Y. Ziv, 2008

Proctology

• Hemorrhoids• Anal - Fissure• Fistula - Ani• Constipation (Obst. Defacation Syndroms)• Incontinence• Tumors (Benign & Malignant)• Infections (Viral, Bacterial, Fungi, Chemical,

Allergic, Others)

Yehiel Ziv, MD, Assaf-Harofe Med. Ctr.Chairman, The Isreal Society of Colon & Rectal Surgeons

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Anal canal

Int. anal sphincter

Ext. anal sphincter

Levator ani muscle

anal columns

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Anal canal

Int. anal sphincterExt. anal sphincter

Levator ani musclerectum

deep part

superficial part

subcutaneus part

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anal column

anal valve

tributaries of superior rectal vein

external anal sphincter

internal anal sphincetr

tributaries of inferior rectal vein

ANAL SINUS

conjoint longitudinal muscle

intermuscular groove

[white line of Hilton]

pecten

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Levator ani muscle

Ano-rectal line

anal gland

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levator ani muscle

external anal sphincer

internal anal sphincter

ischioanal fossa

fibrous septum of ischioanal fossa

conjoint longitudinal muscle

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Hemorrhoids

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Hemorrhoids

• Normal components (sub-mucosal vascular tissue) of human anatomy

• External (Inf. Hem. Plexus, Somatic Nerve)

• Internal (Sup. Hem. Plexus, Above DL, Senseless)

• Mixed

• 2 – Right Side, Anterior & Posterior• 1 – Left Side• M = F, Peak = 45-65y

Y. Ziv, 2008

Hemorrhoids

• Pathogenesis : - Increased age

- Ch. diarrhea or constipation

- Increased Intra - Abdominal Pressure

(prolonged sitting, pregnancy etc.)

• Hypothesis: Hypertrophy or

Increased Muscle Tone

Y. Ziv, 2008

Hemorrhoids

• Internal Hem. Classification• 1st deg : project into lumen & bleed.

• 2nd deg : protrude – spont. reduction

• 3rd deg : protrude – manual reduction

• 4th deg : irreducibly prolapsed.

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Hemorrhoids

• Diagnosis• Medical History

• Physical Examination

Inspection

Digital Exam.

Rectoscopy

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Hemorrhoids

• Symptoms :

– Ext, Hem.• Pain, bleed, swelling

– Int, Hem.• Bleed, swelling, soilage, itching, pain, discharge, protrusion.

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Hemorrhoids

• Medical Treatment :

• Sitz baths,• Diet,• Hygiene,• Stool modifiers,• Topical creams, Suppositories.

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Hemorrhoids

• Minimally Invasive Treatment :• Int, Hemorrhoids (Grade 2-3)

• RBL

• IRC

• Sclerotherapy

• Cryo

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Hemorrhoids

• Surgical Treatment :

• Ext, Hem.• Thrombectomy (Emergency)• Excision (Failed Med. Treat.)

• Int, Hem.• Excision or Resection with Anopexy or DHL

(Failed Med. or Invasive Treat. 4th degree, Association with other anal disease)

Y. Ziv, 2008

HemorrhoidsSurgical Treatment :

• Anal Dilatation (rarely used)

• Excision:- Open (Milligen-Morgan)

- Closed (Fergusson)- Semiclosed

• Resection with Anopexy (Longo Proc.)

• Trans Anal Ligation of Hem. Arteries

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Hemorrhoids• Surgical Options :

• Scissors & Scalp

• Ligasure

• Harmonic Scalpel

• Laser

• Stapler

• DHL

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Hemorrhoids

• Surgical Treatment :•Complications :

– Incontinence, Stenosis,

– Bleeding, Urinary Retention

– Infection (absc., fistula) > Sepsis

– Persistent Hemorrhoids

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Hemorrhoids

• Incarcerated Hemorrhoids

• Treat Medically !!!

(Rest, Magnesium Sulphate 30%,

Suppsitories, Stool-softeners)

Avoids Complications Rate

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Hemorrhoids

Hemorrhoids in Pregnancy• Treat Medically or Minimally Invasive

• Failure

Surgery

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Anal Fissure

• Vertical tear in squamous epihelial lining of the anal canal between the anal verge and the dentate line

• Location :

Post – 85%, Ant - 10%, Lat – 5%

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Anal Fissure

• Acute – No secondary changes

• Chronic– > 30d

– Symptoms > 50%

– Secondary changes

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Anal Fissure

• Secondary changes:– Sentinel tag (sometimes w fistula)

– Hypertrophied anal papilla

– Indurated edges

– Exposed Int. Sphincter fibers

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Anal Fissure

• Etioligy :- Trauma

- Spec. underlying Disease :

Chlamidia, Gonorrhea, Herpes, Syphillis, Aids, TB, Neoplasia, Crohn, Ulcerative Colitis.

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Anal Fissure

• Pathogenesis :- Repeated trauma- Raised Mean Rest. Pressure- Spasm, ischemia “Stress fractures of the anal canal“- Underlying disease

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Anal Fissure

• Symptoms :– Pain, bleeding, discharge,

swelling, itching.

Diagnosis :- Inspection, palpation- Anoscopy/rectoscopy (not recom.)

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Anal Fissure

• Treatment• Acute AF

– Medical : Diet, Bulk laxatives,

Sitz baths, Topical creams.

• Chronic AF– Medical, Surgery

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Anal Fissure

• Medical Treat. of Chronic AF- Diet, Bulk lax., Sitz baths, Creams.

“Chemical” Sphincterotomy- NTG, ISDN - NO transmitor- Nifedipine - Ca Channel Blocker- Botolinum A - ACE Inhibitor- Alpha-1 adrenoceptor blockade

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Anal Fissure

• Surgical Treat. of Ch AF

- Open / Closed LIS

- Anal Dilatation (only in special cases)

- Fissurectomy

- Advancement Flap (from inside or outside)

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Anal Fissure

• Surgical Treat. of Recurrent Ch AF

- Open / Closed LIS (other side, after TRUS)

- Anal Dilatation (only in special cases)

- Fissurectomy

- Advancement Flap (from inside or outside)

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Anal Fissure

• Complications– Incontinence Conservative, Surgery

– Stenosis Dilatation, Surgery

– Hemorrhage Hemostasis

– Infection, Ab, Drainage – Urin. Reten. Cateterization

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Anal Fistula

Pathogenesis :• Infected Anal Glands

(open to Dentate Line)

• Ductal Obstruction lead to ;

Stasis, Infection, Abscess.

50% develop Fistula

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Anal Fistula

Signs & Symptoms :• Pain, Pruritus, Bleeding, Discharge.

• Pressure (evacution, cough, sitting)

• Swelling

• Fever

Ano-rectal Pain & High Temp.

= Abscess, until proven otherwise !

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Anal FistulaDiagnosis:• History & Physical Examination• Digital Examination• Ano/Rectoscopy• EUA• Fistulography• TRUS• CT-Fistulography• MRI (Ext., Coil)

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Anal Fistula

• Park’s Classification:– Trans - Sphincteric

– Inter - Sphincteric

– Supra - Sphincteric

– Extra - Sphincteric

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Anal Fistula

• Other Classification:– Simple Vs Compound (horseshoe)– Low, Middle, High (Anal Canal)– Small, Large (Int. opening)

• Special Fistulas Recto - Vaginal Fistula,

Associated with Underlying Disease

(TB, IBD, Irradiation, Infections)

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Anal Fistula

• Asymptomatic Fistulas

Require No Therapy !!!

• Medical Treatment May Cure Simple Mild Symptomatic Fistulas (sitz-baths, antibiotics)

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Anal Fistula• Surgical Treatment :

Fistulotomy or FistulectomyFibrin GlueAnal PlageSeton Placement (Loose, Tight)RAF (Mucosal or Full Thickness)ColostomyAnterior resectionPatches (Omentum, Muscles)

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ODSObstructive Defacation Syndroms

מצב שבו החולה אינו מסוגל להתרוקן באופן רגיל ונאלץלהשתמש במשלשלים, חוקנים או אמצעים אחרים.

כאבים בזמן יציאה–צורך במאמץ חריג על מנת להתרוקן–ישיבה ממושכת בשירותים– ימים5-10מרווחים ארוכים בין היציאות –אי נוחות באזור חייץ הנקבים בזמן עמידה– =Tenesmusתחושה מתמדת של חוסר התרוקנות – =Incomplete Evac התרוקנות לא רציפה –Incontinence = הפרעות בשליטה–

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של ODSאבחנה

השבועות האחרונים 12הופעה קבועה ביותר מרבע היציאות ב-של:

מאמץ מוגבר ביותר ביציאה–צואה קשה וגושית–הרגשה של חוסר התרוקנות–הרגשה של הפרעה או חסימה ביציאה– שימוש ביד לצורך יציאה- לחץ וגינאלי, רקטלי, לחץ על –

חיץ הנקביםפחות משלוש יציאות לשבוע–

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הקליני הברור

לפני הניתוח על החולה לעבור סדרה של בדיקות אשר יגדירו האם הוא מתאים ליפול שמרני או

ניתוח

דפקוגרפיה•

מנומטריה •

אלקטרומיוגרפיה EMGבדיקת •

TTIבדיקת זמן מעבר •

TRUSבדיקת •

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ל ODSגורמים

Intussusceptions (rectal Intussusceptions (rectal invagination)invagination)

RectoceleRectocele

Genital ProlapseGenital ProlapseEnteroceleEnterocele

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Thank You !