ANORECTUM ( FISTULA IN ANO,PILONIDAL DISEASE,ANAL NEOPLASMS,RECTAL PROLAPSE)

FISTULA IN ANO     usually associated with anorectal abscess; could indicate IBD  an inflammatory tract with internal os at ...

FISTULA IN ANO 

 

1. usually associated with anorectal abscess; could indicate IBD 
2. an inflammatory tract with internal os at dentate line, external os on skin according to Goodsall's rule
3. intermittent or constant purulent discharge from para-anal opening,
4. pain palpable cord-like tract

 

Goodsall's rule relates the external opening of an anal fistula  to its internal opening. It states that the external opening situated behind the transverse anal line will open into the anal canal in the midline posteriorly. An anterior opening is usually associated with a radial tract.

Treatment

1. identify internal opening
2. istulous tract identification (probing or fistulography) under anesthesia 
3. unroof tract from external to internal opening, allow drainage
4. seton (thick suture) can be placed through tract
5. promotes drainage
6. promotes fibrosis and decreases incidence of incontinence
7. delinates anatomy
8. post-op: sitz baths, irrigation and packing to ensure healing proceeds from inside to outside complications
   recurrence, fecal incontinence

See Video : FISTULA IN ANO  

 

PILONIDAL DISEASE 

 

1. acute abscess or chronic draining sinus in sacrococcygeal area usually asymptomatic until acutely infected
2. develops secondary to obstruction of the hair follicles in this area ---> leads to formation of cysts, sinuses or abscesses

Treatment

1. acute abscess - incision and drainage
2. chronic disease - pilonidal cystotomy or excision of sinus tract and cyst +/- marsupialization
   

RECTAL PROLAPSE

 

1. protrusion of full thickness of rectum through anus that initially reduces spontaneously until continuously prolapsed. Must be differentiated from hemorrhoidal prolapse
2. increased incidence in gynecological surgeries, chronic neurologic/ psychiatric disorders affecting motility
3. fecal and flatus incontinence secondary to dilated and weakened sphincter
4. occurs in extremes of age
   < 5 years old spontaneously resolve with conservative treatment (stool softeners)
   > 40 years old usually
5. require surgical treatment: anchoring rectum to sacrum (e.g. Ripstein procedure), excision of redundant rectum followed by colon anastamosis to lower rectum
   

ANAL NEOPLASMS 

 

1. Epidermoid carcinoma of anal canal (above dentate line)
1. most common tumour of anal canal (75%)
2. squamous cell or transitional cell
3. presents with rectal pain, bleeding, mass
4. treatment of choice is chemotherapy, radiation +/- surgery with 80% 5 year survival 
2. Malignant melanoma of anal margin
1. 3rd most common site after skin, eyes
2. aggressive, distant metastases are common at time of diagnosis
3. early radical surgery is treatment of choice
4. < 15% 5 year survival