37
Haemorrhoidectomy, Anal Fissure and Anal Fistula Current Management Options Christopher Tracey 29/8/06

Hemorroids Anal Fissure and Fistula

Embed Size (px)

Citation preview

Page 1: Hemorroids Anal Fissure and Fistula

Haemorrhoidectomy Anal Fissure and Anal Fistula

Current Management Options

Christopher Tracey 29806

Haemorrhoids

Haemorrhoid gradingFirst degree ndash above pectinate line do not descend upon strainingSecond degree ndash protrude below pectinate line during straining but return spontaneouslyThird degree ndash protrude to exterior of anal canal during straining and require manual reductionFourth degree ndash irreducible and remain constantly prolapsed independent of straining or defecation

Haemorrhoids - grading

First degree

Second degree

Third degree

Fourth degree

Haemorrhoids ndash Non operative Mx

Dietary modificationIncreased fibre bran psyllium and waterSymptoms of bleeding but not prolapse can be significantly reduced over 30 to 45 days with increased fibre

Defecation modificationAvoid neglecting first urge reduced time at toilet and reduced straining

Haemorrhoids ndash Non operative Mx

Topical therapyAnusol Proctosedyl Rectinol etcAnecdotal evidence suggesting symptomatic relief with topical medications

Topical GTN (Rectogesic)Use in strangulated internal haemorrhoids by decreasing internal anal sphincter tone

Haemorrhoids ndash Operative Mx

Anal dilatationInitially described in 1968 (Lord) based upon hypothesis haemorrhoids consequence of anal canal narrowing (pecten band)Abandoned due to high incontinence rate (52)

InjectionPhenol in almond oilContraindicated in external haemorrhoid thrombosed or ulcerated internal haemorrhoids or presence of inflammatory or gangrenous piles

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 2: Hemorroids Anal Fissure and Fistula

Haemorrhoids

Haemorrhoid gradingFirst degree ndash above pectinate line do not descend upon strainingSecond degree ndash protrude below pectinate line during straining but return spontaneouslyThird degree ndash protrude to exterior of anal canal during straining and require manual reductionFourth degree ndash irreducible and remain constantly prolapsed independent of straining or defecation

Haemorrhoids - grading

First degree

Second degree

Third degree

Fourth degree

Haemorrhoids ndash Non operative Mx

Dietary modificationIncreased fibre bran psyllium and waterSymptoms of bleeding but not prolapse can be significantly reduced over 30 to 45 days with increased fibre

Defecation modificationAvoid neglecting first urge reduced time at toilet and reduced straining

Haemorrhoids ndash Non operative Mx

Topical therapyAnusol Proctosedyl Rectinol etcAnecdotal evidence suggesting symptomatic relief with topical medications

Topical GTN (Rectogesic)Use in strangulated internal haemorrhoids by decreasing internal anal sphincter tone

Haemorrhoids ndash Operative Mx

Anal dilatationInitially described in 1968 (Lord) based upon hypothesis haemorrhoids consequence of anal canal narrowing (pecten band)Abandoned due to high incontinence rate (52)

InjectionPhenol in almond oilContraindicated in external haemorrhoid thrombosed or ulcerated internal haemorrhoids or presence of inflammatory or gangrenous piles

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 3: Hemorroids Anal Fissure and Fistula

Haemorrhoids - grading

First degree

Second degree

Third degree

Fourth degree

Haemorrhoids ndash Non operative Mx

Dietary modificationIncreased fibre bran psyllium and waterSymptoms of bleeding but not prolapse can be significantly reduced over 30 to 45 days with increased fibre

Defecation modificationAvoid neglecting first urge reduced time at toilet and reduced straining

Haemorrhoids ndash Non operative Mx

Topical therapyAnusol Proctosedyl Rectinol etcAnecdotal evidence suggesting symptomatic relief with topical medications

Topical GTN (Rectogesic)Use in strangulated internal haemorrhoids by decreasing internal anal sphincter tone

Haemorrhoids ndash Operative Mx

Anal dilatationInitially described in 1968 (Lord) based upon hypothesis haemorrhoids consequence of anal canal narrowing (pecten band)Abandoned due to high incontinence rate (52)

InjectionPhenol in almond oilContraindicated in external haemorrhoid thrombosed or ulcerated internal haemorrhoids or presence of inflammatory or gangrenous piles

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 4: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Non operative Mx

Dietary modificationIncreased fibre bran psyllium and waterSymptoms of bleeding but not prolapse can be significantly reduced over 30 to 45 days with increased fibre

Defecation modificationAvoid neglecting first urge reduced time at toilet and reduced straining

Haemorrhoids ndash Non operative Mx

Topical therapyAnusol Proctosedyl Rectinol etcAnecdotal evidence suggesting symptomatic relief with topical medications

Topical GTN (Rectogesic)Use in strangulated internal haemorrhoids by decreasing internal anal sphincter tone

Haemorrhoids ndash Operative Mx

Anal dilatationInitially described in 1968 (Lord) based upon hypothesis haemorrhoids consequence of anal canal narrowing (pecten band)Abandoned due to high incontinence rate (52)

InjectionPhenol in almond oilContraindicated in external haemorrhoid thrombosed or ulcerated internal haemorrhoids or presence of inflammatory or gangrenous piles

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 5: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Non operative Mx

Topical therapyAnusol Proctosedyl Rectinol etcAnecdotal evidence suggesting symptomatic relief with topical medications

Topical GTN (Rectogesic)Use in strangulated internal haemorrhoids by decreasing internal anal sphincter tone

Haemorrhoids ndash Operative Mx

Anal dilatationInitially described in 1968 (Lord) based upon hypothesis haemorrhoids consequence of anal canal narrowing (pecten band)Abandoned due to high incontinence rate (52)

InjectionPhenol in almond oilContraindicated in external haemorrhoid thrombosed or ulcerated internal haemorrhoids or presence of inflammatory or gangrenous piles

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 6: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Operative Mx

Anal dilatationInitially described in 1968 (Lord) based upon hypothesis haemorrhoids consequence of anal canal narrowing (pecten band)Abandoned due to high incontinence rate (52)

InjectionPhenol in almond oilContraindicated in external haemorrhoid thrombosed or ulcerated internal haemorrhoids or presence of inflammatory or gangrenous piles

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 7: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Operative Mx

Banding

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 8: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Operative Mx

BandingOriginally described in 1954 by Blaisdell1-2 bands only Triple banding has been reported with an incidence of post ligation pain of up to 3760-70 can be treated with a single sessionComplications (2)

Pain secondary thrombosis of external componentVasovagal responseDelayed bleeding or haemorrhagePelvic sepsis

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 9: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Operative Mx

HaemorrhoidectomyMilligan-Morgan wounds are left openFerguson following ligation of pedicle the wound is closed

Closed method thought to be associated earlier healing but no obvious change in post-operative pain

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 10: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Operative Mx

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 11: Hemorroids Anal Fissure and Fistula

Haemorrhoids ndash Operative Mx

Haemorrhoidectomy ndash ComplicationsPost-op pain

Mx with analgesia stool softeners and fibreUrinary retention (up to 10-15)

Assoc with spinal anaesthesia rectal pain and packing bulky dressings

BleedingAcute (1) ndash often require re-operationDelayed (2) 1-252 post op ndash treat with pressure or adrenaline injection

Infection (lt1)Delayed complications

Anal fissure (1-2) or fistula (05)Anal stenosis (1)Incontinence (04)Recurrence (1)

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 12: Hemorroids Anal Fissure and Fistula

Stapled haemorrhoidectomy

Based on concept that interruption of superior and middle haemorrhoidal vessels and upward lifting of anorectal mucosa with re-positioning of anal cushions cause haemorrhoidal tissue to atrophyAdvantage of reduced post-operative painComplications

As per open haemorrhoidectomyRisk of recto-vaginal fistula ndash prevented by checking purse string prior to firing stapler

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 13: Hemorroids Anal Fissure and Fistula

Stapled Haemorrhoidectomy

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 14: Hemorroids Anal Fissure and Fistula

Prolapsed haemorrhoids

External thrombosedMay be managed conservatively if not excessively painfulOption of excision under LA

Internal prolapsed thrombosedConservative treatment (bed rest Sitz baths analgesia stool softerners) Reduction of prolapsed componentHaemorrhoidectomy following once swelling settled down

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 15: Hemorroids Anal Fissure and Fistula

Haemorrhoidectomy - special circumstances

HIV ImmunosuppressionAvoid haemorrhoidectomy and banding due increased risk of infection and non healingBenefit from sclerotherapy

PregnancyHaemorrhoids settle after pregnancy best managed conservatively

Inflammatory bowel diseaseAvoid haemorrhoidectomy in Crohns only perform in UC if in remission

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 16: Hemorroids Anal Fissure and Fistula

Anal FissureMedical Mx

Warm Sitz baths bran and bulking agents reported fissure healing rates up to 87Relief of sphincter spasm (heal up to 70)

Topical GTN (Rectogesic)Topical diltiazem 2 - as effacacious as GTN but fewer side effectsBotulism toxin (74 healed 5 transient incontinence)

Surgical MxPartial lateral internal sphincterotomy (98 healed)Anorectal advancement flap

Low anal pressures failed sphincterotomySevere anal stenosis

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 17: Hemorroids Anal Fissure and Fistula

Anal Fissure

Open sphincterotomy

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 18: Hemorroids Anal Fissure and Fistula

Anal Fistula

Incidence of 8-9100000 per year (Finnish data)26-37 of pts with perianal abscess will have identifiable fistula

MF of 21Commonly seen btw 20-45 yrsNo body habitus diet bowel habit associated with fistulas

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 19: Hemorroids Anal Fissure and Fistula

Anal Fistula

Abscess locationPerianal (60)Ischiorectal (20)Intersphincteric (5)Supralevator (4)Submucosal (1)

Presence of fistula after drainage of abscess is around 30

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 20: Hemorroids Anal Fissure and Fistula

Anal Fistula

Horseshoe abscess

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 21: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Locations

Intersphincteric (the most common) The fistula track is confined to the intersphinctericplane (45-70)

Trans-sphincteric The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter (25-30)

Suprasphincteric Similar to trans-sphincteric but the track loops over the external sphincter and perforates the levator ani (4-20)

Extrasphincteric The track passes from the rectum to perineal skin completely external to the sphinctericcomplex (1-5)

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 22: Hemorroids Anal Fissure and Fistula

Anal Fistula

Goodsallrsquos ruleAn external opening anterior to a horizontal line traversing the anus will lead to a straight radial tractA posterior opening will lead to a curved tract and an internal opening at the posterior commissureMisleading if opening greater than 3cm from anal verge

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 23: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Management Principles

Identify tractPalpate for indurationGentle probing ndash anticipating the anatomy based upon the Goodsall rule (Lockhart-Mummery probes)Identification with methylene blue or peroxide via infant feeding tube

Drain primary intersphincteric infection as well as primary and secondary tracts

FistulotomySetonAdvancement flapsFibrin glue

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 24: Hemorroids Anal Fissure and Fistula

Anal Fistula - Fistulotomy

For submucosal intersphincteric low trans-sphincteric fistulaeComplications

Recurrence (0 - 9)Incontinence (32 - 7)Delayed wound healingAnal stenosisMucosal prolapse

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 25: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Complex Fistulae

Horseshoe configurationsSecondary tractsInterconnecting tractsExtension into supralevator space or abscessesConcurrent disease

CrohnrsquosPrior irradiation

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 26: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Endoanal Ultrasound

Defines muscular anatomy of anal sphincters in relation to fistula

Tracts ndash hypoechoicInternal opening not often identified

Hydrogen peroxide injection

Improves accuracy from gas reflections

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 27: Hemorroids Anal Fissure and Fistula

Anal Fistula - MRI

More accurate than USS

Differentiate between scar tissue and an active trackIdentify external sphincterIdentify secondary tracksUseful in complex fistulas with Crohnrsquosdisease

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 28: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Seton placement

IndicationsFistulae involving greater than one-fourth to one-half of sphincter musclesWomen with anterior fistulaePatients with inflammatory bowel disease HIVElderly patients with poor sphincter functionMultiple prior sphincter operations injuries

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 29: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Seton placement

ComplicationsRecurrence (0-17)Incontinence (0-25 for flatus 0-17 for stool)Urinary retentionFaecal impactionThrombosed external haemorrhoidsPain BleedingPruritis ani

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 30: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Rectal Advancement Flaps

Indications ndash same as for seton placementFlap consists of mucosa submucosaand muscle to cover internal openingAdvantages

Low risk of post-op incontinenceGood primary healing 50-70 success rate

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 31: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Fibrin Glue

Injection of fibrin glue (with and without antibiotic impregnation) of complex fistulas

Complete healing of fistula btw 40-83May need re-application

Significant improvement of symptoms in 29 of pts not completely healedPerianal septic complications in 3 requiring drainage

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 32: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Crohnrsquos

High risk of failure of local treatment and recurrenceOccur in almost 20 of Crohnrsquos ptsIncontinence

Sphincter damage from disease or surgeryAnoperineal fistulasRectovaginal fistulasLoss of rectal compliance

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 33: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Crohnrsquos

Advancement flap Fistulotomy

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 34: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Crohnrsquos

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 35: Hemorroids Anal Fissure and Fistula

Anal Fistula ndash Prior Irradiation

High failure rate with local treatmentIf minimal symptoms ndash conservative RxSurgical Mx

Vascularised muscular flapsDefunctioning or even permanent stoma

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 36: Hemorroids Anal Fissure and Fistula

References

ANZ Journal of Surgery 2005 7564-72Dis Colon Rectum 2005 Dec48(12)2167-72 Surg Today 200636(2)166-70 Dis Colon Rectum 2006 Mar49(3)371-6 Radiologic Clinics of North America 2003 41(2) 443-57Surgical clinics of North America 2002 82 (6)1139-51Surgical clinics of North America 200282 (6)1153-1167Surgical clinics of North America 2001 81169-83Sabiston Textbook of Surgery 2004Cameron Current Surgical Therapy 2004

  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References
Page 37: Hemorroids Anal Fissure and Fistula
  • Haemorrhoidectomy Anal Fissure and Anal Fistula
  • Haemorrhoids
  • Haemorrhoids - grading
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Non operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Haemorrhoids ndash Operative Mx
  • Stapled haemorrhoidectomy
  • Stapled Haemorrhoidectomy
  • Prolapsed haemorrhoids
  • Haemorrhoidectomy - special circumstances
  • Anal Fissure
  • Anal Fissure
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula
  • Anal Fistula ndash Locations
  • Anal Fistula
  • Anal Fistula ndash Management Principles
  • Anal Fistula - Fistulotomy
  • Anal Fistula ndash Complex Fistulae
  • Anal Fistula ndash Endoanal Ultrasound
  • Anal Fistula - MRI
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Seton placement
  • Anal Fistula ndash Rectal Advancement Flaps
  • Anal Fistula ndash Fibrin Glue
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Crohnrsquos
  • Anal Fistula ndash Prior Irradiation
  • References