SURG2 Module 6 Colonic Disorders (TRANS 5) PDF

SURG2 SURGERY 2 Colonic Disorders TRANS 5...

SURG2 SURGERY 2 Colonic Disorders TRANS 5 MODULE 6 Dr. Sherwin G. Alamo September 13, 2024 LECTURE OUTLINE I. DIVERTICULITIS I Diverticulitis A. Etiology and Definition A. ETIOLOGY AND DEFINITION 1. Sigmoid Diverticulitis Case Diverticular disease is an acquired false diverticulum of the pulsion B. Diverticulum Formation type C. Presentation and Incidence of Findings in Acute Sigmoid colon is mostly involved as seen in figure 1 Diverticulitis Right colon involvement is not rare in Asia D. Differential Diagnosis It is likely produced by increased intraluminal pressure E. Diagnosis and Investigation Diet is an important etiologic factor F. Staging and Grading Majority of the affected people are asymptomatic, however in G. CT Features of Acute Diverticulitis 10-30%, it may present as diverticulitis or lower GI bleeding H. Major Complications of Acute Diverticulitis Diverticulitis is defined as diverticula-associated inflammation, I. Management infection, or both J. Operative Procedures For Complicated Diverticular It is likely initiated by erosion of the thin diverticular wall by Disease increased intraluminal pressure K. Operative Procedures and Outcomes 1. Small Bowel Obstruction Due to Abscess 2. Diverticular Stricture of Sigmoid Colon 3. ​Colovesicular Fistula II Hemorrhoids A. Grading of Hemorrhoids B. Minimally Invasive Procedures 1. Rubber Band Ligation 2. Sclerotherapy 3. Infrared Coagulation 4. Bipolar Diathermy 5. Laser 6. Dopper-Guided Hemorrhoidal Artery Ligation C. Indications for Surgery Figure 1. Sigmoid colon with diverticulum D. Techniques for the Operative Treatment Colonic Disorders: Diverticulitis Lecture Video 1. Closed and Open Hemorrhoidectomy 2. Procedure for Prolapse and Hemorrhoids (PPH) 3. Excision of a Thrombosed External Hemorrhoid E. Summary for Hemorrhoids III Anal Fissures A. Surgical Anal Canal B. Essential Features of Anal Fissures C. Pathogenesis of Anal Fissures D. Clinical Diagnosis E. Diagnostic Investigation F. Treatment 1. Treatment for Chronic Anal Fissures G. Summary for Anal Fissures IV Anorectal Abscess and Fistula A. Anatomy of the Anal Canal Figure 2. Sigmoid Diverticula as seen via colonoscopy B. Essential Features of the Anorectal Abscess and Fistula Colonic Disorders: Diverticulitis Lecture Video C. Clinical Diagnosis D. Diagnostic Investigation of Anorectal Abscess and Fistula 1. SIGMOID DIVERTICULITIS CASE 1. Endoanal Ultrasound E. Management of Anorectal Abscess and Fistula CASE Sigmoid Diverticulitis with Abscess 1. Anorectal Abscess 1 2. Anal Fistula 3. Goodsall Rule Not responsive to antibiotic treatment alone 4. Fistulotomy The small bowels have walled up the abscess 5. Seton Placement The surgeon is trying to open the abscess cavity in order to drain it 6. Ligation of Intersphincteric Fistula Tract (Lift) 7. Dermal Advancement Flap 8. Fibrin Glue Injection (Anal Fistula) 9. Porcine Collagen Anal Fistula Plug F. Summary for Anorectal Abscess and Fistula LECTURE OBJECTIVES 1. Select appropriate surgical management for hemorrhoids 🧠 Must Know 📖 Book 📝 Previous Trans Figure 3. Small bowel walling off pelvic abscess Colonic Disorders: Diverticulitis Lecture Video Group 6B | Colonic Disorders 1 of 15  submucosal area, and this pierces through your circumferential muscles. When there is increased pressure in the luminal area, it pushes the wall down that forms the outpouching. ○ This usually happens when patients do not eat a high-fiber diet. It is hard to push the bowel if you are not on a high-fiber diet, which predisposes for a diverticulum to later form. Two problems associated with a diverticulum: ○ Diverticulitis: the thin area can perforate and cause infection Figure 4. Abscess in between bowel loops ○ Diverticular bleeding: the presence of blood vessels can Colonic Disorders: Diverticulitis Lecture Video lead to bleeding C. PRESENTATION AND INCIDENCE OF FINDINGS IN ACUTE DIVERTICULITIS Perforation of a diverticulum can lead to complicated and uncomplicated diverticulitis Abdominal pain is usually felt at the left lower quadrant (LLQ) since the sigmoid is the most common area affected Table 1. Presentation and incidence of findings in acute diverticulitis Figure 5. Culture samples taken Uncomplicated Disease Complicated Disease: Colonic Disorders: Diverticulitis Lecture Video 75% to 80% 20% to 25% Samples of the abscess are taken for cultures. The sigmoid diverticulum is underneath the abscess cavity Localized Phlegmon Abscess (up to 16%) Free perforation with peritonitis Abdominal pain (up to 10%) Fever Fistula or bowel obstruction (up to 2%) Leukocytosis Stricture (up to 5%) Anorexia/Obstipation Source: Colonic Disorders: Diverticulitis Lecture Video Figure 6. Placement of JP drain Doctor’s Notes Colonic Disorders: Diverticulitis Lecture Video Most common uncomplicated disease is sigmoid diverticulitis Once drained, JP (Jackson-Pratt) drain will be placed. It is used to remove fluids Abdominal pain on the LLQ is elicited commonly in elderly that build up in an area of the body after surgery. patients, but nowadays it is also seen in 30 year old patients Most commonly formed fistulas the the colovesical fistulas – B. DIVERTICULUM FORMATION The artery penetrates the colon from serosa to submucosa through 🧠 from the sigmoid colon to the urinary bladder Urinary bladder is a common area where the diverticulum adheres and perforates → forming fistulas oblique septum in circular muscle near the taenia The diverticulum develops through and widens connective tissue cleft D. DIFFERENTIAL DIAGNOSIS The artery is placed over the dome of the diverticulum Differential diagnosis for diverticulitis include: 1 Colorectal cancer 📝 LLQ pain in an elderly patient can be cancer, diverticulitis Presents with RLQ pain, when there is Appendicitis/Right- 2 a problem with cecal diverticulum it will sided diverticulitis present like appendicitis Presents with abdominal pain and can Irritable bowel 3 be with diarrhea (as well as syndrome inflammatory bowel diseases). Inflammatory 4 Same as Irritable bowel syndrome bowel disease 5 Ischemic colitis 📝Presents with severe abdominal pain Intestinal Obstruction from colon cancer (i.e. severe strictures) Gynecologic disease from cancer (i.e. 6 Others ovarian tumor) Figure 7. Diverticulum formation Urologic disease (i.e. kidney problem, Colonic Disorders: Diverticulitis Lecture Video ureteral or bladder tumor) Doctor’s Notes Aside from diverticulitis, diverticular bleeding can also occur but E. DIAGNOSIS AND INVESTIGATION not at the same time Mainly based on history and physical examination ○ Lower GI bleeding from a diverticular bleed (nice to know) Studies done in the acute stage to confirm diagnosis and rule out other causes of acute abdominal pain is usually made through the abdominal CT scan with triple contrast [BATCH 2025] INFORMATION [F2F LECTURE] ○ It has become the optimal diagnostic test when diverticulitis is How does your diverticulum form? suspected Usually due to the piercing of your arteries Elective work-up following resolution of diverticulitis should You have your blood vessels going from the serosa to the evaluate the entire colon Group 6B | Colonic Disorders 2 of 15  A colonoscopy should be done 6 weeks after resolution of Figure 9. Acute sigmoid diverticulitis with mesenteric fat infiltration and bowel abdominal pain thickening Colonoscopy and barium enema are contraindicated if the patient Colonic Disorders: Diverticulitis Lecture Video has an acute presentation [BATCH 2025] INFORMATION [F2F LECTURE] CT scan ○ Modality of choice for diverticulitis ○ If you suspect diverticulitis, you need to grade these patients according to the location of the abscess or the overall affectation using abdominal CT scan with triple contrast Barium ○ Usually not recommended anymore ○ Many uses in detecting diseases of the colon and not just for Figure 10. Multiple inflamed diverticula in the sigmoid with inflammatory colon cancers infiltration into the pericolic path, low density intramural abscesses, and engorged vasa recta Colonic Disorders: Diverticulitis Lecture Video F. STAGING AND GRADING The following are the stages of diverticulitis by imaging HINCHEY SCORING 1 Stage I Small, 2) Fecal peritonitis procedure vs. 6% vs 4 Inability to exclude carcinoma Stage IV with intestinal diverting colostomy – 0.2% communication and omental mortality 5 Fistula formation pedicle graft Others: Generalized peritonitis, Undrainable abscess, High grade Source: Colonic Disorders: Diverticulitis Lecture Video 6 bowel obstruction The higher the stage, the higher the morbidity and mortality. 5. PRINCIPLES OF ELECTIVE RESECTION FOR Dr. Alamo DIVERTICULAR DISEASE Procedure: Open or laparoscopic techniques 1. SMALL BOWEL OBSTRUCTION DUE TO ABSCESS Primary resection margins ○ From proximal rectum where taenia coli coalesce to normal caliber proximal colon with minimal diverticula Oncological operation ○ Performed with end duct dissection in higher vascular ligation with malignancy cannot be ruled out J. OPERATIVE PROCEDURES FOR COMPLICATED DIVERTICULAR DISEASE Figure 20. Small Bowel Obstruction due to Abscess Colonic Disorders: Diverticulitis Lecture Video Small bowel obstruction (Image A). Scan showing an air fluid level with identified abscess (Image B). Note the dilated fluid-filled small bowel loops Doctor’s Notes Sometimes the small intestines kink, hence they become obstructed as well 2. DIVERTICULAR STRICTURE OF SIGMOID COLON Figure 18. Operative procedures for complicated diverticular disease Colonic Disorders: Diverticulitis Lecture Video Image A is a proximal diversion with drainage and omental patch. Image B is Hartmann's procedure wherein we resect the sigmoid area, close the proximal rectum and exteriorize temporary colostomy. Image C is the resection with primary anastomosis. Image D shows a resection with primary anastomosis and a diversion in the form of ileostomy. Doctor’s Notes Ileostomy are protective because the bowels that the surgeon 🧠 has anastomosed may leak → operate Hartmann's procedure is the most commonly done operative procedure Figure 21. Diverticular stricture of a sigmoid colon, can mimic colon cancer K. OPERATIVE PROCEDURES AND OUTCOMES usually seen as a thickening of the sigmoid colon Colonic Disorders: Diverticulitis Lecture Video Table 2. Operative procedures for Complicated Diverticular Disease Image A shows a narrowed caliber of sigmoid with corresponding dilation Hinchey Operative Anastomotic Overall Stage Character Procedures Leak Rate Morbidity of the proximal bowel. Image B & C shows an extensive diverticular and non-distensible wall Resection with thickening. Pericolic or primary Image D, on sigmoidoscopy shows that there’s no visible mass, just a Stage I intramesenteric anastomosis 3.8% 22% narrowing which signifies a stricture from sigmoid diverticulitis. abscess without diverting stroma Resection with primary Stage II Pelvic abscess 3.8% 30% anastomosis ± diversion Group 6B | Colonic Disorders 5 of 15 3. COLOVESICAL FISTULA Grade I No prolapse, might bleed Figure 25. Internal Hemorrhoid viewed through the anal scope Colonic Disorders: Hemorrhoids Lecture Video Figure 22. Colovesical fistula. Can also form as a complication of diverticulitis Colonic Disorders: Diverticulitis Lecture Video Grade II Image D shows air within the urinary bladder which is usually not seen in Will prolapse the urinary bladder and adjacent diverticulum is seen in a sigmoid area. On colonoscopy, this demonstrates the fistula with surrounding mucous. but might be Image E is a polypoid inflammatory reaction. reduced Image F is the fistula site. spontaneously Figure 26. Internal prolapse reduced spontaneously Doctor’s Notes Colonic Disorders: Hemorrhoids Lecture Video On colonoscopy, a diverticulum might be seen On cystoscopy, granulation tissue might be seen (not an Grade III indication of cancer) Prolapses when you defecate, need to be pushed manually inward Figure 27. Internal prolapse requiring manual reduction Colonic Disorders: Hemorrhoids Lecture Video Grade IV Figure 23. Colovesical fistula. Even if Colonic Disorders: Diverticulitis Lecture Video manually Left - urinary bladder attached to the sigmoid area (resected and repaired reduced, it is individually through partial cystectomy) Right - the fistula’s opening was still outside removed Figure 28. Strangulated internal and thrombosed external II. HEMORRHOIDS Colonic Disorders: Hemorrhoids Lecture Video Most prevalent ailments associated with significant impact on quality of life Management options for hemorrhoidal disease are diverse ranging B. MINIMALLY INVASIVE PROCEDURES from conservative measures to a variety of office and operating Indicated mostly for Grade II and some Grade III internal room procedures hemorrhoids Fourth leading cause of outpatient gastrointestinal consult Mostly office procedures which can be done on outpatient basis accounting for approximately 3.3 million ambulatory care visits in 1 Rubber Band Ligation (RBL) the United States Incidence: 10 million per year, corresponding to 4.4% of the 2 Sclerotherapy population Peak incidence for both genders: 45-65 years old 3 Infrared (IR) Coagulation 4 Bipolar Diathermy NOTE: Prerequisite readings: Anatomy and physiology lectures of the anal canal 5 Laser Medical management of hemorrhoids 6 Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL) A. 🧠GRADING OF HEMORRHOIDS 1. RUBBER BAND LIGATION Advancement of the band onto the ligator using a conical Doctor’s Notes attachment Internal hemorrhoid - above the dentate line Hemorrhoid is identified proximal to the dentate line External hemorrhoid - below the dentate line The area is tested for sensation before banding Hemorrhoid is drawn into the ligator prior to firing the instrument Banded hemorrhoids typically slough off in one week Doctor’s Notes Thrombosed Only done in internal hemorrhoids (NOT in external or mixed) external hemorrhoid 12 months (LOWEST) compared to 1 Recurrence Rate sclerotherapy and infrared coagulation Figure 24. Thrombosed external hemorrhoid Patients with significant bleeding tendency 2 Contraindication Colonic Disorders: Hemorrhoids Lecture Video and treatment with warfarin and heparin Group 6B | Colonic Disorders 6 of 15  Figure 33. Laser Colonic Disorders: Hemorrhoids Lecture Video Figure 29. Rubber Band Ligation Colonic Disorders: Hemorrhoids Lecture Video 6. DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION 2. SCLEROTHERAPY Indicated for Grade I and Grade II internal hemorrhoids Performed through an anal scope, internal hemorrhoids are located and injected with a sclerosing material, typically a solution including phenol into the submucosa The sclerosant subsequently causes fibrosis Excision into the anal canal and eventual obliteration of the redundant hemorrhoidal tissue Figure 34. Doppler Probe (A); Suture Needle Placement (B); Multiple arterial ligations - placement of a running suture for hemorrhoidopexy (C1) hemorrhoidopexy suture tied (C2) prolapse is lifted (C3) Colonic Disorders: Hemorrhoids Lecture Video C. INDICATIONS FOR SURGERY Figure 30. Sclerotherapy 1 Failure of medical and non-operative surgery Colonic Disorders: Hemorrhoids Lecture Video 2 Symptomatic Grade III-IV, or mixed hemorrhoids 3. INFRARED COAGULATION Symptomatic hemorrhoids in the presence of a concomitant 3 Effective outpatient treatment for Grade I and II hemorrhoids anorectal condition that requires surgery The infrared probe is applied to the base of the hemorrhoids Patient preference after discussing treatment options with the through the bronchoscope to produce a circular 2 mm deep burn 4 referring physician and surgeon Exposure of this for one second at each side Results are similar to banding and sclerotherapy but the procedure is less painful D. TECHNIQUES FOR THE OPERATIVE TREATMENT OF Repeated therapy is necessary HEMORRHOIDS 1 Closed hemorrhoidectomy 2 Open hemorrhoidectomy Stapled hemorrhoidectomy aka procedure for prolapse and 3 hemorrhoids 1. CLOSED AND OPEN HEMORRHOIDECTOMY In doing hemorrhoidectomy, the hemorrhoidal part is ligated at the base A V-shaped incision is carried from the anoderm and this section is Figure 31. Infrared Coagulation extended to the pedicle Colonic Disorders: Hemorrhoids Lecture Video The hemorrhoid is then ligated 4. BIPOLAR DIATHERMY 1 Closed hemorrhoidectomy Wound is closed by suturing Uses electric current of very high frequency 2 Open hemorrhoidectomy Wound is left open The electric energy is then used to thicken the affected tissue May just require several sessions before one could get rid of it all Figure 35. Closed Hemorrhoidectomy. Colonic Disorders: Hemorrhoids Lecture Video Figure 32. Bipolar Diathermy Colonic Disorders: Hemorrhoids Lecture Video 2. PROCEDURE FOR PROLAPSE AND HEMORRHOIDS 5. LASER (PPH) For circumferential grade III hemorrhoids, use of stapler The hemorrhoid is vaporized or excised using CO2 or laser ○ Due to strictures The smaller laser beam allows for precision and accuracy Not done anymore due to perineal sepsis Success rate: 98% in one study A Obturator and dilator is inserted B A purse string is placed in the submucosa and mucosa C Angle position proximal for the first string Group 6B | Colonic Disorders 7 of 15  D Stapler casing advance prior to firing E Completed PPH with staple line properly placed 2-4 cm above dentate line Figure 38. Surgical Anal Canal. Colonic Disorders: Anal Fissures Lecture Video 1. MECHANISMS OF PRESERVING CONTINENCE Internal anal sphincters act involuntarily Figure 36. Prolapse and hemorrhoids procedure and excised hemorrhoid. External anal sphincters are controlled voluntarily Colonic Disorders: Hemorrhoids Lecture Video 3. EXCISION OF A THROMBOSED EXTERNAL HEMORRHOID 1 Injection of anesthetic 2 Excision of external component 3 Closure with two or three interrupted absorbable sutures Figure 39. Mechanism of preserving continence. Colonic Disorders: Anal Fissures Lecture Video Figure 37. Excision of Thrombosed External Hemorrhoid. Colonic Disorders: Hemorrhoids Lecture Video B. ESSENTIAL FEATURES OF ANAL FISSURES Fissures are a cut or a wound found at the anal verge area E. SUMMARY FOR HEMORRHOIDS Table 3. Summary 1 Linear ulcers in the lower half of the anal canal Severity 2 Posterior midline the most common site FINDINGS TREATMENT (Degree) 3 fissures that are relatively common Anterior midline No prolapse; painless among females First Supportive tx bleeding Prolapse with straining and RBL, IRC, Bipolar C. PATHOGENESIS OF ANAL FISSURES Second spontaneous reduction diathermy, Pathogenesis possibly related to: Mild discomfort and bleeding Sclerotherapy, DGHAL ○ Internal sphincter hypertonia ○ Mucosal ischemia Prolapse with straining, ○ Passage of hard stool in the form of trauma or prolonged which requires manual diarrhea reduction Closed Pathophysiology sequelae: Third Some throbbing pain, itching, Hemorrhoidectomy ○ A tear in the anoderm causes spasm of the internal anal bleeding, and mucus sphincter discharge ○ This results in pain, increased tearing and decreased blood Permanent prolapse that supply to the anoderm (Schwartz Principles of Surgery 10th cannot be reduced ed.) Closed This cycle precedes the development of a poorly healing wound Fourth Pain and bleeding common Hemorrhoidectomy which eventually becomes a chronic fissure Potential for thrombosis and strangulation Lesions with bizarre sites and numbers are likely to be secondary fissures Source: Colonic Disorders: Hemorrhoids Lecture Video D. CLINICAL DIAGNOSIS OF ANAL FISSURES III. ANAL FISSURES There is usually a history of pain during and after defecation There is bright blood on stool or on the tissue paper A. SURGICAL ANAL CANAL Starts at the level of the levators and extends distally to include the anal transition zone and dentate line, up to the anodermal junction with the anal verge The anal margin extends from anal verge to a 5 cm radius around the verge and contiguous with the perianal skin Figure 40. Acute and Chronic Anal Fissures. Colonic Disorders: Anal Fissures Lecture Video Group 6B | Colonic Disorders 8 of 15 1. ACUTE ANAL FISSURES F. TREATMENT OF ANAL FISSURES There is a history of anal pain with bleeding upon defecation What you can see is just a fissure; a cut or a wound on the anal Table 4. Treatment of Anal Fissures verge ACUTE CHRONIC Increased oral fluids Involves the treatment for acute anal fissure High fiber diet 0.2-0.4% Nitroglycerin cream Fiber supplements Calcium channel blockers Hot sitz bath Botulinum Toxin A Injection Stool softeners Lateral Internal Sphincterotomy (LIS) Source : Colonic Disorders: Anal Fissures Lecture Video Figure 41. Acute Anal Fissures in the posterior midline. Colonic Disorders: Anal Fissures Lecture Video Doctor’s Notes 2. CHRONIC ANAL FISSURES For acute, never force bowel movement if there is no urge The symptoms may have been going on for more than 6 weeks. Partial Lateral Internal Sphincterotomy is the surgical treatment You can see the triad: of choice for chronic anal fissures ○ Sentinel piles ○ Anal fissure 1. CHRONIC ANAL FISSURES TREATMENT ○ Hypertrophied anal papilla Also involves the treatment for acute anal fissure 0.2 - 0.4% Nitroglycerin cream Applied to the anal area Side effect: Headache Long term success has been questioned in this medical management Calcium channel blockers Topical Nifedipine or 2% Diltiazem cream Figure 42. Chronic Anal Fissures in the posterior midline. (A) Anterior and Side effect: Headache, which may be less common than posterior anal fissures with anterior and posterior tags; (B&C) Chronic anal Nitroglycerin cream fissure with hypertrophied papilla. Colonic Disorders: Anal Fissures Lecture Video Botulinum Toxin A Injection Injected towards the hypertrophied internal anal sphincter Figure 44. Botulinum Toxin A Injection. Colonic Disorders: Anal Fissures Lecture Video Lateral Internal Sphincterotomy (LIS) Standard treatment Figure 43. Triad of Chronic Anal Fissure. Colonic Disorders: Anal Fissures Lecture Video Doctor’s Notes 🧠 Sentinel piles or skin tag is usually mistaken as a hemorrhoid Hemorrhoid is accompanied by severe pain and bleeding [BATCH 2025] 📝 CLINICAL DIAGNOSIS OF ANAL FISSURES Acute Anal Fissures ○ In acute anal fissure, there is a history of tearing pain in the anus accompanied with bleeding (hematochezia) on Figure 45. Lateral Internal Sphincterotomy (LIS). defecation Colonic Disorders: Anal Fissures Lecture Video ○ A superficial tear of the distal anoderm and almost always (Upper left) Intersphincteric groove incision heals with medical management (Upper right) Exposed fibers of the hypertrophied internal sphincters (Lower left) Division of the internal sphincter with scissors Afterwhich, the suture closure of the sphincterotomy site is done Chronic Anal Fissures ○ Presence of ulceration and heaped up edges with white fibers of the internal anal sphincter visible at the base of the ulcer (Schwartz Principles of Surgery 10th ed.) ○ This is often associated with external skin tags and/or a hypertrophied anal papilla internally ○ This fissures are more challenging to treat and may require surgery ○ Fissures located at the lateral region may be indicative of an underlying disease such as: Crohn's disease, HIV, syphilis, tuberculosis or leukemia ○ Symptoms manifest for more than 6 weeks E. DIAGNOSTIC INVESTIGATION FOR ANAL FISSURES History and PE serves as the basis for the diagnosis Endoscopy is used to rule out malignant or inflammatory disease Biopsy of ulcer is used in suspected secondary fissures Group 6B | Colonic Disorders 9 of 15 Doctor’s Notes 1 Primary Primary suppuration and fistula result from Internal anal sphincter is contributes ~15% of the sphincter suppuration and non-specific cryptoglandular infection closure fistula Even if there is dissected, the external anal sphincter can give 2 Abscess: fistula Abscess represents acute phase you 80% of control Fistula is the chronic sequelae ~5% of the continence is contributed by the hemorrhoids Everybody has hemorrhoids but not everyone has 3 Anal gland Starts as the anal gland infection in the hemorrhoidal disease infection intersphincteric space as intersphincteric abscesses Others 4 Secondary Secondary lesions may be due to Glyceryl trinitrate lesions malignancy, Crohn’s disease, hidradenitis ○ An ointment that relaxes the internal anal sphincter suppurativa, TB, and others 1. 🧠 PLANES OF EXTENSION OF INTERSPHINCTERIC ABSCESSES TO DEVELOP FISTULAS Intersphincteric space is where the abscess usually starts Figure 46. Glyceryl trinitrate. ○ It can extend to the perianal area and form perianal abscess Colonic Disorders: Anal Fissures Lecture Video ○ It can traverse the external sphincter and form ischiorectal [BATCH 2025] 📝 CHRONIC ANAL FISSURES TREATMENT abscess ○ It can extend cephalad and form supralevator abscess (rare but very difficult to treat) 0.2 - 0.4% Nitroglycerin cream When these abscesses do not heal, chronic sequelae is the ○ This is used to improve blood flow formation of fistula-in-ano Botulinum Toxin A Injection ○ From perianal abscess, you can have intersphincteric fistula ○ Causes temporary muscle paralysis by preventing ○ Ischiorectal and ischioanal abscesses form transsphincteric acetylcholine release from presynaptic nerve terminals fistula ○ Used as an alternative to surgical sphincterotomy ○ Supralevator abscesses form suprasphincteric fistula Lateral Internal Sphincterotomy (LIS) Extrasphincteric fistula is different in that it is not caused by ○ Goal: decrease the spasm of the internal sphincter by perianal abscesses. dividing a portion of the muscle, after which the suture ○ It may be caused by diverticulitis, TB, other infections and even closure of the sphincterotomy site is done cancers of the colon. ○ Healing is achieved in more than 95% of patients, accompanied with immediate relief post op ○ Recurrence occurs in less than 10% of patients ○ Risk of incontinence ranges from 5% to 15% 🧠 Primary G. SUMMARY OF ANAL FISSURES fissures are likely produced by internal sphincter hard stool (📝 or prolonged diarrhea) hypertonia and subsequent mucosal ischemia after a passage of Ulcers (being secondary fissures) should be considered and ruled out Primary fissures are usually located along the posterior midline ○ If at the side, check history and suspect STI, TB, HIV, or IBD as the cause Partial Lateral Internal Sphincterotomy is the surgical treatment Figure 48. Planes of Extension of Intersphincteric Abscesses to Develop of choice for chronic anal fissures Fistulas IV. ANORECTAL ABSCESS AND FISTULA Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula A. ANATOMY OF THE ANAL CANAL 2. PERIANAL SPACES AND PATHS FOR HORSESHOE Abscess formation is usually cryptoglandular in origin ABSCESS Take note of the anal gland location and the opening at the anal crypt, and its relationship with the muscles, the internal and The figure above shows perianal spaces as sites of anorectal external anal sphincters, and the spaces abscesses. ○ Perianal abscesses need anal verge ○ Intersphincteric abscesses in between the internal and external sphincter ○ Ischioanal abscesses lateral to the external sphincter ○ Supralevator abscess superior to the levator muscle Figure 47. Anatomy of the Anal Canal Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula B. ESSENTIAL FEATURES OF ANORECTAL ABSCESS AND FISTULA Figure 49. Perinatal Spaces as Sites of Anorectal Abscesses Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula Group 6B | Colonic Disorders 10 of 15  The figure below shows the paths for the development of potential PARKS AND GORDON CLASSIFICATION OF ANORECTAL circumferential or horseshoe abscesses FISTULA ○ There can be a horseshoe abscess in the: Intersphincteric space Ischiorectal space Supralevator space Figure 51. Parks and Gordon’s Classification of Anorectal Fistula Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula Figure 50. Paths for Horseshoe Abscess From perianal abscess Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess 1 Intersphincteric Fistula (A) located in between the And Fistula sphincters C. CLINICAL DIAGNOSIS From ischioanal abscess 2 Transsphincteric Fistula (B) traversing both the sphincters 1. ANORECTAL ABSCESS 3 Suprasphincteric Fistula (C) From supralevator abscess 1 Anal or perianal pain Rare but they are the most 4 Extrasphincteric Fistula (D) 2 Perianal or rectal induration and swelling problematic 3 Purulent or bloody drainage D. DIAGNOSTIC INVESTIGATION OF ANORECTAL 4 Perineal sepsis (in severe cases) ABSCESS AND FISTULA 📝 CLINICAL DIAGNOSIS OF ANORECTAL Imaging studies show air or contrast material within the fistula [BATCH 2025] Imaging studies are used only for complex or recurrent fistulas ABSCESS Different imaging studies include: ○ Fistulography Especially on those patients who are diabetic or ○ Endoanal ultrasonography immunocompromised and are not being treated ○ CT scan Example: Fornier’s gangrene (infection started from the perianal ○ Pelvic MRI area, patient did not take any medicine + is a known diabetic →1 All of these may be requested to determine the type of week after: scrotum is swollen and has foul-smelling wounds → fistula, to know how many tract and pouches there are, referred for emergency surgery) help in planning for surgery Mortality for Fornier’s gangrene is as high as 50% ○ Best imaging studies to diagnose these cases are: Endoanal ultrasound Pelvic MRI 2. ANORECTAL FISTULA OR FISTULA-IN-ANO 1 External opening with mucopurulent or bloody drainage 2 Palpable firm fistulous tract 1. ENDOANAL ULTRASOUND 3 Internal opening Palpated upon digital rectal examination (DRE) as an induration [BATCH 2025] 📝 CLINICAL DIAGNOSIS OF ANORECTAL FISTULA (FISTULA-IN-ANO) Usually chronic (more than 6 weeks) Recurrent, has discharge, starts with an abscess and the the patient will feel relief when drainage is done (some would opt not to follow up even with the presence of discharge) ○ There is cases of recurrence of pain and swelling when the opening closes ○ Usually patient would go for check-up once they notice the drainage External opening with mucopurulent or bloody drainage Palpable firm fistulous tract Internal opening can be palpated as an induration when digital Figure 52. Picture of endoanal ultrasound device (upper pictures). (Below) are rectal examination is performed ultrasound images with (A) a normal subject with intact hypoechoic internal anal sphincter and intact thicker hyperechoic external sphincter. (B) subject with fecal incontinence due to obstetric injury causing large anterior defect in both internal and external anal sphincter Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula Group 6B | Colonic Disorders 11 of 15  Ligation of intersphincteric fistula tract (LIFT) ○ Preferred treatment for high transsphincteric fistula with mature tract Advancement flap ○ Done several months after seton placement SPHINCTER PRESERVING PROCEDURES Injection of fibrin glue Insertion of porcine small intestine (SIS) plug LIFT Seton placement 3. 🧠GOODSALL RULE Upon inspection of the perianal area, external opening can be visualized Used to determine the location of the internal opening ○ To do this, make a transverse anal line that divides the anus into anterior and posterior halves All external openings located anteriorly and less than 3 cm from the anal verge will have a straight tract while those more than 3 cm will have a curvilinear tract towards the posterior midline All external openings located posteriorly will have a curvilinear tract towards the posterior midline Figure 53. (Uppermost picture) a transsphincteric, hypoechogenic tract extending towards the posterior midline, the tract is enhanced by hydrogen peroxide injection into the external opening. (Middle picture) a complex fistula tract and collections seen with/without hydrogen peroxide enhancement Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula 2. MRI Figure 55. Goodsall Rule Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula 4. FISTULOTOMY Standard of fistula treatment Figure 54. Axial MRI picture showing a left transsphincteric fistula with intersphincteric and left anal fossa compartment of the abscess Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula Figure 56. Fistulotomy Doc Alamo’s Anorectal Abscess And Fistula Lecture Video E. MANAGEMENT OF ANORECTAL ABSCESS AND FISTULA Fistulotomy wound done by opening the tract followed by A curettage 1. ANORECTAL ABSCESS Antibiotics B Fistulotomy wound after completion of Marsupialization ○ Not necessary for the average patient Surgical drainage 5. SETON PLACEMENT ○ Treatment of choice Patient is positioned in the prone jack-knife ○ Prompt drainage and antibiotics are indicated in diabetics or immunocompromised patients Fistulotomy ○ May be delayed if the internal opening is not readily identified during surgery 2. ANAL FISTULA Management is dependent on: ○ Type of fistula ○ Degree of involvement of external anal sphincter Fistulotomy Figure 57. Seton Placement ○ Procedure of choice for subcutaneous, superficial, and Doc Alamo’s Anorectal Abscess And Fistula Lecture Video intersphincteric fistula-in-ano Seton placement Fistula probe inserted into a superficial posterior and a deep A ○ Used for immature transsphincteric fistula anterior fistula tract Group 6B | Colonic Disorders 12 of 15  Fistulotomy was done in the posterior superficial fistula and a B seton is placed into the deep anterior fistula tract Cutting seton is a painful procedure and may take a few weeks to months before it cuts the entire external sphincter Cutting seton is replaced and tightened every 2 weeks Scar is formed as the seton is advance Figure 61. Anal fistula: fibrin glue injection Doc Alamo’s Anorectal Abscess And Fistula Lecture Video 9. PORCINE COLLAGEN ANAL FISTULA PLUG Figure 58. Technique of cutting seton management Doc Alamo’s Anorectal Abscess And Fistula Lecture Video 6. LIGATION OF INTERSPHINCTERIC FISTULA TRACT (LIFT) Figure 62. Porcine collagen anal fistula plug Doc Alamo’s Anorectal Abscess And Fistula Lecture Video Hydrogen peroxide flushing of the fistula tract before A Figure 59. LIFT placement of the plug is done Doc Alamo’s Anorectal Abscess And Fistula Lecture Video Initial plug placement and suture anchoring of fat end of the B&C plug at the internal opening A Incision over the intersphincteric groove D Cutting the excess plug at the external opening B Initial dissection E Final appearance of the plug C Isolation of the fistula tract D Where the tract is divided and ligated E The coronal view of the LIFT procedure 7. DERMAL ADVANCEMENT FLAP Figure 60. Dermal advancement flap Doc Alamo’s Anorectal Abscess And Fistula Lecture Video Figure 63. Anal fistula plug A Mucosa over the internal opening is excised Doc Alamo’s Anorectal Abscess And Fistula Lecture Video B Advancement flap is created to cover the internal defect Table 5. Results of techniques other than fistulotomy for anal fistula C Alap is advanced into the anus to cover the mucosal defect treatment D Dlap is sutured in place and the external defect is closed TECHNIQUE EXAMPLES OF REPORTED HEALING Note: The external fistula opening is not closed Advancement flap 85% – 90% 8. ANAL FISTULA: FIBRIN GLUE INJECTION Fibrin glue < 50% After curettage, fibrin glue is injected from the external opening Fistula plug 13.9% - 87% thereby obliterating the tract LIFT 57% - 82% Source: Doc Alamo’s Lecture Video: Colorectal Surgery 2 - Part 3 Anorectal Abscess And Fistula Group 6B | Colonic Disorders 13 of 15 G. SUMMARY FOR ANORECTAL ABSCESS AND FISTULA 7 Which among the following statements are correct. Primary lesions arise from the cryptoglandular infection A. Hinchey Stage 1- Resection with anastomosis is advised Imaging studies are helpful in complex cases B. Hinchey Stage Stage 2- Hartmann's procedure vs. a Surgical drainage is the primary treatment for abscesses diverting colostomy and an omental graph Treatment options for fistulas include fistulotomy, seton C. Hinchey Stage Stage 3- Section anastomosis with or placement, LIFT (Ligation of Intersphincteric Fistula Tract), fibrin without diversion glue injection, porcine small intestine submucosa (SIS) plug, and D. Hinchey Stage Stage 4- Resection with anastomosis is advancement flap advised Treatment is tailored so as to prevent fecal incontinence 8 A patient who needs to manually reduce his internal hemorrhoids into the anal canal has: V. APA REFERENCES A. Grade III hemorrhoids Alamo, S. G. (2024). Colorectal Surgery 1 Diverticulitis [Video B. Grade IV hemorrhoids Lecture]. C. Grade II hemorrhoids Alamo, S. G. (2024). Colorectal Surgery 2 - Part 1 hemorrhoids [Video D. Grade I hemorrhoids Lecture]. Alamo, S. G. (2024). Colorectal Surgery 2 - Part 2 Anal fissure [Video 9 What is the best diagnostic work-up for a 68-year-old male, Lecture]. hypertensive, with two days history of left lower quadrant Alamo, S. G. (2024). Colorectal Surgery 2 - Part 3 Anorectal Abscess pain associated with fever and obstipation? And Fistula [Video Lecture]. A. Abdominal X Ray Brunicardi, F. C. (2019). Schwartz’s Principles of Surgery. (11th ed). B. Colonoscopy USA: McGraw-Hill Education. C. CT Scan of the abdomen D. Ultrasound of the abdomen VI. REVIEW QUESTIONS 10 CT Scan revealed diverticula in the sigmoid colon and phlegmon in a 72-year-old man who presented with left No. QUESTIONS lower quadrant pain and no peritonitis. The appropriate 1 Imaging studies revealed diverticula in the sigmoid colon treatment option for him currently is antibiotics plus: and 20 cc pericolic abscess collection in an 88-year-old A. Percutaneous drainage woman who presented with left lower quadrant pain and B. Hartmann’s Procedure fever. The appropriate treatment option for her at this time C. Supportive management is antibiotics plus: D. Endoscopic stenting A. Hartmann's procedure 11 Purulent peritonitis is classified as Hinchey stage: B. Percutaneous drainage A. IV C. Supportive management B. III D. Endoscopic stenting C. II 2 The treatment of choice for chronic anal fissures is: D. I A. Lateral internal sphincterotomy B. Papillotomy VII. RATIONALIZATION C. Excision of sentinel pile D. Fissurectomy No. RATIONALIZATION 3 After developing perianal abscess at the right side of the 1 CORRECT ANSWER: B. Percutaneous drainage anus 1cm from the anal verge, a 64-year-old man noticed Correct because the initial management for these patients is persistent purulent discharge at the same site of the source control and the appropriate source control step for previous abscess. What type of fistula does he most likely Abscesses are antibiotic treatment and percutaneous drainage. have? A. Intersphincteric a. Hartmann's procedure. Incorrect. Hartmann’s procedure B. Transsphincteric refers to a colon or rectal resection without an anastomosis in C. Extrasphincteric which a colostomy or ileostomy is created and the distal colon D. Suprasphincteric or rectum is left as a blind pouch. This is indicated for Complicated Diverticulitis but is not the initial management. 4 Which of the following is a part of the triad of chronic anal c. Supportive Management, Incorrect. Since there is an fissure? ongoing infection as indicated by the abscess seen, supportive A. Right posterior pile management is not applicable as it will only allow the infection B. Sentinel pile to worsen. C. Right anterior pile d. Endoscopic stenting. Incorrect. This is a procedure done D. Left lateral pile when there is obstruction in the bile ducts. 5 Which of the following procedure for fistula-in-ano is indicated for high transsphincteric fistula with immature Ratio Batch 2024 tract and significant abscess collection? 2 CORRECT ANSWER: A. Lateral internal sphincterotomy A. Seton placement Treatment for Chronic Anal Fissure: B. Fistulotomy 0.2-0.4% Nitroglycerin Cream C. LIFT procedure Calcium Channel Blockers D. Fistulectomy Botulinum Toxin A Injection 6 A 55-year-old diabetic male consults due to severe anal Lateral internal sphincterotomy - standard treatment pain of 2 days duration with fever. On physical examination, you note a fluctuant mass on the left of the B. Papillotomy - emergent procedure for biliary pancreatitis anal verge. Your impression is: C. Excision of sentinel pile - Part of the triad of chronic anal A. Acute anal fissure fissure:hypertrophied anal papilla, anal fissure, sentinel pile. It is B. Condyloma acuminata not part of the treatment options. C. Internal hemorrhoids D. Fissurectomy - one of the options to treat chronic anal D. Perianal abscess fissures however it was found that LIS was still a better treatment option. Ratio Batch 2024 Group 6B | Colonic Disorders 14 of 15  3 CORRECT ANSWER: A. Intersphincteric 9 CORRECT ANSWER: C. CT Scan of the abdomen This fistula is classified as a perianal fistula, since it developed This is a case of acute diverticulitis which is common among at the same site as the previous abscess, which is a perianal hypertensive elderly patients. CT scan is the best diagnostic abscess. The question asks for “most likely” fistula, so out of modality for acute diverticulitis. the four possible perianal fistulas, intersphincteric is the most common with a 70% occurrence. This is followed by Ratio Batch 2025 transsphincteric at 25%, suprasphincteric at 5%, and extrasphincteric at 1%. 10 CORRECT ANSWER: C. Supportive management Ratio Batch 2024 The patient presents with diverticulitis with no peritonitis; thus, this case does not require surgical treatment yet. However, all 4 CORRECT ANSWER: B. Sentinel pile patients, for 48 hours, receive supportive management such as broad spectrum antibiotics, bowel rest, and total parenteral Sentinel pile is part of the triad of chronic anal fissures, nutrition. alongside anal fissure and hypertrophied anal papilla. The other choices are not part of this triad. A is incorrect because drainage of the abscess is done for grade 3 perforation. Ratio Batch 2024 B and D are both surgical procedures; Hartmann’s procedure is 5 CORRECT ANSWER: A. Seton placement indicated for complicated diverticular disease. Seton placement used for immature transphincter fistula. Ratio Batch 2025 Fistulotomy is a procedure of choice for subcutaneous, superficial, and intersphincteric fistula-in-ano. 11 CORRECT ANSWER: B. III LIFT procedure is a preferred treatment for high transphicter fistula with mature tract. Free perforation causing purulent peritonitis falls under Stage III Fistulectomy is a procedure that fully removes the fistulous of Hinchey’s Diverticulitis Staging. tract. A is incorrect because Stage IV is characterized by fecal Ratio Batch 2024 peritonitis caused by free perforation. 6 CORRECT ANSWER: D. Perianal abscess C is incorrect because Stage II is characterized by larger mesenteric abscess spreading towards the pelvis. Anal/perianal pain is the most common complaint in acute anal fissures, along with perianal/rectal induration and swelling, and D is incorrect because Stage I is characterized by small, < 3 purulent or bloody drainage. cm, pericolic abscess. A is incorrect because acute anal fissures may have a history of Ratio Batch 2025 anal pain and bleeding upon and during defecation. However, there is no mass. B is incorrect because this was not part of the lecture. C is wrong because internal hemorrhoids present with prolapse, bleeding, and straining. Thus, there is no mass. Ratio Batch 2025 7 CORRECT ANSWER: A. Hinchey Stage 1 resection with anastomosis is advised Hinchey Stage 1 resection with anastomosis is advised Stage 2 the section anastomosis with or without diversion Stage 3 and 4 Hartmann's procedure versus a diverting colostomy and an omental graph The higher the stage the higher the morbidity and the mortality Dr. Sherwin G. Alamo’s Lecture on Colonic Disorders 8 CORRECT ANSWER: A. Grade III hemorrhoids Internal prolapse such as Grade III hemorrhoids require manual reduction. B is incorrect because Grade IV hemorrhoids are permanently prolapsed. Thus, a patient cannot reduce his hemorrhoids into the anal canal. C is incorrect because in cases of Grade II hemorrhoids, internal prolapse is reduced spontaneously. D is incorrect because in cases of Grade I hemorrhoids, hemorrhoids do not protrude, but may bleed. Ratio Batch 2025 Group 6B | Colonic Disorders 15 of 15