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Mediquest - June '08 Edition |
CONTROVERSIES IN THE MANAGEMENT OF BENIGN ANAL DISEAS ( Personal View )
Dr. N. Mohan, Consultant BRS Hospital
Emeritus Prof. of Surgery,
Tamilnadu Dr.M.G.R. Medical University, Chennai
It is common experience with all surgeons, that anal fissure, piles and fistula in ano are of daily occurrence and every surgeon deals with them. There are different treatment modalities for these conditions and ofcourse controversies too in their management.
A. Anal Fissure :
This results from a tear of the anal verge while a hard faecal mass is pushed out by excessive straining leading to over stretching of the anoderm ending in tear.
Controversies :
It has been found that the resultant tear leads to sphincteric spasm and increased anal pressure which inturn results in decreased blood supply ( relative ischaemia ). Due to this patient has pain and burning sensation and non healing of the ulcer.
Some patients have an increase in the resting anal pressure. This increased anal pressure, which is pre-existent leads to ischaemia and non healing of the ulcer.
Thus these two contradict each other! The post mortem angiographic studies support ischaemia theory. Probably both the factors, increased resting anal presure and ischaemia, work in a combined way to produce a non healing painful ulcer.
Treatment :
1. Glyceryl trinitrate ointment.
This is supposed to increase the blood supply locally to correct ischaemia. The problems are;
a. It is cumbersome to apply the ointment.
b. Nitroglycerine produces headache.
Recurrance is possible. I have no experience in the usage of this agent.
2.Surgery : The usual procedure followed is lateral sphincterotomy, but if not done carefully, wound infection and incontinence will result.
Of late, I have not done much of the procedure of sphincterotomy. I feel the basic cause of fissure is constipation and hardened stool. I have been following a conservative line of treatment consisting of local application of an ointment containing hydrocortisone and lingnocaine ( eg. anovative, ultrproct etc.) three times a day ( half an hour before defaecation in the morning if possible, after the toilet and at bed time) and a stool softner with a laxative. I have found this line of treatment results in wound healing though it takes time. Education of impressing on proper bowel habits, goes a long way in preventing fissure in ano. I have observed, majority of us, especially the educated community, do not have proper bowel habits!!
When associated with other anal conditions like haemorrhods and fistula in ano, I feel one can still perform lateral sphincterotomy. I have not seen any incidence of incontinence as claimed in the literature. The guideline for sphincterotomy is never to cut the sphincteric fibres beyond the Hilton's line.
Some practice local advancement flaps for covering the ulcer.
B. HAEMORRHOIDS
1. Etiology :
It is a disputable structure: some say it is a type of varicose veins while some describe it as vascular and anal cusions! Whatever it is, a patient with hemorrhoids complains of bleeding per rectum. The common factor for many peri-anal conditions is straining at toilet and not developing a proper bowel habit, dating back to childhood! I have seen in all families, parents tell and insist on their children about good education, games, cleanliness, good nutrition, behavior etc, but not many parents nsist on daily evacuvation of bowels in the morning! Longer it stays in the colon, drier becomes the faecal matter leading to difficulty in evacuation. The example I give my people is of putting a hand full of ground nuts or cashew or almonds into the mouth and munching. Till the salaiva is absorbed one can munch and after that it is common experience one finds muching or chewing or swallowing difficult: with some water one can continue. Same thing happens at the other end! Longer is the delay in evacuation, drier becomes the faecal matter and evacuation becomes difficult. The result is : a person spends more time in toilet and strains. It is common observation to find veins standing on the necks of people blowing trumpets or wind instruments, speakers or singers; same ting happens in anorectum on straining and once the hard stool rubs and moves against these dilated vascular cushions, it bleeds! This is a long drawn process - a wrong habit begining in the childhood leads to piles / fissure in the adolescence and adult stage.
Lesson : Develop proper bowel habits right from the younger days to avoid fissure / piles later.
2. Surgery and post operative pain :
Definite sugical procedures are conventional hemorrhoidectomy or stpler hemorrhoidectomy. The latter is very expensive but post op pain is very less.
In conventional hemorrhoidectomy, many patients have severe pain because of the raw area left behind. Local anaesthetic agents help. But injection of lignocaine or sensorcaine with 1:200,000 adrenaline as an infiltrate before the actual procedure reduces pain and bleeding. Gentle handling is very important and my experinece is that patiens do not complain of unbearable pain. I dont use analgesics and antibiotics routinely.
3. Reactionary and secondary bleeding :
I have had one patient in each category - one patient had blood thinness pre-op and probably stopping them for 5 days pre-op was not enough. The second occurred in an elderly person on the 7th post op day; I found he was using the rigid plastic nozzle supplied with cream for applicatio! Obviously the rigid nozzle injured the raw area leading to bleeding.
