Surgery Anorectal Region
Surgery Anorectal Region
Haemorrhoids are swollen blood vessels around the anus (where they are called external haemorrhoids), or inside the lower part of the rectum (where they are called internal haemorrhoids). They often develop during pregnancy or because of straining when the person has constipation. Internal haemorrhoids can protrude out of the anus, and this may cause itching, bleeding and pain. The usual treatments for haemorrhoids include steroid creams and a high-fibre diet or laxatives to prevent constipation. If these do not work, the haemorrhoids and nearby tissues can be removed in an operation. Circular stapled haemorrhoidectomy is a newer treatment for internal haemorrhoids. A special circular stapler is inserted into the rectum, to cut out a circular strip of the lining of the rectum (which is called the rectal mucosa) above the haemorrhoids. This reduces the blood supply to the haemorrhoids, so that they shrink.
How well it works?
Patients who had circular stapled haemorrhoidectomy had less pain and were able to go back to everyday activities sooner than people who had the usual type of surgery for haemorrhoids. In one study, people who had the procedure went back to work an average of 6 days later, and people who had the usual surgery went back after an average of 15 days.
Risks and possible problems
Problems such as bleeding after the procedure are less common with circular stapled haemorrhoidectomy than with the usual type of surgery.
Anal Fissure Overview
An anal fissure is a tear in the lining of the anus, the opening where faeces are excreted. The tear typically extends into a circular ring of muscle called the internal anal sphincter. The fissure is described as acute if it has been present for less than six weeks, or chronic if present greater than six weeks.
Once a fissure develops, the internal anal sphincter typically goes into spasm, causing further separation of the tear, impairing healing and causing pain. Exposure to faeces also slows healing.
There are no reliable estimates of the frequency of anal fissures in the general population; some studies suggest that as many as one in five persons develop a fissure during their lifetime. This may be an underestimate since some people may be too embarrassed to discuss it with their healthcare provider.
Symptoms of Fissure
Patients with an anal fissure may first note bleeding and a sensation of tearing, ripping or burning following a bowel movement. Once a fissure develops, these symptoms can occur after every bowel movement; the rectal pain can last several minutes to hours.
Bleeding is usually mild and limited to a small amount on toilet paper or the surface of stool. However, the bleeding may discolour the toilet bowl, giving it the appearance of heavy bleeding. As the fissure becomes chronic, the bleeding may stop, although the pain persists. Some patients also note itching or irritation of the skin around the anus.
Diagnosis
Anal fissures can usually be diagnosed based on the symptoms described above and a physical examination. The physical examination involves gently separating the buttocks, allowing for visual inspection of the region around the anus. A fissure most commonly appears in the 12 or 6 o’clock position.
Once healing has occurred or if the diagnosis is unclear, a sigmoidoscopy or colonoscopy is usually recommended, especially if there has been rectal bleeding. A colonoscopy is preferred in patients 50 years and older, and can also be used to screen for colorectal cancer. In younger patients with no risk factors for colorectal cancer or intestinal diseases, a sigmoidoscopy or regular monitoring may suffice.
Treatment
The goal of treatment for anal fissures is to relieve the pain and spasm and heal the fissure. Those with a chronic anal fissure usually require additional therapy.
Initial treatment is aimed at eliminating constipation, softening stools and reducing anal sphincter spasm. These measures are successful in 60 to 90 percent of patients. However, some patients may not heal or develop frequent recurrences. Such patients may require surgery, which is successful in more than 95 percent of the time.
Fibre therapy — avoiding hard bowel movements will prevent over-distension of the anus, which could open a healing fissure. Increasing fibre in the diet is one of the best ways to soften and bulk the stool. Fibre is found in fruits and vegetables.
Sitz baths — During Sitz baths, the rectal area is immersed in warm water for approximately 10 to 15 minutes two to three times daily. It is also possible to use a bathtub as a sitz bath by simply filling it with 2 to 3 inches of warm water. Sitz baths work by improving blood flow and relaxing the internal anal sphincter.
Topical nifedipine and topical nitroglycerine — Topical nifedipine is a blood pressure medication that works by reducing the internal anal sphincter pressure. Nifedipine is available in pill form for other indications, but is best used for fissure treatment when compounded into gel form and applied directly to the fissure. Nitroglycerine side effects can include headache and low blood pressure.
Surgery — surgical procedures are generally reserved for people with anal fissure who have tried medical therapy for at least one to three months and have not healed. The procedure of choice is called lateral sphincterotomy, which relaxes the internal anal sphincter by cutting a small nick into the internal anal sphincter of the anal canal. This is generally performed as a day surgery after the patient is given general anaesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.
However, this immediate post surgical incontinence is rarely permanent and is usually mild. The risk should be discussed with your surgeon.
Comparison among surgery and nitroglycerine, botulinum toxin, and nifedipine or diltiazem reveals that surgery has a higher success rate. In one study, close to 100 percent of patients with fissure who underwent surgery were completely healed by two months after surgery.