Anal Stenosis And Mucosal Ectropion

Surg Clin N Am 82 (2002) 1225–1231

Anal stenosis and mucosal ectropion Jorge A. Lagares-Garcia, MD, Juan J. Nogueras, MD* Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA

Definition, etiology, and incidence Anal stenosis (AS) or stricture is defined as the loss of compliant natural elasticity of the anal opening, which then becomes abnormally tight and fibrous. It is a very disabling condition, worsened by the patient’s embarrassment, yet uncommon. AS may follow any circumstance that causes scarring over the anordermal area. Khubchandani has classified anal stenosis as congenital, primary, and secondary. Among the congenital forms are imperforate anus and anal atresia. Primary stenosis can be seen as the senile form or involutional stenosis [1]. The vast majority of cases of AS are secondary to trauma, iatrogeny, inflammatory diseases, or neoplasia, or are postradiation. Due to the rarity of this pathology and the different referral patterns among institutions, etiology ranges widely between published reports, as seen in the list below: Hemorrhoidectomy, 31%–62% Bowen’s disease, 26% Fistulectomy, 4%–17% Ileoanal anastomosis, 5%–10% Paget’s disease, 7%–53% Chronic laxative abuse, 17% MOHD chemosurgery, 10% Condyloma acuminata, 6% Melanoma resection, 5% Sphincteroplasty, 5% Gracilis transposition, 5% Cryosurgery, 4% * Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331. E-mail address: [email protected] (J.J. Nogueras). 0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 8 1 - 6

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Postanal repair, 4% Radiation, 4% Fissurectomy, 2% Hemorrhoidectomy is the most common surgical cause, with incidence ranging between 3.8% and 1.5% [2,3], followed by Paget’s and Bowen’s disease. Fistulectomy and ileoanal anastomosis are also common causes. Nonspecific inflammatory causes and infections such as tuberculosis and venereal diseases can also produce AS. Radiation or perineal burns can decrease the natural compliance of the perineal tissues with subsequent fibrosis and AS [4,5]. Depending on the severity, AS can be classified as mild, moderate, or severe. The passage of an index finger or medium Hill-Ferguson retractor tightly, with forceful dilation or the inability to perform such maneuvers hallmark each of the categories, respectively. Level of involvement is classified as Low AS located over the distal anal canal at least 0.5 cm below the dentate line; mid AS extends from the previous point to 0.5 cm distal to the dentate line; high AS lies proximal to 0.5 cm above the dentate line [6].

Symptoms and diagnosis There is a low correlation between the clinical findings and the symptomatology of the patient. Elderly patients with a narrow anal canal opening can have a relatively comfortable lifestyle and show no signs of AS. Symptoms of constipation, a decrease in stool size, dyschezia, and tenesmus will prompt patient evaluation. Symptoms and rate of occurrence are listed below [1,7,8]: Pain, 37%–71% Constipation, 22%–37% Bleeding, 21%–47% Leakage, 10%–23% Diarrhea, 14% Digitalization, 11% Pain seems to be the most common complaint, followed by constipation or bleeding. Frequently all of these symptoms overlap. Constipation may be so severe that the patient may require digital assistance for evacuation of the fecal material, provoking further trauma and aggravating the condition. Diarrhea from chronic laxative use (‘‘paraffin anus’’) or from overflow fecal impaction may also be a form of presentation. With time, this outlet obstruction causes a retrograde distension of the rectal ampule and subsequent megarectum [5]. Physical examination immediately reveals the source of the complaints through visualization of cicatricial tissue from previous perianal interventions. Specifically, these appear as raised, irregular, scaly, brownish plaques

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with eczematoid features such as in Bowen’s disease; ulcerative, crusty or papillary presentations of Paget’s disease; raised and pearly border ulcerations of basal cell carcinoma; or the hard, flat, ulcerated masses from squamous cell cancer. Anal condyloma or the malignant variant verrucous carcinoma present as cauliflower-like lesions. They can be only histologically differentiated with local invasion and minimal dysplasia. Perianal sexually transmitted diseases are part of the differential diagnosis and we refer the reader to other sources for the manifestations in each specific pathology.

Treatment Nonoperative or conservative management Mild stenosis with minimal symptoms can usually be managed with dietary modifications and ‘‘bulking’’ agents. Anal dilatation should be done with the ‘‘natural’’ stretch of the passage of the fecal bolus through the rectum and the anal canal. Despite reports in the literature of self-dilatation after an initial exam and dilatation under anesthesia, using a Hegar’s dilator, the resultant hematoma and further fibrosis may worsen the AS [1]. In patients with inflammatory bowel disease, however, this may be a reasonable option, due to the chronicity and high risk of recurrence. Surgical therapy There are multiple surgical techniques that have been described for the correction or improvement of AS. Moderate or severe AS is the usual indication for operative treatment. For mild and benign forms of AS, Notaras advocates lateral internal sphincterotomy, which may be performed bilaterally if needed [9]. Before performance of bilateral internal sphincterotomy, however, a complete examination, including the patient’s continence status as well as physiologic testing, is recommended to avoid potentially resultant fecal incontinence. Replacement of diseased nonpliable tissue with elastic and compliant neoanoderm is the basis for surgical therapy of AS. Advancement, transfer, or rotational flaps are the main techniques of the colorectal surgeon for excision and coverage of the perianal area. The vascular supply of these flaps is from unnamed vessels that perforate in the submucosal or subdermal vascular plexus, or in subcutaneous tissues. More complex rotational flaps based on named vascular pedicle can also be performed if multiple procedures have already been performed or a wider area of coverage is needed. We will briefly describe mucosal advancement flaps and tissue transfer flaps. Complex reconstructions such as pedicled scrotal island skin flaps [10], Limberg-type transpositions flaps [11], the sliding-skin-graft method [12], internal pudendal flaps [13], or the use of

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prepuce flaps [14] for coverage of the anodermal area are seen in the literature as sporadic case reports; however, no defined, large prospective series with a relatively long-term follow-up have been described. Mucosal advancement anoplasty Kubchandani [1] reported his results with a previously modified technique [15] in 53 patients with anal stenosis. This technique is performed in the prone jackknife position after standard bowel preparation. An incision is made lateral and perpendicular to the dentate line, extending into the anal verge. The mucosa in undermined 2 cm to 5 cm, resulting in a transverse wound. The scar tissue and excessive mucous membrane are excised and the mucosa is sutured to the distal border of the internal sphincter at the anal verge with interrupted polycolic acid sutures. The external part of the wound is left open. Forty-four bilateral and 9 unilateral anoplasties were performed with good results (82%) in the majority of patients, whereas 11.3% had fair improvement of their symptoms. Y-V anoplasty The initial incision is made radially at the level of the stricture, making the vertical limb of the Y. The wide portion of the Y is located further out in the perianal area. Subdermal division of the tissues is undertaken to improve mobilization. The resultant V flap is advanced at the base of the vertical limb. Good results are obtained in between 64% to 100% of cases (Table 1). Suture dehiscence, ischemic contracture, hematoma, flap necrosis, or restricture are described complications. V-Y advancement anoplasty Rosen [16] initially described this technique for ectropion, but it has subsequently been applied to the treatment of anal stenosis. After a radial excision of the stenosed segment, a V shaped flap that is at least 2 cm in length is advanced to the mucocutaneous junction. A recent series by Hassan [17] of 15 patients reported easily managed complications, such as superficial wound separation, flap hematoma, or recurrent stenosis. Flap necrosis was not seen in this series, which may be explained by the broader base of the advancement flap used. Some degrees of incontinence for gas or liquid were seen in the nondiverted patients, with eventual resolution of symptoms.

Table 1 Y-V anoplasty Author

Year

n

Results

Maria [26] Angelchik [7] Ramajunan [27] Gingold [28]

1998 1993 1988 1986

29 12 21 14

90% 100% 85% 64%

complete resolution and healing excellent or satisfactory excellent complete satisfaction

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Rectangular flap An initial description of this technique by Sarner [18] included a rectangular full-thickness graft that is mobilized to the dentate level in a tensionfree manner. Interrupted sutures are used for securing the graft. Multiple sites up to four quadrants can be done and closure of the donor site is not required. Adequate relief of AS has been described using this technique. Diamond flap The diamond advancement flap was initially described by Caplin and Kodner in 1986 [19]. The excision of the diseased portion of skin is done, leaving a diamond defect. This is then covered by a flap designed in the same shape that will be advanced to the intra-anal portion of the defect. Excellent results are reported with this technique (Table 2) and complications similar to Caplin and Kodner can be seen. House flap A longitudinal incision is made extending from the dentate line to the distal end of the stricture. The length of the incision corresponds to the length of the ‘‘walls’’ of the proposed house flap, and the sides of the flap measure equally to the stenosis; the ‘‘roof’’ is made with the peak as high as the length of the sides. The completed house flap is advanced, lining the entire length of the anal canal, and sutured in place (Fig. 1). As initially described in 1992, then in a four-year retrospective review published in 1996, Christensen et al and Sentovich et al [20,21] obtained complete satisfaction in 82% of patients and improvement of the symptoms in 89%. At the Cleveland Clinic Florida, our most recent experience showed 50% of patients with complete or almost complete improvement of the symptoms and 50% with slight improvement of the symptoms using this technique [8]. S-plasty Initially described for the correction of the ectropion secondary to a Whitehead hemorrhoidectomy, the abnormal tissue is removed and replaced with skin, fixing the mucocutaneous junction at the normal position. The skin coverage is provided by a double-rotational flap, outlined by a large ‘‘S,’’ with the anal canal in the center. After mobilization of the flaps, the apex is brought to the anterior cut edge of mucosa and sutured in place with interrupted sutures. The side of the flap is sutured to the lateral wall as far as Table 2 Diamond flap anoplasty Author

Year

n

Results

Caplin [19] Angelchik [7] Pidala [24] Maria [26]

1986 1993 1994 1998

16 7 28 13

100% 100% 91% 100%

satisfactory satisfactory improved healing

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Fig. 1. House flap. A longitudinal incision is made extending from the dentate line to the distal end of the stricture. The length of the incision corresponds to the length of the ‘‘walls’’ of the proposed house flap and the sides of the flap measure equally to the stenosis; the ‘‘roof’’ is made with the peak as high as the length of the sides. The completed house flap is advanced, lining the entire length of the anal canal, and sutured in place.

the posterior canal. The lower flap is similarly fixed to the anal canal. Excellent results are reported in all patients undergoing this type of repair, with minimal morbidity. Anal ectropion Anal ectropion defines the abnormal position of anal mucosa into the anodermal junction or more distal into the perianal skin. Classically, it is seen after hemorrhoidectomy and was initially described by Ferguson following the Whitehead procedure [22]. Despite the initial description, later reports in 556 patients from Wolff and Culp had no ectropion using such technique [23]. General complaints include discomfort with seepage, pruritus, bleeding, pain, and occasionally, tenesmus. This gets translated into the ‘‘wet anus’’ syndrome. On physical examination, an area of ectopic mucosa is seen further out of the mucocutaneous junction. Lichenification of the skin from chronic pruritic changes, erythema, or maceration of the skin may be added physical findings. The goal for therapy is to restore the ectopic mucosa to the original level proximal to the dentate line. Flap selection will include most of the alternatives used for anal stenosis, with good results overall reported in the literature. For short areas of ectropion, diamond-shaped, house-shaped, or V-Y advancement flaps have been used [16,19,24]. Larger areas of ectropion can be repaired using S-plasty with excellent anatomic results [25].

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