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5 Anal Fissure 113
Fig. 5.4 a The ridge is an hypertrophied internal sphincter in a patient with fissure. b Isolated
internal sphincter about to be divided in an LIS. c Completed LIS with an intact external sphincter
at the base. Does it support the anal canal better here than in the poster mid line?
until the anus could accommodate a two finger insertion, a much more conservative
procedure than Maisonneuve’s or Boyer’s procedures. It was subsequently found
that the presumed fibrosis was intact spastic internal sphincter fibers. By the late
1930s, attention had shifted to the external sphincter with injections or actual
division of external fibers by Gabriel [6]. Kilbourne also raised the possibility that
fissures could be caused by tuberculosis or syphilis at that time [7].
Then in 1951, Eisenhammer [8] described the partial lateral internal sphincterotomy (LIS), though he combined this with a rather liberal dilation of the anal
canal after the sphincterotomy. He is, I believe the first to list the number of patients
treated by his method (181) and states that none had any defecation difficulties
afterwards [8] Fig. 5.4.
114 R. Nelson
This procedure was enthusiastically adopted by surgeons around the world. It
was also thought by others that incontinence was not an issue [9]. The first publication to quantify continence disturbanc e was in 1985. It stated that, out of 306
patients who had had an LIS at least one year earlier, only 15 suffered from any
degree of incontinence. This was principally to flatus. In no patient was it severe
enough for the patient to wear a pad [10].
However in 1989 everything changed. Khubchandani published a large case
series of follow-up after LIS, in which 36% of the patients were incontinent to flatus
and 5% to solid stool [11]. In 1996, from the University of Minnesota, which had
reported such low incontinence rate in 1985 [10] in a retrospective comparison of
open versus closed LIS now found that 30.3% of their patients were incontinent to
flatus and 11.8% to solid stool [12]. The age of GTN (glyceryl trinitrate), Botox, and
calcium channel blockers was born. In many countries it appears that LIS had been
abandoned in favor of medical therapy [13]. In a systematic review of anal incontinence following LIS, 22 studies, mostly nonrandomized case series or cohorts
found an overall incontinence rate of 14% with less than 1% having incontinence to
solid stool [14]. Yet patient satisfaction with LIS has been reported to be high [1].
The often crippling pain of fissure is almost immediately relieved. And the rest of us
colorectal surgeons wondered: “Where are all these incontinent patients?”
The most recent update of the Cochrane review of medical therapy for anal
fissure, 28 different medical therapies are investigated in randomized clinical trials
[15]. If it was assumed that the only available treatments were GTN, Botox, and
calcium channel blockers, all of which appeared in the late 1990s, then it could be
surmised by this explosion of new therapies that the older ones were not doing so
well. Again, in the Cochrane review that has not been found not to be the case.
Whereas LIS has an efficacy of between 90 and 95% in systematic reviews (7.9% in
the aforementioned review [1]), no medical therapy has achieved a long term cure
rate of 50% [15]. And in the mean time, patients are in pain.
So how big is the anal incontinence problem after LIS really? With the first
Cochrane review, looking at all randomized trials of LIS, it was 10%, which was
almost, as with Garg, incontinence to flatus [1]. These numbers do not mat ch the
findings of Khubchandani [11] and Garcia-Aguilar [12]. These two reports were
both from retrospective surveys comparing open LIS and closed LIS from single
practices including 715 and 549 patients, respectively. The Cochrane reviews
include 143 randomized trials of both medical and surgical treatment of anal fissure
published from 1976 to 2016 of which 2523 had LIS and postoperative continence
assessment [1, 15]. These data were collected according to an established protocol
prospectively. The main difference between the retrospective cohorts and the
studies included in the Cochrane reviews is selection bias, e.g., the responders to the
retrospective surveys could well have been those with the worst outcomes.
What is more interesting is that with each subsequent update of the of the two
Cochrane reviews (There is one only comparing surgical procedures and another
Cochrane review comparing any medical therapy to any other therapy, which in 29
of the included studies the comparitor was LIS) the risk of incontinence had
declined. From the risk in the original review published in 2000 of 10%, it has
5 Anal Fissure 115
declined to 3.4% for those studies published since 2000. Though this may seem
significant if nonsurgical therapies had no risk of incontinence, in fact incontinence
developed after therapy (for whatever reason) in 1.1% of those using GTN, 2.2% of
those using botox and 1.4% of those using calcium channel blockers [15].
Why did the risk of incontinence decline? There are several possibilities to
consider. More haphazard ascertainment is unlikely. The protocols of all randomized trials are carefully scrutinized by ethics committees. The operation might have
changed? I think this is likely only insofar as all surgeons are extremely aware of
the risk of incontinence related to LIS. If anything, the extent of sphincterotomy (or
concomitant dilation) has diminished without apparen tly diminishing efficacy. This
is exactly what was described by Bodenhamer in the USA in the 1860s, wherein
the LIS, which was quite extensive in the description of Boyer, was barely more
than a mucosal incision with, as he described good results [4]. The length of the
sphincterotomy has been studied: either extending proximally to the dentate line, or
just to the level of the proximal margin of the fissure. The longer incision showed
an insignificantly better efficacy but slightly worse continence [1].
Or possibly different patients are getting the surgery. I also think this is also
likely. There may be more careful selection of those patients with an obviously
hypertrophied internal sphincter and stenotic anal orifice, and not just anybody with
an anal fissure for surgery. Reasonable medical therapies were now available for
most fissure patients. This also suggests that for instance patients with fissure but no
hypertrophy or stenosis may have been more prone to postoperative incontinence
and are now being treated medically. But these are both guesses.
There is one more facet of anal fissure surgery in which history of the early to
mid-nineteenth century has repeated itself: forced anal dilation. From Maisonneuve,
we can fast forward to Lord and in recent years Bodenhamer to Renzi or Gaj, and
others who have investigated a measured anal dilation, in place of the older forced 8
finger wide stretch. So far no incontinence has been reported in the modern dilation
groups, which include just six studies, and efficacy is superior to GTN [14].
Myths Concerning Fissure and Incontinence
Posterior midline partial internal sphincterotomy, unlike LIS, is thought to leave a
keyhole defect in the distal anal canal that results in incontinence of flatus
(Fig. 5.5).
All internal sphincterotomies, open or closed, posterior or lateral, leave a keyhole defect and there have been no data from randomized trials to suggest that either
efficacy or incontinence are greater with any of these procedures [1].
Acute anal fissure should never be operated upon. It is generally thought that
chronic fissures arise from preexisting acute fissures (of course) but that the
hypertrophy and stenosis of the sphincter take time to develop, and this will not
happen in most acute fissure patients, and that surgery not be considered until this
has happened. Fine. In order to defend the above statement, step one is for there to
116 R. Nelson
Fig. 5.5 a Completed posterior midline internal sphincterotomy b The resulting keyhole defect
be general agreement as to what constitutes an acute anal fissure. Physical findings
can separate them. With many fissures there is no doubt that they are chronic. But
there is no general agreement as to duration. In today’s climate most patients with
an acute looking fissure will be started on GTN and by the time it has failed, they
have usually crossed the chronic fissure dateline. LIS probably should still not be
considered in these patients unless sphincter hypertrophy and anal stenosis are
present, and its appearance is otherwise not atypical.
Virtually every paper published in the past 20 years has a sentence prominently
placed in its first paragraph that LIS causes permanent incontinence. Anybody who
runs an incontinence clinic knows there is no such thing as permanent inconti-
nence. A broad range of excellent therapies exist for anal incontinence, and most
are nonsurgical. Internal sphincter repair has been performed, and should work
well, since the muscles are otherwise normal, unlike childbirth-related incontinence.
But only a very small percentage of colorectal surgeons have undertaken this
operation [16]. What makes these rather alarming statements irresponsible is not
just that they are not true, but also that none of these authors have undertaken
studies that rigorously characterized the presumed incontinence or investigated
various therapies for incontinence in randomized trials. One would have thought
that the patients would have demanded it. Presumably they have not.
What Else?
Abscess: I have seen abscess in the sphincterotomy incision in open LIS that has
not happened since I switched to closed LIS 20 years ago. That does not seem
logical. The randomized studies showed no difference in abscess between the two
forms of LIS [1].
5 Anal Fissure 117
Other procedures for which there are insufficient data to establish efficacy or risk
of complications, or even to characterize complications include:
fissurectomy
dermal flap coverage of the fissure
bilateral LIS
levatorplasty
removal of anal papillae
Ayurvedic sutures.
References
1. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S. Operative procedures for
fissure in ano. Cochrane Database Syst Rev. 2011;(11): update in press.
2. AL-Humadi AH, Al-Samarrai S. Treatment of Anorectal Diseases by al-Rāzī. JIMA.
2009;41:122–34.
3. Power D. Treatises of Fistula m Ano Haemorrhoids, and Clysters of John Arderne. Kegan
Paul: Oxford University Press; 1910.
4. Bodenhamer W. Practical observations on the aetiology, pathology, diagnosis and treatment
of anal fissure. New York: Wm Wood & Co.; 1868.
5. Abel AL. The pecten, pecten band, pectenosis and pectenotomy. Lancet. 2 April, 1932v
1;5666:714–8.
6. Gabriel WB. ANAL FISSURE. Br Med J. 1939;1(4079):519–21.
7. Kilbourne NJ. The injection treatment of anal fissure. Cal West Med. 1931;35(5):384.
8. Eisenhammer S. The surgical correction of chronic internal anal (sphincteric) contracture.
S African Med J 1951;25:486–9.
9. Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal
sphincterotomy vs. fissurectomy–midline sphincterotomy. Dis Colon Rectum.
1980 Jan-Feb;23(1):31–6.
10. Walker WA, Rothenberger DA, Goldberg SM. Morbidity of internal sphincterotomy for anal
fissure and stenosis. Dis Colon Rectum. 1985;28(11):832–5.
11. Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano.
Br J Surg. 1989;76(5):431–4.
12. Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD. Open versus closed
sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum. 1996;39
(4):440–3.
13. Ommer A. Management of complications of fissure and fistula surgery. Chirurg. 2015;86
(8):734–40.
14. Garg P, Garg M, Menon GR. Long-term continence disturbance after lateral internal
sphincterotomy for chronic anal fissure: a systematic review andmeta-analysis. Colorectal Dis.
2013;15(3):e104–17.
15. Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane
Database Syst Rev. 2012;15:2.
16. Najarian M. Surgeons’ beliefs and experiences with the surgical treatment of anal fissure. Sem
Colon Rectal Surg. 2006;17:116–119.
Pilonidal Cyst
Sany Thomas and Johan Nordenstam
Overview
Pilonidal disease is an acquired benign condition of the skin and subcutaneous
tissue of the sacrococcygeal region [1–3]. The term pilonidal is derived from the
Latin word pilus meaning hair and nidus meaning nest, describing the disease of the
hair follicle in the ‘nest’ formed in the natal cleft [4–6]. The disease was first
described in 1833 by British pathologist, anatomist, and surgeon Harold Mayo, who
described the finding of a hair follicle containing sinus in the sacroc ocygeal region
in a female patient [4]. Hair in the natal cleft is thought to be the culprit as per the
causative theory [7]. Bascom stated in his original paper that pilonidal disease was
caused by enlargement of the midline pits in the natal cleft that contained distorted
hair follicles. He further described that the enlarged pits had keratin accumulation
and the distorted hair pushes inferiorly causing coalescence of adjacent follicles.
This results in inflammation in the subcutaneous tissue and progresses to abscess
formation [8, 9].
Pilonidal disease is more common in obese individuals, people with thick hair in
the natal cleft, patients with sedentary lifestyles and following trauma to the
sacrococygeal region [7, 10–12]. Buie referred to it as ‘Jeep disease’ in 1944 and
Hardaway called it ‘Jeep rider disease’ in 1958. This was because young male
soldiers, who were p redominately affected, had the highest risk of disease. It was
suggested that the soldiers’ frequent sitting on the uncomfortable jeep seats, in
combination with uneven driving condition caused coccygeal trauma resulting in
the disease [5]. The etiology of disease is not completely understood, but it is
6
S. Thomas J. Nordenstam (&)
Division of Colon and Rectal Surgery, Department of Surgery,
University of Illinois at Chicago, 840 South Wood Street, 518 E CSB,
Chicago, IL 60612, USA
e-mail: drjohan@uic.edu
© Springer International Publishing AG 2017
H. Abcarian et al. (eds.), Complications of Anorectal Surgery,
DOI 10.1007/978-3-319-48406-8_6
119
120 S. Thomas and J. Nordenstam
thought that the anatomy of the natal cleft is the culprit. The natal cleft has minimal
subcutaneous tissue with the skin being closely adherent to the sacrum and coccyx.
The gluteal region adds downward strain to this tightly adherent skin, due to the
weight of the musculature. In addition to the anatomy, the natal cleft, like the axilla,
is more likely to be an area of moisture and bacterial accumulation. The mechanics
of walking allows the skin of the gluteal folds and natal cleft to rub against each
other, causing the migration of debris as well as skin trauma. These factors contribute to pilonidal disease formation [5, 12].
The disease often has a chronic course, initially presenting with pilonidal abscess
formation, with most patients experiencing disease recurrence [5, 7]. The disease
affects males more often than females (3:1 prevalence), affecting males between the
ages of 15–30 [2, 3, 5, 11, 12]. The most common presentation is pain, swe lling,
and/or drainage from the natal cleft [2]. The disease can also be asymptomatic in
3.7% of affected individuals, with one or more blind sinus openings in the natal
cleft [3].
Management
The aim of treatment is to cure disease in the simplest way possible, while causing
little pain and minimal effect on patients’ lifestyles, while achieving low recurrence
rates [1, 4, 6, 13]. Treatment can be divided into conservative and surgical
approaches to management of both disease and recurrence (Figs. 6.1, 6.2 and 6.3).
Fig. 6.1 Midline pits
(Photograph courtesy of
Charles O. Finne MD,
Minneapolis)
6 Pilonidal Cyst 121
Fig. 6.2 Pilonidal sinus
(Photograph courtesy of
Charles O. Finne MD,
Minneapolis)
Conservative Approaches
Controlling hair growth in the sinuses is important in preventing disease progression in early pilonidal disease and preventing recurrences as hair growth in the natal
cleft has been linked to pilonidal disease [7]. Hair growth can be controlled by
shaving, waxing, electrolysis, and use of depilatory creams [7]. Another technique
for hair removal is laser depilation. Khan et al. had good results in preventing
disease recurrence using this technique. Photoelectrolysis has the advantage of
being able to reach deep areas not easily accessed by other techniques of hair
removal [7]. The complications of laser depilation include skin erythema and irritation, hyperpigmentation or hypopigmentation, and skin crusting [7]. The paper
emphasized the adherence to hair removal techniques and suggested that lapse in
adherence as the cause in disease recurrence.
Phenol injection into pits has been suggested. The mechanism of action is
thought to be due to destruction of the epithelium in the pit, leading to inflammation
and scar formation [14]. The procedure is performed under local anesthesia on an
outpatient basis. Weekly phenol instillation in addition to local hair removal has a
success rate of approximately 60% [6] with recurrence rate of approximately 11%
[15]. High recurrence rate is a disadvantage of phenol injection, and is thought to be
due to inadequate phenol penetration of extensive sinus tracts [3]. The
122 S. Thomas and J. Nordenstam
Fig. 6.3 Chronic pilonidal wound (Photograph courtesy of Charles O. Finne MD, Minneapolis)
complications of this therapy are local toxicity, resulting in skin irritation, burns,
cellulitis, and abscess formation [6]. This is avoided by protecting the surrounding
skin and with the application of ointment containing nitrofurantoin prior to phenol
application which can reduce the risk of skin burns [6, 16]. Analgesia, topical
anesthetics use, and wound care can aid in skin healing if phenol toxicity occurs
(Figs. 6.4, 6.5, 6.6, and 6.7).
Antibiotic use has a limited role in conservative management of pilonidal disease. The use of preoperative antibiotics has not shown benefit in wound healing,
preventing complications, or disease recurrence [16]. Equivocal data exists for the
use of antibiotics postoperatively [2, 16]. In chronic pilonidal disease, antibiotic use
is only recommended in cases of associated cellulitis, immunosuppression, and
systemic illness [14].
Surgical Approach
Surgical approaches are offered when there is failure of conservative management
and in cases of chronic pilonidal disease [1, 15]. There are several approaches
ranging from minimally invasive procedures, such as pit picking and more extensive procedures such as wide local excision.
6 Pilonidal Cyst 123
Fig. 6.4 Pilonidal sinuses
Fig. 6.5 Connection
between pilonidal sinus tracts
delineated following peroxide
injection