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46544 Anal Stenosis After Hemorrhoidectomy: Avoidance and Management
Fig. 44.3 Perianal flap techniques for anal stenosis.
a Y-V flap. b V-Y flap. c Diamond flap. d House flap.
e rotational S-flap (With permission from [40] © Springer)
individual case, it may be prudent to obtain preoperative anal manometry to determine the patients’ sphincter function prior to considering this
approach. It is a rare circumstance where the authors would favor this approach to stenosis after
hemorrhoidectomy.
Lateral Mucosal Advancement Flap
The most common procedure used for proximal
anatomic anal stenosis is a lateral mucosal or endorectal advancement flap (Fig. 44.3) [27]. This
procedure is initiated by making a lateral incision in the perianal skin and transition zone such
that the scar is completely divided (and a lateral
internal sphincterotomy may also be performed
simultaneously, if favored by the surgeon). Following scar division, the rectal mucosa is then
mobilized proximally in a triangular or tonguelike formation proximally into the distant rectum
in the muscular plane for 4–6
the flap
can easily reach to interpose across the
cm, ensuring that
scar/stenosis with little to no tension. While this
flap is referred to as a mucosal flap, it is vitally
important to include mucosa, submucosa, and a
portion of the circular muscle of the rectal wall,
as flaps including only the mucosa and submucosa are prone to developing recurrent stricture due
to ischemia. Additionally, the width of the flap
base (proximal) should be approximately twice
the width of the apex (distal) as another method to ensure adequate blood supply. The flap is
then sutured to the anoderm distal to the stenosis
using absorbable sutures in an interrupted, fullthickness fashion (the authors favor 3-0 vicryl, or
more rarely, 3-0 chromic for smaller flaps). It is
important that the mucosal flap is not fixed distal
to this point, as this may lead to ectropion formation. Any portion of the excision of the stricture
external to the intersphincteric groove should be
left open to heal by secondary intent to avoid ectropion formation and minimize the risk of recurrent stricture. This procedure is generally well
tolerated by patients in terms of postoperative
pain with good long-term outcomes, and the procedure may be able to be performed with sedation and local anesthesia [21, 27, 28]. While this
method is useful for proximal stenoses, perianal
skin advancement flaps are better techniques for
more distal anatomic stenoses.
Y-V Advancement Flap
One widely performed procedure is the Y-V
advancement flap, especially for low and midstenoses. The Y-V advancement flap is accomplished by making a wide-based V-shaped incision with the apex just distal to the stenosis and
the base of the flap laterally on the anoderm and
perianal skin at least 2–3-cm wide, after which
the “Y” extension is made from the apex of the
“V” through the entire length of the area of stenosis (Fig. 44.3). The flap is then mobilized by
dividing the deeper subcutaneous attachments
466 J. B. Mitchem and P. E. Wise
Fig. 44.4 V-Y advancement flap. a Excision of anal stricture and “V” incision into the perianal skin. b Flap mobiliza-
tion including the subcutaneous fat and closure in “Y” formation
perpendicular to the skin while taking care to
ensure both preservation of the subdermal blood
supply and a tension-free repair, commonly requiring mobilization to the level of the underlying fascia depending on flap location. The apex
of the V is then sutured to the distal corner created by the Y extension at the level of the internal-most aspect of the stenosis using interrupted
longer term absorbable sutures (for example, 4-0
or 3-0 Monocryl or PDS), which creates the final
“V” configuration of the repair. This technique
has been described as very effective for relieving
patients’ symptoms [29–31]. The procedure can
be performed in the posterior or lateral positions,
and bilaterally, if necessary [20].
V-Y Advancement Flap
Another option for treatment of distal anal stenosis is the V-Y advancement flap (Fig. 44.3).
To begin the operation, the area of stenosis is
excised approximately 5 mm proximal to the
dentate line (Fig. 44.4a). After excision of the
stenosed segment, the V-Y advancement flap is
accomplished by creating a wide V-shaped incision with the apex of the V extending into the
healthy surrounding perianal skin. The base of
the V should again be approximately 2–3-cm
wide on the side of the stenosis, and the distal
extent of the incision should be approximately
two to three times the width of the base. Again,
meticulous dissection is used to fully mobilize
the flap while preserving the subdermal vascular plexus and ensure adequate mobilization to
ensure a tension-free repair. After mobilization,
the base of the V is sutured to the base of the
area of excision, and the apex of the V is closed
primarily to create the “Y” extension of the repair
(Fig. 44.4b). It is generally felt that a 2-cm flap
is adequate for a good repair [26]. While initially
described for the treatment of mucosal ectropion
[32], it has been applied to anal stenosis from a
variety of causes with good results [33].
Diamond-Shaped Flap
To carry out the diamond flap, the scarred anoderm is incised across the stenosis laterally extending just into healthy tissue proximally (above
the stenosis) and may have a slight diamond
shape to facilitate flap placement (Fig. 44.3a,
b and 44.5a-c). A diamond-shaped flap at least
2–3-cm wide (depending on the degree of stenosis, it may need to be wider) is then created in the
surrounding perianal skin with one apex at the
external end of the incision across the stenosis.
Again, this flap is then fully mobilized, taking
care to preserve the subdermal fat and vascular
plexus. After achieving full mobilization, the flap
is then sutured with interrupted full-thickness sutures to the proximal aspect of the incision across
the stenosis and then the surrounding remaining
46744 Anal Stenosis After Hemorrhoidectomy: Avoidance and Management
Fig. 44.5 Bilateral diamond flaps. a Preoperative depic-
tion of anal stricture. b Incisions through the anal stricture
to create the opening for flap placement. c Depiction of
anoderm after which the donor site is closed primarily in a linear fashion. An advantage of the
procedure is that it may be used multiple times to
cover multiple areas of stenosis or large defects.
Results using this procedure have been reported
as excellent [34], and in one study, the results
were slightly better than the Y-V advancement
flap [29], perhaps due to bringing a wider portion
of vascularized skin into the site of the stenosis.
House Flap
The “house” flap, as originally described by
Christensen et al., is another method of flap reconstruction (Fig. 44.3) [35]. It was designed to
treat large areas of distal stenosis. The operation
is begun by making a linear or rectangular, superficial incision in the right or left lateral position
of the stenosis extending from the dentate line or
most proximal edge of the stenosis through to the
distal edge of the stenosis. The base (or “foundation”) of the house-shaped flap is recommended
to be approximately the entirety of the anal canal
on the affected side (at least 2–3-cm wide), and
the distal extent out onto the anoderm should be
two to three times the width of the base, similar
to the Y-V flap as discussed above. Transverse
incisions extending laterally from the outer edge
of the stenosis are made with the most lateral aspects of the anoderm incisions being brought together to form the apex of the “roof” of the house
flap. The flap is then mobilized as described
previously for the diamond flap, preserving the
subdermal blood supply. The base/foundation of
the house flap is then mobilized into the defect
flap creation and mobilization, including the subcutaneous fat. d Final appearance at closure
created in the stenosis, and the flap is sutured
in place with interrupted full-thickness sutures,
after which the anoderm is closed laterally at the
“donor” site (similar to a V-Y closure). The house
flap was designed to provide coverage for severe
stenoses and can be performed multiple times in
the same patient, with no single flap covering
more than 25 % of the stenotic area [21]. This
technique has been employed with good success
rates in several studies with high levels of patient
satisfaction in follow-up to 26 months after repair [35–38]; although in one study there was a
reported 44 % rate of primary (donor site) wound
separation [37], which will usually close primarily with local wound care.
U-shaped Flap
The U-shaped flap is similar to the diamond flap
and has been described for use in patients with
anal stenosis and mucosal ectropion [39]. This
procedure is begun by incising the area of stenosis followed by making a U-shaped incision in the
healthy perianal skin. The flap is then mobilized
and sutured in place to cover the defect. This approach provides a larger distal extent of the flap
to potentially avoid the concern for possible tip
ischemia associated with V-Y flap advancement.
Postoperative Care
Patients undergoing limited procedures, such as
sphincterotomy, can generally be handled on an
outpatient basis. When a more extensive operation
468 J. B. Mitchem and P. E. Wise
is undertaken involving flap reconstruction, these
patients are generally admitted at least overnight
to the hospital to ensure adequate pain control.
While some of these patients were admitted for
3–4 days in the past and kept NPO for the first 2
days of hospitalization, followed by subsequent
initiation of a high-fiber diet, laxatives, and mineral oil to avoid constipation, there are no data
to support this approach. Instead, most patients
are immediately advanced to a high-fiber diet and
stool softeners with or without laxatives. Patients
are provided adequate analgesia in the form of
oral pain medications, sitz baths, or showers are
used for comfort as well as to clean after bowel
function, and the patients are instructed to otherwise keep the area clean and dry. Prolonged sitting and strenuous activities are discouraged for
the first 2 weeks postoperatively. It is not routine
practice to use closed drainage unless a large flap
is created, and this should be removed at the surgeon’s discretion, usually when the output is less
than 5–10
oral antibiotics is not indicated postoperatively
unless infection occurs. Short-term postoperative complications are similar to other perineal
and anal operations and include urinary retention
and local infection. Significant bleeding is rare.
Flap ischemia may occur and is usually managed with local wound care, although operative
debridement may rarely be needed. Long-term
complications include ectropion formation, leakage/incontinence, and/or recurrence of stenosis.
These complications are relatively infrequent, if
the appropriate surgical approach is chosen and
performed by experienced surgeons.
cc/day
. Routine use of topical and/or
Summary
Anal stenosis is a rare complication of hemorrhoidectomy and can generally be avoided by performing meticulous dissection in the submucosal
plane, avoiding injury to the underlying muscle,
and ensuring adequate normal intervening anoderm during the index operation. Most patients
with anal stenosis can be managed nonoperatively using a combination of increased dietary
fiber, hydration, and stool softeners; however, it
is important to confirm that there is not a more
concerning underlying process, such as anal or
rectal neoplasia. It is uncommon for patients with
mild stenosis to require operative intervention,
but in patients with mild to moderate stenosis in
whom non-operative methods fail, a trial of serial dilations commonly provides resolution. In
patients with nonresponsive moderate stenosis or
severe stenosis, there are a multitude of options
for intervention including sphincterotomy and
various methods of flap anoplasty. Surgical therapy should be guided by location and the ability
to create a tensionless flap and preserve integrity
of flap blood supply. After surgical intervention,
patients should be maintained on high-fiber diet
and stool softeners, as well as being provided
adequate analgesia, as these will help to prevent
postoperative complications and lead to good
outcomes and resolution of symptoms in the vast
majority of patients.
Key Points: Managing Complications
1. Managing anal stenosis after hemorrhoidec-
tomy starts with the index operation. To avoid
this complication:
a. Employ techniques of meticulous dissec-
tion in the submucosal plane, avoiding
injury to the internal sphincter muscle.
b. Ensure adequate intervening normal ano-
derm between excisions, generally considered ~ 1 cm.
c. When possible, limit the number of sites of
hemorrhoid excision at each intervention.
d. Complex hemorrhoidal disease should be
managed by surgeons experienced in the
treatment of perianal conditions.
2. Anal stenosis can be due to a functional defect
in the internal sphincter complex, anatomic
strictures of the anal canal, or a combination
of both. Each of these issues may be managed
slightly differently, so it is important to arrive
at the appropriate diagnosis preoperatively.
3. The diagnosis of anal stenosis is primarily one
based on history and physical examination;
however, adjunctive assessments may be nec-
essary in the appropriate clinical setting.
46944 Anal Stenosis After Hemorrhoidectomy: Avoidance and Management
4. The majority of patients with mild and moderate stenosis can be managed nonoperatively.
5. There are a number of techniques used to treat
this condition operatively, and the approach to
each patient should be individualized based
on severity of stenosis, location, and patient
symptoms.
6. Postoperatively, patients should be provided
adequate analgesia and maintained on a regimen of high-fiber intake, increased fluids, and
stool softeners.
7. Complications are rare when the techniques
are performed as described; however, complications may include the following:
a.
The most common
immediate postoperative complication is flap ischemia/necrosis,
which can generally be managed with local
wound care.
b.
Long-term complications can
include
ectropion, leakage/incontinence, and recurrent stricture. These complications are best
treated preventatively by adherence to surgical principles during the index operation.
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anoplasty
Part V
Other Considerations
Delivering Bad News: Conversations with My Surgeon
Murray F. Brennan
45
Introduction
Almost all successful human interrelationships
succeed because of shared and understood expectations whether between spouses, parents
and children, employee and employer, business
partners, or doctor and patient. If expectations
are understood by both participants, then much
of the rancor and future potential conflict can be
avoided or ameliorated.
No better example of this is seen than between
surgeon and patient prior to the performance of a
major surgical procedure. Much of the difficulty
and angst encountered in delivering “bad news”
occurs because of the failure to anticipate a poor
outcome because of either unrealistic expectations of the patient, his or her family, or the failure of the surgeon to convey the potential for less
than a perfect outcome. No surgical procedure
can ever be perfect and there are situations when
unanticipated problems do occur. The ability to
minimize the unanticipated is foremost in making delivery of bad news tolerable and less likely
to engender anger.
M. F. Brennan ()
Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, NY, USA
e-mail: brennanm@mskcc.org
Informed Consent
Informed consent is intended to convey just that,
“informed” consent. It is your devoir. The importance is underappreciated by the surgeon who
delegates consent to a junior member of the team.
We need be cognizant that informed consent is
often offered at a time when the patient is most
vulnerable, and often obtained at a time when patient receptivity is at a minimum. Presentation of
a diagnosis of cancer of the pancreas or the anticipation of a pancreatic cancer is accompanied
by mind numbing shock and rarely delivered in a
situation where calm and considered “informed
consent” can be obtained. Legal requirements of
informed consent are often vague, poorly understood, or interpreted by patient and surgeon alike
[1]. When one anticipates that some form of complication minor or major occurs in up to 50 % of
patients undergoing pancreaticoduodenectomy,
one realizes how infrequently such potential
events are described. Conversely, the willingness
to emphasize complexity of any procedure and
the potential of some complication occurring is
essential to future rapport. This can be simplistically conveyed when talking about the duration
of hospital stay. The mention of the anticipated
postoperative stay, that is the statistical median,
should always be tempered by “should a complication occur hospital stay will be prolonged.”
Hospital readmission is not uncommon and
should not be feared but anticipated. With the
current emphasis on early discharge, the patient
should be informed of the likelihood of readmis-
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_45,
© Springer Science+Business Media New York 2015
473
474 M. F. Brennan
sion. Currently 25 % of complications of major
procedures occur post initial discharge, and the
majority of those will require readmission [2].
The personal investment of the responsible
surgeon’s time in obtaining his or her own informed consent is an excellent investment in the
long-term surgeon–patient relationship. The inclusion of the family in this discussion is crucial.
No greater potential for misunderstanding occurs
than when conversations with the family either
do not occur or occur in the absence of the patient, such that subsequent interpretation is seen
differently by either side. A simple hand-drawn
diagram outlining the planned procedure can
often convey a sense of intimacy that is well appreciated.
Of additional importance for all major procedures is that all members of the team are “on
the same side.” This is of most help, if one has a
personal nurse or assistant who is familiar with
your approach to procedures and can reinforce
and explain, always being consistent. As a junior
faculty member this may not be possible as variable support staff is available at the time of the
initial visit. This means even greater importance
of the participation of the primary surgeon. If you
are unaware of the approach of your support staff
to patients, your personal involvement must increase.
The simple offer of a willingness to discuss
things further between the time of initial visit and
consent and the planned procedure can do much
to allay concern and defray the potential for misunderstanding. This offer sets the awareness that
the surgeon and members of his team are available and willing to address concerns of the patient and family both pre- and postoperatively.
Empathetic informed consent should rarely, if
ever, be obtained with either surgeon or patient
standing. The simple effort of sitting beside or
in front of the patient as the consent is carefully
considered conveys an air of understanding and
empathy. The perception of being rushed to “sign
here” is not worth the few minutes it may potentially save.
Other situations can be anticipated at the time
of consent and the family and patient prepared
for eventualities unrelated to the complications
or outcome. The simple suggestion that the procedure “normally takes 4 h” can be conveyed
with the understanding that if the procedure is
particularly difficult it will take longer. Conversely, a very short procedure will anticipate a
very different outcome; usually in cancer surgery
it will mean that the tumor cannot be removed.
The patient and the family are then clearly prepared; should they learn that only an hour has
passed and the surgeon is coming to speak with
them. This is an important strategy when diagnostic laparoscopy precedes an intended complicated procedure. The setting of expectations cannot be overemphasized.
The potential for having to deliver bad news
has begun at the initial patient encounter and at
the time of informed consent.
The Family Does Not Want the Patient to be Fully Informed
The false belief that by not mentioning the word
cancer the patient will be reassured or the family’s guilt assuaged should be confronted. For
example, you come to see a patient. The family
is hovering outside the room and begins with,
“You know, doctor, he does not know he has cancer” and more concerning, “We do not want him
told.” The truth is rarely that. The family does
not want to discuss the frightening diagnosis, and
rather than being reassured, the patient is often
more terrified than justified. The situation has to
be confronted with empathy and directness but
absolute truthfulness.
Telling the truth does not need to be presented
as a crucifixion. There are many strategies. From
the simple as in my case, “Do you not think the
patient knows the name of this hospital?” Or “Do
you not think he knows what kind of surgeon I
am?” Although seemingly more arrogant, “Do
you trust your father?” followed by, “Will he be
able to trust you if he learns that you have not
been honest with him?” Or perhaps even more
superficially arrogant, “Do you think your mother/father is intelligent?” followed immediately
by, “Of course, you do. Do you not think he/she
deserves the respect of his family?” There are
47545 Delivering Bad News: Conversations with My Surgeon
many ways to address this issue. The importance
is that avoidance of reality will only lead to difficulties in subsequent encounters.
Perioperative Death
In major operations, the potential for intraoperative or perioperative death should always be
mentioned. The concept of “is there a risk of you
dying?” can always be presented in the context
of “of the last 100 patients undergoing this operation in our institution two did not survive the first
30 days.” This emphasizes the potential seriousness of the procedure without drama or inappropriate terror.
Intraoperative death is far less frequent today
than it was 20 years ago. It is a rare situation
where an intraoperative complication cannot be
successfully managed to have the patient leave
the operating room and be received in the postsurgery and anesthesia care unit. In that situation,
the family can prepare at the bedside or nearby
for an anticipated demise. Certainly, in a situation
where a major intraoperative disaster occurs, the
ability of one of the surgical team communicating
to the family that difficulties have been encountered, and that they can anticipate the surgeon
responsible speaking with them but not until the
problem is addressed, is most helpful. This reinforces the importance of continued communication between surgical team and the patient’s family. The awareness of the patient and the family
that there will be a nurse who will communicate
with the family as to progress of an operative
procedure provides an excellent resource. If the
patient is aware that communication is available,
then a wise surgeon encountering difficulty or
even awareness that the procedure will be prolonged can have that communicated to the family. When serious life-threatening intraoperative
problems occur, the ability to forewarn the family leads to a gradual anticipation of a potentially
lethal event.
All of these scenarios are such that the delivery of bad news can be anticipated and planned
for. The suggestion that the family be moved to
a private consulting room ahead of the surgeon’s
arrival provides similar anticipatory understanding.
When an Intraoperative Death Does Occur
When an intraoperative death occurs, it is essential that the surgeon responsible assumes that
responsibility and discusses it with the family.
The preparation of the family by giving them
awareness that problems have been encountered
is helpful. The invitation for the family to move
to a private consulting room forewarns them
of the gravity of the situation. It can be helpful
to have the nurse who is dealing with the family accompany the surgeon to the family, but it
should not be several members of the operating
team who confront the family. This is the primary
surgeon’s responsibility. This conversation does
need to take place in a quiet environment with
everyone sitting and composed. The initiation of
the conversation can be difficult. Most often, the
patient will be able to be resuscitated to where
they will reach the recovery room. In that situation, the conversation can begin with, “Unfortunately, things have not gone well, and we have
encountered a problem that is not solvable.” This
can be followed by the actual description of the
circumstances and must, if the anticipated outcome is demise, include a comment to the effect
that, “We do not expect Mr. X to survive.” Such
comments can always be tempered by a caveat as
to the seriousness of the situation, the anticipation of permanent morbidity or organ failure if
initial recovery does occur. Again, in the absence
of absolute demise everything should be done to
set the scene for the anticipated outcome. It is
often most valuable once the anger and angst is
tempered to suggest that you, the responsible surgeon, are going once again to see the patient and
then will return to bring the family or the most
closely associated members of the family to the
bedside to reinforce the anticipated outcome.