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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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Leventoglu S, Mentes B, Balci B, Kebiz HC. New Techniques in Hemorrhoidal Disease but the Same Old Problem: Anal Stenosis. Medicina (B Aires) 2022; 58:medicina58030362. [PMID: 35334538 PMCID: PMC8954788 DOI: 10.3390/medicina58030362] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/28/2022] Open
Abstract
Anal stenosis, which develops as a result of aggressive excisional hemorrhoidectomy, especially with the stoutly use of advanced technologies (LigaSure®, ultrasonic dissector, laser, etc.), has become common, causing significant deterioration in the patient’s quality of life. Although non-surgical treatment is effective for mild anal stenosis, surgical reconstruction is unavoidable for moderate to severe anal stenosis that causes distressing, severe anal pain, and inability to defecate. The problem in anal stenosis, unlike anal fissure, is that the skin does not stretch as a result of chronic fibrosis due to surgery. Therefore, the application of lateral internal sphincterotomy does not provide satisfactory results in the treatment of anal stenosis. Surgical treatment methods are based on the use of flaps of different shapes and sizes to reconstruct the anal caliber and flexibility. This article aims to summarize most-used surgical techniques for anal stenosis regarding functional and surgical outcomes.
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Affiliation(s)
- Sezai Leventoglu
- Department of General Surgery, Faculty of Medicine, Gazi University, Cankaya, Ankara 06560, Turkey
- Correspondence:
| | - Bulent Mentes
- Department of Surgery, Proctology, Ankara Memorial Hospital, Cankaya, Ankara 06520, Turkey;
| | - Bengi Balci
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Yenimahalle, Ankara 06105, Turkey;
| | - Halil Can Kebiz
- Faculty of Medicine, Gazi University, Cankaya, Ankara 06560, Turkey;
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Combination of simple advancement flap and fistulectomy to treat complex anal fistula as a complication of hemorrhoidectomy: Case report. Ann Med Surg (Lond) 2022; 73:103203. [PMID: 35028135 PMCID: PMC8715064 DOI: 10.1016/j.amsu.2021.103203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/11/2021] [Accepted: 12/19/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction After hemorrhoidectomy, anal stenosis occurs, which is an uncommon but severe consequence. The majority of severe cases require advancement flap anoplasty. Presentation of case A 50-year-old female patient with a history of hemorrhoidectomy 10 months prior to admission complained of difficulty defecating, pain, and incomplete evacuation sensation, as well as a hole on the right side of the anal canal through which feces unintentionally passed. On the physical examination, we found that the anal lumen was partially obstructed, which did not allow the insertion of a finger. There was an impression of a perineal fistula at 5 and 7 o'clock, which was connected to the anal canal 3 cm from the edge of the anus. The patient was diagnosed with severe anal stenosis with perianal fistula. The patient underwent fistulectomy and advancement flap with perianal skin. In the outpatient follow-up clinic in the first and second weeks, the patient showed no complications, and no recurrence of her complaints was found. Discussion Several corrective surgical techniques have been applied to restore a healthy lining to the constricted portion of the anal canal. We performed a combination of simple cutaneous advancement flap and fistulectomy to manage the patient with severe anal stenosis following hemorrhoidectomy with concurrent anal fistula. Conclusion A combination of fistulectomy and simple cutaneous advancement flap anoplasty is a simple, safe, and effective surgical option for the management of severe anal stenosis with concomitant anal fistula. Uncommon but severe consequence of hemorrhoidectomy is anal stenosis. A combination of fistulectomy and simple cutaneous advancement flap anoplasty is a simple, safe, and effective. First to report the combination of surgical technique in managing severe anal stenosis.
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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
Anorectal surgery is well tolerated. Rates of minor complications are relatively high, but major postoperative complications are uncommon. Prompt identification of postoperative complications is necessary to avoid significant patient morbidity. The most common acute complications include bleeding, infection, and urinary retention. Pelvic sepsis, while may result in dramatic morbidity and even mortality, is relatively rare. The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain.
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Affiliation(s)
- Hiroko Kunitake
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Vitaliy Poylin
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
We describe a novel technique to treat anal stenosis by reconstructing the anal canal by the use of a full-thickness skin graft from the abdominal wall. This treatment was successfully applied in our institution and showed positive results.
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Pescatori M. Anal Condylomata and Anorectal Stricture. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:121-134. [DOI: 10.1007/978-88-470-2077-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Mucosal Advancement Flap Anoplasty for Chronic Anal Fissure Resistant to Conservative Therapy. World J Surg 2011; 35:900-4. [DOI: 10.1007/s00268-011-0959-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pescatori M. Condilomi anali e stenosi anorettale. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:123-134. [DOI: 10.1007/978-88-470-2062-7_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Lolli P, Malleo G, Rigotti G. Treatment of chronic anal fissures and associated stenosis by autologous adipose tissue transplant: a pilot study. Dis Colon Rectum 2010; 53:460-6. [PMID: 20305447 DOI: 10.1007/dcr.0b013e3181b726b2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE A substantial body of recent evidence suggests that autologous adipose tissue transplant promotes healing in different lesions associated with local ischemia. We report the outcome of lipoaspirate transplant in hard-to-treat chronic anal fissures. METHODS Eight patients were included in this pilot study, 5 with single and 3 with multiple fissures. All had intense anal pain and had previously undergone proctologic surgery, with internal sphincterotomy performed in 6 patients. Severe stenosis was present in 3 patients and moderate stenosis in 2. Preoperative assessment included anoscopy, anorectal manometry, colonoscopy, and microbiological tests to exclude inflammatory, neoplastic, or infectious diseases. Surgical treatment consisted of transplant of purified autologous fat retrieved from the hypogastrium. Follow-up was scheduled after 1 week, at 2, 3, 6, and 12 months, and thereafter on a yearly basis. RESULTS All of the patients were discharged several hours after surgery. No early postoperative complication was observed. Complete healing and pain remission were achieved in 6 patients (75%), 4 of whom were treated in a single session, whereas 2 patients required 2 and 3 sessions. Anal stenosis was resolved in 4 of 5 patients (80%). The therapy was unsuccessful in 2 patients (25%). Mean follow-up was 18 months (range, 3-36 months). CONCLUSION Perianal autologous fat transplant can be safely performed for the treatment of complex anal fissures. It is well tolerated and offers encouraging results, although further research is warranted because of the small number of patients treated and the relatively short follow-up time.
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Affiliation(s)
- Paola Lolli
- Department of Surgical and Anesthesiological Sciences, University of Verona, Verona, Italy.
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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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Brisinda G, Vanella S, Cadeddu F, Marniga G, Mazzeo P, Brandara F, Maria G. Surgical treatment of anal stenosis. World J Gastroenterol 2009; 15:1921-8. [PMID: 19399922 PMCID: PMC2675080 DOI: 10.3748/wjg.15.1921] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.
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Casadesus D, Villasana LE, Diaz H, Chavez M, Sanchez IM, Martinez PP, Diaz A. Treatment of anal stenosis: a 5-year review. ANZ J Surg 2007; 77:557-9. [PMID: 17610693 DOI: 10.1111/j.1445-2197.2007.04151.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Benign anal stenosis is an uncommon, disabling and incapacitating disease, occurring mainly after anorectal surgery. Both non-surgical and surgical treatments have been devised in the treatment of anal stenosis with good results. We described the results of the treatment of this disease in the Coloproctology Department of our institution. METHODS A retrospective clinical study was undertaken over a 5-year period for consecutive patients operated on for anal stenosis. RESULTS Twenty-three patients with benign anal stenosis were treated in our department. Haemorrhoidectomy was the most common cause of anal stenosis (74%). Nineteen patients with moderate to severe symptoms of anal stenosis underwent surgical treatment. Lateral mucosal advancement flap was the most frequently carried out operation (63.1%). Four patients were treated with anal dilatation (17.3%). All patients had remission of the preoperative symptoms. There was no re-operation and only minor complications were present in four patients: three patients with anal pruritus and one patient with temporary incontinence. CONCLUSION The easy performance, the absence of major complications and the good results obtained confirm that these methods are effective and safe in the treatment of anal stenosis.
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Affiliation(s)
- Damian Casadesus
- Department of Coloproctology, Calixto Garcia University Hospital, J and University, Plaza, Havana, Cuba.
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Habr-Gama A, Sobrado CW, de Araújo SEA, Nahas SC, Birbojm I, Nahas CSR, Kiss DR. Surgical treatment of anal stenosis: assessment of 77 anoplasties. Clinics (Sao Paulo) 2005; 60:17-20. [PMID: 15838576 DOI: 10.1590/s1807-59322005000100005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Anal stenosis is a rare, incapacitating, and challenging condition, occurring mainly after hemorrhoidectomy, for which several surgical techniques have been devised. The purpose of this study was to describe early and late (1 year) results of 77 anoplasty operations performed in the Colorectal Unit of our institution. METHODS From 1977 to 2002, 77 patients with moderate to severe anal stenosis underwent surgery using two sliding graft techniques: 58 underwent Sarner's operation and 19 underwent Musiari's technique. Bilateral flaps were used in 7 patients. RESULTS Early morbidity was due to pruritus occurring in 2 patients, urinary infection in 1, and temporary incontinence in 1 patient. One patient needed early reoperation following suture line dehiscence. Late results (1 year) were classified as good in 67 cases (87%). There was no reoperation due to recurrence of stenosis. CONCLUSION The ease of performance, good functional results, and lack of severe complications show that Sarner's and Musiari's flap advancement techniques are effective and safe methods for surgical correction of anal stenosis, particularly when cutaneous fibrosis plays a major role in its etiology.
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Affiliation(s)
- Angelita Habr-Gama
- Colorectal Unit, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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