Removal of Hypertrophied Anal Papillae and Fibrous Polyps Improves Outcome of Anal Fissure Surgery

Original Article

Removal of hypertrophied anal papillae and fibrous polyps improves outcome of anal fissure surgery

Pravin J. Gupta Consulting Proctologist, Gupta Nursing Home, D/9, Laxminagar, Nagpur-440022, India. E-mail: [email protected]

ABSTRACT Background: The presence of Hypertrophied anal papillae and fibrous anal polyps are often ignored in the proctology practice. But the experience is that they tend to produce minor but disturbing symptoms. This study is aimed to assay the impact and utility of attending to these two conditions concurrently while dealing with cases of fissure in ano. Material and Methods: A study was carried out in 136 patients of chronic anal fissure having concomitant hypertrophied anal papillae or fibrous anal polyp. After relieving sphincter spasm by sphincterotomy, the polyps or papillae were destroyed using the radio frequency device. A comparison was made for the associated complaints like pruritus, pricking sensation, wetness, crawling in the anus etc. before and after removal of the papillae or polyps by an independent observer blinded to the procedure. Results: After one month of the procedure, the associated symptoms were reduced to a significant amount along with a near total decline in the primary complaints of pain and bleeding. There was significant reduction in pruritus (P=0.0003), discharge per anus (P=0.0006), crawling sensation in the anus (P=0.0004) and sense of incomplete evacuation (P=0.001) At the follow up after 18 months, only 9% patients had recurrence of either anal fissure or symptoms like pruritus. Conclusion: This study establishes that removal of hypertrophied anal papillae and fibrous polyps should be carried out as a routine during surgical treatment of anal fissure. This would add to effectiveness and completeness of the procedure.

KEY WORDS Hypertrophied anal papilla, Fibrous anal polyp, Radio frequency, Anal fissure, Sphincterotomy

How to cite this article: Gupta PJ. Removal of hypertrophied anal papillae and fibrous polyps improves outcome of anal fissure surgery. Indian J Surg 2004;66:164-8.

INTRODUCTION mechanism after defecation.2 Occasionally, a red edematous papilla is encountered with local pain and Anal papillae,1 which are also called as anal fibroma, a purulent discharge from the associated crypt. This papillitis hypertrophicans, or “cat tooth”, are the fine condition2 is called as ‘papillitis’ with `cryptitis.’ points of projections of the extreme upper end of anal canal skin at the mucocutaneous junction. The enlargement of the existing anal papillae is a consequence of a chronic inflammatory process and Small Papillae remain usually asymptomatic. An fibrotic proliferation within the range of the Linea elongated anal papilla associated with pain and/or dentata, the ano rectal zone and the distal rectal bleeding at defecation is sometimes encountered in mucosa. The hypertrophied anal papillae are prone to infancy. Hemorrhage into a hypertrophied anal papilla undergo considerable fibrous thickening to acquire a can cause sudden rectal pain. A prolapsed papilla may rounded expanded tip, which is then known as a fibrous become nipped by contraction of the sphincter polyp.3 Occasionally the occurrence of hypertrophied

Address for correspondence: Pravin J. Gupta, Consulting Proctologist, Gupta Nursing Home, D/9, Laxminagar, Nagpur-440022, India. E- mail: [email protected] Paper Received: August 2003. Paper Accepted: August 2003. Source of Support: Nil.

164 Indian Journal of Surgery 2004 Volume 66 Issue 3 (June) © 2003 Indian JournalRemoval of ofSurgery hypertrophied www.indianjsurg.com anal papillae anal papillae is reported after operational interferences In 17 of the studied patients, anal polyp was found in in the anal region. association. 16 of these patients had a single polyp while in one patient, there were two. Out of these, 11 Dilated vein, white area and a large hypertrophied anal patients had polyps of prolapsing type, which used to papilla are often found in prolapsing types of project out during defecation and getting reduced hemorrhoids.4 In the literature, the prevalence of these spontaneously after the act. The remaining 6 were of papillae varies between 6% and 60% of all non-prolapsing type. anoscopically-examined patients.5 They are equally found in both the sexes. The anal papillae, if get Exclusion criteria hypertrophied or are converted into anal polyps, can Only those patients of chronic fissure in ano who had produce a foreign body feeling and discharge from the associated anal papillae or fibrous polyps or both were anus. Subsequently, a toxic irritative anal eczema may selected. This was irrespective of the age, sex, or develop. duration of pathology. Patients suffering from fissure but not having hypertrophied papillae or polyp were Histologically, the papillae consists of an edematous, excluded from the study. This assessment was carried loosened up, fibrotic connective tissue in parts, with out using a pediatric anoscope after instilling a 5% increase in capillary contents. Occasionally akanthosis lidocain ointment in the anal canal to reduce the pain and widened disk epithelium may be seen, but they during examination. Similarly, patients having never proceed to malignant degeneration.6 associated sentinel piles, internal bleeding hemorrhoids were not considered. The papillae and polyps should be differentiated from subanodermal anal venous thrombosis, condyloma, An informed consent was obtained from all the patients. and rectal adenoma.7 No special pre operative preparation was carried out. The study was approved by the local ethics committee Patients with fibrous polyp complain of projection of and was carried out according to the declaration of something inexplicable from the anus. A case of giant Helsinki. All of the patients received a dose of laxative hypertrophied anal papilla complicated by massive anal [Lactulose 20ml] on the night before the procedure. bleeding and prolapse is reported.8 Radio frequency surgery for the hypertrophied anal The objective of this study was to demonstrate that papillae and fibrous anal polyps. hypertrophied anal papillae and fibrous anal polyps are Few surgeons practice removal of the papillae or polyps responsible for minor but disturbing complaints on the by snipping them with scissors or shaving them with part of the patient and hence should necessarily be scalpel or electrocautry after being crushed.9 We, attended to and be removed during surgical treatment instead, have used the radio frequency technique to of anal fissure and further that they can conveniently effectively destroy these papillae and polyps. be removed by the radio frequency surgical device. Radio frequency surgery is a method of simultaneous MATERIAL AND METHODS cutting and coagulating of the tissues.10 We used a dual radio frequency generator 4 MHz from Ellman This non-randomized study was conducted at Fine International, Hewlett, N.Y. for this procedure. Morning Hospital and Gupta Nursing Home, Nagpur, India, between July 1999 and December 2000. An interchangeable ball electrode for coagulation and a round loop electrode for shaving the desired tissue In all, 136 patients of chronic fissures in ano with were extensively used in the procedure. hypertrophied anal papillae and/or fibrous polyp were studied. All the patients under study had hypertrophied Procedure anal papillae. The numbers of papillae were ranging To begin with, lateral subcutaneous internal from 2 to 4 [mean of 3.2]. The papillae, which felt on sphincterotomy was done in a short general anaesthesia digital examination, were considered ‘large’. Papillae, with a muscle relaxant to relieve the spasm. This was which were not palpable and were visible only on followed by anoscopy to locate the anal polyp or anoscopy, were termed ‘small’ papillae. papillae. Small papillae were directly coagulated with

Indian Journal of Surgery 2004 Volume 66 Issue 3 (June) 165 Gupta PJ the ball electrode kept on the coagulation mode of the Table 1: Symptom comparison before and after radio frequency unit. treatment of anal fissure and hypertrophied anal papillae and fibrous anal polyps The commonest sites where the papillae were seen were at 3, 7 and 11’O clock position with the patient Symptoms Before After P Treatment Treatment in a lithotomy position. The next common sites were Itching 36 [26.4] 6 [4.5] 0.0003 at 1, 5 and 9’O clock. Feeling of uneasiness 45 [33] 3 [2.2] 0.0001 Discharge per anus 32 [23.5] 4 [2.9] 0.0006 The base of large papillae and fibrous polyp were Sense of incomplete 35 [25.7] 9 [6.6] 0.0004 circumferentially coagulated by the ball electrode first Evacuation and then they were excised by the round loop electrode Crawling sensation 48 [35.2] 4 [2.9] 0.001 In the anus of the radio frequency surgical unit. Minor bleeding, Prolapse during 11 [8] Nil 0.0023 when encountered, was coagulated by touching the defecation source with the ball electrode. This additional Percentage of patients in parentheses. P < 0.05 Student’s procedure of removal of papillae or polyps took a mean unpaired t-test period of 2 minutes to complete. lasted for a maximum period of four days. The patients were given analgesics [Ketoprofen 250 mg twice a day] for a week and were prescribed a stool The comparison of the findings at a follow up after 1 softener [Lactulose 15 ml at bed time] for a month. All month is given in Table 1. the patients were discharged within 12 hours of the procedure. They were reviewed after 30 days. Subsequent follow up after 18 months 18 patients [13%] were lost to follow up. In the Comparative study remaining 118 patients, 3 patients [2.5%] had An independent observer, blinded to this study noted recurrence of the fissure. 7 patients [6%] complained down the symptoms in a questionnaire form especially of pruritus. Out of these, 4 patients were found to have prepared for this study. This included symptoms like developed anal papillae. But none of the patients itching, feeling of uneasiness in the anal canal, treated for anal polyp had any recurrence. Most of the discharge, sense of incomplete evacuation, crawling associated complaints like feeling of uneasiness, sensation and prolapse. These complaints were noted discharge and sense of incomplete evacuation, crawling down in each of the patients before and after the sensation, and prolapse were reported absent. procedure. DISCUSSION Statistical analysis Data were entered in to a database and analyzed using Anal papillae are present in almost 50-60% patients statistical software (Graph pad Software, San Diego, examined. Usually, these are small, cause no CA). An unpaired student’s t-test was used to measure symptoms, and could be regarded as normal pre and postoperative parameters. The level of structures.11 statistical significance between groups was set at 5 per cent. However, if it is a case of hypertrophy and if the papillae start projecting in the anal canal, it requires attention RESULTS and suitable treatment. In such cases, it may lead to increased mucus leak resulting in increased anal After one month, anoscopy showed total absence of moisture. They are liable to cause trauma during the these papillae. The fissures were healed and there was passage of stool and may become inflamed. In addition, no sphincter spasm. Patients who were treated for when papilla is converted into a fibrous polyp, it gives fibrous polyps did have some amount of oedema and rise to symptoms like prolapse, which may require mild elevation at the site of destruction. frequent manual repositioning. The polyp is considered as one of the differential diagnosis of rectal prolapse.12 17 patients [12.5%] complained of postoperative Symptoms like pruritus,13 foreign body sensation, bleeding which was minor, streaking the stool and pricking, a sense of incomplete evacuation and

166 Indian Journal of Surgery 2004 Volume 66 Issue 3 (June) © 2003 Indian JournalRemoval of ofSurgery hypertrophied www.indianjsurg.com anal papillae heaviness in the anal region have also been reported damage to adjacent tissue. In contrast, electrocautery, by the patients. diathermy, and laser temperatures are significantly higher (750-9000C) which result in significant heat As a routine practice, these pathologies are not given propagation in excess of the desired therapeutic need. any importance.14 There is very brief account of this These differences allow for radiofrequency being found entity in the standard textbooks and other references. more accurate, minimally invasive and less morbid Secondary goals of fissure surgery sometimes require without compromising the treatment efficacy and the removal of hypertrophied papilla and skin tag as durability. well as the removal of inflammatory and fibrotic tissue surrounding the fissure.15 Customarily, for symptomatic While techniques using conventional scalpel apparently papillae or polyp, its removal by crushing the base, works in an atraumatic way, the prominence of bleeding excision after ligation or electrocautrization has been from the wound forces the surgeon to coagulate the suggested. We have instead, used the radiofrequency bleeders with traditional electrocautery or diathermy device to successfully tackle these pathologies. more frequently than radiofrequency. The radio waves can seal the small blood vessels without creating any Radio frequency surgery, not to be confused with char, whereas the cautery or elcetrosurgical instruments electro surgery, diathermy, spark-gap circuitry, or create heat at the tip of the instruments to seal the electrocautry, uses a very high frequency radio wave. affected portion with transferred heat, and in the process invariably damage the adjacent healthy tissues, Unlike electrocautry or diathermy, the electrode which consequently cause more edema and releasing radiofrequency waves remains cold. This is postoperative pain. possible because of use of very high frequency current of 4 MHz, as compared to 0.5 to 1.5 MHz used in the Anal papillomata tend to produce a discharge resulting electrocautry, which produces greatest amount of in a sodden perianal skin with itching and discomfort. tissue alteration. In contrast to true cautery, which Wallis believed that hypertrophied anal papillae played causes damage similar to 3rd degree burns, the tissue an important part in the etiology of pruritus ani. A large damage that does occur in radio frequency surgery is papilla that projects at the anus might conceivably superficial and is comparable to that which occurs with interfere with proper anal closure and thus predispose Lasers. Histologically, it has been shown that tissue to leakage of mucus, which could lead to pruritus. damage with radio frequency surgery is much less than Hypertrophied anal papilla should be included in the that of a conventional scalpel and practically equals differential diagnosis of a smooth mass located near the one caused by a cold scalpel.16 the anal verge, especially in a patient with a history of chronic anal irritation or infection.18 The presence of a The radio frequency device offers several unique fibrous anal polyp is shown to have a statistically advantages over conventional surgical modalities. It significant association with operative treatment.19 provides for a controlled balance in simultaneously cutting and coagulating through a single instrument.17 Though we have used the radiofrequency equipment Since it is used in direct contact with tissues, the to tackle these pathologies, we do not intend to surgeon gets the tactile feedback and continues to exert promote the same. The procedure can also be carried the same familiar and confident control over the job as out with sharp excision with scissors or electrocautery. is experienced during the traditional knife technique. The equipment used by us is significantly more The technique has a self-sterilizing effect and leaves expensive that other methods. behind a bacteria free zone around the place of application. The radiofrequency device allows cutting We, nevertheless, admit that the associated symptoms and coagulation of tissues in an atraumatic manner, found in patients of anal fissure are partly due to the contrary to the electric bistoury. The advantages of primary disease itself and are partly getting alleviated radiofrequency over electrocautery and laser energy after the treatment of fissure. A prospective and surgery reside in its precision in ablating tissues and in randomized comparative study between removal and its control of operation. With radiofrequency, the no removal of the papillae and polyps would have been targeted tissue temperatures stay localized within a more conclusive of this contention. But after comparing 60-900C range thus limiting heat dissipation and the symptoms before and after removal of the papillae

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