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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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IBD—Crohn disease (555.X) (Ch. 4)
Fistula-in-Ano–Fistulotomy vs Seton (Ch. 5)
PILONIDAL DISEASE (CYST/SINUS/FISTULA, 685.0/1)
Overview
Pilonidal disease ("hair nest") is most common in young adults, essentially nonexistent in those > 45–50 years.
Males:females = 3:1. Overweight common but not exclusive. Condition is not life-threatening but is annoying and causes
significant work/school absences. Range of presentations: asymptomatic pits in the sacrococcygeal region that cause a local
infection with acute abscess, recurring abscesses, draining sinus or fistula.
Pathogenesis: hair penetration/development beneath the skin results in foreign body–type infection. Two theories:
1. Congenital: embryologic skin fusion error with resultant entrapment of hair follicles in the sacrococcygeal region.
2. Acquired: external origin (maceration, microtrauma, ingrowth) introduces hair follicles into the subdermal area.
Epidemiology
Prevalence of asymptomatic pilonidal disease unknown. Risk of recurrent abscess: ~30–50% after resolved first episode, 80–
90% after two episodes.
Symptoms
Pain (inability to sit down), erythema, swelling, purulent drainage from pits or secondary openings, chronic/intermittent
discomfort, chronic/intermittent drainage, secondary skin irritation.
Complications: squamous cell carcinoma (after 20–30 years), sacral osteomyelitis, necrotizing fasciitis, toxic shock syndrome,
and meningitis.
Differential Diagnosis
Hidradenitis suppurativa: not uncommonly overlap between and coexistence of both.
Perirectal fistula: cryptoglandular origin.
Presacral tumor.
Meningomyelocele.
Lipoma.
Sebaceous cyst.
Acne inversa.
Pathology
Cystic structure of varying size, containing hairs, debris. Fistulous tracts extending to the skin (midline pits). Varying degrees
of acute and chronic inflammatory reaction (neutrophils, lymphocytes). Abscess rupture and/or incision resulting in off-
midline openings.
Evaluation
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REQUIRED MINIMAL STANDARD
Clinical examination: midline pits, off-midline openings, induration, erythema, tenderness.
Digital rectal exam: rule out presacral tumor.
ADDITIONAL TESTS (OPTIONAL)
If presentation not classical x-ray or CT/MRI to rule out spinal fusion malformation.
Classification
Asymptomatic/quiescent pilonidal disease.
Acute pilonidal abscess.
Recurrent acute pilonidal disease.
Chronic pilonidal sinus/fistula.
Nonoperative Treatment
Asymptomatic or quiescent pilonidal disease: no treatment needed, prophylaxis impossible.
Mild acute flare-up: suppression with antibiotics (avoid antibiotic abuse).
Operative Treatment
INDICATION
Acute pilonidal abscess.
History of recurrent acute pilonidal disease (two or more episodes).
Chronic pilonidal sinus/fistula.
Cancer ( combined-modality treatment).
OPERATIVE APPROACH
Emergency
Acute abscess incision and drainage (in local anesthesia if possible).
Elective
Treatment parameters = simplicity, associated pain, hospitalization/down time, recurrence rates, wound care, return to
normal activity; no surgical approach meets all goals!
Fistulotomy and Curettage
Unroofing sinus tracts including pits and secondary openings conversion to open wound for healing by secondary intention.
Advantage: easiness, no limitations to physical activity. Disadvantage: prolonged wound care, requires patient cooperation
(meticulous wound care, hair shaving). Time to healing 4–6 weeks; recurrence rates 5–20%.
Lord/Millar/Bascom Procedure
Excision of pits, removal of hairs, brushing out the tracts.
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Primarily Open Wide Excision (with or without Marsupialization of Wound
Edges)
En-bloc excision of cyst, pits, secondary openings, inflammation with creation of shallow funnel-shaped wound, possible
marsupialization of skin edges. Advantage: easiness of surgery, easiness of wound care (showers, scrubbing, no packing), no
limitations to physical activity, lowest recurrence rates. Disadvantage: prolonged open wound, requires patient cooperation
(scrubbing of wound, hair shaving). Time to healing 1–5 months; recurrence rates 1–6%.
Excision with Primary Closure
Midline approach: symmetrical excision, primary closure, possibly with deep retention sutures and external
compression roll. Advantage: faster overall recovery (if uncomplicated healing). Disadvantage: limitations of physical
activity (bed rest, minimal walking) for 2 weeks, 30% risk of wound separation
worse outcome of secondarily
opened wound compared to primarily left open wound. Time to healing 2 weeks; recurrence rates 15–25%.
Lateral approach: lateral incision, unroofing of sinus and fistula tracts, excision of pits with lateral closure.
Advantage: faster overall recovery (if uncomplicated healing). Disadvantage: limitations of physical activity (minimal
walking) for 2 weeks, risk of separation. Time to healing 2–3 weeks; recurrence rates 10%.
Excision and Skin Grafting
Complete excision with skin grafting (primarily or after wound conditioning). Advantage: accelerated wound closure.
Disadvantage: prolonged down time, risk of graft failure, discomfort/wound care at harvest site. Time to healing 2–4 weeks;
recurrence rates 5–10%.
Flap Procedures (Z-Plasty, Limberg Flap, Etc)
Complete removal of all sinus tracts and infected cutaneous and subcutaneous tissue with tension-free closure using healthy
tissue. Advantage: reduced midline tension, faster overall recovery (if uncomplicated healing). Disadvantage: limitations of
physical activity (bed rest, minimal walking) for 2 weeks, risk of separation, worse outcome of secondarily opened wound
compared with primarily left open wound. Time to healing 2 weeks; recurrence rates: not confirmed.
Outcome
Factors associated with postsurgical recurrence:
Primarily open approach: unfavorable wound configuration (deep pockets) with inadequate drainage, hair in the
wound, neglected wound care (hair, granulation tissue).
Closed approach: undebrided devitalized tissue, suture line tension, activity shearing forces.
Follow-Up
Every 2–4 weeks until wound healed.
Cross-Reference
Fistula (Ch. 1)
Perianal/-rectal fistula (565.1) (Ch. 4)
Hidradenitis suppurativa (705.83) (Ch. 4)
Presacral tumors (789.3) (Ch. 4)
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Excision of pilonidal cyst (Ch. 5)
HIDRADENITIS SUPPURATIVA (705.83)
Overview
Hidradenitis suppurativa is an inflammatory process originating from the apocrine sweat glands with a high chance of
chronicity. Combination of acute infection with multifocal suppuration and abscess formation, as well as chronic smoldering,
and fistulizing process, may result in progressive disease extension and significant fibroplastic reaction with occasionally
grotesque scarring and tissue deformation. Most common locations are buttocks, groins, perineum, and axillae, but the
process may extend to the intergluteal cleft (overlap with pilonidal disease) or the perirectal area (overlap with perirectal
fistulae).
Pathogenesis: obstruction of apocrine sweat glands (eg, keratin)
retention of secretions infection within the dermis and
subdermis formation of granulation tissue, tracts, and sinuses. Mixed pathogens, often skin-type origin.
Risk factors include: male gender (2:1), African-American ethnicity, obesity, smoking, hormones, familial history. Age:
typically in young adults < 40–45 years. Not proven to be associated with hidradenitis: shaving, depilatory creams,
deodorant usage.
Condition is not life-threatening but is annoying and causes significant work/school absences. If untreated, there is a long-
term risk of malignant transformation into squamous cell cancer (after 20–30 years).
Epidemiology
Prevalence unknown. Most common in young adults (after puberty to age 45 years, comparable to pilonidal disease). Risk of
recurrent abscess: ~30–50% after "successful" treatment.
Symptoms
Pain (inability to sit down), erythema, swelling, purulent drainage from multiple pits or secondary openings,
chronic/intermittent discomfort, chronic/intermittent drainage, secondary skin irritation. Relatively rarely: associated
lymphadenopathy and systemic signs.
Complications: chronic scarring with deformities, squamous cell carcinoma (after 20–30 years), necrotizing fasciitis, toxic
shock syndrome.
Differential Diagnosis
Pilonidal disease.
Cutaneous infections: furuncles, carbuncles, erysipelas, tuberculosis, lymphogranuloma venereum, actinomycosis.
Perirectal fistula/abscess of cryptoglandular origin.
Crohn disease.
Folliculitis.
Sebaceous cyst.
Acne inversa.
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Squamous cell carcinoma.
Pathology
Fistulous tracts extending to the skin with varying degrees of acute and chronic inflammatory reaction (neutrophils,
lymphocytes) and focal abscess formation. Chronicity with fibrous reaction.
Evaluation
REQUIRED MINIMAL STANDARD
Clinical examination (to include all possible locations): multiple openings, diffuse induration, tenderness, areas of erythema.
Palpatory pressure multifocal release of purulent secretions.
Digital rectal exam and anoscopy if location close to anus.
ADDITIONAL TESTS (OPTIONAL)
Cultures: Inconsistent, 50% are culture-negative; most common pathogens: Staphylococcus epidermidis, Streptococcus
milleri, Ecoli, mixed anaerobes, Chlamydia trachomatis.
If presentation is not classical: imaging studies, biopsies.
Classification
Acute suppurative disease.
Smoldering hidradenitis.
Chronic fibroplastic disease.
Nonoperative Treatment
Systemic antibiotics (eg, tetracyclines).
Topical antibiotics (eg, clindamycin).
General measures: weight loss, loose-fitting clothes, antiseptic body care.
Uncertain treatments: isotretinoin (retinoic acid derivative), hormone treatment, leuprolide (gonadotropin-releasing hormone
agonist), immunosuppressants (cyclosporine, etc).
Operative Treatment
INDICATION
Symptomatic disease: (sub-)acute suppurations and abscesses.
Large disease extent: any but very limited disease unlikely to respond to medical treatment.
Refractoriness to conservative treatment.
Cancer appropriate oncologic management with wide excision and combined-modality treatment.
OPERATIVE APPROACH
Unroofing of multiple tracts (lay-open technique, possible marsupialization) open wound care.
Wide local excision open wound care (reliable).
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Wide local excision with skin grafting.
Wide local excision with flap reconstruction: particularly in anatomically critical areas.
Outcome
Recurrences or persistent disease very common: perianal < perineal < inguinoperineal. Proactive re-debridements to be
anticipated and planned.
Follow-Up
Every 2–4 weeks until wound healed.
Cross-Reference
Fistula (Ch. 1)
Perianal/-rectal fistula (565.1) (Ch. 4)
Pilonidal disease (Cyst/Sinus/Fistula, 685.0/1) (Ch. 4)
FECAL INCONTINENCE (787.6)
Overview
Fecal incontinence is the common final pathway of multiple independent etiologies. It is defined as the involuntary loss of
rectal contents (feces, gas) through the anal canal and the inability to postpone an evacuation until socially convenient.
Consequences of incontinence are significant: (1) secondary medical morbidity (eg, skin maceration, urinary tract infections,
decubitus ulcers), (2) substantial direct and indirect financial expenses (to patients, employer, insurance), (3) impact on
quality of life (self-esteem, embarrassment, shame, depression, need to organize life around easy access to bathroom,
avoidance of enjoyable activities, etc).
Problem: lack of standardization of definitions, lack of correlation between subjective and objective parameters, lack of
knowledge about anorectal and continence physiology.
Scoring systems: do not include physiologic components to accurately reflect clinical severity, mostly based on subjective
patient-reported assessment of severity and frequency. Easiest and most commonly used score: Cleveland Clinic Florida
(Wexner) fecal incontinence score: frequency of incontinence to gas, liquid, solid, of need to wear pad, and of lifestyle
changes.
Epidemiology
Very common but difficult to assess (taboo). Estimated prevalence: only known for subsets of population wide variability
depending on method of assessment and target population. International population-based studies: 0.4–18%. US telephone
survey: 2.2% (30% > 65 years old, female/male 63%/37%), clinic patients: 5.6% (general outpatients) and 15.9%
(urogynecology patients). Disproportionate 45–50% of affected individuals have severe physical and mental disabilities.
Symptoms
Primary symptom: worsening lack of control for different components: solid stool, liquid/semi-formed stool, gas. Descriptive
grades: staining < soilage < seepage < accidents.
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Daytime/nighttime variation. Reduced sensation for arriving stool, reduced urge-suppressing capacity, shortened maximal
deferability.
Associated symptoms: urinary incontinence, vaginal bulging (rectocele, cystocele), prolapse (hemorrhoidal, mucosal, full-
thickness rectal), altered bowel habits.
Secondary symptoms: pruritus, perianal skin irritation.
Differential Diagnosis
Typically less doubts about the diagnosis of "fecal incontinence" than its underlying etiology.
Rectovaginal fistula.
Colovaginal fistula.
Perirectal fistula.
Pathology
Plug Deficit
Insufficient outlet resistance (pressure, pressure profile): defect or dysfunction of sphincter muscles (IAS, EAS,
puborectalis muscle), anal canal disconfiguration.
Excessive endoluminal pressure or propulsive force: visceral hyperactivity (diarrhea, IBD, IBS), overflow incontinence
(incomplete evacuation, fecal impaction).
Stool Alteration
Decreased consistency (diarrhea): dietary, drug-induced, irritants (bile acids), infectious, IBD, IBS.
Increased gas formation: IBS, dietary, bacterial overgrowth.
Capacity Dysfunction
Decreased rectal compliance: proctocolitis, rectal scar/anastomosis, radiation-induced.
Increased rectal compliance: rectocele, megarectum.
Neurologic Sensory or Motor Dysfunction
Central neurologic deficit: focal (stroke, tumor, trauma, multiple sclerosis); diffuse (dementia, multiple sclerosis,
infection, drug-induced)
Peripheral neuropathy: localized (parity-induced pudendal neuropathy, pelvic radiation), diffuse (diabetes mellitus,
drug-induced).
Functional dysfunction: visceral hypersensitivity (IBS).
Evaluation
REQUIRED MINIMAL STANDARD
History: quantitation of complaint and its impact, time of onset, number and type of vaginal deliveries, history of anorectal or
spine surgeries, length of interval, underlying diseases (diabetes, stroke, etc), current medications, stool quality, passage of
stool/gas through vagina, incomplete evacuation? Prolapse? History of previous colonoscopies? Past treatment failures,
current management?
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Clinical examination:
Visual inspection: stool smearing, skin irritation, perineal descent, patulous anus, gapping to lateral traction,
preserved anocutaneous sensation and reflex, radial folds, perineal body, keyhole deformity, prolapse or ectropion,
etc?
Digital rectal exam: sphincter integrity, sphincter tone (rest/squeeze), compensatory auxiliary muscle contraction
(gluteus muscle), length of anal canal, rectocele, palpable mass?
Anoscopy/proctoscopy: rule out other pathologies: anorectal cancer, hemorrhoids, proctitis, etc.
Full or at least partial colonic evaluation as per general screening guidelines prior to further investigation or intervention.
ADDITIONAL TESTS (OPTIONAL)
Administration of quality of life instruments: eg, FIQL.
Anorectal ultrasound: method of choice to assess sphincter defect.
Anophysiology studies (highly recommended where available): manometry including sensation/compliance, pudendal nerve
terminal latency.
Assessment for suspected associated pelvic floor dysfunction:
Defecating proctogram.
Dynamic MRI.
Urodynamics.
GYN evaluation.
Classification
Structural vs functional incontinence.
Based on etiology of incontinence: see above.
Based on severity: mild, moderate, severe incontinence.
Based on onset: acquired vs congenital incontinence.
Nonoperative Treatment
Dietary changes:
Avoidance of foods that cause diarrhea or urgency.
Supplementary fiber.
Bowel habit training: timing after meals.
Supportive measures:
Barrier creams (zinc oxide based).
Rectal washouts, scheduled enemas.
Medications:
Antidiarrheal medications (loperamide, diphenoxylate, opiates).
Bile-acid binders (cholestyramine).
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Amitriptyline (antidepressant).
Caveats: Patients with overflow incontinence (eg, fecal impaction) may rather need routine enemas or laxatives.
Hormonal replacement therapy? role not defined.
Physical therapy and biofeedback training: simple, cheap, no adverse physical effects:
Improve contraction of the external anal sphincter in response to rectal distention.
Coordination training.
Sensory training.
Strength training.
Operative Treatment
INDICATION
Treatment-refractory fecal incontinence.
Incontinence with obvious and correctable deformity: cloaca-like deformity, keyhole deformity.
OPERATIVE APPROACH
Restoration of Residual Sphincter Function
Sphincter repair (sphincteroplasty) where structural defect identifiable ultrasound = most important diagnostic tool.
Correction of visible deformities (anus, rectum).
Sacral nerve stimulation: restimulation of dysfunctional, but anatomically intact anal sphincter muscle.
Replace Sphincter or Sphincter Function
Narrowing of anal canal: increase of outlet resistance, but no functional element:
Thiersch, related procedures: anal encirclement (silver wire, silastic band): even if foreign body has to be removed
due to infection ~50% improvement (scar-related).
Secca procedure: radiofrequency ablation to create controlled scar in anal canal.
Nondynamic graciloplasty: "bio-Thiersch," high risk of complications, lack of functional component.
Implantation/injection (eg, ultrasound-guided) of implantable microballoons, carbon-coated beads, autologous fat,
silicone, collagen.
Dynamic sphincter replacement:
Implantation of artificial bowel sphincter: functional/dynamic solution, risk of infection/erosion.
Dynamic graciloplasty: electrical stimulation via an implantable pulse generator conversion of the fast-twitch,
fatigable gracilis muscle to a slow-twitch, fatigue-resistant muscle.
Malone Antegrade Continence Enema (MACE)
Reduce fecal load:
Appendicostomy or continent colostomy (if appendix already gone!).
Timed washout of the whole colon.
Problem: leakage of residual colonic fluid during several hours following the irrigation.
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Diversion
If other therapies have failed or if comorbidities preclude more aggressive therapy colostomy: does not restore continence,
but allows control of bowel evacuation:
Fecal diversion = excellent alternative (if done well).
Permits resumption of a normal personal and social life.
Caveat: A poorly constructed or located ostomy may even be worse emphasis to create a well-constructed stoma
at an appropriate site.
Outcome
Sphincteroplasty: 60–88% of patients: excellent or good short-term outcome, 15–20%: no change or worsening. Long-term
success deteriorating < 50% continence after 5 years.
Predictors of failure: multilevel fragmentation of anal sphincter muscle, atrophic sphincter muscle during sphincteroplasty,
extensive traumatic damage, extensive scaring, neurologic etiologies with intact sphincter muscle, combination of sphincter
defect with underlying colorectal disease (IBD, IBS, etc), potential impact of pudendal neuropathy.
Follow-Up
Failure after surgical treatment: biofeedback training reevaluation and repeat repair after > 6–12 months? alternative
vs repeat strategy?
Cross-Reference
Discharge (Ch. 1)
Incontinence (Ch. 1)
Anophysiology studies (Ch. 2)
Endorectal ultrasound (ERUS) (Ch. 2)
Fecal control (continence) (Ch. 3)
Overlapping sphincteroplasty (Ch. 5)
Implantation of the artificial bowel sphincter (ABS) (Ch. 5)
Physical therapy/biofeedback training (Ch. 6)
Medications for GI tract (App. 1)
Fecal incontinence scoring systems (App. 2)
PRURITUS ANI (698.0)
Overview
Chronic itching in the perianal area which often triggers an irresistible urge to scratch. May be secondary to a true local
anorectal pathology or a perianal manifestation of systemic disease (eg, dermatoses, leukemia, etc), or may be idiopathic
pruritus ani. Most common underlying problem is fecal incontinence, chronic moisture in the area (prolapsing hemorrhoids,