Management of Rectal Prolapse, and Common Anorectal Conditions

Rectal Prolapse

Profile of Patients Young adultsOften found in psychiatric patients withchronic constipationAssociated with mental subnormality Elderly femaleMultiple vaginal deliveriesOften octogenarian+/– uterine prolapse

Aim of Treatment Primary objectiveEradicate the prolapse and improve thequality of life Secondary gain Improvement in continence and bowelfunction

Investigation in Elective Case Finding ppt. factor At least a flexible sigmoidoscopy Assessment of surgical risk (no effective nonoperativetreatment) Anorectal manometry, pudendal nerve test Predicts functional outcome after surgery

Elective Presentation :Operative TreatmentAbdominalLaparoscopic Vs OpenRectopexyPerinealSutureProsthesis/ meshAnterior/ posteriorResectionMucosectomyAnoplasty+- resection+- pelvic floor repairN.B.: Abdominal procedures produce less recurrence Perineal operations have less morbidity (andmortality)

Perineal Procedures Thiersch Procedure Considered obsolete nowadays! Delorme Procedure The minimum you should do! Altemeier Operation(Perineal Proctosigmoidectomy)

Perineal Procedures :Delorme Procedure Mortality 0-4% Recurrence 4-38% (St Marks 12.5%)N.B.: Good for short prolapse Can be repeated if necessary

Perineal Procedures :Perineal Proctosigmoidectomy(Altemeier Procedure) Mortality 0-5%; complication: pelvic sepsis,leakage Recurrence 0-16% Best if combined with posterior levatorplasty Ideal for incarcerated and strangulated ones Difficult to perform for small prolapseDeen KL Br J Surg 1994:81: 302-304Wexner, Cleveland Clinic Florida; Archieves of Surgery; Jan 2005; 140,1

Abdominal Procedure Rectopexy Sutured Rectopexy Anterior resection alone Resection rectopexy (Frykman-Goldbery procedure) Laparoscopic Vs Open

Abdominal Procedure :Prosthesis or Mesh Rectopexy Makes use foreign materialto evoke more fibrous tissuereaction, examples Anterior Sling RectopexyRipstein Procedure Posterior Mesh repair‣ e.g. Wells OperationProblems: Increased pelvic sepsis and rectal stricture

Abdominal Procedure :Sutured Rectopexy No reported mortality Recurrence (majority 0-8%; ranges 0-27%) Variable response to constipationN.B.: Posterior mobilization to tip of coccyx Division of lateral ligaments on either sides

Abdominal Procedure :Resection Rectopexy Add 1% to mortality Recurrence 0-5% Majority has improved constipation

Abdominal Procedure :A ComparisonProcedureSuturedRectopexyMeshRectopexyResectionRectopexyRecurrence 0-8% 0-13% 0-5%Mortality 0% 0-2.8% 1-4%Complication rare 8-52% Up to 30%Continence improve improve improveConstipation variable Up to 42% improve

Laparoscopic ApproachRectopexy (sutured, stapled, posterior mesh, resection) Recurrence 0-10%As effective as open ( no long term difference)BenefitShorter post-op hospitalizationOverall reduction in costEarlier recoveryLess morbidityEarlier return to workN.B.: Laparoscopic approach is desirable because of Benign nature of the condition Patients are often at high surgical risk for laparotomy

Choice of Operation :IndividualizedAbdominal procedures are ideal for young fit patientand provide best chance of cureSutured rectopexy gives good resultCombination of a resection reduce constipationLaparoscopic approach provides similar results withless morbidityPerineal procedure for frail patients with extensiveco-morbidity, not fit for major abdominal surgery Perineal rectosigmoidectomy, combined withlevatorplasty gives better result than Delorme’soperation

SummaryRectal prolapse (Dx clinically)Emergency tx as indicatedFlexible sigmoidoscopyAnorectal manometry,pudendal nerve testAssess symptomatalogy, patientprofile & Stratify surgical riskConstipation?Incontinence?Young malesexually active?Length of prolapse?Good risk, fitVery high riskAbdominal proceduree.g. Laparoscopic resectionalsutured rectopexyPerineal proceduree.g. Delorme’s operation orAltemeier + levatorplasty

Haemorrhoids

Surgery Definite indication Severe bleeding not responding tosimple office procedures

Hemorrhoidectomy Preop. preparation GA Fleet enema ± Prophylactic antibiotics Facilitates day surgery Less AROU Allows better appreciation of anorectal ring Lithotomy vs Jack-knife No retractor Diathermy instead of scissors or sutureplication

Stapled Hemorrhoidectomy Becoming more popular in recent 10 years Involves transanal, circular stapling of redundantanorectal mucosa with a standard circularstapling device Basically a mucosal-reduction and fixationprocedure (C.W. Delorme’s or RBL) Reduces blood supply to anal cushionsN.B.: Beware of rectal performation andrectovaginal fistula in female patients

Advantages(Level 1 Evidence) Less pain Quicker return to work or normalactivities Shorter hospital stayN.B.: More than 15 RCTs

No Difference Ability to be done as day surgery Frequency of common post-operativecomplications

Limitations Insufficient data for grade 4 piles,external piles, or thrombosed piles(probably better for bleeding than forprolapse)

Thrombosed Hemorrhoids Natural history is that resolution beginsat around day 5 In many patients symptoms are cured bya severe ‘attack’ of thrombosis

Management ofThrombosed Hemorrhoids Severe pain requiring parenteral analgesia(usually onset < 5 days) Surgery Pain controllable with oral pain killers(usually onset ≧ 5days) Conservative

Operation onThrombosed Hemorrhoids Prophylactic antibiotics Anal stretch to disperse oedema No anal retractor Leave sufficient mucocutaneousbridges (tendency to overestimate) Evacuate thrombus from skin bridges

Anal Fissure

Primary Anal Fissure Longitudinal ulcer in lower-half of anal canal(the anoderm just distal to dentate line) 90% posterior; 10% anterior PathogenesisTrauma + ischemia due to high anal pressure(indolent ulcer)

Assessment in the Clinic P/E Gentle eversion of anus with limited digitalexam Feels the increased resting tone EUA + anoscopy and protoscopy might benecessary Anorectal manometry ▬ not indicated intypical case with first attack except History of impaired continence Low anal tone Previous anal surgery

DDX Fissures OFF the midline Ca anus (verge / canal) IBD TB ulcer HIV / Herpes Investigation (biopsy + anorectal manometry,serology, CBC, CRP, etc.) should ALWAYS beundertaken for Atypical symptom (e.g. incontinence) Multiple fissure or fissure atypical in location,appearance or configuration Refractory or recurrent fissure after apparentlyadequate treatmente.g. anterior fissure following labour in a woman whocomplains of flatus incontinence and liquid soiling endoanal USG — sphincter defect manometry — decreased pressure needs sphincter repair and not treatment of fissure!

Treatment ▬ Principles Self-perpetuating cycleForcefuldilatationSplit ofanodermFail to relaxwhen BOIschemia andhealing failureInt. sphincter spasm(85% resting tone)Sympathetic(excitatory)Parasym(inhibitory)Key : Good bowel habit and relieve int. sphincter spasm

Management : Acute Fissure Regulate bowel habit Stool softener Bulk forming agent Pain relief (local + oral) + GTN ointment Healing rate = 85% (1st episode)

Management : Chronic Fissure Conservative measures alone usuallynot successful Chemical sphincterotomy Reduce anoderm ischemia, promotehealing and break the viscious cycle

Management : Chronic Fissure Glyceryl trinitrate (GTN) ointment (0.2%) 1st line agent currently Dosage‣ Twice daily x 6 weeks Healing rate‣ 60-70% Recurrence rate‣ 30% Side-effect‣ Headache (40-50%) and therefore poorcompliance

Management : Chronic Fissure Botulinum toxic (botox) injection More effective than GTN ointment and withoutmajor complication (level 2 evidence)Dosage‣ 15-20 units (0.15-0.2 c.c.) properly diluted andinjected at 2-3 sites (at int. sphincter on eithersides of fissure) in divided dosesHealing rate‣ 80-90% at 8 weeksRecurrence rate‣ 10%Limitations‣ Expensive; development of antibodies; ? atrophy ofEASSecond line agent Other agents Ditialzam (Ca + blockers), nifedipine ointment

Surgery for Persistent or RecurrentFissure After Medical TherapyAnal stretch Obsolete because unacceptablyrisk (level 1 evidence)high incontinenceGold standard Left lateral subcutaneous internal sphincterotomyPreop work-up ▬ manometry (baseline)Technical points Crushing technique Divide up to length of fissure or dentate line Excisionskintagof associated hypertrophiod papilla andNo sutureCaution‣ Women have shorter anal canal Superior to botox in terms of healing rate (95%)and recurrence rate (< 5%) (level one evidence) Limitation Flatus incontinence (5%) Faecal incontinence (

Management of Anal Fissure Acute fissure Education, regulation of bowel habit,analgesia, topical medical therapy (85%) Chronic fissure Medical therapy first and review in 6-8weeks (TNG ointment or botox) Recurrent or refractory cases‣ Surgical sphincterotomy (5% flatusincontinence)

Recurrent Fissure After SurgeryRecurrent FissureIncompleteSphincterotomy(High Pressure)Endoanal USG + Manometry(± Biopsy / AFB smear)Complete Sphincterotomy(Low Pressure Fissure)EUAAnoplastyIntersphincteric AbscessDorsal InternalSphincterotomyNegative FindingsSphincterotomy onContralateral Side, orFissureotomy + Anoplasty(Flap Procedures)

Anal Fistula

Anal Fistula Definition Abnormal communication between theanorectum and perianal skin Etiology Cryptoglandular (infected anal glands) Inflammation or infection(e.g. TB, Crohn’s disease) Trauma, foreign body, iatrogenic Malignancy

Classifications Park’s Classification (1976) Intersphincteric Transphincteric Suprasphincteric extrasphinctericN.B. : High fistula = int. opening above dentate line

Goodsall’s Rule Predictive accuracy of Goodsall’s rule Anterior‣ Accuracy 49% Posterior‣ Accuracy 90%‣ Usually one common track

Assessment in Clinic Simple or complicated fistulae Distance of ext. opening from anal verge 2 o pathology do a rectoscopicexamination

Principles of Surgery Drain all collections Identify and deal with all tracks Division of minimal amount of muscles Create a tear-drop wound (3-D) tofacilitate dressing and healing

Keys to Successful Surgery Assess the patient first; what is thecontinence function? Then drain collection and lay open 2 oextensions first Deal with primary track(s) last

Simple Fistula Clinical examination (overall accuracy70-84%) Usually does not need any investigation Examination under anaesthesia Fistulotomy = Lay Open

Complicated Fistulae Fistula with multiple tracks High fistulae Recurrent fistulae Fistulae due to secondary causes TB, Crohn’s, radiation Recto-vaginal or ano-vaginal fistulae

Complicated Fistulae Clinical assessment History‣ e.g. Recurrence, IBD, TB Digital examination‣ Feel the track, primary and secondary‣ Multiple external openings, anal fissures‣ Anal tone Rigid sigmoidoscopy

Investigations Define the anatomy Assess sphincter function Identify secondary causes

Investigations EUA Colonoscopy Anorectal manometry Fistulogram Falling out of favour because‣ No external opening‣ Accuracy 50%‣ Painful Endoanal USG MRI

Endoanal USG 7MHz – 10MHz rotating probe Accuracy 85-90% Fistula track-hypoechoeic H 2 O 2 to improve resolution PitfallsLimited focal range (not accuratefor extrasphincteric fistula)Sepsis and scar may mimic fistula

MRI Accuracy primary track 86% secondary track 86% horse-shoe extension 97% Endo-coil increase sensitivity ‘Gold-standard’ in UK

Principles Eradicate fistula pathology Preserve sphincter function Consider defunctioning colostomy Multiplicity of technique reflects theirrelative poor success rateN.B.: Sigmoid colostomy is preferred totransverse colostomy for defunctioning

IncontinenceHealingSurgicalFistulotomy(staged)50% 90%Cutting Seton 30% 70%Fistulectomy(core-out) +AdvancementFlap10% 50-60%Fibrin Glue 0%

Seton Drain pus (draining seton) Mark the track For subsequent surgical fistulotomy Cutting seton gradual severance of sphincter followedby fibrosis EUA in 2-4 weeks time Incontinence 10-30% Recurrence rate 4-20%

Crohn’s Anal Fistula Objective Eradication of sepsis (prevents flare-up) Draining seton Refractory case: proctectomy

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