jcoloproctol(rioj).2017;37(1):13–17
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Surgical
management
of
anal
stenosis:
anoplasty
with
or
without
sphincterotomy
Mehdi
Tahamtan,
Leila
Ghahramani,
Hajar
Khazraei
∗,
Yaser
Tolouei
Tabar,
Alimohammad
Bananzadeh,
Seyed
Vahid
Hosseini,
Ahmad
Izadpanah,
Fahime
Hajihosseini
ShirazUniversityofMedicalSciences,ColorectalResearchCenter,Shiraz,Iran
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received7June2016 Accepted8June2016 Availableonline6July2016
Keywords:
Anoplasty Sphinctrotomy Analstenosis
a
b
s
t
r
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c
t
Aim: Analstenosisisanuncommoncomplicationofanorectalsurgery,mostlyresulting fromcircumferentialhemorrhoidectomyorresectionoftheskintaginsurgicalmanagement ofchronicanalfissure.Theaimofanoplastyistorestorenormalfunctiontotheanusby dividingthestrictureandwideningtheanalcanal.Internalsphincterotomymaycausegas incontinenceandifwemanagethestenosiswithoutsphincterotomyitcouldbefailed.Could weuseanoplastywithoutsphincterotomy?
Method:Thepatientswithanalstenosiswereassignedintotwogroups.Thefirstgroup underwent Y-Vanoplastywithoutpartiallateralinternalsphinctrotomyandthesecond oneunderwentY-Vanoplastywithpartiallateralinternalsphinctrotomy.
Result:Atotalof25patients(10maleand15female)underwentanoplasty,14withoutpartial lateralinternalsphincterotomyand11patientswithpartiallateralinternalsphincterotomy. Thehealingrateofstenosiswas91%and93%ingroupsundergoinganoplastywithout par-tiallateralinternalsphinctrotomyandanoplastywithpartiallateralinternalsphictrotomy, respectively(pvalue0.69).Therewasnosignificantchangeinbothgroupsforpost-operative incontinencecomplaints.
Conclusion: Thehealingrateofanalstenosiswasthesameinthepatientswhounderwent Y-Vanoplastywithorwithoutpartiallateralinternalsphinctrotomy.Therewasnosignificant changeinpost-operationincontinencebetweenthetwogroups.Therefore,Y-Vanoplasty wouldbeasafeandsimplesurgicalmethodinselectedpatients.Partiallateralinternal sphinctrotomyprocedurehasbeennoticedinindividualcases.
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:[email protected](H.Khazraei).
http://dx.doi.org/10.1016/j.jcol.2016.06.002
Tratamento
cirúrgico
da
estenose
anal:
anoplastia
com
ou
sem
esfincterotomia
Palavras-chave:
Anoplastia Esfincteroplastia Estenoseanal
r
e
s
u
m
o
Objetivo: Aestenoseanalécomplicac¸ãoincomumdacirurgiaanorretal,sendo principal-menteresultantedeumahemorroidectomiacircunferencialouressecc¸ãodopólipocutâneo notratamentocirúrgicodafissuraanalcrônica.Oobjetivodaanoplastiaéarestaurac¸ãoda func¸ãonormaldoânus,medianteadivisãodaconstric¸ãoealargamentodocanalanal.A esfincterotomiainternapodecausarincontinênciagasosa;esetratarmosaestenosesem esfincterotomia,poderáocorrerinsucesso.Poderíamosusaraanoplastiasem esfincteroto-mia?
Método: Ospacientescomestenoseanalforamdesignadosparadoisgrupos.Oprimeiro grupofoi tratadocomanoplastiaem Y-Vsemesfincterotomia internalateralparcial, e osegundogrupofoitratadocomanoplastiaemY-Vcomesfincterotomiainternalateral parcial.
Resultado: No total, 25 pacientes (10 homens e 15 mulheres) foram tratados com anoplastia–14semesfincterotomiainternalateralparcial,e11comesfincterotomiainterna lateralparcial.Ospercentuaisdecuradaestenoseforamde91%e93%nosgrupostratados comanoplastiasemesfincterotomiainternalateralparcialecomesfincterotomiainterna lateralparcial,respectivamente(p=0,69).Nãoocorreumudanc¸asignificativanosdois gru-poscomrelac¸ãoàsqueixasdeincontinênciapós-operatória.
Conclusão: Opercentualdecuradaestenose analfoi igualnospacientestratadoscom anoplastiaemY-Vcomousemesfincterotomiainternalateralparcial.Nãofoiobservada mudanc¸asignificativanaincontinênciapós-operatóriaentreosdoisgrupos.Portanto,a anoplastiaemY-Vseriaummétodocirúrgicoseguroesimplesempacientes seleciona-dos.Emcasosisolados,oprocedimentodeesfincterotomiainternalateralparcialtemsido observado.
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Anal stenosis is an uncommon serious complication of anorectalsurgery.Thisnarrowingmayresultfromfunctional oranatomicanalstenosis.Functionalstenosisresultsfroma hypertonicinternalanalsphincter,whileintheanatomicone, thenormalanodermisreplacedwithaninelasticcicatrized tissue.1
Anatomicalanal stenosisusuallyresultsfromsurgeryof theanalcanal,inflammationoftheanusinCrohn’sdisease, ulcerativecolitis,radiationtherapy,venerealdisease, tubercu-losisandchroniclaxativeabuse.90%ofanalstenosisiscaused byradicalimputativehemorrhoidectomy.2
Thereareseveralmanagementoptionstodecrease com-plaintsofanalstenosis.Mostoftreatmentsmodalitieshave been non-surgical approaches suchas topical medications ordilation,but insevere analstenosis,surgicalapproaches wouldbeachoice.Asignificantnumberofsurgicalmethods havebeendescribedandthesimpleprocedureispartiallateral internalsphinctrotomy.However,mostofthepatientshave hada historyofperviouspartiallateralinternal sphinctro-tomyandextensivefissurectomy.Differenttypesofanoplasty hadbeenpresentedbeforeinanalstenosis.3Selectionof
surgi-calproceduredependsonlocation,type,extensionofstenosis andsurgeon′sexperience.Numeroussurgicaltechniqueshave
beendescribedforthetreatmentofanalstenosisrefractoryto non-operativemanagement.Theseproceduresincludesimple stricturereleaseandsphinctrotomytocomplexadvancement flaps.
Differentsurgicalprocedureshavebeenperformedifthe patientsneedsurgicalinterventionbecauseinthemajorityof thepatientsmedicalmanagementwouldbeachoice.3
The surgical methodssuch as stricturerelease, sphinc-trotomyandadvancementflaparecommontechniques. Per-formingpartiallateralinternalsphinctrotomywithanoplasty atthesametimehasbeenadebatableissuetoprevent incon-tinenceversusunhealedwound.4
Theaimofanoplastyistorestorenormalfunctiontothe anus bydividingthestrictureand asaresultwideningthe analcanal,thusdecreasingthesymptomsandreliefpain.5In
thisstudy,weevaluatedthesuccessfulrateofY-Vanoplasty inmanagementofsevereanalstenosisandincontinence(the mostimportantcomplicationoftheprocedure).
Materials
and
methods
jcoloproctol(rioj).2017;37(1):13–17
15
Table1–Classificationofanalstenosis.
Mild Stenoticanalcanalcanbeexaminedbya well-lubricatedindexfinger
Moderate Forcefuldilatationisrequiredtododigitalrectal examination
Sever Digitalrectalexaminationisimpossible
ThisstudywasdoneinFaghihiHospitalduring2007–2012 inShiraz,Iran.Eligibility criteriaconsistedofpatientswho hadsevereanalstenosiswithpainfulanddifficultdefecation duetounhealedwoundandrefractoryconstipationand diar-rhea.TheyneedY-Vadvancementflapanoplasty.Whenthe internaldiameterofanalcanalislessthan0.5cm,itissevere stenosisandwhenthediameteris0.5–1cmstenosisis mod-erateand 1–1.5cmdiameterisknown asmildstenosisand surgeondecidedtoperformapartialinternalsphincterotomy forseverestenosis.
Exclusioncriteriawereinflammatoryboweldisease, Tuber-culosis,previousradiotherapy,previousanalmalignancyand previousanoplasty.Allthepatientswhoreferredtocolorectal departmentofFaghihiHospitalwereexaminedbyacolorectal surgeon.
Demographicdata,pastmedicalhistory,typesofpervious analprocedureswerecollectedandfinallythepatientswere evaluatedbymanometry,endorectalsonography(ifpossible becauseofanalstenosis)andWexnerscore.Medicalrecords ofall patientswere evaluatedand allofthem werevisited andexamined.Thequestionnaireusedcontainedinformation abouttheirchiefcomplaintsonadmission(itching,bleeding, pain,andconstipation)(Table1).6
Y-Vanoplastyand partiallateral internalsphinctrotomy weredoneinthepatientsindividually(noticedto manome-try,endo-analsonography,Wexnerscoreandintra-operative decisionmaking). TheY-Vanoplastywasdoneinthesame standardmethod.7
IntheY-Vflap,thefirstincisionwasmadeovertheareaof stricture.TheverticallimboftheYandthenthewidebaseof theYwhichisorienteddistally(trueV-shapedadvancement flap)weresuturedinto theverticallimboftheYinsidethe analcanal.
After the procedure, they were evaluated the 1st, 6th, 9th monthsafteroperationforincontinenceand unhealed wound(pain,itchingandbleeding).Becausemanometryand endo-analsonographywasnotpossibleforallthepatients, incontinencewasevaluatedbyWexnercriteria.
Statistical
analysis
AlldataanalysiswasperformedusingtheSPSS(version16, Chicago,IL,USA).
BothLevene’stestandStudentTtestwereusedtoassess thenormalityofquantitativeandqualitativevariables. Find-ingswereconsideredsignificantwhenp-valuewaslessthan 0.05.
Results
A total of 25 patients (10 male and 15 female), mean age48.1±2.9(St.Error),range 23–73,underwent anoplasty,
14Y-Vanoplastywithoutpartiallateralinternal sphinctero-tomy(A−S)and11patientsY-Vanoplastywithpartiallateral internalsphinctrotomy(A+S).Wexnerscoreingroup under-wentA+Swas1.4±2.2SDandingroupunderwentA−Swas 1.07±2.2SD.
Preoperativesymptomsincludedanalpainin23patients, bleedingin18patients,itchingin15patientsandincontinence in5patients.Allofourpatientscomplainedofconstipation andpainfuldefecation.Twoofthepatientshadseverestenosis andtherestofthepatientshadmoderatestenosis.Theydid notrespondtoconservativemanagements.
Thepreoperative symptoms(pain, itching,bleeding and constipation) betweenthe two groupsin the 1st, 6th, and 9thmonthspost-operationareshowninTable2.Historyof hemorrhoidectomyandprocedureforchronicanalfissurewas seenin18and6patients,respectively.Onepatientdeveloped incontinenceinthegroupundergoingA+S.Therewereno sig-nificantchangesinincontinencedevelopmentinbothgroups in1st,6thand9thmonthpostoperation(p-value0.71,0.71and 0.52respectively).Healingrateofstenosiswas91%and93% inthegroupsundergoingA−SandA+S,respectively.There werenosignificantchangesinwoundhealingwithregardto theircomplaints(pain,bleeding,incontinenceand constipa-tion)inpost-operativecourse(p-value0.69).
Discussion
Althoughanalstenosisisnotacommonproblemafteranal surgeries,thisconditionshouldreceivegreatattentionfrom colorectal surgeons. Therate has been reportedfrom 1.2% till 10% in patients having hemorrhoidectomy in different papers.8Anyintrinsicorextrinsicpathologythatcauses
scar-ringoftheanodermcancreateanalstenosis.Asmentioned previously,thecausesofanalstenosisincludeanalsurgery, inflammatorybowel disease,tuberculosis,venerealdisease, radiation,andlaxativeabuse.2Removaloflargeareasof
rec-tal mucosaand anoderm, with sacrificingmuco-cutaneous bridges,leadstoscarringandchronicstricture.9Also,
steno-sisislessfrequentafterstapledrectalmucosectomy.10Inthis
studyonlyonepatientdidnothaveanyhistoryofpervious analprocedures.
Mostofstenosiscasesareapostoperativecomplicationand therestare duetoinflammatorydiseaseorfunctionalanal spasms.Non-operativemanagementsareusuallydedicated tomildtomoderatestenosisthatbydefinition,donotrequire surgicalintervention.
Conservativeapproachesmayincludehighfiberdiet, lax-ativesandself-digitaldilatation.5
Regularprogressiveself-dilatationbyusingHegardilators wasdescribedbyCasadesusetetal.withsuccessfulresultsin fourpatients.1Hegardilatationisasafemethodwhenused
undergeneralanesthesiaincomparisontodigitaldilatation toavoidexcessivemanualdilatationasitresultsintearingof thesphincter,resultinginfurtherfibrosisandstricture.5
j
coloproctol
(rio
j).
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0
1
7;
3
7(1)
:13–17
Table2–Thehealingrateofpreoperativesymptomsbetweenthetwogroupsinthe1st,6th,and9thmonthspost-operation.
Operation Firstmonth
Bleeding Pain Constipation Incontinence
− + − + − + − +
A+S 8(72.7%) 3(27.3%) 8(72.7%) 3(27.3%) 8(72.7%) 3(27.3%) 7(63.6%) 4(36.4%)
A−S 10(71.4%) 4(28.6%) 8(57%) 6(43%) 9(64.3%) 5(35.7%) 12(85.7%) 2(14.3%)
p 0.649 0.677 0.496 0.71
Operation Sixmonth Ninemonth
Bleeding Pain Constipation Incontinence Bleeding Pain Constipation Incontinence
− + − + − + − + − + − + − + − +
A+S 9(81.8%) 2(18.2%) 9(81.8%) 2(18.2%) 9(81.8%) 2(18.2%) 7(63.6%) 4(36.4%) 9(81.8%) 2(18.2%) 7(63.6%) 4(36.4%) 8(72.7%) 3(27.3%) 6(54.5%) 5(45.4%) A−S 13(92.9%) 1(7.1%) 10(71.4%) 4(28.6%) 10(71.4%) 4(28.6%) 12(85.7%) 2(14.3%) 12(85.7%) 2(14.3%) 8(57%) 6(43%) 9(64.3%) 5(35.7%) 12(85.7%) 2(14.3%)
p 0.407 0.661 0.661 0.71 0.604 0.881 0.496 0.52
jcoloproctol(rioj).2017;37(1):13–17
17
Therearemanycorrectivetechniquesintheliteratureand thechoiceoftheoperationdependsbothfromthesurgeon’s experienceandfromseverityofstricture.11Theprincipleof
anoplastyconsistsofincreasingthediameteroftheanal out-letand removalofcutaneousscarringbyproximalordistal advancement.TheY-Vanddiamondislandflapsarenowthe preferredtechniques,withgoodresults.5Itisdifficultto
inter-pretthe results ofthe various techniquesin the literature becauseadequateprospectivetrialshavenotbeenperformed yet.12
WeselectedtheV-Yanoplastytechniqueforitsgoodlong termresults,ourexperienceandlowcomplications.Besides, thismethodcanbeperformedonbothanalsidesinsevere stenosis.
We compared postoperative complication in the two groups(A+Svs.A−S).
Aftertheprocedures,therewerenosignificantdifferences inthehealingrateofpreoperativesymptoms(i.e.pain,itching, bleedingandconstipation)betweenthetwogroupsinthe1st, 6th,and9thmonthspost-operation.
Ohand Zinberg publishedastudy in which12 patients underwentCanoplastywithahealingrateof91%.13Similar
resultshavebeenreportedinourstudy(91%forA+S). Khubchandaniusedmucosaladvancementflapanoplasty in53patientswithanalstenosiswithatotalhealingrateof 94%4 which was similartoour results(93% forA−S). The
healingratewas100%in23patientswhosufferedfromanal stenosistreatedwithdiamondflapanoplasty.Atotalhealing rateof91.5%was obtainedusingislandflapanoplastyina totalof53patientsaffectedbyanalstrictureandectropion.14
Aitola and coworkers published a study in which 10 patients underwent Y-V anoplasty combined with internal sphincterotomy.Thepatientshadahealingrateof90%after1 yearoffollowup.13Mariaetal.conductedaprospectivestudy
whichcomparedY-Vanoplastywithdiamondflapanoplasty inamedianfollowupof2years.Completeresolutionwas reportedfordiamondflapanoplasty(100%)whilethehealing rateforY-Vanoplastywas90%.8
Inourstudy,wecomparedtwousualmethodsfor treat-ment of anal stricture (A+S vs. A−S). Healing rate of analstenosisandpost-operativecomplications(pain,itching, bleedingandconstipation)wasthesameinthetwogroups withnosignificantdifference(p-value0.69).
Inaddition, postoperativeincontinencewasnot statisti-callysignificantinthetwogroupsin1st,6thand9thmonth post operation, as well. This is comparable to Habr-gama etal.’s study which reportedonlyonepatientwith tempo-raryincontinencetogasandliquidstoolin77patientswho underwentsurgeryusingslidinggrafttechniques.11
Thelimitationofthisstudywassmallsamplesizebecause mostof the patients with anal stenosis did not need sur-gicalintervention.Anotherlimitationwasinabilityofdoing manometryandendorectalsonographyinallpatientsbecause ofanalstenosis.
Conclusion
Anoplastyisasafemethodwithacceptableresultsinrelieving thesymptomsofanalstenosis.Thereisamethodthatneeds partiallateralinternalsphinctrotomyinsomeselectedcases toachievebestoutcomes.Ontheotherhand,insomecases anoplastywithoutpartiallateral internalsphinctrotomydo notleadtorecurrenceofstricture.
SowerecommendY-Vanoplastywithorwithout sphinc-trotomyintreatinganalstrictures.Thatpatientselectionfor eachgroupwouldbecritical.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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