Common Anorectal Disorders Research Articles

English

Objectives: Hemorrhoids is a common ano-rectal disorder, and heamorridectomyis universally accepted procedure. Haemorrhoidectomy can be carried out under severalmodes of anesthesia. Local anesthetic produce a loss of sensation and muscle paralysis ina circumscribed area of body by localized effect on peripheral nerve endings. The aim ofthis study is determine long term and short term outcome of diathermy haemorrhoidectomyunder local anesthesia, in term of early recovery, hospital stay, postoperative pain, bleedingand recurrence. Study Design: Cross sectional, descriptive case series study. Period: 24-02-2014 to 24-02-2015. Setting: Department of General Surgery, Liaquat University of Medicaland Health Sciences Jamshoro / Hyderabad. Method: 50 patients of haemorrhoidectomy. Allpatients of III and IV degree hemorrhoids, which are fit for surgery were included whereasthose patients who had previous anal surgery, co-existing disease i.e. Crohn’s disease, chronicdiarrhea illness, malignancy of anal region, hyper sensitivity to local anesthetics were excludedfrom the study. Data was collected and analyzed in SPSS version 20.0. Results: A total of 50patients of haemorrhoidectomy were included. The mean operative time was 15.04 minutes (n= 50). 9(18.0%, n = 50) patients had the complaint of pain, 15(30.0%, n = 50) patients haditching around anus. Postoperatively 9(18.0%, n = 50) patients got pain relief within one week,no post operative bleeding was observed within the one week. Two patients (4.0%, n = 50) hadtemporary incontinences infection. Only 1(2.0%, n = 50) patient developed anal stenosis withinthe long term period of one month to 1 year. Conclusion: Diathermy hemorrhoidectomy underlocal anesthesia feasible, safe and well tolerated by our environment and population.

OC-066 A National Survey of the Practice and Attitudes Towards Investigations and Biofeedback Therapy for Anorectal Disorders

Introduction Recent international consensus guidelines on anorectal disorders from the Neurogastroenterology and Motility societies (ANMS-ESNM) recommend biofeedback therapy (BFT) for constipation with dyssynergic defecation (DD) and for faecal incontinence (FI).1 We conducted a national survey to understand the current practice and opinions on anorectal function tests and BFT in the UK & Ireland. Methods An online survey was developed by a multi-disciplinary panel with medical, surgical and GI physiology representation. All GI clinicians and physiologists/scientists in the UK & Ireland were invited to take the survey through their national societies BSG, AGIP, AUGIS and ACPGBI. All respondents were asked about their views on anorectal function tests and BFT, whilst GI physiologists and lead clinicians regularly involved in these studies were asked specific questions relating to their clinical practice. Results 313 responses (59% Gastroenterologists) included representatives from 98 GI physiology units. Of the units surveyed, 74% have anorectal manometry (ARM) (High Resolution 35%), 59% offer BFT and most have access to other imaging modalities (endoanal ultrasound 64%, colonic transit studies 86% and defecating proctography 67%). Overall, the majority agreed that anorectal function tests are useful in managing chronic functional constipation (FC) (69%) and FI (76%). In FI, 61% found BFT helpful, whereas opinions were divided in constipation with 52% finding BFT helpful for all forms of FC and 47% indicating BFT is only helpful in the DD sub-group. Surprisingly, a high proportion of respondents ‘did not know’ how useful anorectal function tests (FC 22% and FI 21%) and BFT (FC 26%, DD 33%, FI 31%) were. Responses from GI physiologists/lead clinicians (n = 95) indicated that; 58% have separate rooms for lower GI studies and the numbers of ARMs performed/month in their units (where known) were; none in 20%, 1–20 cases in 37% and >20/month in 28% and similarly numbers of BFTs/month for DD, FC or FI were; none in 37%, 1–20 cases in 21%, >20 in 18%. Only half the GI physiologists/lead clinicians surveyed offer BFT (FI 52%, DD 53% and FC 47%). Conclusion Whilst anorectal function tests are available in most units, BFT appears to be limited to specialist centres, with the majority agreeing that these interventions are useful in managing FC, DD and in particular FI. Up to a third were unsure about the utility of tests and BFT suggesting a worrying lack of knowledge and exposure amongst non-specialists which could affect the management of patients with these common anorectal disorders. Reference 1 Rao S, et al. NMO 2015;27(5):594–609. Disclosure of Interest None Declared

Anorectal Disorders

This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.

Excision Hemorrhoidectomy: New Methods to Improve the Outcomes of an Old Technique

Context: Hemorrhoidal disease is the most common anorectal disorder that requires surgical intervention. Hemorrhoids require treatment when they result in symptoms such as bleeding or prolapse. Surgical intervention is indicated for significant prolapse, and a number of accepted and viable methods are available for treating prolapsing hemorrhoids that do not reduce spontaneously (Grade III and IV). Excision hemorrhoidectomy remains the gold standard treatment for Grade III and IV hemorrhoids despite great interest in alternative procedures such as stapled hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation with mu- copexy. A large body of evidence demonstrates that excision hemorrhoidectomy is an eective, safe, and aordable procedure. Nevertheless, the main drawback of excision hemorrhoidectomy remains its notorious association with significant postoperative pain. Evidence Acquisition: A comprehensive literature search was conducted through MEDLINE and the Cochrane database of system- atic reviews. Only prospective case-controlled studies, review articles, and meta-analyses were considered. Results: Many strategies have been put forward in the literature to address the issue of pain after excision hemorrhoidectomy. These strategies can be broadly categorized into surgical techniques (e.g., LigaSure hemorrhoidectomy) and pharmacological adjuncts (e.g., intradermal methylene blue and chemical sphincterotomy with glyceryl trinitrate ointment). In recent years, meta-analyses and randomized controlled trials have been performed to evaluate their eects. Conclusions: This article evaluates the evidence behind these strategies and outlines the new methods available to improve the outcomes of an old technique.

3D High Resolution Anal Manometry (3DHRAM) on Squeeze Estimates Anal Sphincter Length and Lengths Correlate With Symptoms of Constipation and Fecal Incontinence

Introduction: Constipation and fecal incontinence (FI) are common anorectal disorders, affecting 20% and 8% of the population respectively. Anorectal manometry is a diagnostic modality that assesses function of the anorectum. Addition of 3D HRAM may improve diagnostic value by better illustration of sphincter function and integrity. There is some evidence that 3D manometry catheters, a fixed type of catheter, differ from traditional catheter measurements. We explored value of 3D images in estimating anal sphincter length. Our hypothesis is that the estimated length of anal sphincter is related to symptoms, and that FI patients would have shorter sphincters. Methods: We obtained IRB approval for a retrospective review of 3D-HRAM of clinical studies conducted between Jan 2013 and May 2015 for either FI or constipation, at Johns Hopkins Motility Center. We recorded demographic data. We analyzed 30 3DHRAM studies using ManoView ® software to sequentially review 3D images through baseline, rest, squeeze and bear down. We estimated the length of anal sphincter by measuring the maximum number of sensors with pressure greater than 80 mmHg on 3D imaging during squeeze frame, and multiplying by the distance between sensors (0.4cm). Results: Anal sphincter length for constipated patients on average was 3.85 cm and for those with FI was on average 2.69. This was statistically significant (p value = 0.013). Similarly, mean resting HPZ was 4.13cm for constipated subjects vs 2.85 cm for FI subjects (P value < 0.001). There was no significant difference in age distribution between the groups (correlation factor 0.12) or height (-0.15). Conclusion: The anal sphincter is involved in control of bowel habits, and the size and continuity of the anal sphincter likely related to strength and function. Shorter length of anal sphincter on 3D view during squeeze appears to be correlated with symptoms of FI, and longer length appears to be correlated with constipation. The true value of 3D anorectal manometry is under investigation, but this pilot study offers a glimpse at the role of 3D HRAM in interpretation of anorectal disorders. Further research can determine if this correlation is predictive of patient symptoms.

Common anorectal conditions: evaluation and treatment.

Anorectal conditions are frequently encountered clinical entities but are often misunderstood and misdiagnosed. Although the most common anorectal disorders are not considered life threatening, they can negatively impact patients' activities of daily living and quality of life. Comprehensive anorectal examination, including the use of anoscopy, has become a "lost art," and graduate medical education programs should utilize more formal training in this area. This review discusses the comprehensive anorectal exam and the diagnosis and management of three common anorectal disorders: hemorrhoids, anal fissure, and pruritus ani.

Pathophysiology of hemorrhoidal disease and approach to its management

Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. Hemorrhoids become pathognomonic due the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Early grades of hemorrhoids (Grade I and 2) can be effectively treated with dietary and lifestyle modification, pharmacological treatment, and different office-based procedures. Surgical intervention is indicated in symptomatic and advanced grades of hemorrhoids. Although hemorrhoidectomy is still considered as the gold standard, more recently, newer approaches like Ligasure and ultrasonic hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation have been used with a desirable success. However, post-procedural pain and disease recurrence remain the most challenging problems. This article deals with the pathophysiology and evidence based approach to hemorrhoidal diseases.

Comparison of Vessel Sealing Systems with Conventional

BackgroundHaemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Haemorrhoidal disease is a common anorectal disorder which has symptoms of bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Haemorrhoidectomy is one of most frequently performed anorectal operation worldwide.ObjectivesThe aim of this study was to compare the effectiveness of the LigaSure tissue sealing device, Harmonic Scalpel and conventional MM open haemorrhoidectomy.Materials and MethodsSixty-nine patients with newly diagnosed symptomatic grade three or grade four haemorrhoidal disease, from July 2011 to December 2011 were recruited for the study. Patients were prospectively randomized to LigaSure, Harmonic Scalpel and conventional haemorrhoidectomy. Patients were evaluated on the basis of the mean operative time, postoperative pain, day of discharge, early and late complications.ResultsEach group has twenty-three patients. Ten (14.5 %) were female and fifty-nine (85.5 %) were male. Mean age were 44.5 ± 10.8 for LigaSure group, 39.5±14.4 for Harmonic Scalpel group and 39.8 ± 13.6 for conventional haemorrhoidectomy group. Mean operative time was 12.6 ± 2.9 for LigaSure group, 12.6 ± 2.5 for Harmonic Scalpel group and 22.3 ± 4.5 for conventional haemorrhoidectomy group. Postoperative pain and required analgesic dose were significantly lower for conventional haemorrhoidectomy. Wound healing was also more rapid in conventional haemorrhoidectomy than both LigaSure and Harmonic Scalpel.ConclusionsLateral heat dissipation of energy based cautery such as Harmonel Scalpel and LigaSure is considerably high when compared with conventional methods. More thermal damage which is generated on tissue seems to be the reason for increased degree of postoperative pain and delay in wound healing.

Approach to Hemorrhoids

Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. The current pathophysiologies of hemorrhoids include the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Low-grade hemorrhoids are easily and effectively treated with dietary and lifestyle modification, medical intervention, and some office-based procedures. An operation is usually indicated in symptomatic high-grade and/or complicated hemorrhoids. Whilst hemorrhoidectomy has been the mainstay of surgical treatment, more recently other approaches have been employed including Ligasure hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation. Post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids. This article deals with modern approaches to hemorrhoids based on the latest evidence and reviews of the literature. The management of hemorrhoids in complicated situations is also discussed.

Common Anorectal Disorders for the Intensive Care Physician

Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.

Stapled Haemorrhoidopexy Compared with Conventional Haemorrhoidectomy-A Systematic Review

Haemorrhoids are one of the most common anorectal disorders. Conventional haemorrhoidectomy (CH) is the most commonly practiced surgical technique. Stapled haemorrhoidopexy (SH) [procedure for prolapsed haemorrhoids (PPH)] is newly developed method for the surgical management of Haemorrhoids. This review looks at the surgical management of prolapsed haemorrhoids in light of this recent development and suggests a treatment approach based on this current evidence. A Medline, Pubmed and Cochrane data base search was performed using key words "haemorrhoid" or 'hemorrhoid' and staple. Relevant papers e.g. randomized controlled trials, review and metaanalyses from different parts of the world were collected. Data were analyzed and compiled. Though early small RCTs (stapled haemorrhoidopexy comparing with traditional excisional surgery) have shown stapled haemorrhoidopexy is less painful and it is associated with quicker recovery but recent large meta-analyses and long term follow up have shown SH is associated with a higher long term risk of haemorrhoid recurrence and symptoms of prolapse.DOI: http://dx.doi.org/10.3329/fmcj.v7i1.10297Faridpur Med. Coll. J. 2012;7(1): 37-41

A comparative study of conventional Milligan-Morgan hemorrhoidectomy versus harmonic scalpel hemorrhoidectomy

Hemorrhoidal disease is one of the most common anorectal disorders, affecting, in various forms, almost 50% of people over the age of fifty. Surgical treatment is considered the standard treatment for grade III and IV hemorrhoids. However, although it is considered a minor procedure, the post-operative course is protracted, and the post-operative complications are not negligible. The resulting pain-related complications after conventional hemorrhoidectomy (CH) are often the major factors that prolong hospital stay and delayed recovery. Recently various new treatment modalities have been developed with the aim of overcoming post-operative pain, such as stapled hemorrhoidopexy, Ligasure, and harmonic scalpel, sealing devices. The aim of this study is to evaluate and compare the conventional Milligan- Morgan hemorrhoidectomy (CH) with harmonic scalpel hemorrhoidectomy (HSH) on eighty four patients with symptomatic grade III or IV hemorrhoids operated on at the Department of General Surgery, AL-Jedaani hospital, Jeddah, Saudi Arabia, between May 2008 and January2011. The patients were randomly allocated to undergo either a CH (group]= 42 patients) or HSH (group 2=42 patients). After analyzing the data collected from this study we can conclude that; hemorrhoidectomy with harmonic scalpel can provide a safe, fast, low-morbidity alternative to conventional hemorrhoidectomy.

Stapled and conventional Milligan–Morgan haemorrhoidectomy: different solutions for different targets

Haemorrhoidal disease is one of the most common anorectal disorders. The aim of this study is to compare the results, over the last 10 years, of stapled haemorrhoidopexy (SH) with those of standard Milligan-Morgan haemorrhoidectomy (M&M). Furthermore, we discuss the proper indications for each technique in terms of the lowest rate of complications and long-term results. Three hundred forty-three patients with different degrees of symptomatic haemorrhoids underwent SH or M&M from January 2005 to December 2007. Patients were divided into two groups, age and sex matched. The administration of painkillers drugs, antibiotics and laxatives, complication symptoms and hospital stay in all the patients were recorded after surgical treatment. The mean operative time was shorter in the stapled group compared to that in the open group (31 min versus 40 min). Postoperative pain, hospital stay and return to full activity were shorter in the stapled group. There was a significant difference in the wound healing time between the two groups. We noticed a higher rate of recurrence in patients treated with stapled haemorrhoidectomy for fourth-degree haemorrhoids. According to our experience, the Longo technique is indicated for the treatment of haemorrhoids of second- and third degree. In the latter grades of prolapse, the Milligan-Morgan haemorrhoidectomy can also be applied with good outcomes. We believe that, in case of irreducible prolapse, the M&M is to be preferred. However, operative management varies according to surgeon's interest and is tailored to meet the individual patient's need.

Common anorectal disorders: Diagnosis and treatment

Anorectal disorders affect men and women of all ages. Their management is not limited to the evaluation and treatment of hemorrhoids. Rather, a spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer). Symptoms are nonspecific, which can make the evaluation of patients difficult. In addition, treatment can be frustrating because clinicians are hamstrung by a lack of well-designed, prospective, clinical trials. Some of the most common anorectal disorders include fecal incontinence, pelvic floor dyssynergia, anal fissures, pruritus ani, proctalgia fugax, and solitary rectal ulcer syndrome. This article provides an update on the evaluation and treatment of common anorectal disorders.

What every gastroenterologist needs to know about common anorectal disorders

Anorectal complaints are very common and are caused by a variety of mostly benign anorectal disorders. Many anorectal conditions may be successfully treated by primary care physicians in the outpatient setting, but patients tend not to seek medical attention due to embarrassment or fear of cancer. As a result, patients frequently present with advanced disease after experiencing significant decreases in quality of life. A number of patients with anorectal complaints are referred to gastroenterologists. However, gastroenterologists' knowledge and experience in approaching these conditions may not be sufficient. This article can serve as a guide to gastroenterologists to recognize, evaluate, and manage medically or non-surgically common benign anorectal disorders, and to identify when surgical referrals are most prudent. A review of the current literature is performed to evaluate comprehensive clinical pearls and management guidelines for each topic. Topics reviewed include hemorrhoids, anal fissures, anorectal fistulas and abscesses, and pruritus ani.

Stapled hemorroidopexy: Day surgery or one day surgery?

Hemorrhoidal disease is one of the most common anorectal disorders, from 10% to 20% of all patients admitted at a clinical investigation need to undergo surgery, stapled haemorrhoidopexy is gaining wide acceptance as an interesting, safe and less painful technique, but hemorrhage is one of the most serious early complications and is a severe complication in day surgery. In our day surgery proctology, surgical procedures represent about 32%. Of these, 24% are for hemorrhoidal disease, we present our protocol and experience for early and safe discharge, 6h after stapled hemorrhoidopexy surgery.

Stapled versus conventional surgery for hemorrhoids

Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques. This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids. We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009. All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included. Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model. Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.

Manual dilatation of the anus.

A group of 100 consecutive patients undergoing manual dilatation of the anus between 1980 and 1983 were reviewed retrospectively by examining the clinical presentation, diagnosis, treatment and outcome. Anal fissure was diagnosed in 46 patients, 22 had either first- or second-degree haemorrhoids, and stenosis of the anal canal was identified in seven. Manual dilatation of the anus was performed on 25 patients in the absence of a diagnosis. Dilatation failed to treat 26 anal fissures successfully. Where it was employed alone in ten cases of haemorrhoids and seven of anal stenosis, manual dilatation failed to cure seven and five patients respectively. Of the patients with no diagnosis, 23 were relieved of their symptoms following dilatation. Episodes of incontinence occurred in 27 patients, 21 of whom were female. There should be a reduced role for manual anal dilatation in the treatment of common anorectal disorders.

The diagnosis and management of common anorectal disorders*

Anorectal abscess and fistula are a common clinical problem. In the majority of cases, caused by infection of the anal gland, surgical treatment is usually required. In a minority, when related to Crohn's disease, medical treatment is the mainstay. The aim of treatment is to maximize the healing rate and minimize the risk of incontinence. To achieve these goals, preoperative investigation is necessary for classification and planning. Selection of the technique should be based on the disease (classification and etiology), the patient (physical and continence status), and the surgeon (technique and technology). This chapter provides a review of these conditions, classification, investigation, and treatment options.

Common anorectal disorders

Anorectal disorders are extremely common and are often manifest in the psychiatric patient population. While most conditions are self-limited, there are a variety of problems, from hemorrhoids to infection and venereal disease, that demand diagnosis and treatment. The patient is often unaware of the true nature of the problem and frequently attributes his or her symptoms to “hemorrhoids.” The distal rectum and anal canal are the location of most of the pathology discussed below. Examination consists of inspection of the perianal area, digital examination, and instrumentation with anoscopy and sigmoidoscopy. Most conditions are readily apparent. The examiner must always keep in mind that many common symptoms of anal rectal disorders such as bleeding, pain, and discharge, can be signs of malignancy. Conditions to be discussed include hemorrhoids, fissure in ano, fistulas, abscesses, pruritus ani, pilonidal sinus, condylomata acuminatum, and other venereal infections. This list includes the most common disorders with which the general physician will be confronted. Discussion will be directed toward identification and appropriate therapy.