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454 H. Rossi and D. Rothenberger
Fig. 43.5 a Suprasphincteric fistula. b Extrasphincteric fistula. (With permission from [68] © Springer)
this reputed advantage. Minor disturbance of
continence occurs in 34–63 % of patients along
with impaired anal manometry and postoperative
deformity of the anal canal [41, 48]. Additionally,
cutting setons are not well tolerated because of the
discomfort associated with frequent tightening of
the cutting seton. The two-stage seton fistulotomy results in similar rates of incontinence as the
cutting seton with minor incontinence ranging
from 54 to 66 % and major incontinence ranging
from 4 to 26 % [49, 50]. Injection of fibrin glue
or a collagen plug results in varying success rates
ranging from 33 to 88 % with minimal associated
morbidity or alteration of continence [51–53].
Endorectal advancement flaps have been used
to obliterate the internal fistula opening without
division of the sphincter complex in an attempt
to preserve continence. Following debridement
of the chronic fistula tract(s), a flap of mucosa
and submucosa with or without a portion of internal sphincter muscle is mobilized beginning
distal to the internal opening of the fistula. The
flap is mobilized proximally increasing its width
to maintain good vascularity. The proximal dissection proceeds until the mobilized flap can be
advanced distally over the internal opening of
the fistula and a tension-free repair of the flap
to the anorectum distal to the internal opening
can be achieved (Fig. 43.5). Long-term studies
on advancement flaps report recurrence rates as
high as 33 % in cryptoglandular disease and up to
57 % in Crohn’s associated fistula. Prior attempts
at repair of the fistula have been associated with
increased incontinence following advancement
flaps [41]. This may be due to inadvertent sphincter injury with retractors, inelastic tissue secondary to scarring, and direct injury to the internal
sphincter with mobilization. Identified key steps
for successful flaps include correct identification
of the fistula tract and internal opening. Sepsis
must be resolved and the tract should be dry and
fibrotic. Draining setons should be used liberally
as a first-stage procedure to ready the operative
field for an advancement flap. The external opening should be enlarged to prevent premature closure of the external opening, which could lead to
a postoperative track abscess which may necessitate through the repair [54].
The Ligation of the Intersphincteric Fistula
Tract (LIFT) procedure is another sphinctersparing technique that involves identification and
ligation of the fistula tract in the intersphincteric
groove. Success rates range from 57 to 94 % [55,
56]. Vergara-Fernandez et al. (2013) performed
a review of the current LIFT literature where the
primary outcomes included fistula healing rates,
mean healing time, and patient satisfaction. Eighteen studies were included in the review with an
N of 592. The mean healing rate was 74.6 %.
Several risk factors for failure were identified
and included obesity, smoking, multiple previous
operations, and the long fistula tracts. Mean healing time was 5.5 weeks with a mean follow-up of
42.3 weeks. No de novo incontinence developed
secondary to the LIFT procedure and patient
satisfaction ranged from 72 to 100 % [57]. Currently, there is not enough evidence to assess the
alleged improvement of LIFT variants.
45543 Incontinence After Lateral Internal Sphincterotomy/Fistulotomy
Management
Evaluation
If anal incontinence does occur following a
LIS or fistulotomy, a detailed history to assess
the bowel habits including frequency of bowel
movements, consistency of stools, type of incontinence (gas, liquid, solid, seepage, full bowel
movement, post defecation, etc.), and severity of
incontinence pre and post procedure is essential.
Past history of gastrointestinal, genitourinary and
neurological disorders, details of all prior anorectal procedures, medication use, and attempts
to manage the incontinence should be carefully
reviewed. The desire to pursue treatment of fecal
incontinence depends primarily on the patient’s
subjective symptoms and quality of life. A number of incontinence scales are available to help
objectify these symptoms including the Cleveland Clinic Florida Fecal Incontinence (CCF-FI)
scale, the Fecal Incontinence Severity Index, and
the Fecal Incontinence Quality of Life Scale [58].
The physical exam should include perianal
and perineal inspection looking for scars (post
procedure, episiotomy), unhealed wounds, persistence of a fissure or fistula, possible prolapse
(full thickness, mucosal), or signs of active infection or inflammation. Digital rectal exam is
performed to evaluate possible palpable sphincter defects, assess resting tone (IAS) and squeeze
(EAS). It is also important to look for use of accessory muscles (buttocks), which may be used
to augment squeeze and serve as a marker for
decreased function. Nerve function may be assessed by evaluating the anocutaneous reflex,
which is a brief contraction of the EAS when the
perianal skin is lightly stroked and indicates the
presence or absence of intact sensory and motor
innervation [58]. Proctosigmoidoscopy is done to
exclude neoplasm, evidence of ulcerative colitis
or Crohn’s disease, solitary rectal ulcer, or other
disease states.
A detailed history and physical exam may provide enough information to formulate a conservative treatment plan with medical management.
Frequency and stool consistency may play a sig-
nificant role in the severity of the incontinence
and incomplete emptying of the anorectum can
result in seepage of mucus and small amounts of
feces. Bulking agents and fiber supplements may
play a significant role in reducing the episodes of
incontinence and may be all that is necessary for
those with mild incontinence. In individuals with
diarrhea, it is important to investigate the cause
of the diarrhea. The specific treatment should be
geared toward the cause. Antidiarrheals that slow
colonic transit and limit intestinal fluid secretion
are beneficial for many. In a randomized, controlled trial, loperamide (Imodium) was found to
be more effective than diphenoxylate-atropine
(Lomotil) in patients with incontinence and may
serve to increase sphincter tone [59]. An anal
plug or cotton wick may be beneficial in those
individuals with fecal soiling or seepage.
Biofeedback may be used if conservative
management fails or in conjunction with conservative management. Biofeedback exercises
may increase strength and endurance of the anal
muscles and improve rectal sensation [58]. Success rates of biofeedback for incontinence range
from 38 to 100
but does not preclude the possibility of a good
response.
For those individuals with persisting incontinence of unclear etiology or who fail conservative management and are possible candidates for
surgery, pelvic floor testing may be beneficial to
evaluate pelvic floor function and anatomy. Anal
manometry is used to objectively assess anal resting and squeeze pressures as well as rectal compliance. Endoanal ultrasound and MRI are useful
to detect and quantify sphincter defects. Pudendal-nerve terminal motor latency (PNTML) testing allows one to quantify nerve function.
%. A sphincter
defect may limit
Treatment
Injectables
For patients with passive fecal incontinence (individuals with seepage or soilage secondary to
IAS damage or dysfunction) and/or low resting
456 H. Rossi and D. Rothenberger
anal pressures, intra-anal injectables have been
promising. The mechanism of the injectable is to
provide an increase in the resting tone to compensate for the failed IAS [58, 60]. Various materials have been injected to treat incontinence
and include collagen, silicone, autologous fat,
glutaraldehyde, carbon-coated beads, and dextranomer in hyaluronic acid gel [61]. The technique
involves injection of the agent into the deep submucosa of the anal canal. Several studies have
shown a reduction in fecal incontinence episodes
with significant improvement of quality of life.
However, long-term studies are lacking [61].
Magnetic Bowel Sphincter
The magnetic anal sphincter (Fenix, Torax Medical, Shoreview, MN) is currently experimental
and not available for implantation outside of
study. The sphincter is made of titanium beads
with magnetic cores that are implanted around
the anal sphincter muscle complex. In two separate cohort matched studies, the magnetic anal
sphincter was comparable to the artificial bowel
sphincter (ABS) or sacral nerve stimulator for
improvement of fecal incontinence, quality of
life, and resting anal pressures [62, 63].
Sacral Nerve Stimulator
The indications for sacral nerve stimulation
(SNS) (Medtronic, Minneapolis, MN, USA) have
expanded over the last decade after its introduction for fecal incontinence in 1995. Initially SNS
was reserved for patients with an intact sphincter and impaired function [64]. However, its use
has now evolved to include a wide spectrum of
sphincter dysfunction. Randomized controlled
trials have shown good long-term results with
SNS. Mellgren et al. demonstrated, at 3 years follow-up, improvement of symptoms in 86 % of the
133 patients [65]. Hull et al. reported that 89 %
of patients have continued reduction in fecal incontinence and 36 % had a complete response to
SNS at 5 years [66]. Potential complications of
the SNS include lead displacement, pain, infection, and paresthesias.
Artificial Bowel Sphincter
The ABS is generally reserved for those with severe incontinence who have suffered significant
loss of the sphincter muscle mass. The ABS has
shown good long-term functional and qualitative
results. Improvement of continence has been reported in 75
life scores with the ABS [61]. Complications
include infection (25−40
defecation, and pain.
% of patients as well as quality
%), erosion, obstructed
of
Diversion
For those individuals with severe fecal incontinence, who have failed all conservative and surgical options, fecal diversion is an option that
may substantially restore quality of life.
In summary, LIS and fistulotomy are very effective treatments for CAF and fistula, respectively. However, care must be taken when dividing the anal sphincter complex to avoid any
unnecessary issues with incontinence. Various
techniques have been described for both LIS and
fistulotomy with reported varying degrees of success and rates of incontinence. Preoperative studies including anal manometry, endoanal ultrasonography, and/or MRI should be considered in
higher risk individuals or those individuals more
prone to continence issues.
Should continence issues develop postoperatively, the individual should undergo routine history and physical exam paying particular attention to stool frequency and consistency and perianal exam. Many individuals may note significant improvement in their symptoms by simple
modification of the frequency and consistency
of stool with conservative methods such as fiber
and/or antidiarrheals. Biofeedback may be used
if conservative management fails or in conjunction with conservative management. For those
individuals in whom conservative management
45743 Incontinence After Lateral Internal Sphincterotomy/Fistulotomy
fails, other options to manage the incontinence
are readily available.
Key Points: Strategies to Avoid the Complication of Incontinence
1. Make every effort to avoid surgery for fissure
in ano by using nonoperative conservative
management.
2. When surgery for fissure in ano is required to
alleviate symptoms, base the extent of internal
sphincterotomy on the risk of incontinence.
For patients without special risk factors for
incontinence, perform a limited distal partial
internal sphincterotomy rather than the traditional full-thickness division of the entire
internal sphincter muscle to the dentate line.
Divide even less internal sphincter muscle in
patients with special risk factors for incontinence, for example, individuals over 40 years
of age; women, especially those with a history
of vaginal delivery; anterior fissure; addition
of a synchronous anorectal procedure; and underlying bowel disorders or diseases such as
inflammatory bowel disease or irritable bowel
syndrome.
Preoperative anal manometry and endoanal
3.
ultrasonography or MRI should be considered
in individuals at high risk for incontinence
to
help delineate and define any preexisting
sphincter injury and/or associated sphincter
weakness.
Preoperative imaging including
4.
trasonography or MRI may be useful to define
anatomy, extent of muscle involvement, and
fistula tracts prior to fistula surgery.
If the fistula
5.
tract crosses more than one-third
of the external sphincter or if a fistula is present in an individual with preexisting incontinence, consider an alternative treatment to
fistulotomy such as long-term draining seton,
advancement flap, or ligation of the intersphincteric tract.
endoanal ul-
Key Points: Diagnosing and/or Managing the Complication of Incontinence Either Intraoperatively or Postoperatively
1. During either the open or closed technique,
intraoperative visualization and/or palpation
of the IAS muscle can be used to define its
length and thickness and to facilitate accurate
performance of a limited, partial distal internal sphincterotomy.
Fistula probes, hydrogen peroxide, or methy-
2.
lene blue placed
or injected into the fistula
tract at the time of surgery may help define
anatomy, distinguish simple low tracts from
high complex tracts, and guide the surgeon’s
approach.
Conservative management with bulking
3.
agents, antidiar
rheals, and/or biofeedback
may be all that is necessary to manage some
patients with postoperative incontinence.
For those individuals with persisting
4.
incontinence of unclear etiology or who fail conservative management and are possible candidates for surgery, pelvic floor testing may
be beneficial to evaluate pelvic floor function
and anatomy. Anal manometry is used to objectively assess anal resting and squeeze pressures as well as rectal compliance. Endoanal
ultrasonography and MRI are useful to detect
and quantify sphincter defects. Pudendalnerve terminal motor latency (PNTML) testing allows one to quantify nerve function.
Injectables or implants may be beneficial in
5.
those
individuals in whom conservative man-
agement fails.
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45943 Incontinence After Lateral Internal Sphincterotomy/Fistulotomy
of the
incon-
Anal Stenosis After Hemorrhoidectomy: Avoidance and Management
Jonathan B. Mitchem and Paul E. Wise
44
Introduction
Hemorrhoids are a widely prevalent disease;
however, it is difficult to know the true prevalence. Reports vary from 4 to > 50 % depending
on the data source [1]. Hemorrhoidectomy is the
most effective therapy at eliminating symptoms
associated with hemorrhoids in patients who fail
nonoperative management [2, 3], and among
patients who present with symptomatic hemorrhoids, nearly 10 % undergo operative intervention [4]. Operative hemorrhoidectomy does have
drawbacks, including increased complications
and more pain than nonsurgical therapy [5].
Therefore, in most cases, hemorrhoidectomy is
avoided until nonoperative management options
have failed.
Due to the prevalence of hemorrhoidal disease
and the volume of patients undergoing operative
intervention for the treatment of hemorrhoids,
many different techniques for excisional hemorrhoidectomy have been studied to maximize
benefit and minimize complications. The two
most common methods of operative intervention
are the Milligan–Morgan or “open hemorrhoid-
P. E. Wise ()
Department of Surgery, Section of Colon and Rectal
Surgery, Barnes-Jewish Hospital, Washington
University, St. Louis, MI, USA
e-mail: wisep@wustl.edu
J. B. Mitchem
Department of Surgery, Barnes-Jewish Hospital,
Washington University, St. Louis, MI, USA
e-mail: mitchemj@wudosis.wustl.edu
ectomy” [6], which is most prevalent in Europe,
and the Ferguson or “closed hemorrhoidectomy”
[7], which is most prevalent in the USA. Among
the other methods investigated include circular
mucosal resection, stapled hemorrhoidopexy, as
well as the use of specialized vessel sealing devices (e.g., ultrasonic devices) or Doppler-guided
hemorrhoidal arterial ligation, to name a few.
As previously mentioned, excisional hemorrhoidectomy, while a generally low-risk surgery,
is not without complications. One potentially
life-altering and difficult complication is that of
anal stenosis. Most series report the incidence of
post-hemorrhoidectomy anal stenosis as less than
5 %, although many of these studies only report
short-term outcomes. The incidence also varies
depending on the surgical technique and definition of stenosis (Table 44.1) [8–17]. Hemorrhoidectomy is the most common cause of anal stenosis, and this risk increases with an increase in the
complexity of hemorrhoidal disease [18]. In this
chapter, we will discuss the workup and management of this complicated clinical issue.
Diagnosis
The evaluation and diagnosis of anal stenosis
following hemorrhoidectomy starts with a thorough history and physical examination. The most
common presenting symptoms are pain with
defecation, constipation, narrow stool caliber,
and, less commonly, bleeding [19, 20]. Fear of
defecation may also be present. Often many of
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_44,
© Springer Science+Business Media New York 2015
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462 J. B. Mitchem and P. E. Wise
Tab le 4 4.1 Classification of anal stenosis by degree and level of stenosis
Degree of stenosis Description
Mild Anal canal allows insertion of a lubricated finger or medium anoscope
Moderate Insertion of a finger or medium anoscope requires dilation
Severe Insertion of the little finger or small anoscope requires forced dilation
Level of stenosis Description
Low >
Middle 5
High > 5 mm proximal to the dentate line
5 mm distal to the dentate line
mm distal to the dentate line extending to 5 mm proximal to the dentate line
Fig. 44.1 Anal stenosis with ectropion, also known as
whitehead deformity. (Courtesy of Ira J. Kodner, MD)
these symptoms overlap. Additionally, patients
may present with fecal leakage or paradoxical
diarrhea in the presence of obstructive symptoms
or fecal overflow around impacted stool. These
symptoms, combined with a history of hemorrhoidectomy, should prompt the clinician to
consider the diagnosis of anal stenosis prior to
examination.
Physical examination confirms the diagnosis.
On visual inspection, patients may have a circular narrowing or scar-like appearance to the anal
aperture (Fig.
44.1) [
21]. Digital rectal exami-
nation is often difficult to perform and may be
very painful, and therefore, many patients will
require examination under anesthesia (EUA) to
perform a complete examination. Any suspicious
lesions can also be biopsied at this time to rule
out other more concerning issues including neoplasia. Anoscopy as well as proctoscopy should
be performed, if not previously performed or in
cases where another diagnosis is being entertained. An EUA may also aid in differentiation
between functional and anatomic disorders of
the anal canal [21]. Functional anal stenoses are
the result of impaired relaxation of the internal
sphincter complex without evidence of external
anal scarring. Anatomic anal stenoses are those
that are the result of scarring/contracture of the
anal canal structure itself. Often there are components of both functional and anatomic stenoses
in each patient.
No adjunctive testing is routinely necessary
beyond a thorough examination of the anal canal
unless indicated to evaluate other issues or the
diagnosis is in question after examination. Anal
manometry and/or defecography can be utilized
to rule out other pelvic floor or functional disorders causing tenesmus, constipation, and/or fecal
leakage [22].
Classification of Stenosis
The severity of anal stenosis is classified as mild,
moderate, or severe based on the physical examination. Stenoses are considered mild if the anal
canal can be examined by a lubricated finger or
a medium anoscope, moderate if insertion of a
lubricated finger or medium anoscope requires
forced dilation, and severe if insertion of the little
finger or a small anoscope requires forced dilation. The level of stenosis is related to the distance from the dentate line. Stenoses greater than
0.5 cm distal to the dentate line are considered
low; those that are between 0.5 cm distal and 0.5
proximal to the dentate line are considered middle; and those greater than 0.5 cm proximal to the
46344 Anal Stenosis After Hemorrhoidectomy: Avoidance and Management
dentate line are considered high (Table 44.1)[18].
Both the level of involvement and the severity of
stenosis are important when developing the plan
for managing these patients.
Treatment
Prevention
The best treatment for anal stenosis after hemorrhoidectomy is a meticulous approach in the operating room during the primary operation. The
risk of anal stenosis increases with the complexity and extent of the hemorrhoids treated. Surgical therapy of extensive and complicated hemorrhoids should only be approached by surgeons
experienced in this operation [23]. The keys to
prevention of anal stenosis after hemorrhoidectomy are meticulous submucosal dissection
with avoidance of injury to the internal sphincter
muscle and the preservation of sufficient intact
anoderm between excision sites, generally considered at least 1 cm of intact intervening anoderm. Additionally, limiting the number of hemorrhoids excised in a given setting will also help
to limit the incidence of postoperative stenosis.
Fig. 44.2 An example of pediatric dilators ranging in
size from 15 to 21 mm used for dilation of anal stricture
symptom alleviation with this approach, as will
many patients with moderate stenosis [14, 17, 19,
24]. Manual dilation does have some risks, such
as perforation, but these risks are low [25].
Operative Intervention
Nonoperative Intervention
The cornerstone of therapy for anal stenosis from
all causes is dietary modification, including a
combination approach utilizing stool softeners
as well as increased fiber intake and water consumption. For many patients with mild stenosis,
these simple measures may alleviate the patient’s
symptoms. For patients not initially responsive to
these measures, and those with moderate stenoses, it is reasonable to attempt a course of manual
dilation in addition to the above measures. This
program consists of an initial dilation in the operating room or clinic, if tolerated, followed by
serial dilations at home by the patient using either a finger or a dilator (Fig. 44.2). This can be
facilitated and better tolerated through the use of
anesthetic jelly (e.g., lidocaine 2 %). The majority of patients with mild stenosis will achieve
Operative therapy is usually reserved for patients
with severe stenosis or those with moderate stenosis that have failed nonoperative therapy. Many
different procedures have been described to treat
anal stenosis; however, there are few comparative prospective studies to guide therapy. Different patient-specific issues may lend themselves
to the use of different techniques (Table 44.2).
Anatomic Versus Functional Stenoses
True functional anal stenosis refers specifically
to patients that have a defect in the relaxation
of the sphincter complex. These patients do not
have abnormalities of the anoderm. Patients with
anatomic anal stenoses have a defect in the anoderm, which is not related to relaxation of the
sphincter complex. A common situation is that
patients will have a combined issue, meaning
impaired sphincter complex relaxation as well as
structural scarring. Differentiating true functional
464 J. B. Mitchem and P. E. Wise
Tab le 44. 2 Technique and setting of use for procedures for the treatment of anal stenosis
Technique Setting
Lateral internal sphincterotomy Functional stenoses
Mild low anatomic stenoses
Used in combination with advancement flap techniques
in the treatment of some anatomic stenoses or combined
stenoses
Lateral mucosal advancement flap (endorectal advancement flap)
Perianal skin advancement flaps (V-Y, Y-V, Diamond,
House, U-shaped flaps)
High and some mid-anatomic stenoses
Low and some mid-anatomic stenoses
and anatomic stenosis may be apparent on physical examination; however, patients will often
need further testing to ensure the appropriate diagnosis is obtained. As mentioned, patients with
true functional stenoses will commonly show
relaxation with the induction of anesthesia during EUA and will not have evidence of anoderm
stricturing. Additionally, in the circumstance of
a combined stenosis in patients with previous
anorectal surgery, it is advisable to obtain preoperative anal manometry to help in guiding operative treatment. One of the most potentially devastating complications of the procedures to treat
anal stenosis is loss of continence; therefore, any
operation should be entered into with as much
foreknowledge as possible to determine the best
course of action.
Preoperative Planning
As noted, the diagnosis of anal stenosis is generally made by history and physical examination.
Anoscopy, rigid proctoscopy, and colonoscopy
should be used selectively on a case-by-case
basis. It is recommended that patients undergo
bowel preparation based on surgeon preference,
although this may be difficult for patients with
more severe stenoses. There are no data to support the use of preoperative antibiotic regimens,
especially for more minor procedures; however,
we frequently use intravenous ciprofloxacin and
metronidazole or ertapenem for more extensive
procedures unless there is a concern indicating
usage of broader preoperative antibiotic coverage. The patient is brought to the operating
room and placed in the prone jackknife position.
Depending on the choice of anesthetic, patients
should be intubated under general anesthetic
prior to positioning. Alternatively, if local anesthetic is chosen, the patient may move over to the
bed independently. The buttocks are taped apart
to provide further exposure to the perianal area.
The patient is then prepped and draped in the
standard fashion based on surgeon preference.
After the patient is sufficiently relaxed, local
anesthetic is infiltrated. Local anesthetic can be
considered even under general anesthesia both
for better differentiation of functional stenosis
and for postoperative pain relief.
Lateral Internal Sphincterotomy
For patients with primarily functional stenoses
or mild mid- to low-anatomic stenoses, symptom
relief may be achieved with internal sphincterotomy alone. This may be accomplished by single
[24] or multiple internal anal sphincterotomies
[18], to include bilateral internal anal sphincterotomy [26] in some cases. Good results have been
reported with sphincterotomy in the case of mildto moderate-low anal stenoses, as well as some
mid- or high stenoses, with most patients being
able to be managed in this way [18]. If the patient
does not have sufficient normal anoderm, however, initial relief of symptoms may occur, but
post-procedural scarring may lead to recurrent
anatomic stenosis. To help diminish this issue,
the wound is left open to heal by secondary intention and patients are maintained on an aggressive
post-procedural regimen of stool bulking agents,
laxatives, and increased hydration [20]. An important consideration when considering sphincterotomy is the possibility of postoperative fecal
incontinence. This issue generally resolves with
time and is worse with flatus than stool, but can
be devastating if it persists. Depending on the