benign perianal conditions - cuhk surgery perianal... · benign perianal conditions dr tony ......
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Benign perianal conditions
Dr Tony MakTeam 3Refresher course21‐6‐2013
Benign Perianal Conditions
• Haemorrhoids
• Fistula‐in‐ano
• Anal Fissure
• Rectal prolapse
• Perianal Sexually transmitted diseases
• Pilonidal sinus
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Basic assessments
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• Bleeding
• Pain
• Pruritus Ani
• Swelling
• Tenesmus
• Discharge
Bleeding
• Haemorrhoidal bleeding:
bright red
separate
paper and bowl
may drip
• Beware:
darker bleeding
bleeding mixed with stools
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Anal pain• Character? Sharp / Dull
• When? Pain on defecation
• Duration? Lasts few days…… prolonged
• Associated symptoms….. Swinging Fever……. Local swelling
• Proctalgia fugax
• Severe spasm of anal pain
• Last only a few minutes
• Often at night
Pruritus AniSystemic illness
Diabetes mellitus
Hyperbilirubinemia
Leukemia
Aplastic anemia
Thyroid disease
Mechanical factors
Chronic diarrhea
Chronic constipation
Anal incontinence
Soaps, deodorants, perfumes
Over‐vigorous cleansing
Hemorrhoids producing leakage
Prolapsed hemorrhoids
Alcohol‐based anal wipes
Rectal prolapse
Anal papilloma
Anal fissure
Anal fistula
Tight‐fitting clothes
Allergy to dyes in toilet paper
Intolerance to fabric softener
Food sensitivity
Tomatoes
Caffeinated beverages
Beer
Citrus products
Milk products
Dermatological conditions
Psoriasis
Seborrheic dermatitis
Intertrigo
Neurodermatitis
Bowen's disease
Various squamous disorders
Atopic dermatitis
Lichen planus
Lichen sclerosis
Contact dermatitis
Infections
Erythrasma (Corynebacterium)
Intertrigo (Candida)
Herpes simplex virus
Human papillomavirus
Pinworms (Enterobius)
Scabies
Medications
Colchicine
Quinidine
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Perianal swelling• Where is it??
• Does it comes and goes?
• Is it getting bigger?
• Hard or soft?
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Examination• Inspection
• Scars
• External opening/Sinus
• Lesions: fissures, thrombosed haemorrhoids, condyloma
• Skin conditions: dermatitis
• Palpation
• Painful?
• Induration
• Lesions: Fibroepithelial polyps, low rectal tumours
• Anal tone
• Rigid endoscopies (Rectum and Anal canal)
• Visual confirmation
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Haemorrhoids
Famous people with troublesome haemorrhoids….
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Were Napoleon’s haemorrhoids the cause of his defeat at the Battle of Waterloo?
Karl Marx (1818‐1883)
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Ernest Hemingway (1899‐1961)
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?
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Most patients assume problems with their bottoms are due to piles
Haemorrhoids are common,at least 50% of people will suffer
symptoms at some time
Anal vascular cushions contribute to anal closure
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Haemorrhoids: blood supply
• 6 (4‐8) terminal branches of Superior rectal artery
Terminal branches from Superior Rectal Artery
3
711
Left lateralLeft lateral
Right posteriorRight posteriorRight anteriorRight anterior
Anal Cushions: constant positionAnal Cushions: constant position
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Gradual loss of support of anal cushions
Detach from internal sphincter
Loose and bulge into anal canalDilatation & engorgement of AV plexuses
Aetiology of haemorrhoids
Aetiology of haemorrhoids
Thomson Thomson ‐‐ ““Vascular Cushion TheoryVascular Cushion Theory””
Anatomical support weakens
Aging (deterioration after the third decades)
Straining, increased abdo pressure
Hormonal influence
Genetic predisposition
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Classification – anatomical origin
Internal Internal haemorrhoidshaemorrhoids (endoderm)(endoderm) Arise above the dentate line
Microscopically covered by transitional or columnar epithelium
Lack of somatic sensation
External External haemorrhoidshaemorrhoids (ectoderm)(ectoderm) Situated below dentate line
Microscopically covered by modified skin epithelium
Goligher Grading
No protrusion of No protrusion of haemorrhoidshaemorrhoids
Stage I
Protruding haemorrhoids Protruding haemorrhoids that spontaneously that spontaneously reducereduce
Haemorrhoids
Stage III
Protruding Protruding haemorrhoids, haemorrhoids, possible possible to push back in to push back in manuallymanually
Protruding Protruding haemorrhoidshaemorrhoidsthat canthat can‘‘t be pushed back t be pushed back in manually anymore in manually anymore
Stage IVStage II
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Bleeding
• Haemorrhoidal bleeding:
bright red
separate
paper and bowl
may drip
• Beware:
darker bleeding
bleeding mixed with stools
Haemorrhoidal symptoms
• Bleeding
• Prolapse
• Burning or pressure sensation
• Pain (when thrombosed)
• Pruritis ani
• Anaemic symptoms
Also associated with many other anal pathologies
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Differential diagnosis
• Anal/rectal cancer
• Perianal haematoma
• Fissure‐in‐ano
• Anal skin tags
• Anal warts
• Prolapse
• Perianal Crohn’s disease
Who do I investigate ?
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Conservative therapy
• Diet
• Wt loss
• Avoid Straining
• Stool softeners
• Topical creams
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Principles of invasive procedures
1. Fixation Injection sclerotherapy
Rubber band ligation
Thermal methods
PPH
2. Excision Haemorrhoidectomy
3. Destruction of haemorrhoidal arteries DG‐ HAL / THD
Laser photocoagulation
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Procedures carried out in ClinicProcedures carried out in Clinic
5% Phenol in almond oil
INJECTION SCLEROTHERAPY
First and Second Degree where bleeding is principle symptom.
Irritant sclerosant solution (phenol in oil) injected into submucosaproximal to each haemorrhoidal plexus
Simple, safe , painless
Complications related to incorrect application.
Long-term success rate - sparsely reported.
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RUBBER BAND LIGATION
• Local obliteration of submucosal vessels• Ischaemic necrosis• Ulceration (7‐10 days post banding)• Fixation of mucosa by fibrosis (the area healed by 3‐4 weeks)
• 79% symptomatic control but approximately 33% relapse at 5 years
• Complications: pain, bleeding, post banding sepsis
Apply the band at least1cm above dentate line
Maximum: up to 3 banding
Can be repeated
Thermal Methods
• Thermal methods has been used for hundreds of years ranging from heating to freezing
Infrared
Laser
Diathermy
Cryotherapy
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Infrared Thermocoagulation• Infrared radiation penetrates the tissue to a predetermined depth
• Instantly converted into heat (slightly above 100 0C) protein denaturation
• Coagulate vessels & fix the mucosa to underlying tissues
Results
• Safe and well‐tolerated clinic procedure
• Works best with small 1st / 2nd degree piles
• Almost immediate return to normal activity
• Less post‐treatment discomfort than RBL
Poen et al 2000 Eur J Gastroenterol hepatol
• Inferior to rubber band ligation Higher rate of recurrence (54% vs 27%)
Walker et al 1990 Int J Colorectal Dis
Need multiple treatments
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Procedures in clinic ‐ Caution
• Bacteraemia
Beware of existing cardiac disease
Presence of metallic heart valve
Newly implanted vascular graft / artificial joint
• Anti‐coagulant Therapy
• Clopidogrel
Consider inConsider in--patient treatmentpatient treatment
Management of Haemorrhoidal Disease
“For many years there has been an increasing tendency to perform less and less surgery for haemorrhoids. This follows on from the expectation on behalf of patients and surgeon that haemorrhoidectomy is extremely painful and requires prolonged hospital stay and time off work.However, all surgeons are familiar with the frequency at which patients re‐attend over many years when treated by injection sclerotherapy and rubber band ligation.”
Peter Loder, “Colorectal Surgery, A Companion to Specialist Surgical Practice” Chapter 13 (Edited by Robin K Phillips)
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OPERATIVE HAEMORRHOIDECTOMY
Classification of HaemorrhoidsDegree of prolapse
1st degree - No prolapse 2nd degree - Spontaneously reducible
3rd degree - Prolapse requiring manual reduction Fourth degree - Permanent prolapse
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HAEMORRHOIDECTOMY
• Surgical excision is one of the oldest treatments for piles
• Most effective and long‐term cure
• <5% recurrence rate
• Several described techniques
• None has been shown to be the best
OPEN HAEMORRHOIDECTOMY
III/IV Degree
Milligan-Morgan (1937)
General Anaesthetic
External component and internal
haemorrhoids grasped with forceps
and retracted.
Dissection of external haemorrhoidal tissue off internal sphincter.
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Dissection continues to top of anal cushion
Pedicle is ligated and transected
(ligature may be unnecessary with diathermy)
Defects left open leaving three raw areas
separated by bridge of skin and mucosa
“3-leaf Clover”
Healing in 5 -6 weeks
OPEN HAEMORRHOIDECTOMY
CLOSED HAEMORRHOIDECTOMY
Ferguson (1959)
Haemorrhoidectomy with primary repair
Preferred technique in USA
Prone, jack-knife position
Defect closed with continuous suture
Improves healing?
Less painful?
Reduces stenosis?
Post-op morbidity similar
Risk of wound dehiscence
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Technical modifications• Energy source for dissection
• Minimize bleeding
• Avoid pedicle transfixion
• Minimize post‐op pain
Complications
Operator dependant
Often done as day cases but still painful
Urinary Retention 10-32%
Formation of skin tags 6%
Bleeding 2-4%
Anal Fissure 1-2.6%
Anal stenosis 1%
Incontinence <0.4%
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Urinary retention
• The most common complication
• Predisposing factors:Pain and anal spasm
Fluid overload
Rectal packing
Drugs (narcotics, anticholinergics)
Pre‐existing outflow tract obstruction
• Leave the catheter for 24 hrs (RU > 500ml)
Haemorrhage
• Reactional haemorrhage
Technical error
Requires immediate surgical intervention
• Delayed haemorrhage (D7‐10 post‐op)
Ranging from mild‐massive bleeding
Warrants examination
Occurs in 2% haemorrhoidectomies
Sepsis in the pedicle
Usually not a preventable complication
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Motives behind new development
• Pain
• Hospital stay
• Resume normal activity
• Wound discomfort
• Discharge
• bleeding
• Continence disturbance
Treatment of haemorrhoidal disease by reduction of the mucosa and haemorrhoidal prolapse with a circular suturing device:A New Procedure
Antonio LongoUniversita di Palermo
Proceedings of the 6th World Congress of Endoscopic Surgeryand 6th International Congress of European Association for Endoscopic Surgery (EAES) 777‐84Rome, Italy. 3‐6 June 1998
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Procedure for Prolapse and Haemorrhoids
The Longo Technique
PPH-03 Kit
Haemorrhoidal Circular Stapler HCS 33mm
Suture Threader
Dilator
Purse-String Suture Anoscope
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Remaining externalcomponent
12 trials, 955 patients
Stapled Haemorrhoidectomy – more likely to have recurrent haemorrhoids– C/O symptoms of prolapse.
2010
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Stapled haemorrhoidectomy concerns
The ACPGBI consensus document stated that adverse events were related to the possibility of a full thickness excision to the rectal wall, with the potential for injury to the internal anal sphincter. In addition, stretching of the anal sphincter by the stapler head may, in theory, cause injury.
Interventional procedure guidance 34 Dec 2003
Interrupting the arterial inflow to anal cushions
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Doppler‐guided HALOHaemorrhoidal artery ligation operation
• Introduced in 1995 Morinaga K
• Identification and ligation of the terminal branches of the superior rectal artery
• Proctoscope equipped with a doppler probe
Haemorrhoidal artery ligation
Doppler US to identify arteries
Usually (3 ‐ 7) feeding arteries ligated using absorbable sutures
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Recto Anal Repair (RAR)
Continuous absorbable sutures used to fix the haemorroidal prolapse back in its original position by means of mucopexy
Before
After
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Transanal Haemorrhoid Dearterialisation• Identify the haemorrhoidal arteries (originate from sup rectal artery) at 2‐3cm above dentate line
• Suture them
• Lift the redundant prolapse by running sutures down to 5mm above dentate line
• Fix the cushion back into anal canal
Do
pp
ler
tran
sdu
cer
Do
pp
ler
tran
sdu
cer
HALO outcomes
• Less post operative pain
• Resolution of haemorrhoids
• Relief of symptoms
Bleeding
Prolapse
Pain
Itching
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National Institute for Health and Clinical Excellence
Current evidence on haemorrhoidal artery ligation shows that this procedure is an efficacious alternative to conventional haemorrhoidectomy or stapled haemorrhoidopexy in the short and medium term, and that there are no major safety concerns.
Interventional procedure guidance 342 May 2010
Clinical outcome following Doppler‐guided haemorrhoidal artery ligation: A Systematic ReviewPoucher et al Colorectal Diseases 2013
• 28 studies, 2904 patients
• Poor quality studies
• Operation time 19 – 35mins
• Recurrence rate 3 – 60%
• Safe & efficacious with low level of post op patin.
• Safe to be considered for treatment of grade II/III haemorrhoids
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Thrombosed internal haemorrhoids
• Significant prolapse• Gripped by the anal sphincter• Venous return obstructed• Edema and thrombosis set in• Pain promotes reflex sphincter spasm• Vicious cycle of spasm and swelling
Acutely prolapsed haemorrhoids
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Treatment• Manage conservativelyRelief of pain
Resolution of the pathology
Analgesics
Stool softeners
Ice packs
Elevate
• Avoid surgery
• BUT….. Emergency haemorrhoidectomy
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Thrombosed external haemorrhoid
• Acute perianal haematoma
• Rupture / thrombosis (external vein) at a single / multiple sites
• Sudden sharp rise in intraluminal pressure (forceful straining)
• Painful bluish tense lump
Perianal haematoma(thrombosed external haemorrhoid)
• Management: acute
Evacuate haematoma
• Management: chronic
Leave alone
Stool softeners
Analgesics
Local anaesthetic
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Clinical course• Acute stage (24‐48 hrs)
Pain and edema
• Pain resolved in 7‐10 days
• Spontaneous discharge of clot leaving a temporary crater
• Complete healing (<3 weeks)
Summary
• Haemorrhoids are a common problem
• Consider differential diagnoses
• Try conservatively first!!
• First degree RBL or Injection sclerotherapy
• Second degree RBL / HALO / Staple
• Third degree RBL / HALO/ haemorrhoidectomy /Staple
• Forth degree haemorrhoidectomy
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Fistula‐in‐ano
Definition
• 1882 Goodsall and Miles
• �Complete, Blind external, Blind internal• Subcutaneous, Submuscular, Submucosal
• 1934 Milligan and Morgan
• Low or Anorectal
• 1959 Steltzner
• Intersphincteric, Transphincteric, Extrasphincteric
• 1962 Thompson
• Simple and Complex: relation to puborectalis
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Halligan S , Stoker J Radiology 2006;239:18-33
1976 Parks et al.
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High or Low?• High
• At or above the anal sphincter complex
• Involving large amount of muscle
• Low
• Below anal sphincter complex
• Involving minimal muscle fibre
Simple or Complex?
• Simple
• Single tract
• Low transphincteric tracts which cross <30% of external sphincter
• Often follows Goodsall’s rule
• Complex
• Multiple tracts
• High transsphincteric Suprasphincteric Extrasphincteric
• Associated Abscesses
• Underlying pathologies
• Anovaginal fistulas
• Horseshoe fistulas
• Repeated operations
• Often does not follow Goodsall’s rule
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External opening situated behind the transverse anal line will open into the anal canal in the midline posteriorly.
Anterior opening is usually associated with a radial tract.
ComplexHorseshoe fistula
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Complex FistulaAnterior Type Females
Complex FistulaCrohn’s
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Complex FistulaMalignancy
Aetiology
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Causes of FIA
Cryptoglandular- ~90%
Causes of FIA• Crohn’s disease
• Tuberculosis
• Hydradenitis Suppurativa
• Actinomycosis
• Malignancy
• Radiation
• HIV
• Foreign bodies
• Trauma
Crohn’s disease
Radiation-induced rectovaginal fistula
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Management
• Sepsis‐ drainage close to anal verge
• Nutrition
• Anatomy + eradicate fistulous tract
• Preserving sphincter function
• Treat underlying cause
Do not delay treatment of sepsis!
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UK: ACPGBI 2006 US: ASCRS 2011
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Investigations
• EUA +/‐ insertion of seton (loose) +/‐ drainage of sepsis
• Fistulography – low accuracy
• MRI rectum +/‐ Endocoil >90%
• Endoanal USS – 80%‐89% • 3D …. Comparable to MRI
• Anorectal Manometry
• Colonoscopy
• CT abdomen + Pelvis
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Treatment options: Complex/high fistula
• Use of seton and staged fistulo/ectomy
• Advancement flaps
• Fibrin glue injection
• Fistula collagen plugs
• LIFT procedure
• Stem Cells
• Defunctioning
EUA + fistulotomy + seton
• Seton can be used in a staged fashion
• Initial placement as “loose” to control sepsis
• Followed by second stage procedure• Advancement flap
• Fibrin glue
• Anal plug
• Fistulotomy can be used to shorten the tract (down to the sphincter)
• Fistulectomy can be used if tract is away from sphincter
• Cutting Seton‐ less common for complex fistula
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Seton insertion
Seton
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EUA + fistulectomy + seton
Post‐fistulectomy wound
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EUA + Fistulo/ectomy + Seton
ACPGBI ASCRS
Advancement flap• Involves curettage of the tract
• Mobilisation of “flap” to cover the internal opening
• Recurrance rate of 13% to 56%
• Quality of the flap seems to be related to failure‐ Crohns, Radiation, Active Proctitis, ischaemia
• “U” shaped flap recommended
• Sphincter function may be affected
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Advancement flap
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Advancement flap
Advancement flap
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Advancement flap
Jarrar et al. 2011
Advancement flap
ACPGBI ASCRS
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Fibrin glue injection
• Wide range of healing rate in non‐randomised series: 10%‐67%
• Randomised trial n=29• Fibrin glue vs conventional
• 1° healing rate
• Complex tracts
• 69% vs 13%
Fibrin glue injection
ACPGBI ASCRS
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Surgisis® anal fistula plug (AFP)
• A biodegradable lyophilized porcine submucosal plug
(collagen plug)
• Acts as a scaffold for host tissue incorporation and
remodeling
High intersphincteric FIA
External opening
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Probing of internal opening
Irrigation with H2O2
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Rehydration of AFP
AFP insertion
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Closure of internal opening
External opening (final)
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Surgisis®AFP – the procedure• Initial report promising
• Healing rates for complex fistula – 71% to 81% at 1 year Follow‐up
• Complex fistula
• Healing rates ranges from 10%‐67%
Ellis et al. 2010
Anal Fistula Plug
ACPGBI
• Insufficient evidence
• But FIAT 500 currently recruiting• Trial ends 2015
ASCRS
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LIFT• Ligation of the Intersphincteric Fistula Tract
• Placement of seton‐ tract fibrosis
• Via intersphincteric plane‐ tract is idenitfied then ligated
+/‐ closure of internal opening
+/‐ widening of external opening
Complex FistulaLIFT Procedure
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Complex FistulaLIFT Procedure
Complex FistulaLIFT Procedure
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LIFT
ACPGBI
• Was not available
ASCRS
Crohn’s fistula• 40% to 80% of Crohn’s patients
• Drain Sepsis
• Apply loose seton
• Avoid unnecessary tissue destruction
• Antibiotics
• Infliximab (Remicade®)
• Long‐term seton
• Diversion stoma
• Proctectomy
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Crohn’s fistula
ACPGBI ASCRS
Malignant fistula
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Malignant fistula
Malignant fistula
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Malignant fistula
Malignant fistula
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Malignant fistula
Malignant fistula
ACPGBI
• Bx for Longstanding fistulas
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Others
Anal fistuloscopy
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Anal fistuloscopy
• Direct visualization of
fistula tracts
• Identify additional
fistula tracts and
primary openings
• Potential therapeutic
options
Johnson EK et al. ASCRS Annual Meeting 2005.
Anal fistulotomy with radiofrequency
• Advantages over conventional
fistulotomy:
• Shorter operative time
• Less blood loss
• Less pain
• Shorter hospital stay
• Earlier return to normal activity
• Shorter wound‐healing time
Gupta PJ. Curr Surg 2003; 60: 524-8.
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Stem cells• Adipose‐derived Mesenchymal stem cells
• Small number study
• 20‐60 million ASCs
• 71% healing compared to 16%
• Recurrance rate of 17.6% after 1 year
• Expensive and requires specialised laboratory
Conclusion
• Complex fistula‐in‐ano requires detailed investigation
• Understanding underlying pathology is essential
• Treatment of Sepsis, Preservation of Continence, Eradicate fistula tracts
• Clinical judgement and experience is important
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QUIZ……..What is this?
What fruit does it look like?
How can it be treated?
Perianal Haematoma
Treatment:
Conservative
Or
Incise and evacuate
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Fissure‐in‐ano
Fissureinano
• Symptoms
Bleeding
Pain‐on‐defecation
• Findings
Spasm
Tenderness
Visible fissure
Sentinel pile
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Sentinel pile
Fissure‐in‐ano• Chronic fissure:
• non‐healing fissure >6weeks despite treatment
• Visible sphincter
• Evidence of sentinel pile.
• Usually at 6 O’clock but 2.5‐10%@12 O’clock
• Multiple fissures‐ IBD/TB/Syphilis/HIV
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Fissure‐in‐ano
• Aetiology
• ?Constipation
• ?Internal sphincter hypertonia
• Lack of blood supply
Treatments• Conservative
• High Fibre / Increased Water intake
• Local anaesthetic gel
• 0.02% GTN ointment
• 0.2% Diltiazem ointment
• Botox injection 50 IU
• Surgical
• Lateral Sphincterotomy
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Anal skin tags
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Anal skin tags• Treatment
• Conservative
• Surgical
• Excision
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Perianal Crohn’s Disease
• Treatment
• Conservative!!!
• Leave them alone!!!
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Rectal Prolapse
Full thickness prolapseFull thickness prolapseMucosal prolapseMucosal prolapse
These patients need referringThese patients need referring
What is rectal prolapse?
• Full‐Thickness rectal prolapse describes the entire rectum protruding through the anus
• Mucosal prolapse describes only the rectal mucosa (not the entire wall) prolapsing
• Internal intussusception where the rectum collapses but does not exit the anus.
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Investigation + Treatment• Clinical examination
• Full colonoscopic assessment
• Examination under anaethesia
• Mucosal prolapse
• Mucosectomy / Rubber band ligation
• Full thickness prolapse
• Abdominal approach
• Open/Laparoscopic +/‐ large bowel resection
• Ventral mesh rectopexy
• Suture/Mesh rectopexy
• Perineal approach
• Delorme’s operation
• Altemeier’s operation
Incarceration• An incarcerated rectal prolapse is rare.
• Sugar!!• Emergency resection is required if the prolapse cannot be reduced and the viability of the bowel is in question.
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Abdominal procedures• Suture rectopexy
• Mesh rectopexy
• Resection rectopexy
• Lap vs Open
Posterior suture rectopexy
First described by Cutait in 1959Mobilisation an upward fixation by fibrosis and suturing
Recurrence 0-9%
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Posterior mesh rectopexy
To create more fibrosis – Sponge used by Wells in 1959Also a variety of absorbable and non absorbable meshes
Resection rectopexy
• Resection of redundant rectosigmoid
• Straight course of left colon – more fixation
• Relief of constipation
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Posterior mesh rectopexy• Low recurrence and low mortality
• Pelvic sepsis – 2‐16%
• Haematoma should be avoided by draining pelvis (esp if considerable ooze)
• Incontinence improved but constipation made worse
Ventral rectopexy
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Perineal approach• Low morbidity
• Possibly high recurrence rates
• Avoids abdominal surgery and pelvic dissection
• ‘cutting off an upturned sock – not fixing it’
Delorme’s operation
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Delormes• Mortality 0 ‐ 4%
• Recurrence 0 ‐ 38%
• Improvement in constipation – 13‐100%, Incontinence – 32‐67%
Altemeier’s operation
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Altemeier
• Recurrence 0‐16%
Summary of resultsRecurrence
•Delormes 0‐38%
•Altemeier 0‐16%
•Posterior suture rectopexy 0‐9%
•Mesh posterior rectopexy 0‐6%
•Resection rectopexy 0‐5%
•Post operative constipation in up to 50% of rectopexy patients
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Sexually transmitted disease
STDs• Bacterial
• Campylobacter jejuni
• Chlamydia
• Gonorrhoea
• Syphilis
• Parastitic
• Amoebiasis
• Cryptosporidium
• Isospora
• Virus
• Human immunodeficiency virus
• Human papilloma virus
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Condylomata acuminatum(aka. Anal Warts)
Condylomata accuminatum• Most common STD seen by colorectal surgeons
• Human papilloma virus:
• 6,11 Most common
• 16,18 More aggressive
• Treatment:
• Excision/Cryotherapy/Laser/Immunotherapy
• Podophyllin/podophyllotoxin/ Bichloroacetic acid (BCAA)
• Interferon
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Perianal syphilis
Gonorrhea
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QUIZ?
?
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Pilonidal sinus• Subcutaneous sinus containing hair
• Lined by granulation tissue
• Usually in natal cleft
• Foreign body reaction
• Rx:
• Advise pt to keep area hairless
• Elective
• Excision
• Phenol injection
• Skin flap
• Emergency
• Incision and drainage
Pilonidal disease
Nature Clinical Practice Gastroenterology & Hepatology (2009) 6, 20-22
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Bascom procedure
Nature Clinical Practice Gastroenterology & Hepatology (2009) 6, 20-22
Thank you