Anoplasty for Post-hemorrhoidectomy Low Anal Stenosis: A New Technique

World Journal of Surgery, Mar 2018

Sami Asfar

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Anoplasty for Post-hemorrhoidectomy Low Anal Stenosis: A New Technique

Anoplasty for Post-hemorrhoidectomy Low Anal Stenosis: A New Technique Sami Asfar 0 1 0 Department of Surgery, Faculty of Medicine, Kuwait University , P.O. Box 24923, 13110 Safat , Kuwait 1 & Sami Asfar Background Post-hemorrhoidectomy anal stenosis though rare is very disturbing and devastating complication. Many surgical procedures have been described, but despite good results, many complications can ensue like flap necrosis, mucosal ectropion, and restenosis. Objective We report a new simple technique for repair of severe/moderate anal stenosis which requires no extensive flap mobilization or many sutures. Patients and interventions This is a personal series of 65 patients treated over a period of 20 years. The data were prospectively recorded by the author. The essence of this simple procedure is mobilizing the anal mucosa to the dentate line via a vertical incision and mobilizing the adjacent perianal skin and subcutaneous fat to allow a completely tension-free approximation of the perianal skin and the anal mucosa which are sutured together transversely. A tension-releasing incision is made in the perianal region which is left to heal by secondary intention. Results Fifty-nine patients (90.8%) continued the 5-year follow-up, and 6 patients left the country after 2 years of follow-up. There was only one case of recurrence after 2 years, which was treated by a second anoplasty. Four patients (59-66 years old) developed transient urine retention after surgery. One patient developed partial dehiscence of the suture line which was treated conservatively. No mucosal ectropion or perianal skin necrosis was observed. Complete healing of the perianal tension-releasing wound was within 2-3 months. By the third week after surgery, all the patients discontinued use of stool softeners or laxatives and were able to defecate comfortably. Conclusions This procedure is simple and requires little dissection and only a few sutures with minimal complications. It is suitable for low severe and moderate anal stenosis. Introduction Benign stenosis of the anal canal affects 1.5–3.8% of patients after surgical hemorrhoidectomy [ 1 ]. It is a rare disabling condition causing the patient a lot of discomfort, and patients usually complain of anal pain, difficult defecation, and incomplete evacuation with narrow stools caliber. Most patients will become habitual users of laxatives and enemas. It has been reported that hemorrhoidectomy accounts for about 90% of anal stenosis cases [ 2, 3 ]. The severity of postsurgical anal stenosis is classified into three degrees: (a) mild stenosis: tight anal canal that can admit well-lubricated index finger or medium size Hill–Ferguson retractor, (b) moderate stenosis: the lubricated index finger or the medium size Hill–Ferguson retractor can only be admitted after forceful dilatation of the anus, (c) severe stenosis: neither the lubricated little finger nor the small Hill–Ferguson retractor can be admitted. In addition to severity, the level of the stenosis is important in planning repair, and three levels have been identified: (a) low level: distal to 0.5 cm below the dentate line, (b) middle: a zone 0.5 cm distal and proximal to dentate line, and (c) high: proximal to 0.5 cm above the dentate line [ 4–6 ]. Many procedures have been described in the literature for repair of anal stenosis [ 2 ]. Despite the reported good results (60–100% healing rate) of these procedures, many complications have been reported like anal mucosal ectropion, seepage of mucus or liquid stools, pruritus, suture dehiscence, flap retraction, ischemic necrosis especially at the corners of the flaps, donor site infection, incontinence, and restenosis. We describe a very simple procedure for the repair of moderate and severe low anal stenosis which does not require raising flaps with only one suture line at the normal anatomic junction of the anal mucosa with the anal verge skin. Materials and methods We report our personal experience in treating 65 patients suffering from moderate and severe low anal stenosis over a 20-year period. All were complications of Milligan– Morgan’s open hemorrhoidectomy, and the average duration of their symptoms was 1–3 years. These patients have tried several conservative measures with no benefit and were desperate to have something done. All the cases were referred from surgical colleagues, and none of them had hemorrhoidectomy in our hospital. Because of the tight anal orifice, no preoperative proctoscopic or digital examination was performed, and likewise, no cleansing rectal enemas were possible. Five days before the date of surgery, patients were advised to take stool softeners (normacol granules ‘‘Sterculia’’ one sachets or one big spoonful in a glass of water twice daily) and be on a fluid diet with no fiber-containing food. They were admitted to hospital 1 day prior to surgery. All patients received intravenous antibiotic (metronidazole 500 mg) 30 min before surgery, which was continued for 5 days postoperatively as 400 mg tablets three times daily. In addition to its antibacterial effect, prophylactic metronidazole was reported to decrease postoperative pain after hemorrhoidectomy in a double-blind, randomized controlled trial [ 7 ]. Surgery was under general or spinal anesthesia (left to the discretion of the anesthetist in agreement with the patient), and all procedures were done in the lithotomy position. After antiseptic cleaning of the area and draping, the anal verge was inspected, and by palpation, the most pliable and least scarred area was chosen for the procedure. In all our cases, this area was either between 6:30 and 8:00 O’clock or 4:00 and 5:00 O’clock (lithotomy position). After choosing the area, to decrease bleeding and facilitate mobilization and undermining of tissues (anal mucosa and perianal area), we used one vial of adrenaline (1:100,000) diluted in 10 ml of normal saline to infiltrate the anal submucosa up to the dentate line and horizontally for about 1.5–2 cm to the right and left of the injection site. Then, the perianal area which is in continuity with the chosen site is likewise infiltrated for an area approximately 5 cm from the anal verge making sure that the infiltration is deep to the subcutaneous fat. Afterwards, a straight vertical incision of about 1.5–2 cm is made from the dentate line to just beyond the anal verge; then, a second slightly curved incision (counter incision) is made 3–4 cm distal to the first incision in the perianal area down to the subcutaneous fat (Fig. 1). A blunt ended small artery forceps is used to gently undermine the anal mucosa sidewise and to the dentate line (the area of adrenaline infiltrate). Then, the tip of the artery forceps is directed down (via the caudal end of the incision) to dissect the previously infiltrated perianal area raising the skin and a good layer of subcutaneous fat (to ensure good vascularity). At the end of the undermining procedure, the skin and subcutaneous fat in the area should be mobile and free from any attachment to deep fat so that it can easily slide toward the anal verge (Fig. 2). After ensuring that the mobilized tissues (anal mucosa and perianal skin) can come together at the anal verge with no tension, the vertical anal incision is now sutured transversely with interrupted 4/0 vicryl sutures starting from the corners leaving the central sutures to the end. By doing so, the operator will ensure a gentle and uniform sliding of the mobilized anal mucosa and perianal skin to meet at the normal anal verge territory with no tension Fig. 2 Undermining of tissues. a Shows the vertical incision in the anodermal region, from the dentate line to just beyond the anal verge. b Undermining the anal mucosa to the dentate line and sidewise. c Undermining the perianal skin and subcutaneous fat via the caudal end of the vertical incision. d Full mobilization of the perianal skin with good thickness of subcutaneous fat (Fig. 3). The counter incision in the perianal region now looks gaping (releasing the tension on the suture line) and is left open to heal by secondary intention. During the procedure, no cautery should be used, especially in the anal mucosal area to avoid inducing ischemia to this delicate and valuable tissue. At the end of the procedure, a 4 9 4 sterile gauze is soaked with 2% Xylocaine jelly, only the tip is inserted in the anal verge (no packing of the anal canal), and the remaining is used to cover the suture line with few other dry pieces on top followed by an elastoplast to keep the dressings in place. The perianal wound is cleaned and covered with a non-adherent dressing, e.g., Sofra tulle. Upon full recovery from anesthesia, patients are allowed to drink and eat a normal diet and to continue the stool softener (as needed) for 2–3 weeks postoperatively. The anal verge dressing can be removed with the first bowel motion followed by regular sitz baths twice daily and after each bowel movement. The perianal wound is changed daily with non-adherent dressing until complete healing by secondary intention. Patients were discharged from hospital after 24–48 h. Though we have advocated routine sphincterotomy of the internal sphincter to reduce post-hemorrhoidectomy pain [ 8 ] which was confirmed in a recent literature review [ 9 ], we did not practice routine sphincterotomy in this group of patients because of lack of information about details of the previous procedures on the region and for fear of damaging the sphincter in case it was cut previously. Only in 6 patients, the internal sphincter was fibrotic within the operative field, and it was partially incised to facilitate tissue mobilization. Patients were prescribed oral pain killers to take regularly for the first week and until the pain decreases then as needed. They are advised to apply 2% Xylocaine jelly on the anal wound 15 min before passing a motion and after defecation. Follow-up in the surgical outpatient was scheduled weekly for the first 8 weeks, monthly for 6 months, and then annually for the coming 5 years. After the first four visits (when the pain in the area is less) and to ensure a successful outcome, the lubricated index finger is completed, the artery forceps demonstrates the free mobile perianal skin. The (left right arrow) shows the thickness of the mobilized subcutaneous fat which is essential for the viability of the mobilized tissues gently passed through the anal verge. This will assure both the surgeon and the patient that there is no more stenosis. Results Over a period of 20 years, we treated 65 patients with severe and moderate anal stenosis (about 3 patients a year). The mean age ± SD was 45.57 ± 10.59 (23–66 years). The majority were males (n = 53). Fifty-nine patients (90.8%) completed the scheduled follow-up of 5 years, and the other 6 patients (9.2%) were expatriates who left the country after completing 2 years of follow-up. Four male patients (59–66 years old) developed postoperative urine retention, which was treated by Foley’s catheter for 24-h. Perianal pain was minimal during the first 10 days postoperatively which was well controlled by oral analgesics and local 2% Xylocaine jelly. During the first 2 weeks, most patients reported moisture at the anal verge or some yellowish-pink soiling of the underwear, with no stools or gas incontinence reported. By the third week, all patients were able to discontinue all types of stool softeners or laxatives; they continued to consume bulkforming diets (rich in fiber). All the patients were grateful and were able to defecate with no pain for the first time since their ordeal started. Complete healing of the open perianal wound (tension-releasing) was achieved in all the patients within 2–3 months. There were no cases of mucosal ectropion or necrosis of the mobilized perianal skin or anal mucosa. One patient, in our early experience, developed partial dehiscence of the suture line which was treated conservatively. One female patient developed recurrence after 2 years; a second anoplasty was performed (avoiding the previous site) with no recurrence in the following 5 years. Discussion Stenosis of the anal canal is a devastating problem which may complicate overzealous surgery (usually by the novice young surgeon) for the treatment of hemorrhoids. Surgical procedures to treat hemorrhoids are usually kept at the end of the surgical operating list. It is unfortunately left to the junior staff of the team to perform with no supervision. Limited experience and an attempt to remove all that they see may result in taking excessive tissue with no consideration to leave anodermal bridges between the surgical wounds around the clock in the anal canal, resulting in excessive scarring and stricture formation. This is especially so during emergency surgery for fourth degree prolapsed/thrombosed hemorrhoids. This overzealous surgery would lead to narrowing of the anal canal. Though it only complicates 1.5–3.8% of patients post-hemorrhoidectomy [ 1 ], yet to the patient, it is a very disturbing, painful, and disabling condition. Mild stenosis can be treated conservatively by daily digital and/or instrumental dilation by Hegar dilators in addition to diet adjustment by increasing fiber-rich diet, bulk-forming agents, and stool softeners. Moderate and severe stenoses mostly require surgical intervention. Many procedures have been described in the literature for repair of anal stenosis, e.g., Y–V advancement flap, V–Y advancement flap, diamond-shaped flap, house-shaped flap, U-shaped flap, C-flap, and rotational S-flap. No single procedure fits all, and choice of the procedure depends on the severity and level of the stenosis (for a full review see Brisinda et al. [ 2 ], Shawki and Costedo [ 5 ], Katdare and Ricciardi [ 6 ]). Despite the reported good results of these procedures (60–100% healing rate), many complications have been reported like anal mucosal ectropion, seepage of mucus or liquid stools, pruritus, suture dehiscence, flap retraction, ischemic necrosis especially at the corners of the flaps, donor site infection, incontinence, and restenosis. In their review, Brisinda et al. [ 2 ] stated that ‘‘it is extremely difficult to interpret the results of the various anoplastic procedures in the literature for the obvious reason that prospective trials have not been performed.’’ Designing such trials is not possible because the condition is not a common encounter in the general surgical practice, on the average we have seen about 3 cases a year (65 patients in 20 years) which is the same as reported by Habr-Gama et al. [ 10 ] who managed 77 patients in 25 years and Casadesus et al. [ 11 ] who treated 23 anal stenosis patients over a 5-year period, i.e., 4.6 cases per year. Moreover, by the time such patients find an experienced surgeon in the field, they have tried many conservative methods (forceful anal dilatation under anesthesia, internal sphincterotomy, self-dilation by metal dilators or digital) for a long time but to no avail. They are frustrated and desperate for a solution of their agony which understandably makes them reluctant to accept randomization. As stated by Brisida et al. [ 2 ] ‘‘the ideal procedure should be simple, should lead to no or minimal early and late morbidity, and should restore anal function with good long-term outcome.’’ In this report, a new and simple procedure is described to repair low anal stenosis which requires no extensive flap dissection and not many sutures. It is hoped that this technique would avoid the complications of flap necrosis and minimize the infection rate. The essence of this procedure is mobilizing the anal mucosa to the dentate line and mobilizing the corresponding adjacent perianal skin and subcutaneous fat to allow a completely tension-free approximation of these two components. The success of the procedure depends on leaving a good layer of subcutaneous fat beneath the mobilized perianal skin (to preserve blood and nerve supply), and to leave the perianal wound open to heal by secondary intention (tension-releasing wound) and hence eliminating any tension on the suture line. By observing these principles, we have achieved excellent results with only two complications; one patient, in our early experience, developed a partial breakdown of the suture line which was treated conservatively and one patient had a recurrence of stenosis requiring a second procedure 2 years after the first anoplasty. There was no necrosis of the mobilized skin or anal mucosa. The followup was excellent as 90.8% of the patients continued the 5 years, and this is basically because these patients know that the procedure is new (only done by the author) and would not seek the advice of other surgeons. Limitation of this report: It is a personal series over 20 years, and the author operated on all the patients. No comparison was made with other procedures as the nature of the problem does not lend itself to randomization because the case flow is irregular and sporadic, i.e., about 3 cases per year. No pre- or postoperative manometric studies were performed in this report, and finally, this procedure is only suitable for low anal stenosis. Conclusions The procedure described here is suitable for low severe and moderate anal stenoses. It is simple and requires little dissection and only a few sutures. The results of 5-year follow-up are excellent with only one recurrence. Acknowledgements The author thanks Dr. Ali Shuaib, Assistant Professor, Biomedical Engineering Unit, Department of Physiology, Faculty of Medicine, Kuwait University, for his help in preparing the art work. 1. Eu KW , Teoh TA , Seow-Choen F , Goh HS ( 1995 ) Anal stricture following haemorrhoidectomy: early diagnosis and treatment . Aust N Z J Surg 65 ( 2 ): 101 - 103 2. Brisinda G , Vanella S , Cadeddu F , Marniga G , Mazzeo P , Brandara F , Maria G ( 2009 ) Surgical treatment of anal stenosis . World J Gastroenterol 15 ( 16 ): 1921 - 1928 3. Shevchuk IM , Sadoviy IY , Novytskiy OV ( 2015 ) Surgical treatment of postoperative stricture of anal channel . Klin Khir 9 : 20 - 22 4. Milson JW , Mazier WP ( 1986 ) Classification and management of postsurgical anal stenosis . Surg Gynecol Obstet 163 ( 1 ): 60 - 64 5. Shawki S , Costedo M ( 2013 ) Anal fissure and stenosis . Gastroenterol Clin N Am 42 ( 4 ): 729 - 758 6. Katdare MV , Ricciardi R ( 2010 ) Anal Stenosis . Surg Clin N Am 90 : 137 - 145 7. Carapeti EA , Kamm MA , McDonald PJ , Philips RK ( 1998 ) Double-blind randomized controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy . Lancet 351 : 169 - 172 8. Asfar SK , Juma TH , Ala-Edeen T ( 1988 ) Haemorrhoidectomy and sphincterotomy: a prospective study comparing anal stretch and sphincterotomy in reducing post-haemorrhoidectomy pain . Dis Colon Rect 31 : 181 - 185 9. Emile SH , Youssef M , Elfeki H , Thabet W , El-Hamed TM , Farid M ( 2016 ) Literature review of the role of lateral internal sphincterotomy (LIS) when combined with excisional hemorrhoidectomy . Int J Colorectal Dis 31 ( 7 ): 1261 - 1272 10. Habr-Gama A , Sobrado CW , de Arau´jo SE, Nahas SC , Birbojm I , Nahas CS , Kiss DR ( 2005 ) Surgical treatment of anal stenosis: assessment of 77 anoplasties . Clinics (Sao Paulo) 60 ( 1 ): 17 - 20 11. 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Sami Asfar. Anoplasty for Post-hemorrhoidectomy Low Anal Stenosis: A New Technique, World Journal of Surgery, 2018, 1-6, DOI: 10.1007/s00268-018-4561-6