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Nakatsuka K, Karakawa R, Fuse Y, Yoshimatsu H, Yano T. Bilateral Transposition Flap for Postoperative Anal Stenosis after Reconstruction for Paget Disease. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5142. [PMID: 37547347 PMCID: PMC10400041 DOI: 10.1097/gox.0000000000005142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023]
Abstract
One of the complications of anal surgery or disease is anal stenosis. To release the tension of the anus, a tension-releasing incision in the perianal skin and various anoplasty procedures are usually considered. The aim of this article is to describe a straightforward technique with local flaps for severe anal stenosis after anal reconstruction. A 57-year-old man presented to the clinic with diverticulitis secondary to severe anal stenosis, and reported difficulty with defecation after perianal skin resection around the anus and surgery to create a V-Y advancement flap for perianal primary Paget disease 9 months previously. After improvement of the diverticulitis using antibiotics, bilateral transposition flaps were transferred to release the anal stenosis. The surgical treatment for severe anal stenosis has been known to entail several complications, including infection, incontinence, anal mucosal ectropion, pruritus, wound dehiscence, and restenosis. In this severe case, because the scars were situated at the 6 o'clock and 12 o'clock positions on the anus due to the previous V-Y advancement flap, bilateral rotation flaps were transferred from the 3 o'clock and 9 o'clock positions of the anus to prevent wound dehiscence and partial flap necrosis. Three months later, the size of the anus was unchanged, but additional surgery was performed at the patient's request. A bilateral transposition flap procedure was used, with flaps designed and elevated from the 6 o'clock and 12 o'clock positions. The postoperative course was uneventful, and the anal stenosis was improved.
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Affiliation(s)
- Kengo Nakatsuka
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuma Fuse
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Gallo G, Picciariello A, Di Tanna GL, Pelizzo P, Altomare DF, Trompetto M, Santoro GA, Roviello F, Felice C, Grossi U. Anoplasty for anatomical anal stenosis: systematic review of complications and recurrences. Colorectal Dis 2022; 24:1462-1471. [PMID: 35792887 PMCID: PMC10086798 DOI: 10.1111/codi.16248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/12/2022] [Accepted: 06/14/2022] [Indexed: 01/07/2023]
Abstract
AIM The optimal surgical treatment for anatomical anal stenosis (AS) remains to be determined. The aim of this study was to determine the rates of complications and recurrence after anoplasty for anatomical AS and, wherever feasible, compare the outcomes for the various techniques. METHOD A PROSPERO-registered systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, PubMed, Embase, Cochrane Library of Systematic Review, Scopus and Web of Science were searched for articles published up to May 2021. Studies that assessed the outcomes of anoplasty in adult patients with anatomical AS were selected. The primary outcomes were complications and recurrence. The methodological quality of studies was appraised using the Joanna Briggs Institute critical appraisal tools. RESULTS From the total of 2705 unique screened records, 151 were assessed for eligibility. Only 29 studies (two prospective) met the inclusion criteria, reporting data on 556 patients [mean age 53 (18-83) years, 46% female]. Previous history of surgery for haemorrhoidal disease accounted for three quarters of cases. A total of 14 types of anoplasty were found, with the Y-V flap being the most performed technique [27% of cases (n = 149)]. Complications frequently occurred, with a pooled prevalence of 10.2% (95% CI 3.9%-24.1%) after Y-V flap and 11.5% (5.3%-23.0%) after rhomboid/diamond flap. Patients undergoing house flap achieved better results in terms of clinical improvement, satisfaction and quality of life compared with Y-V flap and rhomboid/diamond flap. When considering only studies with at least 12 months of follow-up, the pooled prevalence of recurrence was 4.7% (2.2%-9.8%), with significantly higher rates observed in the prospective versus retrospective series [pooled prevalence 18.9% (11.5%-29.5%) vs. 3.6% (1.7-7.8%), respectively; p < 0.001]. CONCLUSION Both complications and recurrence were significantly lower after house flap compared with rhomboid/diamond and Y-V flap. Better designed multicentre studies with longer follow-up are needed to confirm these findings. PROSPERO REGISTRATION NUMBER CRD42021239493.
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Affiliation(s)
- Gaetano Gallo
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and NeurosciencesUniversity of SienaSienaItaly
| | - Arcangelo Picciariello
- Surgical Unit ‘M. Rubino’, Department of Emergency and Organ TransplantationUniversity ‘Aldo Moro of Bari’BariItaly
| | - Gian Luca Di Tanna
- Statistics Division, The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Patrizia Pelizzo
- II Surgery UnitRegional Hospital Treviso, AULSS2TrevisoItaly
- Department of Medicine – DIMEDUniversity of PaduaPaduaItaly
| | - Donato Francesco Altomare
- Surgical Unit ‘M. Rubino’, Department of Emergency and Organ TransplantationUniversity ‘Aldo Moro of Bari’BariItaly
| | | | | | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and NeurosciencesUniversity of SienaSienaItaly
| | - Carla Felice
- Department of Medicine – DIMEDUniversity of PaduaPaduaItaly
| | - Ugo Grossi
- II Surgery UnitRegional Hospital Treviso, AULSS2TrevisoItaly
- Department of Surgery, Oncology and Gastroenterology – DISCOGUniversity of PaduaPaduaItaly
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Weng YT, Chu KJ, Lin KH, Chang CK, Kang JC, Chen CY, Hu JM, Pu TW. Is anoplasty superior to scar revision surgery for post-hemorrhoidectomy anal stenosis? Six years of experience. World J Clin Cases 2022; 10:7698-7707. [PMID: 36158502 PMCID: PMC9372861 DOI: 10.12998/wjcc.v10.i22.7698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anal stenosis is a rare but frustrating condition that usually occurs as a complication of hemorrhoidectomy. The severity of anal stenosis can be classified into three categories: mild, moderate, and severe. There are two main surgical treatments for this condition: scar revision surgery and anoplasty; however, no studies have compared these two approaches, and it remains unclear which is preferrable for stenoses of different severities.
AIM To compare the outcomes of scar revision surgery and double diamond-shaped flap anoplasty.
METHODS Patients with mild, moderate, or severe anal stenosis following hemorrhoidectomy procedures who were treated with either scar revision surgery or double diamond-shaped flap anoplasty at our institution between January 2010 and December 2015 were investigated and compared. The severity of stenosis was determined via anal examination performed digitally or using a Hill-Ferguson retractor. The explored patient characteristics included age, sex, preoperative severity of anal stenosis, preoperative symptoms, and preoperative adjuvant therapy; moreover, their postoperative quality of life was measured using a 10-point scale. Patients underwent proctologic follow-up examinations one, two, and four weeks after surgery.
RESULTS We analyzed 60 consecutive patients, including 36 men (60%) and 24 women (40%). The mean operative time for scar revision surgery was significantly shorter than that for double diamond-shaped flap anoplasty (10.14 ± 2.31 [range: 7-15] min vs 21.62 ± 4.68 [range: 15-31] min; P < 0.001). The average of length of hospital stay was also significantly shorter after scar revision surgery than after anoplasty (2.1 ± 0.3 vs 2.9 ± 0.4 d; P < 0.001). Postoperative satisfaction was categorized into four groups: 45 patients (75%) reported excellent satisfaction (scores of 8-10), 13 (21.7%) reported good satisfaction (scores of 6-7), two (3.3%) had no change in satisfaction (scores of 3-5), and none (0%) had scores indicating poor satisfaction (1-2). As such, most patients were satisfied with their quality of life after surgery other than the two who noticed no difference due owing to the fact that they experienced recurrences.
CONCLUSION Scar revision surgery may be preferable for mild anal stenosis upon conservative treatment failure. Anoplasty is unavoidable for moderate or severe stenosis, where cicatrized tissue is extensive.
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Affiliation(s)
- Yu-Tse Weng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | | | - Kuan-Hsun Lin
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Chun-Kai Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Zuoying Branch, Kaohsiung Armed Forces General Hospital, Kaohsiung 813, Taiwan
| | - Jung-Cheng Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei 105, Taiwan
| | - Chao-Yang Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Je-Ming Hu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Ta-Wei Pu
- Division of Colon and Rectal Surgery, Department of Surgery, Songshan branch, Tri-Service General Hospital, National Defense Medical Center, Taipei 105, Taiwan
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A novel four quadrant laser sphincterotomy for idiopathic severe anal stenosis. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2017.09.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AbstractAnal stricture or stenosis, though uncommon, is disabling condition. It affects the quality of life due to pain, bleeding and difficulty in defecation, incontinence or increased frequency. It occurs when the normally pliable anoderm is replaced with fibrotic connective tissue, leading to an abnormally tight and inelastic anal canal. Mostly it occurs secondary to trauma, iatrogeny, inflammatory diseases, radiation or neoplasia. The treatment of anal stricture is generally considered to be difficult and various methods of treatment have been suggested. It is often unresponsive to conservative medical management. The surgical procedures such as dilatations and anoplasty are associated with significant complications which make it a difficult treatment challenge. Several good treatment options are available currently. Through this case, we report and explore a new medical treatment for anal strictures with four quadrant laser sphincterotomy.
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Ripamonti L, Maternini M, Chiarelli M, Guttadauro A. A new surgical approach in circumferential anal giant condyloma acuminatum: analysis of 13 cases. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Li YF, Wang XF, Li HS. Diagnosis and treatment of iatrogenic anorectal stenosis. Shijie Huaren Xiaohua Zazhi 2016; 24:1632-1638. [DOI: 10.11569/wcjd.v24.i11.1632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Iatrogenic anorectal stenosis is one of serious complications after anorectal surgery, and it is often caused by improper operation in surgical resection of hemorrhoids and anal fistula, procedure for prolapse and hemorrhoids (PPH), internal hemorrhoid agent injection and saving anal sphincter in low rectal cancer. Because of the difficulty of defecation, severe anal pain may occur. Stenotic ring can be directly touched in anal and low rectal stenosis. The degree and extent of the stenosis can be observed by colonoscopy in upper rectal stenosis. Mild stenosis can be temporarily treated with conservative therapy. If the degree of stenosis does not relieve or stenosis is more severe, we can choose different types of surgery according to the position, scope and the reasons of stenosis, which include scar closed procedure, longitudinal incision and transverse suture procedure, thread-drawing procedure, reconstruction of the anus by skin flap transposition or colostomy. Although only one procedure was adopted in the majority of cases, two or more procedures can be combined. This article reviews the diagnosis and treatment of anorectal stenosis.
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Abstract
BACKGROUND Regarding anoplasty for anal stenosis, it is not clear to what extent the final anal caliber should be targeted. OBJECTIVE The aim of this study was to investigate the results of diamond-flap anoplasty performed in a calibrated manner for the treatment of severe anal stenosis due to a previous hemorrhoidectomy. DESIGN AND SETTING Prospectively prepared standard forms were evaluated retrospectively. PATIENTS AND INTERVENTIONS Anoplasty with unilateral or bilateral diamond flaps was performed for moderate or severe anal stenosis, targeting a final anal caliber of 25 to 26 mm. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis staging (Milsom and Mazier), anal calibers (millimeter), the Cleveland Clinic Incontinence Score, and the modified obstructed defecation syndrome Longo score were recorded on pre-prepared standard forms, as well as postoperative complications and the time of return to work. RESULTS From January 2011 to July 2013, 18 patients (12 males, 67%) with a median age of 39 years (range, 27-70) were treated. All of the patients had a history of previous hemorrhoidectomy. The number of previous corrective interventions was 2.1 ± 1.8 (range, 0-4), and 2 patients had a history of failed anoplasty. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24-26), and 25 ± 1 mm (range, 23-27) (p < 0.0001, for immediate postoperative and 12-month postoperative anal calibers compared with the intraoperative). Preoperative and 12-month postoperative Cleveland Clinic Incontinence Scores were 0.83 ± 1.15 (range, 0-4) and 0.39 ± 0.70 (range, 0-2) (p = 1.0). The clinical success rate was 88.9%. No severe postoperative complications were observed. LIMITATIONS This study was limited because it was a single-armed, retrospective analysis of prospectively designed data. CONCLUSION Diamond-flap anoplasty performed in a standardized and calibrated manner is a highly successful method for the treatment of anal stenosis caused by previous hemorrhoidectomy.
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Comparative study of the house advancement flap, rhomboid flap, and y-v anoplasty in treatment of anal stenosis: a prospective randomized study. Dis Colon Rectum 2010; 53:790-7. [PMID: 20389213 DOI: 10.1007/dcr.0b013e3181d3205a] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Anal stenosis represents a technical challenge for surgical management. We compared the effects of house flap, rhomboid flap, and Y-V anoplasty procedures in a randomized study in patients with anal stenosis. METHODS Consecutive patients treated for anal stenosis at our institution were evaluated for inclusion. Participants were randomly allocated to receive house flap, rhomboid flap, or Y-V anoplasty. Follow-up visits were after 1 week, 1 month, 6 months, and 1 year. Study variables included caliber of the anal canal (measured with a conical calibrator), clinical improvement, patient satisfaction (visual analog scale), incontinence (Pescatori incontinence scale), and quality of life (GI Quality of Life Inventory). RESULTS : Sixty patients with anal stenosis were randomized and completed the study. Operative time was 62 +/- 10 minutes for house flap, 44 +/- 13 minutes for rhomboid flap, and 35 +/- 9 minutes for Y-V anoplasty (P = .042). At 1 year, anal caliber was 23.9 +/- 2.33 mm for house flap, 18.1 +/- 2.05 mm for rhomboid flap, and 16.4 +/- 2.05 mm for Y-V anoplasty (P = .04), with a highly significant increase for the house flap (P = .001). The groups differed significantly regarding clinical improvement at 1 month (95% for house flap, 80% for rhomboid flap, and 65% for Y-V anoplasty, P = .01) and differences persisted at 1 year. Significant differences were seen among groups at 1 year in GI Quality of Life Inventory scores (P = .03), with significant improvement only for the house flap (P = .01). CONCLUSION Anal stenosis can be effectively managed with the house flap procedure, with the sole disadvantage of longer operative time. Although all 3 procedures are simple and easy to perform, the house flap appears to produce the greatest clinical improvement, patient satisfaction, and improvement in quality of life, with the fewest complications.
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Abstract
Anal stenosis occurs most commonly following a surgical procedure, such as hemorrhoidectomy, excision and fulguration of anorectal warts, endorectal flaps, or following proctectomy, particularly in the setting of mucosectomy. Patients who experience anal stenosis describe constipation, bleeding, pain, and incomplete evacuation. Although often described as a debilitating and difficult problem, several good treatment options are available. In addition to simple dietary and medication changes, surgical procedures, such as lateral internal sphincterotomy or transfers of healthy tissue are other potentially good options. Flap procedures are excellent choices, depending on the location of the stenosis and the amount of viable tissue needed. This article presents the definition, pathophysiology, diagnosis, and treatment of anal stenosis, and methods to prevent it.
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Affiliation(s)
- Mukta V Katdare
- Department of Colon and Rectal Surgery, Lahey Clinic, 41 Mall Road, Burlington, MA 01805, USA
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Alver O, Ersoy YE, Aydemir I, Erguney S, Teksoz S, Apaydin B, Ertem M. Use of "house" advancement flap in anorectal diseases. World J Surg 2009; 32:2281-6. [PMID: 18679744 DOI: 10.1007/s00268-008-9699-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A retrospective review of 28 patients who had "house flap" anoplasty was carried out to evaluate the therapeutic effectiveness of the procedure. METHODS House flap anoplasty was performed at Istanbul University Cerrahpasa Medical School, General Surgery Department, in 28 patients over 4 years. Indications were chronic anal fissure, anal stenosis, high transsphincteric fistula, low rectovaginal fistula, anal neoplasia, and obstetric third-degree perineal tear and incontinence. After rectangular excision of the anal or perianal lesion, the "walls" and "roof" of the house flap were incised to the depth of ischiorectal fat. The "base" of this house-shaped flap was then fixed to the top of the excised area. RESULTS Median postoperative hospital stay was 4.86 (range = 2-12) days. Postoperative complications included three patients with minimal wound dehiscence and one with rectovaginal fistula recurrence. At a median follow-up of 26.4 (range = 1-46) months, excluding the patient with recurrence, all patients were satisfied with house flap anoplasty. CONCLUSION House advancement flap anoplasty is a relatively simple procedure, combining the beneficial features of rectangular flaps and V-Y plasties. It can be used in nearly all types of anoderm deficiencies with a high rate of success and patient satisfaction.
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Affiliation(s)
- Olcay Alver
- General Surgery Department, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
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Klaristenfeld D, Israelit S, Beart RW, Ault G, Kaiser AM. Surgical excision of extensive anal condylomata not associated with risk of anal stenosis. Int J Colorectal Dis 2008; 23:853-6. [PMID: 18548258 DOI: 10.1007/s00384-008-0494-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2008] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Surgical treatment of extensive and confluent anal condylomata results in large open wounds, which in other contexts of anorectal surgery (e.g., hemorrhoidectomy), have been associated with a relevant risk of stricture formation. The aim of our study was therefore to revisit the issue and assess this risk and the general morbidity in patients undergoing extensive excision and fulguration of anal warts. MATERIALS AND METHODS Records of 41 consecutive patients undergoing with excision/fulguration of extensive, i.e., >50% confluent anal condylomata were retrospectively reviewed. Excluded were patients with a lesser degree of warts and patients lost to follow-up before complete wound healing. Data recorded included patient characteristics and evolution of the local area after the surgery. RESULTS Forty-one patients (40 males and one female) underwent excision and fulguration of a large anal condyloma with an average follow-up of 6 months (range, 1-36 months). The majority of patients (97.6%) were HIV-positive with 80% taking antiretroviral medication. Half of the patients had not received any previous medical or surgical treatment, whereas one fourth had undergone surgical excisions or fulgurations before. Recurrent warts developed in 19 patients (46.3%). The surgical morbidity after the extensive excision consisted of bleeding (22%). However, none of the patients showed any evidence or complaints of postoperative stricturing and anal stenosis at follow-up. CONCLUSIONS Excision of extensive anal condylomata has a known high probability of recurrences, but the risk of developing anal stenosis is low. Careful primary excision of even confluent warts can therefore be safely performed without major primary flap reconstructions.
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Affiliation(s)
- Daniel Klaristenfeld
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA, 90033, USA
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