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172
H. H. Aydinli and E. Gorgun
Table 21.1 Hurley clinical staging system for
Hidradenitis Suppurativa
Stage I-mild
disease
Stage II-moderate
disease
Stage III-severe
disease
With permission from Johnson EK.Pilonidal Disease and
Hidradenitis Suppurativa. In: Steele SR, Hull TL, Read
TE, Saclarides TJ, Senagore AJ, CB. The ASCRS
Textbook of Colon and Rectal Surgery. Springer,
NewYork, 2016; 289-307 © Springer
Table 21.2 Modied Sartorius staging system for
Hidradenitis Suppurativa
Anatomical regions involved:
axilla, groin, gluteal (anal) or
other region
Numbers and scores of lesions
for each region
The longest distance between
two relevant lesions (or size of
lesion if single) for each region
Whether all lesions are
separated by normal skin?
Table 21.3 Latent or phenotypic classication proposed
by Canoui-Poitrine etal.
Latent
classication Phenotype Affected region
LC1 Axillary-
LC2 Follicular Ears, chest, backs,
LC3 Gluteal Gluteal folds (anal)
Latent or phenotypic classication created sub groups of
HS based on clinicopathological features to help the clinician identify the disease nature more properly
With permission from Johnson EK.Pilonidal Disease and
Hidradenitis Suppurativa. In: Steele SR, Hull TL, Read
TE, Saclarides TJ, Senagore AJ, CB. The ASCRS
Textbook of Colon and Rectal Surgery. Springer,
NewYork, 2016; 289-307 © Springer
Single/multiple abscess formation
without sinus tracts or scarring
Recurrent abscesses with sinus
tracts and scarring, single or
multiple widely separated lesions
Diffuse or almost diffuse
involvement, or multiple
interconnected sinus tracts and
abscesses across the entire area
– 3 points for each
region
– nodule 1 point
– stula (sinus
tracts) 6 points
– scars 1 points
< 5cm, 1 point
5–10cm, 3 points
> 10cm, 9 points
– yes, 0
– no (=Hurley III),
9 points
mammary
Axilla, breast,
perineum, inguinal
legs, axillary, breast
spondyloarthropathy, genetic keratin
disorders and acne. HS prevalence in patients
diagnosed with IBD ranges from 1.8% to
12.8%. In a review of 61 patients diagnosed
with anal HS, 24 patients (39%) had a concurrent diagnosis of Crohn’s disease.
Diagnosis of HS in the presence of anal stulas can be challenging, but usually these stulas are limited to the distal two thirds of the
anal canal when secondary to HS.
Squamous cell carcinoma (SCC) arising in
the setting of HS is fairly uncommon but has
been reported in the literature and is associated with a worse prognosis and eventual
mortality. The incidence of SCC in patients
with chronic perianal HS is 3.2%. This relatively high incidence specially in perianal HS
most likely reects the fact that patients do
not always seek treatment and diagnosis can
be challenging, leading to a late diagnosis of
perianal disease. Due to the increased morbidity and mortality, the nal diagnosis
should be conrmed with the surgical pathology, and SCC should be kept in mind in
patients with longstanding severe HS.Rarely
perianal HS can extend to sacrum. In such
cases management can become challenging
and requires multidisciplinary approach
including colorectal, spine/orthopedic and
plastic surgery.
F. HS is a chronic, relapsing disorder that
requires long-term treatment. Management
depends on the disease stage and patient preferences. Warm compresses and topical cleaning agents can be used to relieve pain and
clean affected areas in early lesions. Life
style modications including weight loss,
smoking cessation and diet modications
might benet patients with Hurley stage
I.Patients with Hurley stage I and II are candidates for medical treatment. Topical antibiotherapy with Clindamycin has shown to
reduce the number of lesions in patients with
Hurley I and mild II disease. Systemic antibiotherapy with tetracycline or clindamycinrifampin regimens are usually suggested for
widespread and severe disease. Combination
therapy with clindamycin and rifampin has
shown to decrease patient Sartorius scores
with a partial or complete improvement of
HS. Many studies have reported clinical
improvement with adalimumab (a fully
human, IgG1 monoclonal antibody specic
21 Anal Conditions: Hidradenitis Suppurativa
173
for TNF-α) and iniximab (a chimeric
human, IgG1 monoclonal antibody specic
for TNF-α) in patients with moderate to
severe disease, but some found no benet.
Recently published results of two Phase 3 trials (double blind, placebo-controlled periods)
showed that adalimumab use for moderate to
severe HS improved clinical response by
week 12 when compared to placebo. It is
important to note, however, that none of the
patients enrolled in those studies achieved a
complete response after adalimumab treatment. Recurrence rates ranges from 43% to
71% during long-term follow up after iniximab and adalimumab use, respectively. The
immunosuppressive nature of these medications requires a comprehensive assessment
before treatment to prevent possible infectious complications. Other treatment options
including cyclosporine & tacrolimus
(Calcineurin inhibitors, immunosuppressive),
anakinra (IL-1 inhibitor), methotrexate
(immunosuppressive), azathioprine (purine
antagonist-immunosuppressive), colchicine
(anti-inammatory) and ustekinumab (IL12/23 inhibitor) have not been studied extensively, and further randomized clinical trials
are needed.
There are no consistent clinical data to
support the use of retinoids (Vitamin A derivate; isotretinoin, acitretin) as monotherapy
in the management of HS.
G. Different surgical procedures are available
for patients with disease resistant to medical
treatment or those for with recurrent disease.
Patients with widespread disease (Hurley
stage III) should also be evaluated for surgical resection. Local incision and drainage
can be used to relieve pain in acute disease
with little benet in long-term management
due to high recurrence rates. In patients with
sepsis and abscesses, antibiotherapy accompanied by abscess drainage should be considered prior to denitive surgical treatment.
Unroong and scanner-assisted carbon dioxide laser therapies are good options for
patients with recurrent lesions in xed areas
to preserve healthy tissue around the lesions.
They can be performed in an ofce setting
under local anesthesia and are associated
with recurrence rates of 29% (363 operations
in 113 patients) and 11.8% (34 patients),
respectively. Local excision and primary closure is another option for patients with mild
to moderate disease (Hurley stage I-II). The
main principle is to achieve disease-free margins to reduce the recurrence rate after surgery. Reported recurrence rates ranges from
15% to 69.8% % in the operative eld and
surrounding elds. In advanced disease—
Hurley stage III disease—radical wide excision of affected skin and subcutaneous tissue
to fascia level is the only curative treatment
Fig.21.3b–d. Excision can be followed with
subsequent secondary healing, ap creation
or skin grafting. Skin grafting over granulation tissue can be performed in patients with
large defects. Flap creation—usually in the
perianal area—expedites the healing process.
In these advanced cases, excising as many
apocrine glands as possible has been reported
to lower the risk of disease recurrence.
Recurrence rates after radical excision ranges
from 0% to 38% in the literature. Risk factors
for recurrence after surgical management of
HS are identied as young age, multiple surgical sites, and incision and drainage-type
procedures.
The authors prefer local excision and secondary healing with daily packing, Sitz baths and
daily showers in patients with anal HS.If secondary healing cannot be achieved after granulation tissue (Fig. 21.3e) is formed, skin
grafting can be planned with plastic surgery.
In cases where deep defects occur after resection of the perianal HS lesions or SCC large
pedicle aps can be created to close the
defects. Routine fecal diversion in patients
with severe perianal HS has been reported in
the literature but this practice has not been
widely accepted. Diversion should be considered in non-compliant patients with anal HS
and/or in patients who are not fully mobilized
due to comorbid conditions.
In addition to painful and extensive skin
lesions, patients might also suffer from depression and sexual dysfunction. Decreased quality of life due to pain, draining lesions,
174
ab
cd
H. H. Aydinli and E. Gorgun
e
Fig. 21.3 This series of images show the surgical management of a patient with Hurley II perianal HS. (a–d)
operative images when patient was positioned in the modied lithotomy position during operation. Image e was
taken while patient was positioned in knee-chest position
during follow up appointment at 2weeks after excision.
Healthy healing process with granulation tissue can be
observed
21 Anal Conditions: Hidradenitis Suppurativa
175
disruption of self-respect and interpersonal
relationships is not always well recognized by
the caregivers, which might negatively affect
patient compliance and overall outcome.
Patients should be offered mental wellness
and psychological support if needed.
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Anal Conditions: Anorectal Trauma
DavidM.Schwartzberg, MitchellA.Bernstein,
andAlexisL.Grucela
22
Refer to Algorithm inFig. 22.1
A. Anorectal trauma is associated with blunt
and penetrating injuries. Gunshot and seatbelt injuries are common to the colon and,
despite improvements in critical care, continue to yield a septic complication rate of
20%. Anorectal injuries are not subject to the
same treatment algorithms of colon trauma,
mostly because of the bony connes of the
pelvis. Blunt injuries to the pelvis are associated with a 2% rate of rectal injuries in pelvic
fractures, and penetrating trauma (gunshot
and stab wounds) accounts for >80% of rectal injuries. Because the intraperitoneal rectum is only 6–8 cm from the anal verge,
intraperitoneal injury in anorectal trauma
must always be considered, especially with
foreign body insertions. As with any trauma
algorithm germane to anorectal trauma, the
two primary objectives are to control bleeding and limit contamination.
D. M. Schwartzberg
Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell; Harbor View Medical Services,
Port Jefferson, NY, USA
e-mail: David.Schwartzberg@NYUMC.org
M. A. Bernstein · A. L. Grucela (*)
Division ofColorectal Surgery, Department
ofSurgery, NewYork University Langone Medical
Center, New York, NY, USA
e-mail: Mitchell.Bernstein@nyulangone.org;
Alexis.Grucela@NYUMC.org
B. A thorough history of the incident is needed
with description of the nature of the trauma
(Fig.22.2).
C. Identication of injuries must start with
inspection of the perineum, perianal skin,
and adjacent organs (vagina and scrotum)
followed by assessment of blood in the rectal
vault and anal tone with a digital rectal examination. Rigid proctoscopy should be performed and can accurately diagnose up to
95% of extraperitoneal rectal injuries.
D. Contrast enema has a role but is largely sub-
jective. Plain x-rays of the chest, abdomen
and pelvis are needed to assess for pneumoperitoneum and/or placement of a foreign
body (Fig.22.3). Triple-phase contrast computed tomography (CT) may also help assess
the extent of the injury and indicate if it
involves the genitourinary system (occurs at
a frequency of 30–64% with rectal injury).
E. If the index of suspicion is high for intraperi-
toneal injury, or the patient has signs of peritonitis, a laparotomy or diagnostic
laparoscopy must be performed. Prior to
making a colotomy to extract a foreign body,
manipulating it into the rectum for assisted
transanal excision is encouraged if possible.
If not possible, a longitudinal colostomy is
made which is then closed transversely.
F. For foreign body insertion trauma, a thor-
ough inspection of the mucosal surfaces and
sphincters must be performed.
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_22
179
180
Fig. 22.1 Algorithm for evaluation and management of Anorectal Trauma
D. M. Schwartzberg et al.
Fig. 22.2 Broken glass in the rectum, representing the importance of a thorough history of the incident to predict treatment plans. Courtesy of Dr. R.Steinhagen
G. The foreign body may be removed with seda-
tion and nerve block, epidural or general
anesthesia. If the index of suspicion is high
for intraperitoneal injury or the patient has
signs of peritonitis, a laparotomy or diagnostic laparoscopy must be performed
(Fig.22.4).
H. For anal or perineal injury, assess the anus,
perineum and sphincter for damage.
I. For minor perineal and sphincter damage:.
J. Wide debridement, primary sphincteroplasty,
tetanus and antibiotic prophylaxis against
aerobic and anaerobic bacteria are sufcient.
K. For major sphincter and/or perineal damage.
L. Wide debridement of non-viable tissues is
needed with a delayed sphincteroplasty. An
exploratory laparotomy or diagnostic lapa-
roscopy is needed to assess intraperitoneal
injury and to perform a diverting sigmoid
colostomy (loop or end-colostomy with
22 Anal Conditions: Anorectal Trauma
Fig. 22.3 Showing the importance of imaging to aid in determining operative versus non-operative treatment strategies
to remove a foreign body
181
Fig. 22.4 Foreign body removed under sedation via a transanal route, after pneumoperitoneum was ruled out on
imaging
mucus stula). Therapeutic antibiotics are
indicated along with tetanus prophylaxis.
M. Rectal injuries should be assessed with a dig-
ital rectal exam and rigid proctoscopy. CT
imaging may be helpful.
N. For extraperitoneal rectal injuries: assess
contamination.
O. For extraperitoneal rectal injuries without
contamination.
P. Closure of the wound may be possible if con-
tamination is minimal. Rectal irrigation
peranus, prophylactic antibiotics and tetanus
prophylaxis are necessary.
Q. For extraperitoneal rectal injuries with
contamination.
R. A diverting colostomy with mucous stula is
created and distal rectal irrigation via the
mucus stula is not advised as it can cause
182
D. M. Schwartzberg et al.
elicit intraluminal soiling of the pelvis.
Rectal irrigation per anus is needed, along
with prophylactic antibiotics and tetanus
administration. Although they have not been
shown to reduce infections complications,
presacral drains can be considered and
brought out through separate stab incisions,
followed by reassessment and possible primary closure 3–5days postoperatively.
S. For intraperitoneal rectal injury, a digital rec-
tal exam and rigid proctoscopy are needed
along with an exploratory laparotomy or
diagnostic laparoscopy.
T. For an intraperitoneal rectal injury in a stable
patient without gross contamination.
U. Resection and primary anastomosis, prophy-
lactic antibiotics and tetanus administration.
Oversewing of gunshot wounds is not recommended as bullets cause heat destruction of
surrounding tissue making it inadequate for
suture placement.
V. For an intraperitoneal rectal injury with gross
contamination.
W. Proximal diverting ostomy, prophylactic
antibiotics and tetanus administration, and
debridement of non-viable tissues. Presacral
drain placement has not been found to reduce
infectious complications.
Suggested Reading
Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos
MJ, Wexner SD. The ASCRS textbook of colon and
rectal surgery. 2nd ed. NewYork: Springer; 2011.
Gonzalez RP, Falimirsky ME, Holevar MR.The role of
presacral drainage in the management of penetrating
rectal injuries. J Trauma. 1998;45(4):656–61.
Gonzalez RP, Phelan H 3rd, Hassan M, Ellis CN, Rodning
CB. Is fecal diversion necessary for nondestructive
penetrating extraperitoneal rectal injuries? J Trauma.
2006;61(4):815–9.
Herzig DO. Care of the patient with anorectal trauma.
Clin Colon Rectal Surg. 2012;25(4):210–3.
Navsaria PH, Edu S, Nicol AJ.Civilian extraperitoneal
rectal gunshot wounds: surgical management made
simpler. World J Surg. 2007;31(6):1347–53.