Island flap anoplasty for the treatment of anal stricture and mucosal ectropion

Twenty patients with benign anal strictures and five patients with mucosal ectropion were treated with island flap anoplasty. U-shaped or diamond-shaped islands of perianal skin were created, without undermining, and advanced into the anal canal to remedy the stricture or site of ectropion. Over a postoperative follow-up period that averaged 19 months, 16 patients judged their clinical results as excellent and 7 as good. There were two failures. In all patients the skin flaps survived, even in the elderly patients. Island flap anoplasty is a simple, effective alternative to other forms of anoplasty such as Y-V advancement or S-plasty.     

The triangular Island skin flap for treatment of anal ectropion

Another method for repair of anal ectropion is reported. Two triangular island flaps, deeply based, are advanced medially to cover the excised area, thus resurfacing the anal canal with normal skin. The technique is recommended because of its simplicity, reliability, and satisfactory results.     

Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty

PURPOSE: This study evaluated the effectiveness of combining advancement flap with sphincteroplasty in patients symptomatic with rectovaginal fistula and anal sphincter disruption. METHODS: Twenty patients with rectovaginal fistulas and anal sphincter disruptions after vaginal deliveries underwent combined rectal mucosal advancement flap and anal sphincteroplasty between July 1986 and July 1993. The mean age of the patients was 30 (range, 18–40) years and the mean duration of symptoms was 54.8 weeks (range, 7 weeks to 6 years). In addition to mucosal advancement flap repair, 13 patients underwent two-layer repair of anal sphincters (with reapproximation of the puborectalis in 8 of the patients); 6 patients underwent one-layer overlap repair of anal sphincters (with reapproximation of the puborectalis in 2 of the patients); and 1 patient underwent reapproximation of internal anal sphincter alone because squeeze pressures were adequate, as determined by anal manometry. RESULTS: Postoperatively, vaginal discharge of stool and flatus was eliminated entirely in all 20 patients. Perfect anal continence of stool and flatus was restored in 14 patients (70 percent). Incontinence was improved but not eliminated in six patients (4 incontinent to liquid stool and 2 to flatus), and two patients required perineal pads. Subjectively, 19 patients (95 percent) reported the result as excellent or good. There were no complications. CONCLUSION: The combination of mucosal advancement flap and anal sphincteroplasty is a safe and highly effective procedure for correcting rectovaginal fistula with sphincter disruption after obstetrical injuries.Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Treatment of grade 3 anal intraepithelial neoplasia by complete anal mucosal excision without fecal diversion

PURPOSE: The aim of this study was to remove completely the risk of malignant transformation without permanent or temporary fecal diversion in a patient with extensive anal intraepithelial neoplasia. METHODS: All anal canal mucosa and the lowest 1.5 cm of rectal mucosa were excised and the adjacent rectal mucosa and submucosa advanced to the anal verge skin. RESULTS: The patient achieved normal continence within a month after the operation. Multiple anal canal biopsies at 12 months after the operation revealed normal rectal mucosa. CONCLUSIONS: Total anal mucosal excision offers a relatively simple means of removing the malignant risk of anal intraepithelial neoplasia without fecal diversion in selected patients.     

Treatment of high anal fistulae by primary occlusion of the internal ostium,drainage of the intersphincteric space,and mucosal advancement flap

In a prospective study on 224 patients with so-called high-fistula in ano (189 transsphincteric, 35 suprasphincteric) the long-term results of a sphinctersaving operation technique were assessed. The follow-up period was 1 to 7.5 years. This technique consists of onestage fistulectomy as well as of drainage of the intersphincteric space by internal sphincterotomy. The site of the former primary orifice of the fistula is adapted by multiple peranally performed single stitches, including mucosal advancement flap distal to the original fistulous opening. Postoperatively, 24 cases of suture leakage occurred (9% with the transsphincteric and 20% with the suprasphincteric fistula). 27 patient developed late complications like fistula recurrences or combinations of fistula and anal abscess (10.7% with the transsphincteric and 19.9% with the suprasphincteric fistula). Anal manometry was carried out preoperatively as well as postoperatively. A significant decrease in the postoperative resting pressure compared to the preoperative value was determined. The two fistula groups differed statistically both with regard to the resting pressure and the contraction pressure. Significant impairment of continence developed in 21% of patients with transsphincteric fistula but in 43% of patients with suprasphincteric fistula (intermittent fecal spoiling/use of perineal pads). The total percentage of complications rose with the number of previous fistula operations.

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Résumé Les résultats à long terme d'une technique préservant la fonction sphinctérienne ont été établis dans une étude prospective portant sur 224 patients porteurs de fistule anale haute (189 transsphinctériennes et 35 suprasphinctériennes). Le suivi va de 1 à 7,5 ans. La technique consiste en un temps à pratiquer une fistulectomie et un drainage de l'espace intersphinctérien par une sphinctérotomie interne. L'emplacement de l'ancien orifice primaire de la fistule est oblitéré par de multiples points de suture simples réalisés par voi per-anale comprenant un avancement de la muqueuse distale à l'orifice primaire. Dans la période post-opératoire immédiate, 24 désunions de suture ont été observées (9% en cas de fistule transsphinctérienne et 20% en cas de fistule suprasphinctérienne). Vingt-sept patients ont développé des complications tardives: récidives de la fistule ou combinaison d'abcès et de fistules (10,7% lors de fistules transsphinctériennes et 19,9% en cas de fistules suprasphinctériennes). Une manométrie anale a été réalisée en pré-opératoire de même qu'en post-opératoire. Une diminution significative de la pression de repos a été observée en post-opératoire comparativement aux valeurs pré-opératoires. Les deux types de fistule diffèrent statistiquement de manière significative tant en ce qui concerne la pression résiduelle de repos que la pression de contraction volontaire. Des troubles significatifs de la continence se sont développés chez 21% des patients avec des fistules transsphinctériennes et chez 43% des patients avec des fistules suprasphinctériennes (fecal soiling nécessitant de porter une garniture). Le taux de complications augmente avec le nombre d'opérations antérieures.

     

Pneumomediastinum after dilatation of anal stricture following stapled hemorrhoidopexy

Abstract Stapling procedure is a new technique for the surgical management of prolapsing haemorrhoids. Some articles have reported severe adverse effects of this operation. We describe a case of an excessive staple-line stenosis followed stapled haemorrhoidopexy. Proctoscopic dilatation resulted in complications of retropneumoperitoneum, pneumomediastinum, subcutaneous emphysema and perianal abscess. Drainage of the abscess was performed, allowing quick recovery. After discharge from the hospital, the patient continued to perform periodic dilatation. Simple proctoscopic dilatation was conducted in an outpatient setting.     

Repair of iatrogenic hepatic duct stricture in an infant

Summary Iatrogenic fibrosis and stricture of an infants extrahepatic bile ducts was successfully repaired by Roux-en-Y portoenterostomy.     

Repair of simple rectovaginal fistulas

The results of 81 endorectal flap advancements for simple rectovaginal fistulas are reported. Simple fistulas are defined as <2.5 cm in diameter, low or mid vaginal septum in location, and infectious or traumatic in origin. Essentially, the technique is advancement of a flap of mucosa, submucosa, and circular muscle over midline approximation of internal sphincter muscle. The mean patient age was 34 years old (range, 18 to 76 years). The causes were obstetrical injury (74 percent), perineal infection (10 percent), operative trauma (7 percent), and unknown (8 percent). Overall, the repair was successful in 83 percent of patients. Success correlated with the number of previous repairs,i.e., none: 88 percent success; one: 85 percent success; two: 55 percent success. There were 25 concomitant overlapping sphincteroplasty procedures. Only minor complications ensued, with no mortality. This repair is recommended for patients with no or one previous repair because of its lack of mortality, minimal morbidity, ease of concomitant sphincteroplasty, and avoidance of a colostomy. For patients with two or more earlier repairs, a muscle interposition should be considered. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.     

Management of recurrent pilonidal sinus by simple V-Y fasciocutaneous flap

PURPOSE: Several methods of managing the sacrococcygeal pilonidal sinus have been described, and fervent arguments for each form of therapy can be found in the literature. Recurrence unfortunately plagues all forms of therapy, though it is evident that the lowest rates have been reported for procedures involving local flap reconstruction. We conducted this case review to evaluate the validity of a simple reconstructive procedure for recurrent pilonidal disease. METHODS: We describe the application of the V-Y fasciocutaneous advancement flap to reconstruct the defect following radical excision of recurrent pilonidal sinus in five consecutive patients. RESULTS: Tension-free closure offers the benefits of a reduction in postoperative pain, less restriction in activity, and a shorter hospital stay. CONCLUSIONS: Preliminary results offer evidence of the efficacy of the simple reconstructive procedure in the management of difficult cases.     

Fibrin glue treatment for simple and complex anal fistulas

BACKGROUND/AIMS: Surgical management of anal fistulas is associated with considerable morbidity, mainly related to anal sphincter injury. However, treatment with fibrin glue is a safe and simple method associated with less discomfort and complications. A prospective trial was conducted at our institute to evaluate the use of fibrin glue (Tissucol, Baxter, The Netherlands) for simple and complex anal fistulas. METHODOLOGY: From November 2001 until March 2004, 34 patients (22 male, 12 female, median age 40 years) were treated with Tissucol. Twenty-three (67%) fistulas were classified as simple (subcutaneous, intersphincteric and transsphincteric) and 11 (33%) as complex (suprasphincteric, extrasphincteric and/or associated with Crohn's disease, ulcerative colitis or HIV). RESULTS: Twenty-six patients were treated once, 5 patients were treated twice, 2 patients were treated 3 times and 1 patient underwent 4 Tissucol treatments. After a median follow-up of 7 months, 13 of 23 simple fistulas (56%) and 6 out of 11 complex fistulas (54%) healed, accounting for an overall closure rate of 55%. Complications occurred in two patients, who both developed a perineal abscess after glue instillation. CONCLUSIONS: Fibrin glue treatment is safe and effective in 55% of the patients with anal fistulas. It is a good alternative to conventional surgery.     

Comparison of different intervention procedures in benign stricture of gastrointestinal tract

AIM: To determine the most effective intervention procedure by evaluation of mid and long-term therapeutic efficacy in patients of stricture of the gastrointestinal tract (GIT). METHODS: Different intervention procedures were used to treat benign stricture of GIT in 180 patients including pneumatic dilation (group A, n=80), permanent (group B, n=25) and temporary (group C, n=75) placement of expandable metallic stents. RESULTS: The diameters of the strictured GIT were significantly greater after the treatment of all procedures employed (P<0.01). For the 80 patients in group A, 160 dilations were performed (mean, 2.0 times per patient). Complications in group A included chest pain (n=20), reflux (n=16), and bleeding (n=6). Dysphagia relapse occurred in 24 (30%) and 48 (60%) patients respectively during 6-and-12 month follow-up periods in group A. In group B, 25 uncovered or partially covered or antireflux covered expandable metallic stents were placed permanently, complications included chest pain (n=10), reflux (n=15), bleeding (n=3), and stent migration (n=4), and dysphagia relapse occurred in 5 (20%) and 3 patients (25%) during the 6-and-12 month follow-up periods, respectively. In group C, the partially covered expandable metallic stents were temporarily placed in 75 patients and removed after 3 to 7 days via gastroscope, complications including chest pain (n=30), reflux (n=9), and bleeding (n=12), and dysphagia relapse occurred in 9 (12%) and 8 patients (16%) during the 6-and-12 month follow-up periods, respectively. The placement and withdrawal of stents were all successfully performed. The follow-up of all patients lasted for 6 to 96 months (mean 45.3+/-18.6 months). CONCLUSION: The effective procedures for benign GIT stricture are pneumatic dilation and temporary placement of partially-covered expandable metallic stents. Temporary placement of partially-covered expandable metallic stents is one of the best methods for benign GIT strictures in mid and long-term therapeutic efficacy.     

Medium-term results of anal advancement flap compared with lateral sphincterotomy for the treatment of anal fissure

Introduction  

Anal fissure is associated with anal pain and bleeding. Lateral internal sphincterotomy (LIS) has been a common form of surgical management. This can however cause incontinence and hence an equally effective alternative without this risk would be ideal. Anal fissurectomy and an anal advancement flap (AAF) have been used as an alternative to LIS.     

What is the relationship between perineal descent and anal mucosal electrosensitivity?

PURPOSE: Perineal descent is found in many patients with anorectal disorders. There is now substantial evidence against perineal descent causing damage to the motor axons in the pudendal nerves, but the sensory sequelae of perineal descent have been neglected. The purpose of this study was to establish the relationship between perineal descent and anal sensation. METHODS: Perineal position was determined in relation to the bony pelvis by means of defecating proctography. Anal mucosal electrosensitivity was determined by using a constant current generator. RESULTS: This study demonstrated significant correlations between perineal position at rest and sensitivity in each third of the anal canal in the study group overall. In women studied alone, there were significant correlations between perineal position at rest and at squeeze and anal mucosal electrosensitivity in each third of the anal canal. CONCLUSIONS: We propose that perineal descent traumatizes the pudendal nerves, damaging the large diameter sensory axons. This may be a precursor of motor axon damage or may correlate with the global pelvic sensory loss found in patients with perineal descent and fecal incontinence.Read at the meeting of the International Society of University Colon and Rectal Surgeons XVth Biennial Congress, Singapore, July 2 to 6, 1994.Mr. A. S. Gee is supported by the Wellcome Trust, London, United Kingdom.