Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25

Modern trends in ambulatory proctology ______

Tomáš Skřička ______

Bakeš Memorial Hospital, Brno, Czech Republic ______

Abstract

Ambulatory proctology is till now very trombosis (personal experience with 382 anal underestimated discipline, which is out of tromboses) and anal fissures (personal interrest of „big surgeons“. But is is a very experience with 421 patients). We also important field due to incidence of proctological mention the other anal pathologies, which affections and severe social consequences of could be treated by means of modern their inappropriate diagnosis and treatment. proctology (hidrosadenitis analis, anal fistulas). We stress the conservative and semiinvasive Recently, more and more proctological treatment of (personal experience diseases could by treated as the out patient with 5296 patients, to whome 13429 rubber department procedure. band ligations have been applicated), anal

Key words: ambulatory proctology, hemorrhoids – semiinvasive therapy, anal fissure – dilatation

Introduction

Proctologic disease are as old as mankind good knowledge of the medical history helps itself and very „human“. And yet, most people delineate the clinical picture, although the final still fight shyness to talk about their signs and diagnosis cannot be made without symptoms in the anorectal region. Despite performance of a number of diagnostic tests recent effort to provide health education, the and procedures. Internal hemorroids, e.g., are anal region is still considered taboo. In the not readily palpable, but become evident only language of affiliated individual, the wide by means of anoscopy. Such systemic spectrum of proctologic complaints and examination procedure within the framework of manifestations associated with such a proctologic practice has unfortunately still not diseases is reduced to the almost stereotypic gained general acceptance. statement:“Doctor, I have hemorrhoids.“ A

Haemorrhoidal disease

Investigations revealed that about 70% of adult weeping or inflammation. For term population over 30 years of age suffer from „hemorroids“ is commonly used to designate a hemorroids (1). On the other hand it must be variety of anorectal diseases such as fissures, noted that many patients will not consult a rhagades, eczemas, abscesses, internal doctor until overt bleeding has occured. To the hemorroids and anal trombosis. layman, as a rule, all of the symptoms of the The anorectal diseases are generally anal region are hemorrhoids, whether they are associated with leadingsymptoms such as evidenced by pain, pruritus, bleeding, burning, bleeding, pain, and inflammation, which have

www.siccr.org 18 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 been a challenge to the medical profession rectal polyps, which could be also considered concerned with the art of wound treatment as „hemorroids“, without careful examination. from time immemorial. DO NOT TREAT Much more educational work will have to be WITHOUT PROPPER DIAGNOSIS !!!! Much done before patients learn to talk to their worse than above mentioned diseases are doctor early enough and without restraint about delayed diagnoses of rectal cancer, colitis, their anal discomfort. internal rectal prolapse, solitary rectal ulcer,

Diagnosis

Diagnosis of hemorrhoidal disease is the and can be seen at the exterior, only to synthesis of patient´s history, visual control disappear again immediately straining stops. before and during anoscopy and digital Third degree piles are cushions that descent examination, which serves only as a rough to the exterior on straining or defecation and orientation in the anal canal. It has been remain outside until the next bowel movement traditional to grade the hemorroids disease into or possibly the next act of straining. four degrees depending on the extent of „Fourth degree piles“ is the term sometimes prolaps: used to describe mucosal covered internal First degree piles are cushions that do not cushions that are permanently outside the anal descent below the dentate line on straining. By verge and at once inside when they are this strict definition everyone, even those replaced. Much more frequently this category without symptoms, fits into this category. The is used for the complicated third degree definition therefore has to be qualified to (trombosis, inflammation, exulceration). include only those individuals with symptoms, usually bleeding. Correct description of the localization of Second degree piles are cushions that hemorrhoids : 12 is anteriorly (in the direction protrude below the dentate line on straining to the pubis) , 6 posteriorly ( coccygis).

Conservative treatment

Step by step method should be the fist choice - regular bowel movements in the treatment of hemorroids. Taking a closer - diet high in dietary fibre look at the anorectal symptoms and the - ample fluid intake controversial views on the aethiology, it is - careful anal hygiene (but alcalic soap) understandable that a variety of therapeutic could cause anal mycosis and measures has come into widespread use. dermatitis!!) Every type of therapy, however, should - avoidance of laxatives (precise include the various general measures to be diagnosis of constipation, correction of tgaken by the patient himself: e.g. ventral rectocoele!!)

Drug therapy

Is important in most anortectal diseases. Therapy of bleeding Semiinvasive and surgical interventions are The main agents employed are adstringent generally not necessary until conservative metal compounds such as aluminium chloride treatment has failed. hydroxide, bismuth oxide and bismuth aubgallate. According to Mutschler (2), „it is

www.siccr.org 19 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 quite comprehensible that there is only a Antibiotics, antiseptics quantitative difference between adstringent Among the many agents used there are not effect and cauterisation“. only a variety of antiseptics (such a hexachlorophene) and antibiotisc(as e.g. Therapy of pain and irritation framycetine), but also phenylmercuric nitrate. First among theese substances are local Owing to the potential development of anaesthetics such as , , resistance, antibiotisc should be avoided, and polidocanol. Although fast end particularly in long-term therapy. When well acting, local anaesthetics, ultimately, have administered in high doses, phenylmercuric only symptomatic effects. Similar, but weaker nitrate can impair renal function. Its use in action are antihistaminics such as should, therefore, be discontinued. Agents diphenhydramine. As antiallergisc they have offering a broad antimicrobial spectrum, that is, good action in allergically induced both, antibacterial and antimycotic action, eczema, e.g., but seldom relieve pain. On the shold be used by preference to guard against whole, these agents are of quastionable value local infection. in the treatment of pain and irritation. Recent drugs Anti-inflammatory agents Acute hemorrhoidal crisis is recently mostly are still in widespread use as a and successfully treated by combined potent antiphlogistic agents, but leading remedies, e.g. Ginkor fort (containing extract coloproctologists are rather critical to the gingko bilobae, and heptaminol employment of such agents (atrophy of anal hydrochloride). Detralex (micronized, purified mucosa and perineal skin and interference with flavonoidic fraction, , hesperidin). The the healing process). Candida infected perianal above mentioned drugs increase venous tone eczema is the frequent result of by improving venous wall noradrenalin activity, therapy (3). Lesions to the skin and mucosa they increase lymph draninage and they are to be expected already after a treatment protect the microcirculation by fighting period of 2 weeks. precapillary inflammnation, too (4,5,6).

Semiinvasive therapy

Sclerotherapy, cryotherapy, fotocoagulation, rubber-band ligation

Sclerotherapy verge. The sclerotherapy is the first line of First attempts made by J. Morgan in 1869. treatment for minor degrees of hemorroids, Recently the gabriel syringe and needle is particularly causing bleeding without mucosal used (7). 5% in almond or arachis oil is prolapse. One course of injection seems to be drawn up from individual 10ml phials to allow sufficient and probably upward of 70% of for about 3ml of injection into the base of each patients are satisfied with the results of the vascular cushion.. The result is the aseptic treatment. We used this method routinely till st nd inflammation and lately the mucosal fixation. In 1992 in the 1 and some 2 degrees of piles. the USA the phenol is forbidden and they use Now we prefere fotocoagulation and the 5% quinine and urea hydrochlorid in the same sclerotherapy is used very rarely. indication (Figure 2). The anoscope is passed into the anal canal and at the point where the Cryotherapy reddish mucosa changes to the purplish one, Cryodestruction of different lesions, using indicating engorged underlying vascular liquid carbon dioxide (CO2) or liquid nitrogen cushions, the sclerosant is injected (N2) is well known. The freezing of tissue immediately under the mucosa. The procedure bellow –22oC causes permanent destruction should be entirely painless. Pain or discomfort by infarction and trombosis, which occurs indicates either too deep injecting or within 24 hours. The tissue then becomes positioning of a needle too close to the anal necrotic and sloughing and separation of the

www.siccr.org 20 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 frozen tissues from the undamaged ones takes performed at each session and repeated at about 10 days. Liquid N2 cryoprobes are the three week intervals. As to our experiences, it most widely used. The principal disadvantage is also well feasible to perform two or even is that the patient may be frightened by the three ligations in one session and repeat it cold sensation and adequate freezing may eventually after two weeks. The také up to 25 minutes. The use of anesthesia photocoagulation of the strangulated neck or sedation makes the technique less attractive could fasten the necrosis. as an ambulatory procedure. The tip of the Pain is the most common complication of the probe is applied to the anal cushion to produce rubber-band ligation. Mostly, it is very mild (up an iceball over 2 or 3 minutes. The second to 20%) or severe (up to 3%). If the pain is application is advised to the same cushion severe – usually the first or second day -, the after a period of about 5 minutes of thawing. band should be removed.I had to do it only Although enjoying a brief period en vogue in twice after more than 5000 ligations. Some the late 1970s and early 1980s, most surgeons patients´ experience is a fagovagal fainting have now abandoned the technique on the episode on standing up after banding, but it ground of pain and profuse discharge (8). usually passes if they lie back down for a while. Secondary hemorrhoidage can occur Photocoagulation when the tissue included in the rubber-band This method was published by Neiger (9), who separates. patients should be warned that a adapted infrared coagulator for the treatment show of blood may occur between days 4-7 of hemorrhoids. The infrared pulse causes after the banding. This is generally not severe destruction by heating up to 100oC. The enough to require consultation. I had two burned tissue reacts in a similar way to that patients with a severe bleeding, which treated by rubber-band ligation. requiered hospitalisation and vessel suturing in Photocoagulation alone is good and sufficient a short anesthesia. only in the first-degree hemorrhoids. The upper The most alarming report (12) described 4men grades are not indicated. Very good results are (from 34 to 54 years of age), who developed in certain cases with the combination of pelvic cellulitis and died. Although it is rubber-band ligation and photocoagulation in exeprionally rere, it emphasses the importance the 2nd degree of piles. of meticulous technique abd the signs and symptoms of fever, malaise, urinary hesitancy Rubber-band ligation or retention and increasing local discomfort The principle of this method is the tissue loss should be taken very seriously. and ulceration and therefore fixation of the Many articles conclude, that rubber-band mucosa. A small rubber band is applied tightly ligation is the choice for the second degree around the neck of a hemorroidal tissue above hemorrhoids. In the long-term outcomes, there the dentate line. It causes ischemic sloughing could be said, that about 70% of patients are of the mucosa and ulceration over thefollowing totally free of symptoms after rubber-banding few days. The most popular is recently the and up to 7% required the operation. Further, McGivney simpler version of applicator (10). 23%ofpatients require conservative measures, The rectum should not be empty, so that there as e.g. repeated banding, dilatation or other is no necessity to prepare it by means of methods (13,14). enemas. Any position cloud be used. We Residual perianal skin flaps are fit for cutting personally prefer the elbow-knee one. A in local anesthesia as an ambulatory straight oblique-ended proctoscope is passed procedure, too. into the rectum and gradually withdrawn. The whole of the internal cushion is then allowed to Barron himself recommended to combine his prolapse into the lumen so that its apex can be ligation with the cryotherapy (15) with a very clearly seen. The proctoscope is passed back promissing results. up into the upper anal canal and while the Rubber-band ligation enables to achieve assistant or nurse holds the proctoscope in results just as valid as those of traditional position, the apex of the hemorrhoidal cushion methods in the treatment of hemorrhoidal is grasped and a rubber-band applied to its pathology with the advantage that it can be base . The principal problem and complication performed in out-patients´ department, it does of the technique relates to the exact placing of not need local anesthesia, it enables the the rubber-band. If this is too near to the patient to return immediately to normal working dentate line, it may result in considerable pain activity and restricted to the observation period and discomfort. It should be placed at least (follow up 1 year) it allows a satisfactory 1cm above the dentate line !!! In the original control of the disease (16). description by Barron (11) one ligation was

www.siccr.org 21 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 Personal results: 102 patients (1,5%). They were trated by The main indication were the piles of 2nd means of fotocoagulation. 7 patients (0,13%) degree (93%). Normally we put 1 or (less had to be observed in the hospital, 3 of them often) 2 ligations in the genupectoral position operated urgently (suture in the anal canal). on the special proctologic table. We use We observed no death, no pelvic or disposable anoscope, 23 mm of diameter, cold retroperitoneal fasciitis. light. There is no need of any kind of 226 patients with haemorrhoids (4,9%) had anesthesia. The procedure is repeated in 10- also anal fissure. 14days intervals, once, twice or more times. The control examination is done after 2 months We consider the rubber-banding as the best after the last banding. and most safe semi-invasive method of the We treated 5296 patients (3052women and treatment not only the second degree 2244men) in 14 years (October 1988 to June hemorrhoids, but also many of those with the 2002). There were administrated 13429 higher degree (17). ligations to them. As to pain, 45% have moderate pain 1 – Conclusion 2days, 14% 3 or more days. 37% have „strange feeling“ in anal region several hours to Step by step treatment of hemorroids is , on several days. 3% have severe pain 1 – 3 days. one hand, time consuming, but on the other About 1% (67) had severe pain with the hand the best and the most friendly one for the protrusion and trombosis, 15 of them had to be patient. Combination of the diet, improvement operated urgently, 52 patients have been of emptying, pharmacotherapy and the semi- treated in the office (reposition, antibiotics, invasive treatment can treat more than 90% of analgetics, Ginkor or Detralex). patients, suffering from hemorrhoidal disease. Bleeding: slight bleeding has been observed in Also radical hemorrhoidectomy can be safely 72% of patients (day 3 to day 6). Severe done as the ambulatory procedure (18). bleeding, which caused special control was at

Fissures

Fissure in ano is a „crack“ or „cut“ in the lining terminology, they usually complain of of the anal canal. It is an oblong, mostly drop- hemorrhoids. shaped ulcer in the dry, sensitive anoderm area. Ulcer in ano is a fissure in its chronic Etiology stage. The lesion is classically associated with bleeding and intense pain at the time of A traumatic event is thought to cause fissures, defecation. The most common localisation such as the passage of hard stool or severe (about 90%) is on the posterior mid-line. The diarrhea. In the fisrst instance, a mechanical anterior commisure is affected in about 9% of tear results and in the second a chemical burn cases. Atypical fissures are rare and mostly is caused by severe alkalinity, which usually occur in specific inflammations. It has roughly accompanies diarrhea. Most patients are equal distribution between the sexes. unable to relate the beginning of symptoms to a particular event. Thus, in some cases, Incidence symptoms have an insidious onset whereas in The exact incidence of this lesion is unknown. others it is quite dramatic. But apart from hemorrhoids, this disease is the most common condition seen in proctology. Pathology Suffice is to say that it is very common. An unheald fissure gives rise to chronic, Practitioners do not see all patients who suffer intermittent or continuous symptoms that with from this disease, because the lesion is so time change the appearance of the fissure painful, a good guess is that most sufferers from a crack to an ulcer-like crater, most see a doctor for relief of symptoms at some commonly in the posterior midline just bellow time during the course of the disease. As the the level of the dentate line (No. 6). Many general public is unaware of medical patients also present with a skin tag or sentinel „pile“ distal to lesion, signaling the presence of

www.siccr.org 22 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 a fissure just proximal to it. Not infrequently, associated with tagging and redness of the they also have a proximal hypertrophic papilla perianum should strongly suggest the varying in size from less than 1cm to as large presence of anal Crohn´s disease, especially if as 3cm. Fibers of the internal sphincter can be pain is absent. Other conditions, such as clearly seen in its base, it bleeds easily when carcinoma and lesions associated with touched, and it is acutely painful. Painlass immunodeficiency states, should be given lesions could be suspected from Crohn´s careful consideration. disease. The cause of the tag or the hypertropied anal papilla is unknown but may Treatment be associated with „infection“ or the body´s attempt at healing. Fissures are usuallly single Surgery – surgical options are offered for but an anterior and posterior fissure can occur fissures in the chronic state or for intensly together painful fissures that respond slowly to conservative measures. This aaproach is Signs and symptoms common in USA and other countries (19,20). In Most patients complain of „hemorrhoids“. Europe, there are more popular conservative Severe undescribable pain and intense cutting, methods, because of possible complication of tearing and knife-like sensatinos lasting many the surgery (incontinence up to 10%). Some hours are classic symptoms. Bleeding is authors prefere anoplasty, which seems to always bright red and the pain is associated have very limited indications (21). with the immediately follows bowel The treatment of chronic fissure in ano with movements. Many patients are so fearful of nitrate oinment is other promissing having a bowel movement that they „hold it“ conservative possibility (22), but the success and in so doing exacerbate the situation by rate of such a treatment is not satisfactory. producing harder stools. Pain and fear of pain There are some other possibilities, how to treat are so severe that patients may even cry or cry anal fissures. Infiltration by botulotoxin (safe, out during the bowel movement. A very storng but expensive) and dilatation (safe, cheap, but sign is that patients are very reluctant to be time consuming) ( 23,24). examined by anyone. We personally prefere the dilatation therapy (Dilatan, made by Sapimed). Diagnosis Results: 95% of the time the history is so classic that Originally (1988-1996) we treated the chronic the diagnosis can be made by this alone. anal fissure in several different, non- unified Physical examination should be done with way ( 156 patients). Since 1.1.1997 till strong continuous reassurance to the patient 31.12.2002 we treated 265 patients, suffering and great care needs to be used at the time of from chronic anal fissure (122 men and 143 examination. Gradual exposure of the women). perianum after gently separating the buttocks They were treated from 6 weeks to 4 months, is essential. The perianum is carefully everted dilatation was done twice daily. The symptoms with steady traction. The lesion can usually be disappeared completely in 243 patients (92%). seen at the posterior midline. Whe further The fissure helaled in 203 of them (84%). 10 examination is necessary, a well lubricated patients were indicated to partial lateral pediatric anoscope is placed at the perianum sphincterectomy. and the patient is asked to strain down. By The rubber band ligation of concommitant directing pressure away from the lesion, the haemorrhoids was done in 102 of them. There anus can be examined. Digital examination were no complications of the treatment of follows in the same way. chronic anal fissure.

Differential diagnosis Dilatation therapy of chronic anal fissure is Any fissure or ulcer with an unusual time consuming, safe and cheap method. The appearance should be suspect. An edematous, patients are satisfied. Threre is a rare granular, ectopically located, chronic- indication to surgery. appearing lesion, especially when multiple and

www.siccr.org 23 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 Anal trombosis

The perineal subcutaneous hematoma may or hemostatic effect. With the wound held open may not be associated with a hemorrhoidal by assistant, the viscous, yellowish-brown complex. It is always solitary and can occur 1 Monselś solution is spread evenly on the to 3 cm from the anal verge. wound with a cotton swab. Bleeding points may require focal pressure with the swab for a Treatment few seconds to secure hemostasis. A rare The management of anal trombosis depends bleeding vessel may require electrocautery but on when the course of the disease the patient Monselś solution alone nearly always suffices presents. The natural course of this condition (25). Within 5-10 days there is completely starts with trombosis of external . healed perianal skin. Up to 20% there is a This event is often associated with effort or recurrence of trombosis within 1-2 years. straining (moving or lifting furniture, haevy There is no direct connection between anal exercise, etc.) The tissue around these clots trombosis and internal hemorrhoids. swells causing moderate to severe pain. If not treated, in 2-4 weeks, the clot in the trombosed Conclusion vesselswill either spontaneously drain through the thinned overlying skin or be graduallly Ambulatory proctology is a very special field of resorbed and the discomfort will gradually surgery, which can help up to 80-90% patients diminished. After resolution, redundant anal with the proctologic diseases. Very complex is skin will remain which is usually asymptomatic the diagnosis and treatment of constipation and requires no treatment. and fecal incontinence. In the step by step Since 1.1.1997 till 31.12.2002 we treated 382 therapy, there is a wide field to bio-feedback patients with anal trombosis. Our preference is procedures. to make a small incision or excision (3-4mm) Many other anal pathologies can be treated at above the trombosed external hemorroid and the outpatient department, too (some anal to extract the underlying clot . It is not fistulas, abscess, condylomata accuminata, uncommon to encounter bleeding from the anal hidrosadenitis, dermatitis, candidosis and wound. This may be arterial or venous and some others). brisk. Bimanual spreading of the cutaneous wound exposes the bleeding surface and has a

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