the S ap are full thickness and maintain continuity with the surrounding tissue to be rotated into the anal canal. Blood supply is based on both subcutaneous and subdermal vasculature. All types of aps can be performed unilaterally or bilaterally (usually

11 Anal Conditions: Anal Stenosis andStricture

right and left lateral positions) depending on the amount of tissue required to reconstruct the anal canal. The width of a single ap should not exceed 25% of the anal canal circumference. If more tissue is required, bilateral aps should be performed. If scarring or ectropion is localized to a certain position in the anal canal, the ap is constructed in that specic position. Flap choice depends on surgeon familiarity with specic techniques and the level, extent, length, and severity of the stenosis, as well as the presence or absence of an ectropion (Table11.2). Simple stricture release alone is unlikely to provide lasting symptomatic relief and is not recommended as the stricture is likely to reform without the interposition of healthy tissue. Unilateral or bilateral partial internal sphincterotomy can be performed additionally if there is an element of functional stenosis or sphincter brosis.

J. Preoperatively, patients are instructed to

evacuate the rectum with an enema. Complete mechanical bowel prep is required for more extensive procedures such as bilateral house or S-aps. Procedures are performed in the ambulatory setting under total intravenous anesthesia with local anesthesia, spinal anesthesia, or general anesthesia depending on the procedure, patient’s preference, and body habitus. The patient is positioned in prone jack-knife with the buttocks taped apart. The tape may be released during the procedure to allow advancement of the ap. Intravenous antibiotics are administered preoperatively.

K. Rectal mucosal advancement ap

(Fig. 11.3a): Considered a modication of Martin’s anoplasty, this procedure is appropriate for mid or high level stenosis. The stricture is incised or scar tissue excised. A transverse incision is made at the dentate line. A proximal ap of anal and distal rectal mucosa, submucosa, and circular muscle is created, mobilized 2–5 cm proximally, and sutured to the distal internal anal sphincter in a tension-free manner. The distal part of the wound is left open, and care is taken to avoid suturing the ap further distally towards the

Table 11.2 Flap procedures for anal stenosis

Type of ap Indications Mucosal

advancement ap

Y-V ap Low mild-

V-Y ap Low moderate-

Diamond ap

House ap Low and middle

U ap Low and middle

S ap Low and middle

Middle and high level stenosis

moderate stenosis

severe stenosis; localized ectropion

Low and middle moderate-severe longer stenosis; Localized ectropion

moderate-severe longer stenosis; ectropion

moderate-severe stenosis; ectropion

severe stenosis; extensive ectropion requiring reconstruction of >50% of anal canal

Advantages and Disadvantages

Ectropion may occur if ap secured too distally at anal verge

Narrow tip susceptible to necrosis; narrow tissue coverage with poor proximal reach

Wider coverage than Y-V; poor proximal reach

Provides better coverage more proximally in the anal canal

Provides excellent well-vascularized coverage more proximally in the anal canal with low risk of ischemia; allows coverage of large areas of excision of mucosal ectropion; allows closure of donor site

Allows coverage of large areas of excision of mucosal ectropion; donor site left open

Provides tensionfree wellvascularized coverage for an extensive reconstruction; more complex and morbid procedure requiring hospital stay

anal verge to avoid mucosal ectropion. Success rates range between 82% and 97%.

L. Y-V advancement ap (Fig.11.3b): Y-V ano-

plasty is suitable for a low mild-moderate stenosis. The stricture is incised longitudinally creating the stem of the Y.A V-shaped

Fig. 11.3 Operative procedures for the surgical treatment of anal stenosis. (a) Martin’s anoplasty; (b) Y-V advancement ap; (c) V-Y advancement ap; (d) Diamondshaped ap; (e) House-shaped ap; (f) U-shaped ap; (g) Rotational S-ap

S. M. Sidani and M. A. Abbas

11 Anal Conditions: Anal Stenosis andStricture

full thickness ap is then created in the perianal skin with the point of the V originating at the distal end of the stem of the Y.The ap is carried out for 5–8cm, advanced into the anal canal in a tension-free manner, and sutured to the internal anal sphincter and mucosa with interrupted absorbable sutures. Care is taken to avoid narrowing the width of the ap to prevent ischemia. The length of the ap should not exceed 2–3 times the width of its base. The disadvantage of this ap is the risk of ischemia at the narrow tip of the V which precludes its use for higher, more severe stenoses. Success rates range between 64% and 100%.

M. V-Y advancement ap (Fig.11.3c): This ap

is used for low more severe stenoses as a wider ap of skin can be advanced. After incising the stricture, a V-shaped ap of anal skin is created with the wide base of the V oriented proximally. Care is taken to include underlying subcutaneous tissue as perfusion is partly dependent on the subcutaneous vasculature. The ap is then advanced and sutured in place. The donor site is reapproximated distal to the ap to create the stem of the Y. Compared to Y-V anoplasty, the V-Y anoplasty allows for a wider ap for more severe low level stenosis.

N. Diamond ap (Fig.11.3d): This procedure is

useful for low and mid level longer stenoses, with or without localized ectropion, and is frequently performed bilaterally. The stricture is incised creating a diamond-shaped defect. If an ectropion is present, it is excised conservatively. A diamond shaped ap of skin and underlying subcutaneous tissue is created with the leading proximal half of the ap matching the same dimensions as the defect. Care is taken to avoid undermining the ap to preserve its subcutaneous blood supply. The ap is advanced proximally and sutured to the edges of the defect in a tensionfree manner. The donor site is closed primarily. Reported success rates range between 88% and 100%.

O. House ap (Figs. 11.3e and 11.4): The

house ap anoplasty allows for signicant

widening of severe low and mid level long stenosis while allowing for primary closure of the donor site, and is a good option when mucosal ectropion is present. The stricture at the dentate line is incised longitudinally. Proximal and distal transverse incisions centered on the longitudinal incision are made. A house-shaped ap is created with the base positioned proximally at the distal end of the defect, and the apex oriented distally. The width and length of the house should match the width and length of the defect. Subcutaneous tissue is included in the ap and undermining is avoided to prevent ischemia. The ap is sutured in place and the donor site can be closed primarily. For more severe stenosis or extensive ectropion, bilateral house aps can be performed. This wide ap allows for a signicant increase in diameter along a greater length of the anal canal diameter when compared to V-Y and diamond-shaped anoplasties. Furthermore, the risk of ischemia is reduced in comparison to the narrow apex of the Y-V anoplasty. Success rates between 89% and 100% are reported.

P. U-shaped ap (Fig.11.3f): This broad-based

ap is particularly useful when a large mucosal ectropion must be excised. A U-shaped island ap of adjacent anal skin is sutured to the edges of the defect. The donor site is left open to heal by secondary intention.

Q. Rotational S ap (Fig.11.3g): The S ap is

more commonly used to reconstruct large anal canal defects created after extensive excisional procedures for conditions such as Paget’s disease. It can be used for extensive anal stenosis and mucosal ectropion associated with a Whitehead deformity if more than 50% of the circumference of the anal canal requires reconstruction. It is typically performed bilaterally. Full-thickness S-shaped aps on the right and left centered on the anal canal are created with the base equal to its length. The aps are rotated into the anal canal and sutured to the edges of the defect created by excision of the scar and ectropion.

Fig. 11.4 House ap. (a) Anal stenosis with mucosal ectropion after hemorrhoidectomy; (b) House ap procedure; (c) Final result after healing

S. M. Sidani and M. A. Abbas

R. Patients with a purely functional stenosis will

benet from lateral internal sphincterotomy should conservative measures fail. An open approach without reapproximation of the incision may allow release of any overlying brosis.

S. The majority of aps can be performed in the

outpatient setting. Extensive bilateral aps may require a short hospital admission. Patients are instructed to remove dressings on the rst postoperative day or earlier if needed to allow passage of a bowel movement. A high ber diet, ber supplementation, and stool softeners are recommended. Gentle cleansing after a bowel movement is encouraged. Bowel connement is not recommended even for extensive procedures. Oral antibiotics are prescribed for 2weeks. Patients are seen in follow-up at 2weeks and 6weeks postoperatively. A gentle digital rectal exam is performed at 6 weeks. Further follow-up is recommended if wound healing is not complete.

T. Complications after ap procedures

include ischemic ap necrosis, infection or abscess, fecal impaction, suture line dehiscence (from excessive tension, excessively hard stools, or vigorous wiping), inadequate correction of the stenosis with persistent symptoms, ectropion if a mucosal ap is secured too close to the anal verge, donor site wound problems, pruritus, urinary tract infections, and fecal inconti-

nence. Dehiscence is usually treated conservatively with wound care until healing is complete.