ArticlePDF Available

Repair of anal stenosis using a prolapse and hemorrhoids (PPH) stapler procedure: A case report with excellent results

Authors:

Abstract and Figures

Introduction: Anal stenosis post stapled hemorrhoidectomy is a rare but serious complication of anorectal surgery. Stenosis is uncomfortable, where there is a narrowing of the anal canal. A loose fibrous tissue replaces healthy tissue due to stapler manipulations, causing pain at the time of defecation. Presentation of case: Here, we report the case of a 67-year-old male patient complaining of difficulties and pain when defecating. There was a history of stapler hemorrhoidectomy for 4th-grade hemorrhoids. On investigation, we found 3rd-degree anal stenosis. We performed repair of anal stenosis using a PPH Stapler No. 33. Defecation had improved by the fifth-day post-repair. Conclusion: The PPH Stapler technique has the potential to be a promising procedure to treat anal stenosis.
Content may be subject to copyright.
Case Report
Repair of anal stenosis using a prolapse and hemorrhoids (PPH) stapler procedure:
A case report with excellent results
Warsinggih
a
,
*
, M. Iwan Dani
a
, M. Ihwan Kusuma
a
, Ibrahim Labeda
a
, Julianus Aboyaman Uwuratuw
a
,
Muhammad Faruk
b
a
Division of Digestive, Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, 90245, Indonesia
b
Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, 90245, Indonesia
article info
Article history:
Received 15 September 2020
Received in revised form
30 October 2020
Accepted 31 October 2020
Available online 4 November 2020
Keywords:
Anal stenosis
Hemorrhoidectomy
PPH Stapler
Hemorrhoids
Anal canal
Case report
abstract
Introduction: Anal stenosis post stapled hemorrhoidectomy is a rare but serious complication of ano-
rectal surgery. Stenosis is uncomfortable, where there is a narrowing of the anal canal. A loose brous
tissue replaces healthy tissue due to stapler manipulations, causing pain at the time of defecation.
Presentation of case: Here, we report the case of a 67-year-old male patient complaining of difculties
and pain when defecating. There was a history of stapler hemorrhoidectomy for 4th-grade hemorrhoids.
On investigation, we found 3rd-degree anal stenosis. We performed repair of anal stenosis using a PPH
Stapler No. 33. Defecation had improved by the fth-day post-repair.
Conclusion: The PPH Stapler technique has the potential to be a promising procedure to treat anal
stenosis.
©2020 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Anal stenosis is a condition where the narrowing of the anal
canal occurs so that the patient complains of difculty and pain
with each defecation [1]. Anal stenosis is characterized by an
anatomical deformity in the form of changes in the diameter of the
anal canal with cicatrices tissue and reduction of elasticity of the
anal canal [2]. Also, patients complain of a change in the form of
feces (small, thin, slender, and elongated), disposal difculties,
feeling unsatised after defecation, and pain during defecation
[3,4].
Ninety percent of anal stenosis is caused by excessive hemor-
rhoidectomy [2,5]. Patients also sometimes complained of bleeding
during defecation and at stool. Fear of impacted feces and pain
lead these patients to rely on laxatives or enemas. Physical
examination is performed to conrm the diagnosis [1,3,4]. Anes-
thesia can eliminate spasms associated with anal ssure (functional
stenosis), but does not achieve additional cavity diameter [5].
Anorectal manometry is an objective method to evaluate muscle
patterns anus, rectum deated owers, Anorectal sensation, and
verify the integrity of the inhibitory rectoanal reex [3,6]. We re-
ported the case in accordance with the SCARE 2018 guidelines [7].
2. Presentation of case
A 67-year-old male was admitted to the hospital with a chief
complaint of difcult and painful defecation. The patient com-
plained of dissatisfaction after defecation and long stick-shaped
feces. This condition has been manifested since 6 months after
undergoing stapler hemorrhoidectomy surgery, 3 years previously.
The patient reported urinating smoothly. No abnormality was
detected by abdominal examination. The anal region looked darker
than the surrounding area, and the digital rectal palpation gave an
impression of narrowness and elasticity. Routine laboratory ex-
amination and routine blood chemistry analysis found no abnor-
malities. A chest x-ray examination found no abnormalities. The
patient was diagnosed with 3rd-degree anal stenosis. We per-
formed repair of anal stenosis using a PPH Stapler No. 33. The
*Corresponding author. Division of Digestive, Department of Surgery, Faculty of
Medicine, Hasanuddin University, Jalan Perintis Kemerdekaan KM 11, Makassar,
South Sulawesi, 90245, Indonesia. Fax: þ62411585984.
E-mail addresses: kbd.warsinggih@gmail.com (Warsinggih), iwdani@yahoo.co.
id (M.I. Dani), ihwankusuma@gmail.com (M.I. Kusuma), ibrlabeda@yahoo.com
(I. Labeda), boyuwuratuw@gmail.com (J.A. Uwuratuw), faroex8283@gmail.com
(M. Faruk).
Contents lists available at ScienceDirect
International Journal of Surgery Open
journal homepage: www.elsevier.com/locate/ijso
https://doi.org/10.1016/j.ijso.2020.10.013
2405-8572/©2020 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
International Journal of Surgery Open 27 (2020) 43e46
patient was placed in a prone position under the effect of regional
anesthesia. The gluteus maximus muscles of both sides were
stretched laterally using plaster. From a careful examination of the
anal canal, we found that the anal canal narrowing was inicted by
stricture in three positions: in the direction of 3, 6, and 9 o'clock
(Fig. 1). A gentle anal dilatation was conducted with the insertion of
a Hill-Ferguson retractor into the anal canal. The incision was
initially made in the anterior side (12 o'clock direction) of the
dentate line and to be extended 1.5 cm distally through the ano-
cutaneous line and proximally until reaching the rectal mucosa. The
length of the incision was approximately 3 cm.
The mucosaland skin aps were lifted from1.5 cm of the right and
left side of the primary incision. An anocutaneus Y incision was made
in an upward direction, with both wings forming an angle of 90
.
The skin and mucosal aps were gently removed by sharp
dissection with a distance of 1e2 cm. When dissection had been
completed, the anocutaneus point A was juxtaposed to point B on
the mucosa without tension (Fig. 2). We continued to make a purse-
string stitch ±1 cm above the anterior part of the stenosis. After the
purse-string stitch had been encircled completely, the circular
mucosectomy was performed using a PPH stapler no. 33. The ste-
nosis tissue was dissected in the shape of a complete circular tube
with a length of ±3cm(Fig. 3).
At the 5-day postoperative follow-up, the patient reported
improved defecation, was able to defecate as usual, and was dis-
charged in good condition. Postoperative management was a sim-
ple procedure; the patient was given a high-ber diet, laxatives,
and mineral oil. Sitz baths and showers were recommended for
hygiene and comfort. Post-operation analgesics were necessary,
especially for the rst 24 h.
After the evacuation of feces, the operation area was washed
with warm water and neutral soap. Sitz Bath can improve local
hygiene, and is recommended three times per day for 10 days,
starting from the rst postoperative day. Patients could have a meal
immediately after surgery. Providing a diet high in ber and water
can help the digestive function. When the patient is unable to
defecate, spontaneous defecation can be improved by providing
barium enema in small quantities. There was no need to perform a
rectal slinger postoperatively.
At the 2-week, 1-month, and 3-month follow-ups, with obser-
vation in the operating area, there were no complications.
3. Discussion
Anal stenosis is an uncomfortable condition that results from
morphological changes of the anal canal with a consequent
reduction in the function of this organ [3,4]. Anal stenosis is a
serious complication of anorectal surgery. Anal stenosis occurs
when the normal pliable anoderm is replaced with brotic con-
nective tissue causing the anal canal to be abnormally tight and
inelastic [4]. Stenosis can be caused by intrinsic or extrinsic path-
ological processes. Anal stenosis can develop from a variety of
conditions that cause non-cutaneous scarring sores [3,4]. The ste-
notic segment might be localized proximal or distal to the anal
canal, but often the irregularities are noted to be circumferential
involving the entire anal canal [4].
The causes of anal stenosis include trauma, surgery on the anal
canal, inammatory bowel disease, venereal diseases, radiation
therapy, and chronic use of laxatives [3,8,9]. Hemorrhoidectomy is
the most common cause of anal stenosis, with an incidence ranging
from 1.5% to 3.8% [4]. In two retrospective studies, it was stated that
the incidence of anal stenosis after PPH stapler was 8.8% and 1.6%
[10,11]. Hemorrhoidectomy might strip a wide area of anoderm and
rectal mucosa from the lining of the anal canal, leading to scarring
and progressive chronic stricture formation making the anus less
pliable. Anal stenosis can occur following stapling procedures for
hemorrhoids, especially with staple line dehiscence or when the
stapler is placed too supercially in the anal canal leading to scar-
ring (stapled line stricture) [4]. Several factors have been consid-
ered to be related to anal stenosis after stapled hemorrhoidectomy.
There is an attractive theory that stenosis develops as a result of
Fig. 1. Evaluation of the anal canal to identify the narrowed segment and grading of anal stenosis.
Fig. 2. Purse strings on the mucosa.
Warsinggih, M.I. Dani, M.I. Kusuma et al. International Journal of Surgery Open 27 (2020) 43e46
44
micro-dehiscences of the suture line, followed by a submucosa
phlogosis and the subsequent formation of retractile scar tissue.
Certainly, stenosis can be caused by the incorrect execution of the
suture line, too low and\or with wide resection of hemorrhoidal
tissue, or asymmetrical, or too deep, or rather at full thickness [12].
Chew et al. proposed the explanation of the development of the
stapled line stricture, which is related to the formation of an
exceeding anastomotic scar, which creates a hypertrophic brous
circumferential cord [13].
In our case, the anal stenosis was caused by complications of
surgery by using a stapled hemorrhoidectomy mucosectomy. From
our analysis, this complication occurred as a consequence of the
purse string-forming sutures within the rectal mucosa not being
placed at the same layer of depth during the previously stapled
hemorrhoidectomy, which caused a narrowing of rectal mucosa
after the mucosectomy with a stapler was conducted. The third-
degree anal stenosis occurred a few months post-operation.
Anatomical canal stenosis can be classied by the severity of the
stricture and level of involvement in the anal canal (Table 1)
[2,5,14]. In this case, the patient was diagnosed with severe anal
stenosis because of the difculty of performing a digital rectal ex-
amination, even with forced dilation with a little nger.
The treatment approaches must be planned precisely with a
careful diagnosis and assessment of stenosis severity [15]. Mild
stenosis can be given conservative treatment, such as laxatives and
anal dilatation, with or mechanical ngers to be done every day.
Sphincterotomy can be performed for moderate stenosis. Regarding
the severe degree, an anoplasty procedure can be performed to
overcome the loss of the anal canal function [1].
Some studies have identied suitable treatments for anal ste-
nosis, but no anoplasty procedures are universally applicable [3,16].
Several anoplasty techniques have been proposed from various
reports. In this case report, we performed an anoplasty procedure
using the PPH stapler No.33 to repair anal stenosis, and the patient
had an improvement in defecation after the surgery. This technique
was a new invention that had never been reported before.
We chose this method with the rationale that the anal stenosis
was inicted by circumferential stapled line stricture after the
stapled hemorrhoidectomy procedure. Using the PPH stapler, the
stapled line stricture could be resected circumferentially at the
same level as the circumferential stricture.
Anal stenosis repair with PPH stapler has the potential to be a
promising procedure to treat anal stenosis, especially stapled
hemorrhoidectomy-related anal stenosis. However, we need longer
observation and experimental studies to ensure the efcacy and
safety of this new procedure. We hope this case report can trigger
further experimental studies.
Complications that might arise after anoplasty include pain,
obstruction, bleeding, constipation, incontinence, dehiscence, fail-
ure to repair stenosis, infection, alvi incontinence, stula, tenesmus,
perforation, and urinary retention [2,3,15].
4. Conclusion
The anal stenosis repair with a PPH stapler has the potential to
be a promising procedure to treat anal stenosis. However, experi-
mental studies must be conducted to ensure the efcacy and safety
of this new procedure.
Ethical approval
The study is exempt from ethical approval in our institution.
Funding
No funding or sponsorship.
Author contribution
WS, MID, MIK, and MF researched the literature and wrote the
manuscript. WS, MID, and MF operated on the patient and had the
idea for this case report. WS, MID, MIK, and MF checked the
manuscript and made corrections. WS, IL, and MID provided the
overall guidance and support. All authors read and approved the
nal manuscript.
Fig. 3. Inclusion of stapler tool procedure, with a 3-mm Hemorrhoidal Circular Stapler.
Table 1
Classication of anal stenosis [2,5,14].
Classication based on the severity
Mild Stenotic Stenotic anal canal can be examined by a well-lubricated index nger
Moderate Forceful dilatation is required to do a digital rectal examination
Severe Digital rectal examination is impossible
Warsinggih, M.I. Dani, M.I. Kusuma et al. International Journal of Surgery Open 27 (2020) 43e46
45
Conict of interest statement
The authors declare that they have no conict of interests.
Research registration number
None.
Guarantor
Warsinggih.
Consent
Written informed consent was obtained from the patient for
publication of this case report and accompanying images.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ijso.2020.10.013.
References
[1] Okumura K, Kubota T, Nishida K, Lefor AK, Mizokami K. Treatment of complete
anal stricture after diverting colostomy for Fournier's Gangrene. Case Rep Surg
2017;2017:2062157. https://doi.org/10.1155/2017/2062157.
[2] Tahamtan M, Ghahramani L, Khazraei H, Tabar YT, Bananzadeh A, Hosseini SV,
et al. Surgical management of anal stenosis: anoplasty with or without
sphincterotomy. J Coloproctol 2017;37:13e7. https://doi.org/10.1016/
j.jcol.2016.06.002.
[3] Brisinda G, Vanella S, Cadeddu F, Marniga G, Mazzeo P, Brandara F, et al.
Surgical treatment of anal stenosis. World J Gastroenterol 2009;15:1921.
https://doi.org/10.3748/wjg.15.1921.
[4] Katdare MV, Ricciardi R. Anal Stenosis Surg Clin North Am 2010;90:137e45.
https://doi.org/10.1016/j.suc.2009.10.002.
[5] Liberman H, Thorson AG. Anal stenosis. Am J Surg 2000;179:325e9.
[6] Baqir QK, Lefta MJ. Diamond ap anoplasty for severe anal stenosis. Basrah J
Surg 2013;19:23e5. https://doi.org/10.33762/bsurg.2013.81515.
[7] Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP, et al.
The SCARE 2018 statement: updating consensus Surgical CAse REport
(SCARE) guidelines. Int J Surg 2018;60:132e6. https://doi.org/10.1016/
j.ijsu.2018.10.028.
[8] Kroesen AJ, Philip H. Gordon and Santhat Nivatvongs Principles and practice of
surgery for the colon, rectum, and anus. Int J Colorectal Dis 2008;23:451.
https://doi.org/10.1007/s00384-007-0426-4.
[9] Neto JAR, Junior JAR, Kagohara OH, Neto JS, Banci SO, Oliveira LH. High macro
rubber band ligature. J Coloproctol 2013;33:151e6. https://doi.org/10.1016/
j.jcol.2013.08.002.
[10] Ng KH, Eu KW, Seow-Choen F, Tang CL, Heah SM, Ooi SS. Stapled
Haemorrhodectomyeour experience with more than 3000 cases. Color Dis
Suppl 2004;6.
[11] Oughriss M, Yver R, Faucheron J-L. Complications of stapled Hemor-
rhoidectomy: a French multicentric study. Gastroenterol Clin Biol 2005;29:
429e33. https://doi.org/10.1016/s0399-8320(05)80798-5.
[12] Corsale I, Rigutini M, Panicucci S, Frontera F. Domenico mammoliti, stenosis
after stapled anopexy: personal experience and literature review. Clin Surg
2018;3:1e5.
[13] Chew MH, Chiow A, Tang CL. Keloid formation after stapled haemor-
rhoidectomy causing anal stenosis: a rare complication. Tech Coloproctol
2008;12:351e2. https://doi.org/10.1007/s10151-008-0447-1.
[14] Milsom JW, Mazier WP. Classication and management of postsurgical anal
stenosis. Surg Gynecol Obstet 1986;163:60e4.
[15] Basso L, Pescatori M, La Torre F, Destefano I, D'Urso AP, Infantino A, et al.
Emerging technologies in coloproctology: results of the Italian society of
colorectal surgery Logbook of adverse events. Tech Coloproctol 2013;17:
207e11. https://doi.org/10.1007/s10151-012-0906-6.
[16] Scott-Conner CEH. Anoplasty for anal stenosis. In: Chass. Oper. Strateg. Gen.
Surg. An Expo. Atlas. New York, NY: Springer New York; 2002. p. 548e52.
https://doi.org/10.1007/978-0-387-22532-6_62.
Warsinggih, M.I. Dani, M.I. Kusuma et al. International Journal of Surgery Open 27 (2020) 43e46
46
... Anal stenosis, occurring in 1.5-3.8% of post-hemorrhoidectomy cases, is challenging and potentially threatening to a patient's quality of life [1][2][3]. Post-hemorrhoidectomies account for 90% of anal stenosis [2,4,5]. They also tend to occur after emergency hemorrhoidectomies rather than electives [3]. ...
... One potentially life-altering complication of hemorrhoidectomy is anal stenosis. Although it is an uncommon complication, occurring in less than 5% of cases, almost 90% of anal stenosis is due to overzealous hemorrhoidectomies [2,4,5]. Anal stenosis is defined by a circular narrowing of the anal canal with a fibrous band or a scar-like appearance to the anal aperture [1,3]. ...
Article
Full-text available
Anal stenosis occurs in 1.5-3.8% of post-hemorrhoidectomy cases. Post-hemorrhoidectomy anal stenosis accompanied by acute bowel obstruction is extremely rare. We present a 55-year-old lady with acute bowel obstruction after undergoing hemorrhoidectomy procedure. Examination under anesthesia revealed a macerated perianal area with no detectable anoderm layer, and the anal mucosa was adhered cranially, causing an apparent narrowing of the anal canal. We decided on a staged repair. Debridement of the perianal area was performed, and sutures from the overzealous hemorrhoidectomy were removed. We left the wound open for secondary healing with a diverting sigmoid colostomy. Anal stricture developed as the wound healed, and a rhomboid flap anoplasty was done six months after the first surgery. Routine anal dilatation and biofeedback were performed before closure of the ostomy three months after anal reconstruction. Although relatively a low-risk procedure, hemorrhoidectomy could cause debilitating complications. Anal stenosis is a devastating, life-altering complication of an overzealous hemorrhoidectomy.
... La sténose anale peut être définie comme un rétrécissement du canal anal due à une baisse d'élasticité liée au remplacement de l'anoderme par une fibrose cicatricielle [1,2,7]. Au cours de la sténose anale, les fonctions anatomiques et physiologiques du canal anal notamment la défécation et la continence sont perturbées [7][8][9]. Selon l'étiologie, la sténose anale est souvent classée en sténose congénitale, primaire et secondaire [6]. Les causes secondaires des sténoses sont diverses, mais souvent il s'agit des complications de la chirurgie proctologique [10][11][12]. ...
... Les options thérapeutiques comprennent à la fois des approches conservatrices et chirurgicales. D'une manière générale, la première approche doit être conservatrice et l'indication chirurgicale réservée aux échecs du traitement médical et aux sténoses sévères[5][6][7][8][9][10][11][12][13][14]. Dans cette étude, tous nos patients étaient classés au stade de sténose sévère ou modérée. ...
Article
Full-text available
Objective Patients and methods Results Conclusion : To describe our experience on the management of anal stenosis and mucosal ectropion by Sarafoff's procedure. : This is a retrospective collection between 2006 and 2018 at the national hospital of Niamey. Patients operated for non-tumorous anal stenosis by the Sarafoff technique were included. : A total of six patients, five women and one man. The mean age was 31.7±9.3 years. A history of hemorrhoidectomy was found in 5 cases. The time between hemorrhoidectomy and anoplasty ranged from 4 to 48 months. Anal pain was constant and five had dyschezia and constipation. Association of stenosis and ectropion of the anal mucosa was founded in 5 cases. The use of laxatives was found in 5 cases. The average length of stay was 11.5±2.66 days. The average healing time was 5.16±1.83 weeks. Five out of six patients had a good outcome. : Anal stenosis with or without ectropion is a rare and serious complication of hemorrhoidectomy. Its management by Sarafoff's anoplasty remains a simple technique with a good result.
... Anal stenosis is a rare complication in patients with a history of hemorrhoidectomy. This condition causes discomfort to the patient and is considered a serious complication [7]. In one long-term study, it was found that >10 years after hemorrhoidectomy, patients complained of impaired defecation and a sensation of anal constriction [8]. ...
Article
Full-text available
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.
Article
Full-text available
Muayad J Lefta* & Qais K Baqir@ *MBChB, FICMS, CABS, General Surgeon, Department of Surgery, Al-Sadr Teaching Hospital, Basrah, Iraq, @MBChB, FICMS, CABS, General Surgeon, Department of Surgery, Al-Sadr Teaching Hospital, Basrah, Iraq. Lecturer, Dept. of Surgery, Basrah College of Medicine. Abstract Anal stenosis is an uncommon condition usually resulted from hemorrhoid surgery. It is one of the common disabling anal conditions and a lot of surgical techniques have been described to treat this condition. Sixteen cases of severe anal stenosis were included in a prospective study from July 2002 to January 2012 in Al-Sadr Teaching and private Hospitals; there were 14 males and 2 females. All patients received preoperative antibiotics and single enema for bowel preparation. Internal anal sphincterotomy done for all patients, four patients required bilateral flap anoplasty and twelve required only unilateral diamond flap anoplasty. This study included a total of 16 patients, 14 males and 2 females. Mean age was 35.3 years. Main etiology was hemorrhoidectomy (15 cases), most patients suffer from obstructed defecation, painful evacuation and episodes of minor rectal bleeding. Most patients express improvement in postoperative pain and good functional satisfaction (using visual analogue scale VAS). Complications were minor and treated successfully. Anal stenosis although uncommon, is a feared disabling anal condition mostly resulted from hemorrhoid surgery, a lot of surgical techniques have been described to treat severe anal stenosis, no one regarded as superior but all share the property of achieving patient’s satisfaction. In conclusion, diamond flap anoplasty is easy procedure with low complication rate and gives good results for treatment of severe anal stenosis.
Article
Full-text available
Background . Anal stenosis is a rare but serious complication of anorectal surgery. Severe anal stenosis is a challenging condition. Case Presentation . A 70-year-old Japanese man presented with a ten-hour history of continuous anal pain due to incarcerated hemorrhoids. He had a history of reducible internal hemorrhoids and was followed for 10 years. He had a fever and nonreducible internal hemorrhoids surrounding necrotic soft tissues. He was diagnosed as Fournier’s gangrene and treated with debridement and diverting colostomy. He needed temporary continuous renal replacement therapy and was discharged on postoperative day 39. After four months, severe anal stenosis was found on physical examination, and total colonoscopy showed a complete anal stricture. The patient was brought to the operating room and underwent colostomy closure and anoplasty. He recovered without any complications. Conclusion . We present a first patient with a complete anal stricture after diverting colostomy treated with anoplasty and stoma closure. This case reminds us of the assessment of distal bowel conduit and might suggest that anoplasty might be considered in the success of the colostomy closure.
Article
Full-text available
Aim: Anal stenosis is an uncommon complication of anorectal surgery, mostly resulting from circumferential hemorrhoidectomy or resection of the skin tag in surgical management of chronic anal fissure. The aim of anoplasty is to restore normal function to the anus by dividing the stricture and widening the anal canal. Internal sphincterotomy may cause gas incontinence and if we manage the stenosis without sphincterotomy it could be failed. Could we use anoplasty without sphincterotomy? Method: The patients with anal stenosis were assigned in to two groups. The first group underwent Y-V anoplasty without partial lateral internal sphinctrotomy and the second one underwent Y-V anoplasty with partial lateral internal sphinctrotomy. Result: A total of 25 patients (10 male and 15 female) underwent anoplasty, 14 without partial lateral internal sphincterotomy and 11 patients with partial lateral internal sphincterotomy. The healing rate of stenosis was 91% and 93% in groups undergoing anoplasty without partial lateral internal sphinctrotomy and anoplasty with partial lateral internal sphictrotomy, respectively (p value 0.69). There was no significant change in both groups for post-operative incontinence complaints. Conclusion: The healing rate of anal stenosis was the same in the patients who underwent Y-V anoplasty with or without partial lateral internal sphinctrotomy. There was no significant change in post-operation incontinence between the two groups. Therefore, Y-V anoplasty would be a safe and simple surgical method in selected patients. Partial lateral internal sphinctrotomy procedure has been noticed in individual cases.
Article
Full-text available
Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hem-orrhoidectomy. 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, pathophysiol-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 man-plements. 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 vari-the results of the various anoplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.
Article
Full-text available
Objetivo o objetivo de uma ligadura com banda de borracha é promover a fibrose da submucosa com subsequente fixação do epitélio ao esfíncter anal subjacente. Seguindo esse princípio, uma nova técnica de ligadura foi desenvolvida baseada em dois aspectos: 1.macro bandas: para obter uma melhor fibrose e fixação ao atingir um volume maior de mucosa e2.ligadura alta: para obter essa fixação na origem do deslocamento do coxim hemorroidal. Métodos 1634 pacientes com doença hemorroidária interna de grau II ou III foram tratados pela técnica de macro ligadura elástica alta. Não houve distinção de idade, sexo ou etnia. Para executar essa técnica, um novo dispositivo hemorroidário foi especialmente projetado com um diâmetro maior e uma maior capacidade de aspiração de volume da mucosa. Recomenda-se utilizar um anoscópio mais longo e largo para obter uma melhor vista do canal anal, o que facilitará a injeção da submucosa a nível mais alto no canal anal e a inserção do dispositivo elástico. O coxim hemorroidal deve ser ligado a um nível mais alto no canal anal (4 cm acima da linha de pectinato). É preferível o tratamento de todas as hemorróidas em uma única sessão (máximo de três zonas submetidas à ligadura). Resultados a análise foi retrospectiva, sem qualquer comparação com a ligadura convencional. O período de avaliação variou de de um a doze anos. A análise dos resultados mostrou edema perianal em 1,6% dos pacientes, tenesmo imediato em 0,8%, dor intensa (necessidade de analgesia parenteral) em 1,6%, retenção urinária em 0,1% dos pacientes e uma taxa de recorrência sintomática de 4,2%. Todos os pacientes com recorrência sintomática foram tratados com uma nova sessão de macro ligadura elástica. Nenhum dos pacientes desenvolveu septicemia anal ou retal. Uma pequena hemorragia pós-ligadura foi observada em apenas 0,8% dos pacientes. Conclusões a técnica de macro ligadura elástica alta representa um método alternativo para o tratamento da doença hemorroidal classe II ou III, com bons resultados a um baixo custo. A análise dos resultados observados mostrou uma pequena incidência de complicações menores, com alto índice de alívio sintomático.
Article
Introduction: The SCARE Guidelines were published in 2016 to provide a structure for reporting surgical case reports. Since their publication, SCARE guidelines have been widely endorsed by authors, journal editors, and reviewers, and have helped to improve reporting transparency of case reports across a range of surgical specialties. In order to encourage further progress in reporting quality, the SCARE guidelines must themselves be kept up to date. We completed a Delphi consensus exercise to update the SCARE guidelines. Methods: A Delphi consensus exercise was undertaken. All members of the previous Delphi group were invited to participate, in addition to researchers who have previously studied case reports, and editors from the International Journal of Surgery Case Reports. The expert group was sent an online questionnaire where they were asked to rate their agreement with proposed changes to each of the 24 items. Results: 56 people agreed to participate and 45 (80%) invitees completed the survey which put forward modifications to the original guideline. The collated responses resulted in modifications. There was high agreement amongst the expert group. Conclusion: A modified and improved SCARE checklist is presented, after a Delphi consensus exercise was completed. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines.
Chapter
Symptomatic fibrotic constriction of the anal canal not responsive to simple dilatation
Article
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.