Bilateral Rotational S Flap Technique for Preventing Restenosis in Patients With Severe Circular Anal Stenosis: A Review of 2 Cases

Anal stenosis is a late hemorrhoidectomy complication. Sphincterotomy and various anoplasty techniques are used for treatment severe anal stenosis, such as the C flap, House flap, U flap, and rotational S flap, but no procedure is ideal for every patient. We review 2 cases of severe circular anal stenosis. Their complaints included narrow caliber of the stool and feeling unsatisfied defecation. Excision of scar tissue using the circular technique was followed by reconstruction using the bilateral rotational S flap procedure. At the 1-year follow-up, the patient had complaints about neither defecation nor pain, and no longer needed laxative agents. In conclusion, the bilateral rotational S flap technique should be considered as a viable treatment because it can also prevent the occurrence of restenosis, especially given the consideration of adequate blood supply.

A novel four quadrant laser sphincterotomy for idiopathic severe anal stenosis / Nova esfincterotomia a laser nos quatro quadrantes para estenose anal idiopática grave

ABSTRACT Anal stricture or stenosis, though uncommon, is disabling condition. It affects the quality of life due to pain, bleeding and difficulty in defecation, incontinence or increased frequency. It occurs when the normally pliable anoderm is replaced with fibrotic connective tissue, leading to an abnormally tight and inelastic anal canal. Mostly it occurs secondary to trauma, iatrogeny, inflammatory diseases, radiation or neoplasia. The treatment of anal stricture is generally considered to be difficult and various methods of treatment have been suggested. It is often unresponsive to conservative medical management. The surgical procedures such as dilatations and anoplasty are associated with significant complications which make it a difficult treatment challenge. Several good treatment options are available currently. Through this case, we report and explore a new medical treatment for anal strictures with four quadrant laser sphincterotomy.

RESUMO A estritura ou estenose anal, embora incomum, é problema incapacitante. Essa condição afeta a qualidade de vida por causa da dor, do sangramento e da dificuldade de defecação, de incontinência ou aumento da frequência. A estenose anal ocorre quando o anoderma, normalmente flexível, foi substituído por tecido conjuntivo fibrótico, e o resultado é um canal anal anormalmente estenosado e inelástico. Na maioria dos casos, a estenose anal ocorre secundariamente a trauma, por causa iatrogênica, por doença inflamatória, radiação ou neoplasia. Em geral, se considera que o tratamento dessa condição é tarefa difícil, tendo sido sugeridos diversos métodos de tratamento. Com frequência a estenose anal não responde ao tratamento clínico conservador. Procedimentos cirúrgicos como as dilatações ou a anoplastia estão associados a complicações significativas, implicando difícil desafio terapêutico. Atualmente, o cirurgião conta com várias opções terapêuticas satisfatórias. No presente caso, relatamos e exploramos um novo tratamento clínico para estenoses anais, por meio da esfincterotomia a laser nos quatro quadrantes.

Repair of postburn pseudo anal stenosis using rectangular skin flap combined with triangle skin flap / 中华整形外科杂志

Objective@#To investigate the clinical effects of the " rectangle plus triangle flaps" methods to repair the post-burn pseudo anal stenosis.@*Methods@#From Oct. 2014 to Jan. 2017, five cases of pseudo anal stenosis were hospitalized and the durations of their scar contraction were 0.5 to 2 years. Flaps were located: at 3 o′clock and 9 o′clock directions of anus with prone position. Flaps were designed as one rectangle flap plus two triangle flaps. Rectangle flap was located from the exit of the diverticulum (pedicle) to the anus (distal end). Triangle flaps were located between the anus and the distal end of the rectangle flap, perpendicular to the rectangle flap. Flap transfer: ① the rectangle flap was advanced to the anus direction and sutured with the incision edge of the triangle flap closer to the anus; ② the two triangle flaps were rotated by 90 degrees and transferred to the two longitudinal incisions of the rectangle flap.@*Results@#This design could enlarge the diverticulum exit and shorten its distance to the anus. All flaps survived and were well-healed. The follow-ups at 0.5 to 2 years presented favorable clinical results. No flap contracture, recurrent stenosis, unobstructed defecation or cleaning convenience occurred.@*Conclusions@#The " rectangle plus triangle flaps" methods was an effective way to repair the post-burn pseudo anal stenosis, which could enlarge the diverticulum exit and relocate the anus by making use of the perianal scar tissue.

Surgical management of anal stenosis: anoplasty with or without sphincterotomy / Tratamento cirúrgico da estenose anal: anoplastia com ou sem esfincterotomia

ABSTRACT 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.

RESUMO Objetivo: A estenose anal é complicação incomum da cirurgia anorretal, sendo principalmente resultante de uma hemorroidectomia circunferencial ou ressecção do pólipo cutâneo no tratamento cirúrgico da fissura anal crônica. O objetivo da anoplastia é a restauração da função normal do ânus, mediante a divisão da constrição e alargamento do canal anal. A esfincterotomia interna pode causar incontinência gasosa; e se tratarmos a estenose sem esfincterotomia, poderá ocorrer insucesso. Poderíamos usar a anoplastia sem esfincterotomia? Método: Os pacientes com estenose anal foram designados para dois grupos. O primeiro grupo foi tratado com anoplastia em Y-V sem esfincterotomia interna lateral parcial, e o segundo grupo foi tratado com anoplastia em Y-V com esfincterotomia interna lateral parcial. Resultado: No total, 25 pacientes (10 homens e 15 mulheres) foram tratados com anoplastia-14 sem esfincterotomia interna lateral parcial, e 11 com esfincterotomia interna lateral parcial. Os percentuais de cura da estenose foram de 91% e 93% nos grupos tratados com anoplastia sem esfincterotomia interna lateral parcial e com esfincterotomia interna lateral parcial, respectivamente (p = 0,69). Não ocorreu mudança significativa nos dois grupos com relação às queixas de incontinência pós-operatória. Conclusão: O percentual de cura da estenose anal foi igual nos pacientes tratados com anoplastia em Y-V com ou sem esfincterotomia interna lateral parcial. Não foi observada mudança significativa na incontinência pós-operatória entre os dois grupos. Portanto, a anoplastia em Y-V seria um método cirúrgico seguro e simples em pacientes selecionados. Em casos isolados, o procedimento de esfincterotomia interna lateral parcial tem sido observado.

Anal Stenosis Following Sclerotherapy Managed by Anoplasty.

Anal stenosis is a rare but serious disabling condition following ano rectal surgery, anal trauma, carcinoma, post radiotherapy and Crohn's disease. 90% of the anal stenosis is causes by overzealous haemorrhoid surgery. Stricture following sclerotherapy is also mentioned in the literature. In our cases disabling anal stenosis was for last 1 year following sclerotherapy of haemorrhoids leading to severe anal stenosis with diaphragmatic ring like annular stenosis. A formal Y-V anoplasty was performed which relieved the patients of their symptoms leading to satisfactory bowel movements.

Prevalence of Anatomic Anal Stenosis in Patients with Chronic Anal Fissure and Results of Lateral Internal Sphincterotomy

PURPOSE: The aim of this study was to estimate the prevalence of anatomic anal stenosis in patients with chronic anal fissure (CAF) and ascertain the results of lateral internal sphincterotomy (LIS) using a new calibrator. METHODS: Ninety-eight adults with CAF and a control group of 40 normal adults underwent anal calibration under spinal anesthesia. The calibrator was a conical design and the diameter was scaled in increments of 1 mm. The calibration was standardized and the reliability of it was assessed by two independent examiners for the same group (n=45). Confounding effects of age, sex, body weight, and height on the anal caliber were studied. The internal sphincter was divided to the level of the dentate line during LIS. RESULTS: The anal caliber was 34.6 +/- 1.4 mm (mean +/- SD) in the control group and 28.7 +/- 3.0 mm (mean +/- SD) in patients with CAF. Excellent correlation was obtained between the two examiners (r=0.958). The confounding effects of age, sex, body weight, and height were not significant. Therefore, anal stenosis was defined as when the measurement was 31 mm or below (mean-2SD of control value). Stenosis was present in 82 of 98 patients (84%) with CAF. Patients with stenosis had an anal caliber of 27.9 +/- 2.5 mm, with a range of 21 to 31 mm. Following LIS, 91 of 98 patients (93%) with CAF attained the normal range, two patients still had stenosis, and five patients had an anal caliber exceeding the normal value. CONCLUSIONS: Anatomic anal stenosis was found in 84% of the patients with CAF. Ninety three percent of these patients attained a normal anal caliber, 2 percent of the patients still had stenosis and 5 percent of the patients had an anal caliber exceeding the normal value after LIS.

Comparison of C-anoplasty and House Shaped Advancement Flap in Anal Stenosis

PURPOSE: The surgical treatment of anal stenosis includes internal sphincterotomy, rotaton flap and advancement flap according to the stenosis degree, recently, Christensen performed house shaped advancement flap and reported fair results. We compared and analyzed the surgical methods and results in patients with moderate and severe anal stenosis who underwent house shaped advancement flap and C-anoplasty. METHODS: We have performed this study with 6 cases using the house shaped advancement flap and 6 cases using the C-anoplasty. The out come was assessed by clinical characteristics, surgical method, operation time, duration of hospitalization, healing time, postoperative complications, results. RESULTS: The average operation time was 38 min in those house shaped advancement flap cases and 63 min in C-anoplasty cases. The average time of hospitalization was 6 days and 9 days, respectively, and the average time of healing was 28 days and 46 days, respectively. In those house advancement flap cases, surgery could be done in 2 directions at the same time in 4 cases and 3 directions in 2 cases; as for those C-anoplasty cases, surgery could be done in 1 direction in 4 cases and 2 directions in 1 case. Two complications were observed in C-anoplasty, one flap infection and one flap necrosis, and in house shaped advancement flap, no complication was observed. CONCLUSIONS: House shaped advancement flap have several advantages compared to the C-anoplasty, and since house shaped advancement flap could be performed in 2 to 3 directions or even 4 directions at the same time, the anus could sufficiently expanded in severe anal stenosis patients. The house shaped advancement flap might be one of the good method in treating anal stenosis.

Surgical Managements of Anal Stricture

Anal stricture is a mechanical narrowing of the anal canal due to contracture of the epithelial lining which has been supplanted by fibrous connective tissue. We reviewed 82 patients with anal strictures who were admitted at Song-Do Colorectal Hospital from Jan. 1994 to Dec. 1996. The etiology of the strictures were injection therapy with necrotizing agent in 62 patients(78%), secondary to hemorrhoid and fistular operations in 13 patients(17%), and other causes in 7 patients(8.5%). The degree of anal stricture was mild in 40 patients, moderate in 33 patients, and severe in 9 patients. The operation methods used to treat the anal strictures were infernal sphincterotomy in 27 patients, local advancement flap in 42 patients, and rotational flap in 13 patients; the selection of the operation method was based on the cause, severity and level of the stricture. During the local advancement or rotational flap operation, a concurrent internal sphincterotomy was also employed in selected patients who had a fibrotic muscular component contributing to the stricture. We preferred to use a sliding skin graft in the advancement flap operation and a C-flap in rotational flap operation. According to a follow-up study with an average follow-up of 20 months, 24 of the 27 patients with mild stricture, 19 of the 24 patients with moderate stricture, and 7 of the 8 patients with severe stricture had good results, and remained 3 patients with mild stricture, 5 patient with moderate stricture, and 1 patient with severe stricture had fair results. Mild anal strictures were effectively treated by sphincterotomy or one or two sliding skin grafts, moderate to severe anal strictures with diaphragmatic type were treated by anorectoplasty, and moderate to severe low anal stoictures with annular type were effectively treated by two or three sliding skin grafts. Based on these results, sliding skin grafts should be effective in most cases of moderate to severe anal canal stricture, although occasionally a rotational flap may be indicated in cases of severe lack of the anoderm.

A Clinical Study on Sliding Skin Graft for the Treatment of Anal Stenosis

Twenty five patients with moderate to severe anal stenosis were treated with sliding skin graft during the period of time from April 1987 to March 1996. And a follow-up study was carried out on 18 cases among them. The original causes of the anal stenosis were previous necrotherapy in 14, hemouhoidectomy in 3, and cryotherapy in one. Postoperatively, partial disruption of the suture line developed in 2 cases and perianal fistula in one. Long term clinical results were good in 12 cases, fair in 4, and poor in 2. As a result, sliding skin graft is thought to be a simple and effective method for the treatment of moderate to severe anal stenosis.