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11. Benign Anorectal: Hemorrhoids 255
Table 11.10. ASA physical status classifi cation.
Class I: Patient has no systemic disturbance (e.g., healthy, no medical prob-
lems)
Class II: Patient has mild to moderate systemic disturbance (e.g., hypertension,
diabetes)
Class III: Patient has severe systemic disturbance (e.g., heart disease that limits
activity)
Class IV: Patient has severe systemic disturbance that is life-threatening (e.g.,
unstable angina, active congestive heart failure)
Class V: Patient is moribund and has little chance of survival (e.g., ruptured
abdominal aortic aneurysm)
Reprinted from Dis Colon Rectum 2003;46(5):573–576. Copyright © 2003. All rights
reserved. American Society of Colon and Rectal Surgeons.
Preoperative Evaluation
Preoperative Investigations (e.g., Laboratory Studies and Electrocardio-
grams) Should Be Dictated by History and Physical Examination .
Level of Evidence – Class III . Multiple studies have documented
that patient history and physical examination are the key elements of an
appropriate preoperative evaluation. Routine preoperative investigations
that are not warranted on the basis of history and physical seem to provide little further information. There is clear evidence that nonselective
preoperative screening yields few abnormal results.
One study of 1,200 patients undergoing ambulatory surgery revealed
that the vast majority of abnormalities could have been predicted by history
and physical examination. These abnormalities did not predict perioperative
complications or the need for hospital admission. A separate study of
1,109 patients undergoing elective surgery revealed that 47% of laboratory investigations duplicated tests performed within the previous year.
Meaningful changes in the repeat laboratory values were very rare. Such
abnormalities were predictable by the patient’s history. A further study of
5,003 preoperative screening tests revealed 225 abnormal results. Only
104 were of potential importance and the abnormality caused action in
only 17 cases. It was believed that only four patients could have had a
conceivable benefi t from their preoperative screening test.
Similar studies have been performed to investigate the value of specifi c tests. A study of 12,338 patients undergoing invasive procedures
was performed to examine the value of determining activated partial
thromboplastin time as a routine. Ninety-two percent of the patients were
256 The ASCRS Manual of Colon and Rectal Surgery
believed to be at low risk (there were no clinical factors to suggest the
bleeding tendency). In these patients, it was shown that no information
was gained from activated partial thromboplastin time, and therefore,
clotting studies had no role as a screening test in asymptomatic patients.
Similarly, routine cardiac workup seems unjustifi ed. The risk of a perioperative myocardial infarction in patients without clinical evidence of
heart disease is 0.15%. This risk increases signifi cantly in patients who
had a previous myocardial infarction. History and physical examination
are the cornerstones of appropriate preoperative evaluation.
Intraoperative Considerations
Most Anorectal Surgery May Be Safely and Cost-Effectively Performed
Under Local Anesthesia; Regional or General Anesthesia May Be Used
Depending on Patient or Physician Preference .
Level of Evidence – III . The use of local anesthetics such as monitored
anesthetic care for anorectal surgery is safer and has fewer complications than other anesthetic techniques. Perianal infi ltration of local
anesthetics is a simple procedure that is easily learned. Injection of
the local anesthetics can be accomplished in less than 5 min and the
operation begun immediately. However, the anesthetic technique used
for any procedure should be the one that provides for maximal safety
and effi cacy.
Postoperative Considerations
Anorectal Surgery Patients May Safely Be Discharged from the Pos-
tanesthesia Care Unit .
Level of Evidence – II . The time course for recovery from anesthesia
includes early recovery, intermediate recovery, and late recovery. Early
recovery is the time interval for anesthesia emergence and recovery of
protective refl exes and motor activity. The Aldrete score has been used
for 30 years to determine release from phase 1 (early) recovery to a hospital bed or phase 2 (intermediate) recovery. Intermediate recovery is the
period during which coordination and physiology normalize to an extent
that the patient can be discharged from phase 2 recovery in a state of
“home readiness” and be able to return home in the care of a responsible
11. Benign Anorectal: Hemorrhoids 257
adult. The Post-Anesthetic Discharge Scoring System has been shown to
be effi cacious for discharge.
Multiple Modalities May Be Used to Achieve Adequate Postoperative
Pain Control .
Level of Evidence – II . If local anesthetics are not used as the primary
anesthetic technique, their use will provide prolonged postoperative analgesia. Oral narcotics may be used as primary postoperative analgesia. The
use of nonsteroidal antiinfl ammatory drugs, particularly intramuscular or
intravenous Toradol ® (Roche Pharmaceuticals, Nutley, NJ) or sulindac
suppositories has also shown improved analgesia, lower narcotic usage,
and lower rates of urinary retention. Although the effect is unknown, oral
metronidazole shows improved postoperative pain control.
Postoperative Urinary Retention Can Be Reduced by Limiting
Perioperative Fluid Intake .
Level of Evidence – III . Multiple studies have shown that limiting
perioperative fl uid lowers the incidence of postoperative urinary retention. These same studies show confl icting evidence over the relationship
between gender, age, and the quantity of narcotic medication and urinary
retention. Hemorrhoidectomy and the performance of multiple anorectal
procedures have higher rates of urinary retention.
Postoperative Education Should Include Recommendations for Sitz
Baths, Fluid Intake, and Activity Limitations .
Level of Evidence – III . Textbooks of anorectal surgery advocate con-
sistent instructions before discharge from ambulatory surgery. Although
derived from common sense, scientifi c justifi cation does not exist. With
appropriate communication, ambulatory anorectal surgery may be performed with a high degree of patient satisfaction.
12. Benign Anorectal: Anal Fissure
A. Epidemiology
• An anal fi ssure, or fi ssure-in-ano, is an oval, ulcer-like, longitudinal tear in the anal canal, distal to the dentate line.
• Fissures can occur at any age, but are usually seen in younger
and middle-aged adults.
• In almost 90% of cases, fi ssures are identifi ed in the posterior
midline, but can be seen in the anterior midline in up to 25% of
affected women and 8% of affected men.
• Fissures occurring in lateral positions should raise suspicions for
other disease processes, such as Crohn’s disease, tuberculosis,
syphilis, human immunodefi ciency virus (HIV)/acquired immunodefi ciency syndrome (AIDS), or anal carcinoma (Fig. 12.1 ).
• Early, or acute, fi ssures have the appearance of a simple tear
in the anoderm, whereas chronic fi ssures, defi ned by symptoms
lasting more than 8–12 weeks, are further characterized by
edema and fi brosis.
• Typical infl ammatory manifestations of chronic fi ssures include
a sentinel pile, or skin tag, at the distal fi ssure margin and a
hypertrophied anal papilla proximal to the fi ssure in the anal
canal. In addition, fi bers of the internal anal sphincter (IAS) are
often visible at the fi ssure base.
B. Etiology
• Trauma to the anal canal secondary to the passage of a hard
stool is believed to be a common initiating factor. A history of
D.E. Beck et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery, 259
DOI: 10.1007/978-0-387-73440-8_12, © Springer Science + Business Media, LLC 2009
260 The ASCRS Manual of Colon and Rectal Surgery
Fig. 12.1. The location of anal fi ssure suggests their cause.
constipation is not universally obtained, however, and some patients
report an episode of diarrhea before the onset of symptoms.
• Physiologic studies using ambulatory manometry have confi rmed
the presence of sustained resting hypertonia in fi ssure patients.
• Further observations have delineated an inverse relationship
between anal canal pressure and perfusion of the anoderm.
• Schouten et al. measured anodermal blood fl ow in healthy individuals using Doppler laser fl owmetry, and found that the posterior midline had the lowest perfusion when compared with
the other three quadrants. In addition, there was a signifi cant
inverse correlation between posterior midline anodermal blood
fl ow and maximum resting anal pressure in a large cohort of
patients that included normal controls and fi ssure patients.
Those with fi ssures demonstrated the highest resting anal pressures and the lowest posterior blood fl ow of any group.
• These same authors were able to demonstrate normalization
of sphincter hypertonia and anodermal blood fl ow after lateral
internal sphincterotomy (LIS) in anal fi ssure patients.
12. Benign Anorectal: Anal Fissure 261
C. Symptoms
• The clinical hallmark of an anal fi ssure is pain during, and
particularly after, defecation.
• In acute fi ssures, pain may be short-lived, or it can last several
hours or even all day in the presence of a chronic fi ssure.
• The pain is frequently described as passing razor blades or
glass shards. Understandably, patients with anal fi ssures may
often fear bowel movements.
• Rectal bleeding, although not uncommon, is usually limited to
minimal bright red blood seen on the toilet tissue.
D. Diagnosis
• Diagnosis is suggested by patient history and confi rmed by
physical examination. Most fi ssures are readily visible by simply
spreading the buttocks with opposing traction of the thumbs
(Fig. 12.2 ).
Fig. 12.2 . Examination revealing an anal fi ssure.
262 The ASCRS Manual of Colon and Rectal Surgery
• Once the presence of a fi ssure is verifi ed, further attempt to
examine the anal canal with insertion of a fi nger or endoscopic
instrumentation (anoscopy or proctoscopy) is not appropriate.
Most patients are far too tender to justify such invasive evaluation, which should be delayed or deferred until symptoms have
resolved.
• The differential diagnosis includes perianal abscess, anal fi stula,
infl ammatory bowel disease, sexually transmitted disease,
tuberculosis, leukemia, and anal carcinoma.
• Atypical fi ssures, such as those occurring off the midline, multiple,
painless, and nonhealing fi ssures, warrant further evaluation, via
examination under anesthesia and possible biopsy and cultures.
E. Management
Conservative
• Almost half of all patients diagnosed with an acute fi ssure will
heal with conservative measures, i.e., sitz baths and psyllium
fi ber supplementation, with or without the addition of topical
anesthetics or anti-infl ammatory ointments.
• In a double-blind, placebo-controlled trial, fi ssure recurrence
was measured after 1 year in three groups. Signifi cantly fewer
recurrences (16%) were seen in patients receiving 15 g of
unprocessed bran daily, when compared with 60% of patients
receiving 7.5 g daily or 68% of patients on placebo.
Operative Treatment
• Operative procedures, such as manual anal dilatation or internal sphincterotomy, have been advocated as initial modes of
treatment because they produce permanent reductions in maximum resting anal pressures.
Anal Dilatation
• Inconsistencies with regard to technique, specifi cally extent
and duration of sphincter stretch, have cast some doubt about
true success rates of this procedure.
12. Benign Anorectal: Anal Fissure 263
• Additional widespread criticism of the technique stems from
reported complications of incontinence, secondary to diffuse
sphincter damage.
Lateral Internal Sphincterotomy
• Exceptional healing and low recurrence rates have invariably
been reported, and LIS has emerged as the “gold standard” for
the treatment of anal fi ssure (Table 12.1 ).
• Persistent incontinence to gas and stool has emerged as a major
concern after sphincterotomy.
• Littlejohn and Newstead reported a retrospective review of 287
patients who underwent tailored sphincterotomy, i.e., division
of the IAS for the length of the fi ssure, rather than to the dentate
line. There were no reports of incontinence to liquid or solid
stool. The incidence of urgency was 0.7%; gas incontinence,
1.4%; and minor staining, 35%.
• Other technical variations that have infl uenced patient outcomes
after LIS have been described (Figs. 12.3 , and 12.4 ). With regard
Fig. 12.3. Open lateral internal anal sphincterotomy. ( a ) Radial skin incision distal
to the dentate line exposing the intersphincteric groove. ( b ) Elevation and division
of the internal sphincter. ( c ) Primary wound closure.
264 The ASCRS Manual of Colon and Rectal Surgery
Follow-up (type) Follow-up (mo)
a
– C NS
b
Table 12.1 . Results of LIS.
Year Author n Success (%) Recurrence (%) Incontinence (%)
1980 Abcarian 150 100 1.3 0 C NS
1981 Keighley et al. 71 100 25 2 I, E 12
1982 Ravikumar et al. 60 97 0 5 C 24
1984 Hsu and MacKeigan 89 100 5.6 0 C NS
1984 Jensen et al. 30 100 3 0 Q, E 18
1985 Walker et al. 306 100 0 15 I 52
1987 Gingold 86 100 3.5 0 C 24
1987 Weaver et al. 39 93 5.1 2.5 I, E 17
1988 Lewis et al. 350 94 6 6 I 37
Recurrence and persistence combined
Includes seepage and incontinence to fl atus and stool
C chart review; E examination; I interview; Q questionnaire; NS not stated
a
b
1997 Littlejohn and Newstead 352 99.7 1.4 1.4 C 9
1999 Nyam and Pemberton 585 96 8 15 Q 72
2004 Wiley et al. 76 96 NS 6.8 Q 12
1988 Zinkin 151 94.7 NS NS None 0
1989 Khubchandani and Reed 717 97.7 NS 35.1 Q 52.9
1992 Kortbeek et al. 112 95.5 NS NS I 1.5
1994 Pernikoff et al. 500 99 2 16 Q 78
1994 Romano et al. 44 100 0 9 E 8
1995 Leong and Seow-Choen 20 100 NS 0 I, E 6.5
1995 Prohm and Bonner 177 96 3.3 1.6 E 1.5
1995 Usatoff and Polglase 98 90 20 18 Q 41
1996 Garcia-Aguilar et al. 864 96 11 37.8 Q 63.5
1997 Hananel and Gordon 312 98.6 1.4
2004 Parellada 27 100 NS 15 E 2.5
12. Benign Anorectal: Anal Fissure 265
Fig. 12.4. Closed lateral internal anal sphincterotomy. ( a ) Location of the inter-
sphincteric groove. ( b ) Insertion of knife blade in the intersphincteric plane in per-
forming a “blind” lateral subcutaneous internal anal sphincterotomy. ( c ) Lateral to
medial division of the IAS (insert: medial to lateral division of the muscle).
to open or closed sphincterotomy, several retrospective analyses
and at least one randomized trial report similar rates of initial
healing and fi ssure recurrence.
• In a randomized trial, patient satisfaction was rated as excellent
or good after removal of these structures in 84% of patients,
compared with 58% of patients whose polyps and papillae were
left intact.
Advancement Flaps
• One prospective trial of the use of advancement fl aps for chronic
anal fi ssures has been conducted to date. When patients were
randomized to receive LIS or advancement fl ap, there was
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