hemorroids anal fissure and fistula
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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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
- 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
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