Improved Outcomes in Colon and Rectal Surgery part 23 pdf

20 improved outcomes in colon and rectal surgery limited versus full internal sphincterotomy. In one study, early incontinence in patients undergoing full sphincterotomy (10.9%) was increased compared to patients who underwent limited sphincterotomy (2.2%, p = 0.039). (91) However, this difference did not persist with long-term follow-up with only 2 patients who underwent full sphincterotomy reporting persistent incontinence. In the other study, there was no significant difference in posttreatment and baseline incontinence scores between the two types of sphincterotomy.(92) Overall, internal sphincterotomy up to the dentate line has been shown to produce faster healing and pain relief but is associated with increased rates of early incontinence compared to sphincterotomy to the fissure apex. Given the significant variation in incontinence rates after sphincterotomy, several investigators have sought to further characterize incontinence in patients with chronic anal fissure with respect to type, frequency, and permanence. In a study of preoperative and postoperative incontinence in 126 patients with chronic anal fissure, Anmari and colleagues found that 28% of patients had minor preoperative disturbances in continence that persisted postoperatively.(93) Casillas and colleagues found that patients endorsed a higher rate of incontinence in response to a questionnaire than was recorded in their medical record or was reported in a telephone survey.(94) In other studies, risk factors for incontinence were identified.(95–96) These include preexisting sphincter injuries, IAS division >50%, injury to external anal sphincter during the procedure, functional impairment with age, shorter sphincter in females, and posterior keyhole deformity. While external anal sphincter injury during anal stretch and a posterior keyhole deformity after posterior sphincterotomy clearly result in higher rates and more severe forms of incontinence, the presence of other risk factors in patients who are undergoing lateral internal sphincterotomy result in lower rates of minor incontinence which are frequently tempo- rary. In fact, some incontinence scales are so sensitive to changes in continence, that one study identified no impairment in quality of life despite decreases in continence scores.(97) Overall, incontinence after sphincterotomy remains a real complication that must be considered in patients at higher risk (female, older age, previous anorectal surgery) with subsequent modification of the surgical procedure if necessary. Refractory fissures Several recent studies have been performed to identify character- istics associated with fissure persistence despite treatment. In one study the etiologic and manometric differences between anterior and posterior anal fissures which failed to heal with nitrate therapy were examined. When comparing patients with both anterior and posterior fissure who failed medical therapy, Jenkins and colleagues found that anterior fissures were more common in younger women (33 years vs. 44) and were more likely to be associated with obstetric trauma and an occult external anal sphincter defect.(98) Patients with anterior fissure were also more likely to have normal or low anal resting pressures compared to controls. This was significantly different from the elevated resting pressures measured in patients with posterior fissure. In addition, the maximum squeeze pressure was significantly lower than normal controls and patients with posterior fissure. Corby and colleagues also found that postpartum females have lower anal resting pressure and squeeze pressures than they did antepartum.(99) Thus, postpartum females who develop anal fissure (9% incidence) have reduced anal canal resting pressure and treatments to decrease internal sphincter tone can lead to incontinence. Other investigators have sought to identify medical therapy that can act as rescue treatments for patients with persistent anal fissure before a surgical treatment is undertaken. In one study 2% diltiazem ointment was used for treatment of chronic anal fissure refractory to GTN.(100) Fissure healing occurred in 49% of patients with no recurrence over 8 weeks of follow-up. Healing was not dependent on whether a full course of GTN was completed with fissure persistence or GTN treatment was discon- tinued secondary to adverse side-effects. In two other studies BT was used to treat nitrate resistant fissures (GTN and ISDN). (101, 102) Forty-three to 50% of patients with nitrate resistant fissures achieved healing with BT treatment. Patients with nitrate resistant fissures have also been randomized to another course of nitrates or nitrates plus BT.(103, 104) More patients healed their fissures with a combination of BT and nitrates (47–67%) compared to BT alone (20–27%). More studies are needed to determine the optimal treatment for refractory or persistent fissures. Alternative surgical therapies are available for chronic anal fissure associated with low anal resting pressure or for those that persistent after surgical sphincterotomy. These include island advancement flaps. Nyam and colleagues described advancement flaps in a series of patients with low anal resting pressure and maximum squeeze pressure.(105) Some patients had external sphincter defects and others had previous fissure surgery. Patients underwent fissurectomy with flap coverage by perianal skin. All 20 patients healed with one contracture at the donor site and minimal donor site discomfort. Leong et al. compared anal advancement flap to lateral internal sphincterotomy for the treatment of chronic anal fissure.(106) More patients healed with sphincterotomy (100%) compared to anal advancement flap (85%). A number of flaps, such a V-Y anoplasty, have been described for chronic anal fissure with good success (Figure 20.2). A key to reduc- ing complications with flap closure is careful hemostasis, which reduces the risk of hematoma formation, flap loss, and infection. Design of the flap with good length-to-width ratio is important to ensure adequate vascularity and minimal tension. (107) Anal advancement flaps remain an important surgical alternative for patients with low pressure fissures and persistent fissure despite previous anorectal surgery. CoMPliCationS oF Surgery For anal StenoSiS Acquircd anal stenosis can be a late sequela of a variety of anorectal surgical procedures. It has been reported to occur after 5 to 10% of radical hemorrhoidectomies and after fissurectomy, radiation injury, and Moh’s chemosurgery.(108, 109) The cause of these strictures is excessive removal of the anodermal lining of the anal canal: and thus is generally preventable. In cases of severe, symptomatic anal stenosis, a variety of flaps can be used to resurface the anal canal and expand its circumference. The key to success with any of these flaps is that they be carefully designed to maintain vascularity and that subflap hematoma formation is averted to minimize the risk for infection and flap necrosis. 20 surgery and nonoperative therapy of anal fissure Patients should undergo complete mechanical and antibiotic bowel preparation before surgery. After surgery, bowel activity may be restricted with a clear liquid diet for a day or two. After this period, patients are allowed a regular diet and given fiber supplements and laxatives to avert constipation One final, important point is the limitation of patient activity for several weeks so that flap motion is minimal, to allow neovascularity to occur Anal S-plasty (Figure. 20.3) was first proposed by Ferguson (110) as a method to correct Whitehead deformities in 13 patients. Later Corman et al. (111) modified the procedure for use in the management of anal stenosis. The key to the success of this approach is development of ’ large, full-thickness skin flaps with a base-to-length ratio >1.0. Ferguson recommended a base of 7 to 10 cm and maintenance of a thin layer of fat globules on the deep aspect of the flap so that adequate vascularity can be ensured. He further cautioned against overzealous hemostasis on the flap itself so as not to impair blood flow. The flaps are then rotated toward the anal canal so that the anodermal defect can be resurfaced. The flaps are sutured in place, and the remaining semilunar defect is sutured to allow its primary healing. It is wise to use a closed suction drain beneath the flap to avert seroma or hematoma formation. For less severe anal strictures that require less skin coverage, the Y-V anoplasty, is an excellent alternative because it is simple to per- form and is less traumatic for the patient. This technique was ini- tially described by Penn (112) in 1948. Again, successfu1 healing of the flap requires a length-to-base ration <3.0. Gingola and Arvanitis (113) presented a series of 14 patients. Thirteen healed within 14 days with no episodes of infection or hematoma formation. Five patients sloughed a small portion of the flap tip but required no additional treatment. Experiences reported by other authors sup- port the low rate (10 to 25%) of tip necrosis and the high rate (85 to 92%) of stenosis relief associated with this technique (114, 115). It must be remembered, however that Y-V advancement flaps limit how much anal resurfacing can be accomplished. Other uses for the Y-V advancement flap have been advo- cated. Rosen (116) used it to treat anal stcnosis and ectropion (Figure 20.4).The blood supply for this flap is based on perforating vessels in the subcutaneous fat. The Y-V advancemcnt flap is well suited for covering the lower anal canal but has limited application for stenosis above the dentate line. Figure 20.2 V-Y anoplasly. (A) Incisions create a V-shaped or triangular flap which is advanced to close defect. (B) Closure of skin behind “V” pushes the flap into the anal canal, and the flap is sutured in place. (A) (B) Figure 20.3 Ana1 S-plasty. (A) Ectroion is excised and S-shaped incisions are created. (B) and (C) flaps are rotated lo close the defects and sutured in place. (A) (B) (C) 20 improved outcomes in colon and rectal surgery Figure 20.4 Y-V anoplasty. (A) Y shaped incision is made. (B) V-shaped flap is mobilized and advanced to the top of the defect. (C) Flap is and sutured in place. (A) (B) (C) Figure 20.5 House advancement flap. (A) House-shaped flap is created. (B) The flap is advanced into the anal canal and (C) sutured in place. (A) (B) (C) Figure 20.6 Diamond flap. (A) Diamond-shaped flap is created. (B) The flap is advanced into the anal canal to fill the defect. (lnsert demonstrates perforating subcutaneous blood supply). (C) Flap is sutured in place. (A) (B) (C) Other techniques of flap formation have been suggested. Christensen et al. (117). proposed the use of “house” advancement pedicle flaps. The editors prefer the house flap because it is easy to construct, can cover as much as 25% of the anal circumference, and permits primary closure of the donor site (Figure 20.5). If additional coverage is needed, two, three, or four flaps may be used. Caplin and Kodner (118) recommended the use of the diamond flap for many of the same reasons (Figure 20.6). ConCluSion Chronic anal fissure is a common and painful anorectal dis- order. Many treatments are available for benign idiopathic fissures. The goal of treatment is to reduce the high anal resting pressure or internal sphincter hypertonia in fissure patients. First line therapy consists of either topical nitrates or calcium channel antagonists. If topical therapies fail, a repeat treatment course can be prescribed. As second line therapy, botulinum 2 surgery and nonoperative therapy of anal fissure toxin injection or internal sphincterotomy can be performed. Ideally, patients who are at risk of incontinence after internal anal sphincter division should attempt medical therapy (age>50, multiparous female, previous anorectal surgery). If sphincterotomy is contemplated for high risk patients, preoperative anal manometry and ultrasound should be considered. Alternatively, fissurectomy with anal advancement flap can be performed. 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Botulinum toxin A injection in ISDN ointment-resistant chronic anal fissures. Dig Surg 2007; 24: 197–201. 103. Lysy J, Israeli-Yatzkan Y, Sestiery-Ittah M et al. Topical nitrates potentiate the effect of botulinum toxin in the treatment of patients with refractory anal fissure. Gut 2001; 48: 221–4. 104. Jones OM, Merrie A, Cunningham C et al. Randomized clinical trial of botulinum toxin plus glyceryl trinitrate vs. botulinum toxin alone for medically resistant chronic anal fissure: overall poor healing rates. Dis Colon Rectum 2006; 49: 1574–80. 105. Nyam DCNK, Wilson RG, Stewart KJ, Farouk R, Bartolo DCC. Island advancement flaps in the management of anal fissures. B J Surg 1995; 82: 326–8. 106 Leong AF, Seow-Choen F. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissures. Dis Colon Rectum 1995; 38: 69–71. 107. Fleshman JW. Fissure in ano and anal stenosis. In: Beck DE, Wexner SD, eds. Fundamentals of Anorectal Surgery,New York: McGraw-Hill, 1992: 170–82. 108. Leong AFPK, Seow-Choen F. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. Dis Colon Rectum 1995; 38: 69–71. 109. Oh C, Albanese C. S-plasty for various anal lesions. Am J Surg 1992; 163: 606–8. 110. Ferguson JA. Repair of “Whitehead defornllty” of the anus. Sur’g Gynecol Obstet 1959; 108: 115–6. 111. Corman ML, Veidenheimer MC, Coller JA. Anoplasty for anal stricture. Surg Clin North Am 1976; 56: 727–31. 112. Penn JA. A case of anal reconstruction by means of local skin flaps. Br J Plast Surg 1948; 1: 87–8. 113. Gingold BS, Arvanitis M. V-V anoplasty for treatment of anal stricture. Surg Gynecol Obstet 1986; 162: 241–2. 114. Angelchik PD, Harms BA, Starling JR. Repair of anal stricture and mucosal ectropion with V-V or pedicle flap anoplasty. Am J Surg 1993; 166: 55–9. 115. Ramanujan PS, Venkatesh KS, Cohen M. V-V anoplasty for severe anal stenosis. Contemp Surg 1988; 3: 62–8. 116. Rosen L. V- Y advancement for anal ectropion. Dis Colon Rectum 1986; 29: 596–8. 117. Christensen MA, Pitsch RM, Cali RL, Blatchford GJ, Thorson AG. “House” advancement pedicle flap for anal stenosis. Dis Colon Rectum 1992; 35: 201–3. 118. Caplin DA, Kodner IJ. Repair of anal stricture and mucosal ectropion by simple flap procedures. Ills Colon Rectum 1986; 29: 92.   Surgery for pilonidal disease and hidradenitis suppurativa Paula I Denoya and Eric G Weiss CHALLENGING CASE A 35-year-old healthy male undergoes pilonidal cystectomy by wide local excision down to sacral fascia. Six months postoperatively his wound has failed to heal as manifest by a persistent 4 × 4 cm by 2 cm deep granulation bed. CASE MANAGEMENT The patient has a nonhealing pilonidal wound. Options include surgical reexcision with intensive postop wound management or some type of excision and flap closure as described in this chapter. INTRODUCTION Pilonidal disease and hidradenitis suppurativa are both conditions affecting the perianal area, and therefore are often referred to the colorectal surgeon for management. The management of these diseases can be quite challenging. Both conditions may be complicated by recurrent disease and may result in significant scarring or large open wounds in the perianal or coccygeal area. PILONIDAL DISEASE Pilonidal disease is a chronic suppurative condition which occurs most commonly in the sacrococcygeal area. It typically presents as a painless cyst or sinus opening in the gluteal cleft, as an acute or recurrent abscess, or as chronic draining sinuses. It most commonly affects Caucasian males between the ages of 15 and 30 and is essentially not seen after the age of 45. The true incidence is unknown, but pilonidal disease is responsible for the loss of significant healthcare resources and workhours. Historical Perspective Pilonidal disease is believed to have been first described by Mayo (1) in 1833. The term “pilonidal,” originating from the Latin words for “hair” and “nest,” was not coined until 1880 by Hodges. (2) The disease became more widely known during World War II, when the number of soldiers developing it put a burden on the military. At this point, it acquired the name of “jeep disease;” a term coined by Buie (3) based on the idea that the disease was caused by trauma to the skin of the lower back from riding in jeeps for extended periods of time under hot and sweaty conditions. Early in the documented history of this disease, the etiology was believed to be congenital. The pilonidal cysts and sinuses were thought to be embryologic remnants resulting from failed involution of the neural tube structures. This theory was supported by studies of fetuses, which identified remnants of midline structures. It was believed that these structures would normally involute before birth, but sometimes failed to do so and led to the development of pilonidal sinuses.(4) In 1946, Patey (5) introduced a theory of an acquired etiology for pilonidal disease, suggesting that hair piercing into the sacrococcygeal skin caused the sinuses and infected cysts. This acquired theory was later supported by other studies (6–8) and is now widely accepted as the etiology of pilonidal disease. Loose hairs from the head or back fall and accumulate in the gluteal cleft. The hairs are then drilled into the skin deep in the cleft by friction from the buttocks rubbing together while walking. As the person ambulates, the hairs get pulled into the sinus, creating a cyst containing hair and debris. This can periodically get infected and drain spontaneously through lateral sinus tracts, or present acutely as an abscess. Studies of surgical specimens have found cysts containing hair and debris, but hair follicles have never been found in the cyst wall itself, sup- porting the theory that the hair is of external origin.(9) (Figure 21.1) Bascom studied the midline pits and believed that these are likely enlarged hair follicles which are involved in the etiology of the disease.(10) He theorized that ingrown hairs originating in these midline gluteal hair follicles were pushed into the subcutaneous fat and resulted in pilonidal abscess. Pilonidal disease has also rarely been described in other areas of the body, such as the hands of barbers (11), sheep shearers (12), and others who handle loose hairs.(13) This further supports the acquired nature of the disease. Diagnosis The diagnosis is made by physical examination in a patient who generally fits the demographics of being hirsute and in the 2nd or 3rd decade of life. Characteristic findings on exam are small midline pits at the superior aspect of the gluteal cleft, approximately 3–5 cm from the anus. (Figure 21.2) There may be only one or mul- tiple pits present, and there may be tufts of hair or debris in them. Some patients may also have lateral fistula openings which can Figure 21.1 Pilonidal cyst opened after excision showing hair inside cyst cavity.  improved outcomes in colon and rectal surgery undergoing incision and drainage for first presentation of pilonidal abscess, 58% healed the wounds within 10 weeks, and 21% recurred during the 18 month follow-up period.(17) This recurrence rate of approximately 20% is consistent with that found throughout the literature. Management of Chronic Disease Chronic pilonidal disease may present in several forms: a nonhealing wound after initial drainage, chronically draining sinuses, or recurrent pain and infection. The goals of definitive treatment of the disease are to remove the diseased tissue in a manner that will prevent recurrence, to change the local environment of the gluteal cleft, to decrease the chance of recurrence and allow healing, and to allow the patient to resume their normal activities and return to work quickly. There is no one ideal approach to managing this disease. Nonsurgical Treatment There is very little role for purely nonsurgical management of pilonidal disease. In select patients who are found to have asympto- matic midline pits with no evidence of infection, it is possible to just observe the patients. Prophylactically, the patient may be instructed to ensure good hygiene, to keep the area of the gluteal cleft dry, and to periodically shave the area to keep hairs from accumulating. Patients who present with acute abscess will require drainage, but sometimes may be able to be managed nonoperatively afterwards. Figure 21.2 Chronic pilonidal disease showing midline pit. Figure 21.3 Acute pilonidal abscess. Note midline opening with abscess slightly to the right of midline. periodically drain purulent discharge. In the acute presentation, the patient may present with an abscess which is usually found just off the midline, along with the typical finding of midline pits. (Figure 21.3) The differential diagnosis includes perianal abscess or fistula, hidradenitis suppurativa, and other presacral or spinal lesions such as chordoma or ependymoma. However, pilonidal disease can usually be identified by its characteristic location in the gluteal cleft away from the anus, and by the presence of midline pits. In severe cases where there is doubt, imaging with CT scan or MRI (14) may be useful, though usually not necessary. There have been rare reports of malignancy developing in chronic pilonidal sinuses. Most commonly these are squamous cell carcinomas. These tumors are fairly aggressive, with a high recurrence rate and poor prognosis.(15, 16) Management of Acute Disease The treatment for an acute pilonidal abscess is similar to that of an abscess in any other location. Incision and drainage, leaving the wound to heal by secondary intention, is the accepted treatment modality. The patient can be positioned either in lateral decubitus or prone position, though prone is generally preferred. Incision and drainage may be performed under local, regional, or general anesthesia, and may be done in an ambulatory setting such as the office or emergency room. The area should be prepped in standard fashion and local anesthetic infiltrated over the area of fluctuance. A vertical incision or an ellipse of skin should be made over the fluctuant area, 1–2 cm off the midline. Purulent fluid, along with hair or other debris, may be found in the cyst cavity. This should be removed and the cavity packed. An alter- nate technique for patients with a large abscess cavity is to use catheter drainage, as described in Chapter 19. The patient may be discharged on antibiotics to treat the overlying cellulitis if present and instructed in wound care. In a series of 73 patients  surgery for pilonidal disease and hidradenitis suppurativa Approximately 20% of patients who undergo abscess drainage will suffer from recurrent disease. There is little information available regarding the nonoperative treatment of these recurrences. Armstrong et al. (18) reported faster healing in 101 patients who were managed with gluteal cleft shaving and good perineal hygiene following incision and drainage, when compared with 229 patients who underwent surgical management after drainage. Following these initial findings, the authors implemented a policy of nonoperative management for their patient population. They reported only 150 hospital admissions for complications of pilonidal disease during the study period of 17 years, of whom only 23 patients required surgical management. They did not specifically report how many total patients were under their care during the study period. It is likely that the patients who responded well to nonoperative treatment had milder disease than the ones that required further surgery. This conservative approach can be considered in select patients with mild disease, or in patients with significant medical contraindica- tions to surgery. Many surgeons advocate some form of depilation following surgery to aid in healing. Whether this is shaving, waxing, chemical depilation, or laser treatments can be left up to individual patient or surgeon preference.(19) Other methods that have been described with varying success are fibrin glue or phenol injections into the sinuses. Greenberg et al. reported a series of 30 patients treated with fibrin glue injection with no recurrence or infection after a follow-up of 23 months.(20) Another study of six patients who had injection of fibrin glue into the sinus after curettage of pits reported no recurrences at 1 year.(21) However, this technique has not been tested in larger case series or randomized trials. Phenol sclerotherapy has been used for treatment of pilonidal disease with varying success. Early studies showed potential benefit in uncomplicated cases. Dogru et al. reported a series of 41 patients (22) who had crystallized phenol applied to the wounds after limited excision of midline pits. Most patients required 2–3 appli- cations, and 95% healed completely. There were two recurrences of disease. However, another study of 45 patients who had 1–2 mL of 80% phenol solution into the sinus reported 60% healing, and five patients developed abscess requiring operative drainage.(23) Surgical Options for Chronic Pilonidal Disease Operations for chronic pilonidal disease involve excision of the diseased tissue. This may result in a large defect which is difficult to close in an area which is subject to significant tension and mois- ture. This challenge has fueled the development of many different surgical techniques in an attempt to find the ideal operation. So far, no technique has proven to be ideal. This section of the chapter will review the most common operations and give an algorithm for the surgical approach to the management of chronic disease. The operations described may be performed in prone or lateral decubitus position, under regional or general anesthesia. The jack- knife prone position, with the operating table flexed at the waist approximately 30 degrees and the buttocks taped apart, provides the ideal exposure for most operations and is recommended unless contraindicated by individual patient factors. Standard periopera- tive antibiotics are given before incision. There is no need to con- tinue antibiotics postoperatively unless there is overlying cellulitis from acute infection. Many of these operations may be done on an outpatient basis. The more complex flaps require the patients to remain in the hospital on bedrest for approximately 2 days. These patients may also receive postoperative antibiotics for a few days until the drains are removed. Sutures are usually removed between 7 and 10 days after surgery. Wide Local Excision The most commonly performed operation for pilonidal disease is wide local excision. An elliptical incision including all sinus tracks is made and carried down to the sacrococcygeal fascia, so that the entire cyst is removed. There is debate as to the best way to manage the large wound that results. The benefits of leaving the wound open to heal by secondary intention include less chance of infection or wound breakdown, but this is counterbalanced by the increased time required to completely heal the wound, the need for frequent dressing changes, the added discomfort of having an open wound, and the increased time lost from work. There are few randomized trials which examined this problem. (Table 21.1) A series of 120 patients (24) who were randomized to either excision left open to heal by secondary intention or excision with primary Table 21.1 Procedures for pilonidal disease: wide excision with healing by secondary intention or primary closure. Study Closure Number of Patients Hospital Time (days) Healing Time (days) Infection (%) Recurrence (%) Follow-up (months) Sondenaa et al. (24) (1996) Open 60 Outpatient 86 13 5 50 Closed 60 Outpatient 23 30 10 50 Al-Salamah et al. (27) (2007) Open 192 4 (-) 3.12 3 35 Closed 188 3.6 (-) 4.2 3.7 36 Fazeli et al. (45) (2006) Open 72 1.76 41 13.9 4.2 22 Mentes et al. (25) (2006) Closed 493 5.5 (-) 1.2 5.6 18 Tejirian et al. (26) (2007 Open 26 (-) 147 (-) 35 (-) Marsupialization 42 (-) 42 (-) 2 (-) Note: (-) not described. . 20 improved outcomes in colon and rectal surgery limited versus full internal sphincterotomy. In one study, early incontinence in patients undergoing full sphincterotomy (10.9%) was increased. cavity.  improved outcomes in colon and rectal surgery undergoing incision and drainage for first presentation of pilonidal abscess, 58% healed the wounds within 10 weeks, and 21% recurred during. fissures are associated with occult sphincter injury and abnormal sphincter function. Colorectal Dis 2008; 10(3): 280–5. 2 improved outcomes in colon and rectal surgery 99. Corby H, Donnelly VS,

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