anal s-plasty for “whitehead deformity”

4
Anal S-plasty for "Whitehead Deformity"* HAROLD T. FAULCONER, M.D. JAMES A. FERGUSON, M.D. Lexington, Kentucky Grand Rapfds, Michigan ECTROPION Of the rectal mucosa beyond the normal dentate line is frequen.tly called a "Whitehead deformity." The deformity may develop after anorectal operations in which skin of the anal canal is removed and the rectal mucosa is fixed at the anal verge (Fig. 1 A). This usually occurs after the amputative type of hemorrhoidectomy, popularized by Whitehead2 but not done as he described. Unfortunately, the de- formity bears his name. The extension of rectal mucosa outside the anus causes a wet outlet with itching, bleeding, and chronic discomfort. When the deformity involves small quadrants of the anal canal, these areas of ectropic rectal mucosa can be excised by elliptical incisions and the wounds closed. A circular ectropion of mucosa onto the anal verge presents a more complex prob- lem for surgical treatment. Fergusonl re- ported an S-plasty repair in 1959 with encoura~ng results in four cases. It is the purpose of this paper to review the S- plasty operation and its results since its innovation at the Ferguson Clinic in 1955. Technic To correct the deformity, the abnor- mally located rectal mucosa must be re- moved and replaced with skin, fixing the mucocutaneous junction at its normal site, the dentate line. The skin coverage is pro- vided by utilizing a double-rotation flap. The colon is cleansed and the perianal * Read at the meeting of the American Procto- logic Society, New York, New York, June 11 to 14, 1972. Dis. Col. &Rect. Sept.-Oct. 1973 area shaved prior to surgery. This pro- cedure is illustrated as being performed with the patient in the left lateral posi- tion (Fig. 1B). This position provides ex- cellent exposure. It is also recommended because, by having the hips flexed acutely, the perianal area is under maximal tension while the procedure is performed. A cir- cumferential incision is made about the abnormally located mucocutaneous junc- tion down to the external sphincter muscle fibers (Fig. 1C). The mucosa is then mobil- ized up into the anal canal, dearly exposing the internal sphincter muscle. The mucosa is then amputated at its upper limit of dissection at a point where the new muco- cutaneous junction will be located. Bleeders are coagulated or ligated with fine catgut. There is now a denuded cylinder of anal canal to be covered. Double-rotation skin flaps are now outlined by a large "S" mark with the anal canal in the center (Fig. 1D). The flaps should be designed so that the length-width ratio approaches 1:1; it should not exceed 2:1 for circulation reasons. After the flaps are mobilized, the apex of the upper flap is brought to the anterior cut edge of mucosa and fixed with 000 chromic catgut sutures (Fig. 1E). The side of the flap is then sutured to the lateral wall, back to the posterior anal canal, with interrupted 000 chromic catgut sutures. The lower flap is similarly fixed to the anal canal. The ex- ternal donor ellipses will usually close without tension. They can be left open, but it is recommended that they be closed if possible (Fig. IF). 388 Volume 16 Number 5

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Page 1: Anal S-plasty for “Whitehead deformity”

Anal S-plasty for "Whitehead Deformity"*

HAROLD T . FAULCONER, M . D . JAMES A. FERGUSON, M . D .

Lexington, Kentucky Grand Rapfds, Michigan

ECTROPION Of the rectal mucosa beyond the normal dentate line is frequen.tly called a "Whitehead deformity." T h e deformity may develop after anorectal operations in which skin of the anal canal is removed and the rectal mucosa is fixed at the anal verge (Fig. 1 A). This usually occurs after the amputative type of hemorrhoidectomy, popularized by Whitehead2 but not done as he described. Unfortunately, the de- formity bears his name. T h e extension of rectal mucosa outside the anus causes a wet outlet with itching, bleeding, and chronic discomfort.

When the deformity involves small quadrants of the anal canal, these areas of ectropic rectal mucosa can be excised by elliptical incisions and the wounds closed. A circular ectropion of mucosa onto the anal verge presents a more complex prob- lem for surgical treatment. Fergusonl re- ported an S-plasty repair in 1959 with encoura~ng results in four cases. It is the purpose of this paper to review the S- plasty operation and its results since its innovation at the Ferguson Clinic in 1955.

Technic

T o correct the deformity, the abnor- mally located rectal mucosa must be re- moved and replaced with skin, fixing the mucocutaneous junct ion at its normal site, the dentate line. T h e skin coverage is pro- vided by utilizing a double-rotation flap. T h e colon is cleansed and the perianal

* Read at the meeting of the American Procto- logic Society, New York, New York, June 11 to 14, 1972.

Dis. Col. &Rect. Sept.-Oct. 1973

area shaved prior to surgery. This pro- cedure is illustrated as being performed with the patient in the left lateral posi- tion (Fig. 1B). This position provides ex- cellent exposure. It is also recommended because, by having the hips flexed acutely, the perianal area is under maximal tension while the procedure is performed. A cir- cumferential incision is made about the abnormally located mucocutaneous junc- tion down to the external sphincter muscle fibers (Fig. 1C). T h e mucosa is then mobil- ized up into the anal canal, dear ly exposing the internal sphincter muscle. T h e mucosa is then amputated at its upper limit of dissection at a point where the new muco- cutaneous junct ion will be located. Bleeders are coagulated or ligated with fine catgut. There is now a denuded cylinder of anal canal to be covered. Double-rotation skin flaps are now outl ined by a large "S" mark with the anal canal in the center (Fig. 1D). T h e flaps should be designed so that the length-width ratio approaches 1:1; it should not exceed 2:1 for circulation reasons. After the flaps are mobilized, the apex of the upper flap is brought to the anterior cut edge of mucosa and fixed with 000 chromic catgut sutures (Fig. 1E). Th e side of the flap is then sutured to the lateral wall, back to the posterior anal canal, with in terrupted 000 chromic catgut sutures. T h e lower flap is similarly fixed to the anal canal. T h e ex- ternal donor ellipses will usually close without tension. They can be left open, but it is recommended that they be closed if possible (Fig. IF).

388 Volume 16 Number 5

Page 2: Anal S-plasty for “Whitehead deformity”

Volume 16 ANAL S-PLASTY 3 8 9 Number 5

FIG. 1. A, cross section of anorectum, showing Whi tehead deformity wi th abnormally placed mucosa out onto anal verge. B, pat ient in left lateral posi t ion for surgery and S.-plast.y outl ined. C, ectropie mucosa has been dissected up to the proper level of the mucocutaneous junct ion. D, S-flaps out l ined after abnormally located mucosa has been amputa ted . E, upper flap has been advanced so that point A in the flap has been fixed anteriorly at the proper level of the dentate line. ~, complet ion of S-plasty procedure.

Page 3: Anal S-plasty for “Whitehead deformity”

890 FAULCONER AND FERGUSON Dis. Col. & Reet. Sept.-Oct. 1973

Postoperative care consists of protecting the anal canal from excessive fecal con- tamination by restricting the diet to clear liquids for five days. The area is cleansed daily, and systemic antibiotics are sug- gested.

Review of Cases

Patients operated upon for Whitehead deformity from 1955 through June 1971 at the Ferguson Clinic were reviewed. Twenty-five cases were found; of these, 18 had S-plasty repairs. Two additional pa- tients had half of the S-plasty, and the other ten had procedures that included hemorrhoidectomy with elliptical excision of the protruding mucosa. Only those 13 cases in which the complete S-plasty repair was done are reviewed here.

Of the 13 patients, nine were men and four were women, with an age range of 24 to 77 years.

All had had prior anorectal surgery: ten had had hemorrhoidectomies; one, exci- sion of perianal leukoplakia; two, opera- tions for imperforate anus.

T h e patients' complaints varied. Eleven had some degree of rectal bleeding, nine had perianal wetness, two had some degree of incontinence, three complained of itch- ing, six had pain, and seven complained of protrusion.

All of these patients had complete ano- rectal examinations, including sigmoidos- copy. All had the Whitehead type of de- formity with ectropion of rectal mucosa onto the anal verge. One patient also had considerable scarring of the anal area, and two had weakness of the sphincter muscle. Sigmoidoscopic examination did not reveal any disease in these cases.

Eleven of the 13 patients had barium- enema examinations; all were reported as normal except one that showed a single diverticulum of the sigmoid colon.

A review of the associated diseases pre- sent in these patients disclosed nothing significant. One of the patients who had

had an operation for imperforate anus had additional spina biffda and a neurogenic bladder. Three had evidence of cardiovas- cular disease. One had a hydrocele, and one had otitis media.

Results in these patients were reported by the examiner on the final examinat ion as being excellent with regard to relief of the ectropion of rectal mucosa. One pa- tient was a narcotic addict, had multiple complications after her surgery, and even- tually had two operations. However, on her final examination, the examiner felt that there was an excellent anatomic result even though the patient still had pain.

T h e pathology review showed rectal mucosa in all of the specimens, and ten had evidence of chronic inflammation.

T h e follow-up periods of these patients ranged from three months to 16 )'ears postoperatively. Hospital stays ranged from nine to 17 days, averaging about 12 days.

Postoperatively all of these patients were managed in about the same way. All ex- cept one were placed on a l iquid diet post- operatively for three to 12 days before getting a more solid diet, in an effort to prevent early fecal soilage of the wounds. Eleven patients received some form of systemic antibiotic. Th e patients did not have sitz baths immediately postoperatively. Some began having these about the fifth postoperative day, and some not at all. Tw o patients were given paregoric in an effort to preclude early bowel movements. Many were given rectal irrigations and enemas postoperatively to prevent fecal soilage of the wounds. Excluding the narcotic addict, who received 28 shots of narcotics during her first admission, the patients received one to six narcotic injec- tions, but the average was about two shots per patient. All of these patients were seen at least twice after discharge from the hospital.

Nine of the patients were operated upon by one surgeon and the other four by other surgeons at the Ferguson Clinic.

Page 4: Anal S-plasty for “Whitehead deformity”

Volume 16 Number 5

ANAL S-PLASTY 391

Complications

One pat ient (the narcot ic addict) had a complicated course which should be men- tioned. This pat ient was a 40-year-old w o m a n who had had a hemor rho idec tomy three years previously. She compla ined of rectal pain, bleeding, and protrusion. She had a scarred per ianal area, marked ectro- p ion of the rectal mucosa, and a weak sphincter muscle," Fol lowing $-plasty repair, she developed an abscess unde r one flap and, after healing, still had considerable Whi tehead- type deformity. A transverse divert ing colostomy was performed, and later another S-plasty procedure was done. A perianal abscess again developed, bu t eventually healed, and when last seen, as already stated, the pat ient had a good anatomic result bu t still compla ined of pain.

Of the other 12 patients, one had a small abscess under a flap. Ano t he r had necrosis of about a th i rd of one flap, with resul tant

mi ld anal stenosis which responded to anal dilatation. One pa t ien t had a t empera tu re of 102 F for three days, of u n k n o w n cause. One pat ient had an opera t ion for an ulcer- in-ano a year after the S-plasty. One pa- t ient had a small area of mucosal prolapse, which was treated by inject ion of 5 per cent qu in ine and urea.

Summary

T h e S-plasty, or double- ro ta t ion flap, opera t ion for the Whi t ehead deformi ty has proved successful. T h i r t e e n pat ients hav ing the procedure over the past 13 years at the Ferguson Clinic have all had excellent ana tomic results.

Refe rences

1. ~'er~son JA: Repair of "Whitehead deformity" ot~ the anus. Surg Gynecol Obstet 108:115, 1959

2. Whitehead W: The surgical treatment of haemorrhoids. Br Med J 1:148, 1882

Memoir JACKMAN, RAYMOND J., Rochester, Minnesota; born Emmetsburg,

Iowa, May 16, 1906; University of Iowa, 1930; internship Saint Mary's Hospital, Kansas City, Missouri; in private practice until entering Mayo Graduate School, where he received the M.D. degree in proctology in 1938. He was appointed a member of the Mayo Clinic Section of Proctology in 1938 and headed the Section from 1952 to 1967.

Dr. Jackman joined the American Society o[ Colon and Rectal Sur- geons (American Proctologic Society) in 1944 and was elected to Fellow- ship in 1948. He was a member o[ the Society's Council in 1954-1955, and was elected President of the Society in 1966. He was certified by the American Board of Surgery in Proctology and by the American Board of Colon and Rectal Surgery, serving as a member of the board of examiners o[ the latter Board in 1956 and 1957.

Dr. Jackman was a Fellow, American College of Surgeons; Past Presi- dent, Minnesota State Medical Association (1970, 1971); Past President, Minnesota State Board of Health: Past President, Zumbro Valley Med- ical Society; Past Chairman, AMA Section on Colon and Rectal Surgery; and an Honorary Member of the Section on Proctology of the Royal Society of Medicine. He was active locally, serving on the Rochester Charter Commission, Rochester Board of Public Health and -Welfare, and the Clinic Surgical Committee.

Dr. Jackman was Professor os Proctology in the Mayo Graduate School of Medicine until his retirement in 1971. Following his retire- ment, he was appointed Olmsted County Health Officer, a post which he held until the time o[ his death on August 10, 1973.