Hemorrhoids and Fistulas New Solutions To

Current Problems in Surgery 51 (2014) 98137
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Current Problems in Surgery

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Hemorrhoids and Fistulas: New Solutions to

Old Problems
Hemorrhoids
Introduction
The term hemorrhoids is commonly used to describe symptoms of pain, itching, and
bleeding, or any palpable or perceived abnormality in the perianal region.1 However,
hemorrhoids are identiable normal anatomical structures with dened functions. Hemorrhoidal disease properly refers to the symptoms that arise when some inciting process has
altered the normal function or position of these structures. Those suffering from symptoms that
are considered related to hemorrhoids often seek hemorrhoidal removal; control of symptoms is
a safer and more realistic end point and should be introduced as the primary goal of therapy, and
several methods may be employed to attain satisfactory symptom control.
Hemorrhoids are vascular cushions of submucosa containing blood vessels, smooth muscle,
and elastic and connective tissue, which help maintain anal closure and continence, contributing
15%-20% of the anal resting pressure.2-5 A magnetic resonance imaging (MRI) study of the
internal sphincter in vitro and in vivo showed a gap of 7-8 mm that could not be occluded by the
sphincter mechanism alone5; the hemorrhoidal tissue bulk is thought to ll this gap. Continence
to saline infused into the rectum is impaired after surgical hemorrhoidectomy, lending credence
to this theory. The anal canal and hemorrhoidal tissues are able to discriminate exquisitely
between gas and liquid or solid rectal contents, allowing for socially acceptable choices to be
made. The loss of bulk and sensory tissue after hemorrhoidectomy can place some patients at
risk for disturbance of continence, especially if preoperative continence was impaired. Such
disturbance may be temporary or more lasting.
The hemorrhoidal blood vessels are sinusoids rather than arteries or veins, as evidenced by
the lack of muscular walls. Hemorrhoidal bleeding is described as bright red, suggesting blood
that is better oxygenated than venous blood.6 The classic location of hemorrhoids are in the right
anterior, right posterior, and left lateral positions of the anal canal, although variations can occur.
The arterial supply arises from terminal branches of the superior hemorrhoidal artery, with
some contribution from the middle and inferior hemorrhoidal arteries. There are a variable
number of these terminal branches, and the location does not correspond to that of the
hemorrhoidal cushions as noted above (right anterior, right posterior, and left lateral).7 Venous
drainage distal to the dentate line is via the inferior rectal veins into the pudendal veins, and also
via the middle hemorrhoidal veins; both of these pathways drain into the internal iliac veins.
Proximal to the dentate line, venous blood drains through the superior hemorrhoidal veins, into
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J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137
99
the inferior mesenteric vein, and then into the portal system.8 This is an important anatomical
consideration; patients with portal hypertension can develop true varices in the anal canal, and
if so, attempts at hemorrhoidectomy can be extremely challenging.
Sympathetic and parasympathetic nerves innervate the upper anal canal proximal to the
dentate line. The visceral innervation allows perception of fullness and pressure. In contrast, the
anal canal distal to the dentate line and the anoderm are innervated by somatic nerves, which
supply sensitivity to touch, pain, temperature, pressure, and friction.9 This is why rubber
banding can be used to treat internal hemorrhoids, but not external hemorrhoids. The anoderm
is specialized squamous epithelium lacking skin structures such as sweat glands and hair
follicles. These skin appendages reappear on the perianal skin more removed from the
anal canal.
Etiology and epidemiology

The evidence to support any single theory of hemorrhoidal disease is sparse. It seems most
likely that the cause of symptom development is multifactorial, including several patientspecic variables such as diet, toileting behavior, and possibly genetic inuences. The most
commonly accepted theory for pathogenesis of symptomatic hemorrhoids is Thomson's theory
of a downward sliding of the vascular cushions.2 Symptomatic hemorrhoids are associated with
irregular bowel habits and straining, which occur with both hard stools and diarrhea.10 Patients
with hemorrhoids tend to have abnormal anal pressure proles and anal compliance.11 Straining
is more likely to push the cushions out of the anal canal and stretch the submucosal Treitz
muscle (Fig 1), disrupting the xation of hemorrhoidal cushions in the anal canal and allowing
downward slide and subsequent prolapse. Other factors implicated in causation of hemorrhoidal
disease include the erect human posture, a lack of valves in hemorrhoidal plexuses and draining
veins, and increased intra-abdominal pressure causing possible obstruction of venous return.
Fig. 1. Anal cushion showing Treitz muscle bers derived from longitudinal muscle.
100
Portal hypertension may lead to engorgement of the veins draining the plexuses, which can
result in true varices in the area, as also seen in the lower esophagus and periumbilical area.
However, hemorrhoid disease does not appear to be more common in portal hypertension than i
n the population at large. Pregnancy aggravates hemorrhoidal disease, and by mechanisms
not well understood, also predisposes to the development of disease in those who were previously
asymptomatic. However, most women nd that their hemorrhoidal symptoms largely resolve
after delivery, raising the question as to whether pressure and hormonal changes play
distinct roles.
The incidence of symptomatic hemorrhoidal disease is difcult to assess accurately. Many
patients assume that any symptom in the perianal area is hemorrhoidal in origin, and
medication with any of the many over-the-counter products is a common antecedent to the
seeking of specialty advice. In addition, advice may be sought from any of a number of
specialists, including surgeons, gastroenterologists, family practitioners and internists, gynecologists, or practitioners of alternative medicine. Hemorrhoid-related complaints may be
responsible for as many as 36% of patients seeking care in general medical practices.12 The
prevalence of hemorrhoidal disease in the United States is estimated at 4.4%,10 accounting for
2-3.5 million physician visits and 168,000 hospitalizations annually.13 Data related to the volume
of ofce-based treatment are currently lacking.
Nomenclature and classication

Hemorrhoids may be considered external or internal. External hemorrhoids are covered with
anoderm and perianal skin. They may have the appearance of small soft skin folds or thicker,
more eshy appendages, as may occur after longstanding hemorrhoidal disease. External
hemorrhoids contain the portion of the vascular plexus that is distal to the dentate line. Internal
hemorrhoids arise above the dentate line, are covered with transitional and columnar mucosa,
and contain the vascular plexus that arises proximal to the dentate line. Mixed hemorrhoids
describe the setting where both external and internal hemorrhoidal diseases are present.
Internal hemorrhoids are further classied by degree of prolapsed. First-degree hemorrhoids
bulge into the anal canal and cause painless bright red bleeding. Second-degree hemorrhoids
protrude through the anal opening with a bowel movement but reduce spontaneously. Thirddegree hemorrhoids protrude with bowel movements or spontaneously and require manual
reduction. Fourth-degree hemorrhoids are permanently prolapsed and not reducible. It is
important to note that prolapse does not imply incarceration. The mere presence of prolapse
does not require intervention; rather, it is the degree of symptoms and their effect on the
patient's quality of life that best guide appropriate therapy.
Clinical presentation
Anorectal symptoms are frequently thought to be caused by hemorrhoids, both by patients
and physicians unfamiliar with the appearance and differential diagnosis of perianal and rectal
pathology. There are a number of other benign conditions that must be considered, such as
pruritus, stula or abscess, ssure, and condyloma. Malignant conditions must also be excluded,
including intraepithelial neoplasms and cancers of the colorectum and anus. Table 1 details the
differential diagnosis of common anal symptoms; although extensive, it is not exhaustive.
External hemorrhoids may be related to symptoms such as itching or perianal moisture
owing to difculty cleansing the perianal region. The skin-covered external hemorrhoids may
appear edematous at times owing to scratching or vigorous cleansing attempts. Infection is
exceedingly rare. External hemorrhoids do not cause pain unless thrombosis is present. In this
instance, a rm nodule that has a blue or purple tinge is visible and palpable at the anal orice.
These may be nontender or exquisitely painful, and the contained clot can erode through the
overlying stretched skin. When this occurs, the patient should be reassured that the blood seen
101
Table 1
Differential diagnosis of common anal symptoms
Symptom Differential diagnoses to consider
Pain
Bleeding
Pruritus
Mass
Thrombosed external hemorrhoid, ssure, abscess, stula, pruritus, anorectal Crohn disease, and pelvic
oor dysfunction
Internal hemorrhoids, spontaneously expressed external hemorrhoid clot, ssure, stula, cancer
(colorectal or anal), inammatory bowel disease, colitis (ischemic or infectious), and rectal prolapse
Prolapsing internal hemorrhoids, stula, continence disturbance, condyloma, rectal prolapse, idiopathic
pruritus ani, hypertrophied anal papilla, and dermatitis
Thrombosed or prolapsed hemorrhoid, abscess, anal cancer, prolapsing polyp or papilla, skin tag, rectal
prolapse, and condyloma
is evacuation of old clot and not ongoing blood loss. Resolution of thrombosed external
hemorrhoids often leaves a small or larger skin tag. These may reduce in size over time, but
typically do not regress completely, and may be associated with symptoms such as itching and
difculty cleansing the region.
Internal hemorrhoids most often cause painless bright red bleeding with stools, on the toilet
tissue, or dripping, or even squirting into the toilet water. Internal hemorrhoids can also cause
itching and burning, pain or pressure, mucus discharge, and problems with perianal hygiene
including soiling of undergarments. Patients describe their pain variously. Some can identify
itching and burning as the experienced painful sensation, some identify pressure, but many
default to a more vaguely termed pain that is located in the perianal or anal region, or both.14
As internal hemorrhoids do not have somatic innervation, the source of the experienced pain
may not be clear, but it remains important to acknowledge the patient's perceived pain and
search for other causes that may require addressing. A high percentage of patients who complain
of painful hemorrhoids have some element of pelvic oor dysfunction, including entities such
as levator spasm, which causes pain with defecation owing to nonrelaxation of that component
of the sphincter complex, and discoordination, in which the patient confuses squeeze with
push, producing a functional relative outlet obstruction with defecation-associated pain.
Patients with these disorders often complain of more generalized perineal pain or pressure or of
sitting on a ball and have often used over-the-counter hemorrhoidal preparations for weeks to
months with little relief. Proper ofce examination can quickly identify these functional
disorders. Although patients may also have hemorrhoids that prolapse or bleed, it is important
to realize that the hemorrhoidal issue is secondary to the pelvic oor dysfunction, and
addressing the hemorrhoidal issue without also addressing the pelvic oor dysfunction is
therefore unlikely to produce a durable result.
Although painless bright red bleeding with stool is a frequent symptom of hemorrhoidal
disease, patients may not be able to distinguish other patterns of rectal bleeding that may be
more ominous, such as blood streaked on the stool surface or mixed into the stool. Therefore,
bleeding as a symptom must be assessed carefully, and colonoscopic evaluation should be
performed appropriately. Anemia due to hemorrhoidal bleeding is exceedingly rare, and a
complete gastrointestinal evaluation should be performed before assuming that hemorrhoidal
disease is the cause.
Internal hemorrhoids that have lost their xation to the underlying muscle can prolapse into
the anal canal or externally. Related symptoms often include pressure during and after bowel
movements, which is sometimes interpreted as incomplete evacuation; a lump or mass
protruding through the anus; wetness of the perianal region; or difculty cleansing the area
with soilage of undergarments. Patients should be asked if hemorrhoids require manual
reduction; women should be asked about manual splinting of the perineum to assess for
possibly related rectocele symptoms. All patients should be asked about other factors that are
related to development of hemorrhoidal disease such as chronic heavy lifting or chronic cough
from asthma or chronic obstructive pulmonary disease, or unusual toileting behavior such as
withholding or limited access to bathroom facilities.
102
Evaluation
History
A detailed, focused history is mandatory to understand how the patient's symptoms affect his
or her lifestyle, so that an informed decision can be made regarding treatment options. The risk
of the intervention should not outweigh the benets.
The patient's bowel habits must be discussed, with specics regarding frequency and
consistency of stool as well as any changes from the patient's usual pattern. Do not rely on the
patient's reporting of normal stools, or of diarrhea or constipation, as their interpretation
of these terms may not be congruent with the medical denition. Frequency should be recorded
as number of stools per day, or per week. The Bristol visual stool scale (Fig 2) is helpful when
patients cannot describe stool texture or shape. Urgency and disturbances of continence must be
elicited and recorded. Variability of stool frequency and consistency raises the possibility that
the patient may require assessment and management of a functional bowel disturbance; failure
to recognize these underlying functional disorders uniformly leads to poor outcomes of surgical
intervention.
A dietary history can be helpful in identication of some simple interventions that can
resolve symptoms in a high percentage of patients with hemorrhoidal symptoms. Inadequate
intake of ber and noncaffeinated uid is often found. Specic foods can also cause disturbances
in stooling: caffeine, milk or ice cream, chocolate, excessive salads or fruits (except bananas),
beer, and articial sweeteners can cause looser stools, whereas red meats, cheeses, and bananas
are associated with harder and drier stools. Recent changes in diet or medications should be
elicited. Specic note should be made of recent antibiotic therapy or foreign travel, any pelvic or
anorectal surgery, and history of radiation to the pelvis.
A long history of loose stools and anorectal complaints may bring up the possibility of Crohn
disease. A tender lump that drains episodically may herald a stula or other inammatory lesion.
Severe pain during and following bowel movements suggests anal ssure. A history of weight
loss is concerning for systemic disease or malignancy.
Physical examination
A general physical examination should seek to identify health issues that would signicantly
affect the potential range of hemorrhoidal management options, such as chronic obstructive
Fig. 2. Bristol visual stool scale. (Color version of gure is available online.)
103
pulmonary disease, immunocompromise, liver disease, or coagulopathy or use of anticoagulants.

Hard stool within the sigmoid colon can often be palpable on abdominal examination. The
anorectal examination should be approached mindfully. Patients often face this with trepidation.
It is helpful to clearly describe to what degree you expect the patient to disrobe and have a
proper drape or gown at hand. Describe how the examination would proceed, reassuring the
patient that you respect their privacy and do not intend to cause pain. Encourage the patient to
let you know if they experience pain or discomfort during the examination with the express
understanding that if they feel pain, the examination would be terminated. Be sure to let the
patient know that pressure may be felt, and be clear that this is a normal sensation during the
examination. Many patients are fearful that they would not be able to affect a painful situation.
Simply letting them know you are willing to cooperate with them often defuses the situation. As
patients cannot see you during this examination, it is helpful to narrate as the examination
proceeds. The patient can be told to anticipate your touch, normal ndings can be described, and
the patient feels they are a participant in the examination, rather than having something done
to them. Always have an assistant as chaperone for an anorectal examination of either gender
patient. Family members or friends or both should not be expected to ll this role.
Examination of the anorectum is often performed in the knee-chest position; however, many
patients nd this position embarrassing. The lateral decubitus position is less daunting for
patients and is more than adequate for most patients if attention is paid to proper positioning,
lighting, and use of the assistant or chaperone. The examination begins with inspection of the
gluteal cleft and then, with gentle retraction of the buttocks, inspection of the perianal area and
perineum. The skin is inspected for ndings such as external hemorrhoids, skin tags or
hypertrophied papillae, condylomata, skin rash or breakdown, stulous openings, ssures, other
wounds, erythema or mass suggesting abscess, ulcerated mass suggesting neoplasm, and any
gape of the anus at rest. The tissues are gently palpated, noting masses, fullness, tenderness,
decreased pliability, or any deviation from symmetry that cannot be accounted for. If a ssure is
suspected, palpation rst anterior to and then posterior to the anus would often reproduce the
ssure pain and strongly suggest the diagnosis. How and if the examination proceeds may be
dependent on the degree of discomfort caused by this maneuver.
Digital examination of the anus with a well-lubricated gloved nger follows, noting the
resting and voluntary squeeze pressures, and if the patient confuses one for the other, signifying
pelvic oor discoordination. Diminished squeeze strength in any quadrant should be noted in
anatomical terms as anterior-posterior and left-right. Designating anorectal ndings as located
on a clock face should never be done. The rectal wall should be palpated in every quadrant. Note
should be made of any masses found with the location (anterior-posterior and left-right),
distance from the anorectal ring, and xity to surrounding structures. A bidigital examination of
the rectovaginal septum should be performed if felt necessary to adequately assess anterior
ndings; be sure to let the patient know before proceeding with this portion of the examination.
Levator spasm can be palpated as a tight muscular band in the posterolateral area on each side,
which is tender to pressure. This tenderness often eases if the patient can squeeze and relax
several times.
Anoscopy is considered a part of the ofce anorectal examination. There are many types of
anoscopes available for use (Fig 3). Disposable anoscopes are best for routine anorectal
inspection; clear plastic anoscopes allow for clear visualization of the entire anal canal and the
relationship of any pathology to the dentate line. Some of these are self-lighted. Proctitis can
easily be seen with this scope as well; if present, further investigation would be required.
If banding is considered, a slotted or side-viewing anoscope allows prolapse of hemorrhoidal
tissue into the slotted area for best exposure and access. The slotted scope requires repositioning
with the obturator carefully replaced for visualization of each quadrant; if performed incorrectly,
tissue can be pinched between the scope and the obturator. Anoscopes require light for
appropriate viewing; some have attached light sources and others require a handheld or headmounted light source.
Any patient with alarm symptoms of bleeding, change in bowel habits, anemia, or weight
loss, or patients who have a family history suggestive of hereditary nonpolyposis colorectal
104
Fig. 3. Various types of anoscopes used in the clinic setting.
cancer or Lynch syndrome, should be further examined. Rigid or exible sigmoidoscopy can
easily be accomplished in the ofce setting as no sedation is required, and preparation can be
done with a single enema. However, for complete colonic evaluation, colonoscopy, doublecontrast enema, or computed tomography (CT) colography should be performed. It is preferable
to have complete colonic evaluation, when indicated, which is performed before the
intervention for elective hemorrhoidal problems is considered.15-17 When examination does
not reveal a clear cause for patient symptoms, pelvic oor evaluation should be considered. Anal
manometry can reveal abnormalities of the sphincter mechanism and also rectal compliance.
Balloon expulsion claries if patients can generate sufcient force to extrude stool.
Management
Management of symptomatic hemorrhoids is directed by the symptoms themselves.
Management strategies can be categorized as medical management, ofce-based procedures,
or surgical management. Patients may arrive at the consultation determined to have their
hemorrhoids removed. However, proper evaluation should culminate in a management plan
individualized for each patient's particular situation. The risk of intervention should not
outweigh the benet. There is no one-size-ts-all therapy, and a poor outcome after surgical
intervention can negatively affect many areas of a patient's function and lifestyle. In many cases,
symptoms can be managed successfully with modications of diet and lifestyle, which are
minimal and easily accomplished.
Conservative management
Diet and ber
Initial therapy of hemorrhoidal symptoms is best directed at modication of the cause, which
is most often related to lifestyle habits, including diet, uid intake, and toileting behavior, as well
as exercise, sleep habits, and stress management. Hemorrhoidal concerns may be the perfect
example of why attempts to treat the problem without understanding the context tend to fail.
Much of the initial consultation for a hemorrhoid-related problem consists of counseling the
patient on better dietary choices, increasing noncaffeinated uids, including a ber supplement
105
if appropriate; describing healthier toileting behavior when necessary; and underscoring the
value of regular exercise, sleep hygiene, and stress management. Hard or dry stools are usually
caused by inadequate intake of dietary ber and uid in concert. Looser stools, which can
exacerbate hemorrhoidal symptoms, are also often due to dietary choices. Foods most likely to
be associated with loose stools include dairy products (except yogurt and hard cheeses); fruits
and fruit juices (except bananas); lettuce salads, which are generally low in ber; caffeine and
chocolate; beer; and many articial sweeteners. Patients with either hard, dry stools, or loose
stools are likely to have a relative lack of dietary ber; increasing dietary ber is almost always
the rst recommendation in medical management of hemorrhoidal symptoms.
Most Americans eat half or less of the recommended daily ber intake (25 g/d ber for
women and 38 g/d for men). It can be difcult to ingest 25-38 g of ber daily. Bulk-forming
agents such as psyllium ber are inexpensive, well tolerated, and effective. Bulk-forming agents
work by absorbing uid from the intestinal lumen into the stool bolus. In patients with hard, dry
stool, a concomitant increase in oral noncaffeinated uid is needed to produce the desired result
of a formed yet deformable stool bolus that abrades the anal canal tissues less. For patients with
hemorrhoidal symptoms related to loose stools, the bulking agent absorbs the excess uid,
producing a more formed stool and decreasing anal canal irritation due to frequent loose stools.
It is best to have patients ingest the ber supplement during the day as drinking uid with the
ber is important for the mechanism of action. Although the addition of ber to decrease
hemorrhoidal symptoms is considered important by all health care providers managing these
problems, data to support this recommendation are not robust. This may be related to the
difculty inherent in conducting dietary studies. However, a review of 7 trials using ber
revealed a consistent benet in reducing bleeding and other hemorrhoid-related symptoms.18
Stool softeners and laxatives
For those with persistent hard, dry stool, further agents such as a stool softener (docusate) or
lubricant (mineral oil) may be needed in addition to the ber supplement. The mechanism of
action of these agents may enhance the effect of ber, but should not be used in place of ber, as
these agents will not produce the stool bolus, which is the goal of ber therapy. Patients with
hemorrhoid symptoms and true constipation (bowel movement less frequently than once every
third day) may benet from the judicious use of hyperosmolar (polyethylene glycol), stimulant
(senna and bisacodyl), or saline (magnesium citrate) laxatives in the short term, but should be
transitioned as soon as possible to a regimen of ber supplementation with stool softeners as
needed. Long-term use of laxatives should be avoided whenever possible; the variability of
stools makes hemorrhoidal symptom management more difcult. Laxative abuse should be
considered when taking the history, as this has been reported to range from 10%-60% of adults
with eating disorders,19 who also display higher levels of depression.20 Use of senna-containing
laxatives for longer than 9 months often leads to development of dark colonic mucosal
pigmentation termed pseudomelanosis or melanosis coli. This was once thought to increase the
risk of colorectal cancer; however, more recent studies have concluded that there appears to be
no association of increased risk for colorectal adenocarcinoma in melanosis coli.21,22
Toileting behavior
Many patient with anorectal complaints have toileting behavior that is counterproductive,
including repeated straining and spending a long time on the toilet. Although it is not clear if the
behavior causes the symptoms or vice versa, it is key to try and break the cycle of poor toileting
behavior. Patients must be counseled that one need not move bowels at the same time every day
to be healthy. Reading on the toilet is to be avoided. If a call to stool is not productive of a bowel
movement in a few minutes (5 at maximum), the patient should go on about their business until
the call to stool returns. Patients who report the need to strain repeatedly should be evaluated
for possible pelvic oor dysfunction.
106
Patients who describe the need for repeated wiping should be evaluated for imperfect anal
closure, grades of fecal incontinence, and inadequate ber intake. Those with pruritus also often
wipe excessively, eventually causing skin maceration. The use of moistened tissue or
premoistened wipes (sold alongside toilet tissue) helps to minimize abrasion trauma. Remind
patients to blot the area dry after use of moistened wipes because chronic moisture in the
perianal area can lead to skin breakdown. Witch hazel may be soothing to some; however,
others nd it burns, especially if there is skin maceration. Use of a zinc oxide ointment such as
Balmex or other skin barrier lotion such as Balneol helps allow the irritated perianal skin to heal.
Other medical management
There is a wide array of topical over-the-counter agents marketed to treat hemorrhoidal
symptoms, and most patients would have used these for a variable length of time, either on their
own or at the direction of another medical provider. Evidence for any benecial effect is thin.
Product types include creams, gels, foams, wipes, and suppositories. Most proprietary products
include a combination of agents. The classes of agents and the intended effects are listed in
Table 2. Prolonged use can produce irritation due to the delivery vehicle. Steroids in particular are
often overused, which causes thinning of the perianal skin and further opportunity for maceration.
Phlebotonics are a heterogeneous class of drugs used to treat rst- and second-degree
hemorrhoids, episodes of external hemorrhoidal thrombosis, and as adjuncts after surgical
hemorrhoidectomy. Although the mechanism of action is not well established, they are
associated with decreasing vascular endothelial inammation23,24 and normalizing capillary
permeability.25 Most of these are natural plant products (eg, avonoids and sapsonides) but
some, such as calcium dobesilate, are synthetic compounds. The main adverse effects of
avonoids are gastrointestinal symptoms, whereas calcium dobesilate is associated with a risk of
agranulocytosis.26 Most studies of phlebotonics have come out of Europe and Asia, where these
agents are available for oral use. A 2006 meta-analysis reviewed 14 trials evaluating the effect of
avonoids on symptomatic hemorrhoids. The authors noted that methodological variability and
quality made it difcult to ascertain any clear benet.27 A 2012 Cochrane review of the use of
phlebotonics for hemorrhoids showed a statistically signicant benet in pruritus, bleeding,
bleeding after hemorrhoidectomy, discharge and leakage, and overall symptom improvement
when compared with control.28 The outcomes for pain, pain after hemorrhoidectomy, or
postoperative analgesic use did not improve signicantly.
Ofce-based procedures
A variety of ofce-based treatment options are available for the treatment of internal hemorrhoids. All are directed at producing xation of the downward-displaced hemorrhoidal cushion
into a more normal, proximal position. The lack of somatic innervation makes ofce treatment of
internal hemorrhoids attractive. External hemorrhoids, which are somatically innervated, cannot
be treated by these methods. The choice of therapy may depend on surgeon preference and
experience, equipment availability, patient medical comorbidities, and patient preference.
Table 2
Topical over-the-counter agents marketed for treatment of hemorrhoidal symptoms
Anesthetic
Analgesic
Anti-inammatory
Astringents
Barrier or emollient
Vasoconstrictive
Benzocaine, dibucaine, dyclonine, lidocaine, and tetracaine

Camphor, juniper tar, and menthol
Corticosteroids
Calamine and witch hazel
Aluminum hydroxide, cocoa butter, glycerin, kaolin, lanolin, mineral oil,
petrolatum, starch, and zinc oxide
Ephedrine, epinephrine, and phenylephrine
107
Injection sclerotherapy
Injection sclerotherapy uses one of several sclerosing agents injected proximal to the internal
hemorrhoid to produce brosis and proximal xation of the tissue. Commonly used agents
include 5% phenol in oil, 5% quinine and urea, hypertonic saline, 5% sodium morrhuate, and
sodium tetradecyl sulfate. They are injected into the submucosal plane; a more supercial
injection into the mucosa may cause slough without xation, whereas a deeper intramuscular
injection would be more painful. A 25-gauge spinal needle is ideal: the gauge reduces bleeding,
and the length allows the surgeon to clearly view the tissue through the anoscope without
obstruction during the procedure. Two milliliter of the sclerosing solution is injected into the
submucosal plane just proximal to the base of the hemorrhoid.
Sclerotherapy is safe in anticoagulated patients because it produces brosis rather than
slough. The best result is seen in rst- and second-degree hemorrhoids, with a high degree
of initial success in decreasing bleeding and pain.29,30 Long-term durability varies; 20%-53% of
patients are symptom free 4 years after sclerotherapy.31,32 With the simplicity and safety of
sclerotherapy, these rates may be acceptable in patients considered high risk for other
procedures. Several sessions may be needed for best effect; the surgeon must be mindful of
avoiding stricture.
Rubber band ligation

Rubber band ligation (RBL) is one of the most commonly performed ofce procedures for the
treatment of internal hemorrhoids owing to its ease, safety and efcacy, and cost-effectiveness.
A small rubber band is applied at the apex of the internal hemorrhoid to create an inammatory
response and proximal xation of the hemorrhoidal tissue. The correction of the downward
prolapse of the tissue improves the venous drainage and reduces the size of the hemorrhoidal
mass, decreasing symptoms of bleeding. No preparation is required; many surgeons prefer the
patient to have an enema shortly before the procedure to ensure adequate visualization. Either
the knee-chest or lateral position can be used.
The internal hemorrhoids are visualized with a complete anoscopic examination. The
redundant mucosa at the hemorrhoidal apex is drawn into the barrel of the banding instrument
by a grasping clamp or suction. The band is then applied, reducing the prolapse of the tissue and
allowing its xation back into the proper position. The banded tissue becomes ischemic and
sloughs in 5-7 days, leaving a shallow ulcer, which as it heals produces brosis and xes the
hemorrhoidal tissue in place. The band must be placed at least 2 cm proximal to the dentate line
to avoid causing pain from somatic innervation. It is also critical to recognize that the tissue
brought into the banding instrument is the mucosa proximal to the hemorrhoid, not the
hemorrhoid itself. The maneuver is intended to x the hemorrhoidal tissue back into its proper
position while retaining its function, not to cause slough of the hemorrhoidal tissue.
A variety of banding instruments are available, each based on the principle of drawing the
tissue to be banded into the banding instrument (Fig 4). Requirements include proper
positioning, an anoscope, and a bright light. Lighted anoscopes are very helpful (Fig 3). The main
difference is whether the surgeon requires an assistant or can perform the banding alone. The
classic reusable McGivney ligator requires manual loading of the band onto the instrument, and
an Allis-type grasper is used to draw tissue into the barrel; the band is then placed by closure of
the handle (Fig 5). This generally requires an assistant to secure the anoscope while the surgeon
draws the tissue into the instrument barrel and deploys the band. Bands must be loaded again if
additional sites are to be treated. There are several systems that use suction to draw the tissue
into the instrument barrel, allowing the surgeon to perform the banding independently. The
McGown suction ligator is also reusable; the suction barrel is smaller than the McGivney barrel,
so less tissue is banded. Like the McGivney, the McGown instrument also treats 1 site per load.
The disposable ShortShot Saeed Hemorrhoidal Multi-Band Ligator (Cook Medical) has
4 preloaded bands. The barrel is placed over the site for banding, suction is applied by occlusion
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Fig. 4. McGivney (left) and O'Regan (right) rubber band appliers.
of a thumb hole, and the band is deployed. This is convenient if several sites are to be banded at the
same setting. A similar system, the O'Regan ligating system, uses a specially developed disposable
syringe system (Fig 4). The open end of the syringe is placed against the tissue to be banded. The
surgeon draws back on the barrel, producing suction that draws tissue into the barrel; the surgeon's
thumb then deploys the band trigger. Only 1 site can be banded per deployment.
It is safe to band several sites at the same setting,33 although some studies have suggested a
higher incidence of pain and urinary retention if multiple sites are banded.34 For this reason,
some surgeons band 1 site at the rst setting and use the patient's response to guide subsequent
banding. In this instance, the largest hemorrhoid is usually banded rst. Surgeons often load
2 bands for each site, with the thought that if 1 band slips or breaks, the other will hold. If the
patient experiences pain immediately on banding, the site is too close to the dentate line, and
the band should be removed at once. This can be avoided by gently testing the chosen site for
sensation with a forceps pinch before band placement. Patients can resume normal activities
immediately. Patients are also instructed to avoid aspirin and nonsteroidal anti-inammatory
drugs for 7-10 days and are placed on a bowel regimen to avoid hard, dry stools. The band and
some tissue are expected to slough 5-7 days after the procedure; some bleeding may occur, and
patients should be informed of this likelihood. The expected slough and resultant ulcer are the
Fig. 5. Hemorrhoid banding with McGivney bander.
109
reason RBL is relatively contraindicated in patients on anticoagulation or those who have an

elevated INR owing to other medical issues.
Complications after RBL are usually minor. The most common complications are pain,
bleeding, external hemorrhoidal thrombosis, urinary difculty, and vasovagal attack. Patients
should be cautioned that they might feel a pressure or fullness sensation after band ligation,
even with proper placement. This usually resolves in 24-48 hours. Sitz baths may be helpful.
Severe pain is unusual with banding. If it occurs immediately on band placement, the site is too
close to the dentate line and the band should be removed. This may require local anesthetic in
the ofce. If severe, the patient may be taken to the operating room for removal. Delayed severe
pain dictates investigation; if it is owing to external thrombosis, then is managed appropriately
(discussed later in the article). If the cause is not apparent externally, examination under
anesthesia is indicated with band removal, or rarely, operative hemorrhoidectomy. Abscess may
occur, usually at 5-7 days. Examination under anesthesia establishes the diagnosis and allows
drainage. Those patients with latex allergies should be counseled to consider other forms of
treatment, as most rubber bands for this use contain latex.
The most severe complication of RBL is pelvic sepsis, usually heralded by fever, severe pain,
and urinary retention. This is extremely rare but potentially fatal if not recognized early and
managed aggressively. Evaluation should include CT scan of the abdomen and pelvis to assess for
extrarectal inammation and gas, followed by examination under anesthesia with debridement,
and possibly exploratory laparotomy with fecal diversion if indicated. Early reports indicated a
high risk of pelvic sepsis when human immunodeciency virus (HIV)-positive individuals
underwent RBL. More recent information indicates that in the era of highly effective highly
active antiretroviral therapy, RBL is safe and effective.35
Banding has the best outcome with rst- and second-degree hemorrhoids, with 70%-90%
success after 1 treatment.36-38 Several treatments may be needed for the treatment of thirddegree hemorrhoids, and durability is less with bulkier hemorrhoidal disease, or if more than
4 bands are needed.36 Forlini and colleagues37 report 10- to 17-year follow-up, with 69% of the
cases being asymptomatic, 28% having some symptoms, and 3% seeking additional treatment.
Recurrent hemorrhoids can be rebanded with good outcomes; Iyer and colleagues36 reported
success rates of 74%, 61%, and 65% for rst, second, and third recurrences, respectively. A 1997
meta-analysis found that RBL produced more durable results than sclerotherapy or infrared
coagulation, with less pain and fewer complications as compared with excisional hemorrhoidectomy.39 A 2005 Cochrane review comparing RBL to excisional hemorrhoidectomy concluded
that RBL was the treatment of choice for grade 2 hemorrhoids, providing results similar to those
of excisional hemorrhoidectomy with fewer side effects, and suggested that excisional
hemorrhoidectomy be reserved for grade 3 hemorrhoids or recurrence after banding.40
Energy methods of xation

Infrared photocoagulation, bipolar diathermy, and direct current electrotherapy are similar to
RBL in that these energy methods produce xation of the prolapsing hemorrhoid. Patient
preparation, positioning, and selection are essentially the same as those for banding.
Infrared photocoagulation produces heat, which xes the tissue at the apex of the hemorrhoid.
The applicator tip is passed through an anoscope to the desired spot, and 3-4 applications are
delivered at the site. The device produces a 4-mm2 focus of coagulation with a 2.5-mm deep
ulceration. Up to 3 sites can be treated at the same setting. Complications are rare and usually
minor; pain may occur if the site is too close to the dentate line, and bleeding may follow excessive
energy use. Immediate pain is suggested to be less after infrared coagulation than RBL, with
similar efcacy.41 The technique can also be used safely through an endoscope with signicant
symptom improvement.42 The equipment cost is signicantly higher than that for RBL systems.
Bipolar diathermy directs bipolar radiofrequency energy to the point of xation until the
tissue coagulates, with a depth of penetration of 2.2 mm. Success rates are inferior to RBL and
heater-probe treatment in randomized studies.43,44
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Direct current electrotherapy requires 10 minutes to deliver a 110-V direct current to the
chosen site up to the maximum tolerable level, approximately 16 mA. This technique is not widely
used owing to the time required for treatment and the inability to treat grade 3 hemorrhoids.
Historical notes: Cryotherapy and anal dilation
Cryotherapy uses liquid nitrogen or nitrous oxide to cool a probe to freezing temperatures
(between 701C and 1961C). The probe is applied to the area to be treated. The procedure is
time-consuming, and patients experience pain and a foul-smelling rectal discharge that persists
for 5-8 days. Signicant complications including anal stenosis, sphincter damage, and fecal
incontinence have been reported. This technique should be abandoned.
Anal dilatation, also called Lord's procedure, is described as a stretch of the anal canal
sufcient to accommodate 4 ngers of both of the surgeon's hands. This produces uncontrolled
sphincter injury and postprocedure incontinence. This technique has no place in modern
surgery.
Surgical management of internal hemorrhoids

Operative hemorrhoid management
Only 5%-10% of patients with hemorrhoidal concerns require operative treatment. Operative
hemorrhoid management includes excisional hemorrhoidectomy, stapled hemorrhoidopexy
(SH), and Doppler-guided transanal devascularization. Excisional hemorrhoidectomy is the
standard to which all other hemorrhoidal management techniques are compared for pain,
durability, and complications. Operative hemorrhoid management is best used for those who
have failed nonoperative hemorrhoidal management, those in whom the degree of disease is
unlikely to respond to nonoperative techniques, or those with a signicant external
hemorrhoidal component. Hemorrhoids in the presence of other anorectal pathology that
requires surgery may also be best managed with hemorrhoidectomy. Finally, coagulopathic
patients requiring management of hemorrhoidal bleeding are best managed in the controlled
setting of the operating room.
Closed hemorrhoidectomy (Ferguson technique)
The Ferguson procedure (Fig 6) is the excisional hemorrhoidectomy technique most often
used in the United States. Patients may be prepared with an enema alone; bowel preparation
and antibiotics are not required. Prone jackknife, lithotomy, or lateral decubitus position can be
used, but prone jackknife with buttocks taped apart is preferred by most American surgeons for
best visualization. Anesthesia can be general, regional, or local with intravenous (IV) sedation.
The choice of anesthesia varies with surgeon preference and patient comorbidities. Sedation
with local anesthetic is safe and facilitates recovery and discharge to home. Hemorrhoidectomy
always begins with anoscopic examination, and proctoscopy or exible sigmoidoscopy, if
indicated.
The Ferguson procedure involves grasping the hemorrhoidal bundle and dissecting the tissue
in a cephalad manner, starting the incision on the perianal skin and proceeding toward the
anorectal ring. Care is taken to excise the minimal amount of anoderm necessary to avoid
stricture. Scissors, scalpel, or cautery may be used to dissect skin and subcutaneous tissues,
elevating the external hemorrhoid. Dissection proceeds proximally, separating the vascular
bundle from the external and internal sphincter bers, which must be clearly visualized. This is
the critical portion of the procedure. Muscle bers can be swept gently downward off the tissue
to be excised. The apex of the vascular bundle is transxed with a suture ligature. This may be
done before beginning the dissection, after its completion but before amputation of the bundle.
The specimen is amputated just distal to the apex stitch, which is then used to close the wound.
The stitch can be locked for hemostasis. The edges of the anoderm should match up in the stitch
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Fig. 6. Ferguson closed hemorrhoidectomy. (A) Hemorrhoid bundle is grasped; dissection proceeds cephalad. (B) Apex is
transxed with suture; bundle is amputated. (C) Suture is used to close wound, leaving a few millimeters open for
drainage.
closure to avoid mucosal ectropion. The last 5 mm are left open to provide for drainage. One, 2,
or 3 quadrants may be excised, but care should be taken to preserve bridges of viable skin and
mucosa between excision sites to prevent stenosis. Dressings usually consist of antibiotic or
anesthetic ointment, or both, and nonadherent gauze and mesh briefs. Most hemorrhoidectomies are performed as outpatient procedures in the United States. In this author's experience,
sending each quadrant separately for pathologic inspection is sensible. Although the number of
occult cancers found at hemorrhoidectomy is low, knowledge of the exact location of the
neoplasm is invaluable in planning the least morbid treatment. Postoperative care consists of
appropriate pain control, minimizing constipating opiates, and a bowel regimen to avoid hard,
dry stools.
Open hemorrhoidectomy (Milligan-Morgan technique)

The Milligan-Morgan technique is more common in the United Kingdom. Perioperative
management is the same as for the Ferguson technique. The external components are grasped
with clamps and retracted caudally to expose the internal hemorrhoids and these are also
grasped with clamps. Traction exposes the apex of each bundle. A V-shaped incision is made on
the anoderm extending up to the mucocutaneous junction. The bers of the external and
internal sphincters are dissected away from the hemorrhoid as in the Ferguson technique. While
grasping the hemorrhoid bundle in the clamps, the pedicle is suture ligated, and the bundle is
amputated. The wound is left open to granulate. One to 3 columns can be excised, with the same
caveat regarding preservation of viable bridges of skin and mucosa. Postoperative care is the
same as after a closed hemorrhoidectomy.
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Historical note: Whitehead hemorrhoidectomy

The Whitehead hemorrhoidectomy technique involves a circumferential excision of internal
hemorrhoidal tissue and redundant anoderm just proximal to the dentate line. It was more
common in the United Kingdom in years past, but has become much less popular. This procedure
never gained wide acceptance in the United States, in part owing to a high incidence of
postoperative complications including anal stenosis, mucosal ectropion, and disturbed
continence. Most centers have abandoned this approach.
Outcomes of excisional hemorrhoidectomy
The long-term results of hemorrhoidectomy are excellent, with low rates of recurrence
requiring reoperation.45,46 Studies comparing open vs closed hemorrhoidectomy have found
similar postoperative pain, need for analgesics, and complications. Results from a prospective
randomized trial of open vs closed technique noted a shorter operative time, less early
postoperative pain, lower morbidity, and a longer healing time in the open group.47 Sohn and
colleagues48 found a shorter operative time with open technique, but all other outcomes
including morbidity were equal. A prospective randomized trial comparing open vs closed
hemorrhoidectomy revealed a signicantly lower need for postoperative opiates and faster
wound healing after closed technique.49 A meta-analysis evaluating 6 trials of open vs closed
hemorrhoidectomy revealed no difference in cure rate; open technique was again noted to be
faster, while healing was more rapid after closed technique.50
Complications of excisional hemorrhoidectomy
Bleeding is one of the more common complications of hemorrhoidectomy, although delayed
severe bleeding occurs in less than 5% and seems related to the narrow male pelvis and
individual surgeon.51 Although packing of the anal canal and balloon tamponade have been
suggested, this author's preference is for surgical control in the operating room, under direct
vision with good light and anesthesia. The large amount of clot that may be present in the
rectum and sigmoid should be evacuated as much as possible. Other common complications of
hemorrhoidectomy include urinary retention and urinary tract infection, fecal impaction, anal
stenosis and disturbances of continence, and stula in ano.52
The most feared effect of hemorrhoidectomy is postoperative pain, which is variable
among patients. Lasers were studied 2 decades ago; their use in hemorrhoidectomy was
associated with higher cost but no improvement in postoperative pain.53 Diathermy has been
compared with scissor excision with no signicant difference in outcomes.54 A number of
more recent studies have compared radiofrequency energy devices with diathermy excision.
The main differences identied have been less reported pain and less use of pain
medication,55,56 earlier return to work,55 and faster wound healing.56 A Cochrane review
of 12 studies of LigaSure vs diathermy hemorrhoidectomy showed that the pain benet
derived from the use of the LigaSure device disappeared by the 14th postoperative day, and
there was no difference in postoperative complications, bleeding, or incontinence. Patients
treated with LigaSure technique spent 9 fewer minutes in the operating room and returned
to work 4 days earlier on average.57 Previously, studies that included costs often evaluated
only the direct costs: operating room or hospital time, drugs, and supplies used. The cost of
these energy devices is not offset by 9 fewer minutes spent in the operating room. However,
in the near future, how soon patients return to the work force may also be an important
consideration of the cost of a procedure to the third party payer. Further studies of relative
cost-efciency may be in order as new devices and drugs continue to appear in the
marketplace.
Stapled hemorrhoidopexy
SH, rst described by Italian surgeons, is designed to excise a circular strip of mucosa and
submucosa well above the hemorrhoidal zone, elevating and xing the hemorrhoids back into
their usual position, thereby treating hemorrhoidal prolapse and the symptoms thereof while
avoiding the pain of incisions in the perianal area. The excision may devascularize the
113
hemorrhoids, although this is not a primary goal. The main benet is considered to be the lack of
pain as compared with conventional hemorrhoidectomy, to which it must be compared.
Indications are second- and third-degree hemorrhoids that have failed nonoperative methods,
or patient choice. Patients with thrombosed internal hemorrhoids or signicant external
hemorrhoidal disease who require excision are not generally considered candidate for SH nor are
patients with fourth-degree hemorrhoids.
Patient preparation, positioning anesthesia, and perioperative management are identical to
excisional hemorrhoidectomy. The anal canal is inspected as usual. Familiarity with the stapler
kit and steps of the procedure are integral to the successful performance of this procedure. The
stapler comes in a kit with a specially designed disposable anoscope, which is transparent
to allow visualization of the dentate line. It is imperative that the anoscope be inserted to the
appropriate depth or the purse string would be placed too low. The anoscope can be sutured
into place to avoid loss of exposure. The obturator is removed and replaced by a slotted
anoscope, which is also provided in the kit. This allows placement of the purse string suture
(2-0 polypropylene) while protecting the mucosa opposite. The purse string must be placed
2 cm proximal to the hemorrhoidal apex. The slotted anoscope is removed, the head of the
opened stapler is then passed through the purse string suture, and the suture is tightened about
the shaft of the stapler head, drawing the redundant tissue into the stapler. The stapler is closed
and red, excising a 1- to 3-cm wide ring of mucosa and submucosa, and creating a stapled
anastomosis proximal to the dentate line. The stapler is partially opened and carefully extracted.
The staple line must be inspected carefully for bleeding, and if found, oversewing is the
management of choice.
Correct placement of the purse string suture is integral to success. If placed too proximally, the hemorrhoids would not be lifted into their natural position, and if placed too distally,
the staple line would be too near the dentate line and cause pain. The depth of the purse
string suture is also key: if too deep, a full-thickness excision may result, with the risk of pelvic
abscess, stula, or iatrogenic stapled rectovaginal stula. The posterior vaginal wall must be
assessed several times during purse string placement and before stapler ring to avoid this
complication.
Outcomes of SH
A number of prospective randomized studies have been performed to evaluate safety
and efcacy of SH. An American multicenter prospective randomized trial comparing SH and
Ferguson hemorrhoidectomy reported that SH was associated with less postoperative pain and
less analgesic use, with similar symptom control and need for additional hemorrhoid treatment
at 1 year of follow-up.58 However, subsequent studies found that conventional hemorrhoidectomy was superior at preventing long-term recurrence of hemorrhoids.59-62 The consensus
seems to be that SH is safe and offers several short-term benets, but is associated with a
signicantly higher incidence of recurrent hemorrhoids and additional operations compared
with conventional hemorrhoidectomy.62,63
Complications of SH
Rectal obstruction, rectal perforation, retroperitoneal sepsis, and pelvic sepsis have all been
documented as complications of SH.64 There are several complications of SH that must be
specically noted. There is potential for sphincter injury if muscle is incorporated into the
stapler, which has been documented. Iatrogenic stapled rectovaginal stula is of concern as well.
These complications are very rare with conventional hemorrhoidectomy but remain a signicant
concern in SH performance. A small percentage of patients experience continued pain, bleeding,
anal ssure, fecal urgency, and frequency following SH, and most require surgical reintervention.65,66 The most common reinterventions were excisional hemorrhoidectomy, staple removal,
and surgical management for ssure. Reintervention was effective in treating pain and other
symptoms, but a high rate of posttreatment bleeding and soiling was found.65
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Transanal hemorrhoidal dearterialization

Transanal hemorrhoidal dearterialization (THD) is a nonexcisional technique described by
Morinaga and colleagues67 to identify discrete arterial inow to the hemorrhoids with Doppler
technology, allowing transanal ligation of the hemorrhoidal arterial supply. The technique was
introduced in the United States in 2008. The arterial supply is quite variable, with 4-9 arteries
commonly identied, not necessarily related to the location of the internal hemorrhoids.
Interruption of the arterial supply is hypothesized to produce hemorrhoidal shrinkage,
decreased bleeding, and prolapse. Mucopexy or hemorrhoidopexy was added to the procedure
to address the problem of continued postoperative bleeding and prolapse.
Patient preparation, positioning anesthesia, and perioperative management are identical to
excisional hemorrhoidectomy. The anal canal is inspected as usual. A specialized anoscope is
required, which contains a removable Doppler probe. The anoscope is rotated to identify a
feeding artery. A slot in the anoscope allows suture ligation to be performed at the site
identied, well proximal to the dentate line; loss of the Doppler signal conrms successful
ligation. Rotation of the anoscope with arterial ligation continues until no further signal can be
identied. Mucopexy or hemorrhoidopexy follows. The same suture can be used to oversew the
redundant mucosa from proximal to distal, terminating the suture proximal to the dentate line.
The proximal and distal tails of the suture are tied together to lift the hemorrhoid proximally.
The mucopexy is done in 2-4 positions within the anal canal. Early experience showed the THD
procedure to be safe, although the data were not robust. A systematic review published in 2009
which included 17 trials, only 1 of which was randomized, showed that a second THD was
required in 27% of cases for persistent prolapse. In addition, recurrent or persistent prolapse at
1 year was reported in 11% of cases, with bleeding in 10% and pain in 9%.68
More recent randomized trials of THD vs simple suture ligation, excisional hemorrhoidectomy, and SH have failed to demonstrate a durable advantage of THD-mucopexy. In a study of 82
patients with grades 2 and 3 hemorrhoids randomized to transanal artery ligation with and
without Doppler guidance, there was no difference with respect to blood loss, pain, and
defecatory problems. The non-Doppler group had more improvement of prolapse symptoms,
and a higher percentage of the non-Doppler group was complaint-free at 6 months after
operation.69 A study that randomized 40 patients with grades 2 and 3 hemorrhoids to THD vs
excisional hemorrhoidectomy and evaluated outcomes at 2-4 months and 1 year after surgery
showed that the THD group had less pain during the rst postoperative week only. Although
pain, bleeding, and need for manual hemorrhoid reduction were improved in both groups after
1 year, soiling was signicantly decreased only in the excisional hemorrhoidectomy group, and
there was a trend for more THD patients to have persistent grade 2 hemorrhoids after 1 year.70
Another study randomly assigned 124 patients with grades 3 and 4 hemorrhoids to undergo
THD with mucopexy or SH. Patients were followed up by phone interview at a median of 42
months. The primary outcome was recurrent prolapse, which occurred in 16 (25.4%) patients of
the THD group compared with 5 (8.2%) of the SH group.71 It appears that THD has its best
outcome in grade 2 and possibly grade 3 hemorrhoids; however, the risk for recurrent or
persistent prolapse and need for subsequent surgery is not inconsequential.
External hemorrhoids
Thrombosed external hemorrhoids
Acute thrombosis of external hemorrhoids usually evolves over a period of hours. Although
this is thought to be related to an inciting event, such as a hard stool or unusual physical activity
such as heavy lifting, often this history cannot be elicited. The pain is sudden and often intense; a
rm lump can be palpated at the anal opening. The natural history is for the pain to increase for
24-36 hours and then diminish. The thrombus would then begin to resolve. At times, the
thrombus erodes though the overlying skin and necessitates, which may ease the discomfort.
Management is directed at pain relief. If the patient presents in the rst 24-72 hours, and the
thrombus is very rm to palpation, excision of the clot can be performed with good pain relief. If
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Fig. 7. Excision of thrombosed external hemorrhoid: (A) Incision made overlying clot; (B) nest of small clots exposed;
(C) excision of clots with small scissor; and (D) wound may be closed or left open.
the external hemorrhoid is simply edematous with no rm clot, or if the clot has begun to soften
and resorb, nonoperative symptomatic care is indicated.
Excision of the thrombus can be performed in the ofce. It is important to understand that
the thrombus is a group or cluster of small clotted vessels, not 1 large clot, and so would not
resolve with simple incision as is sometimes done in emergency departments. The patient must
be able to cooperate with positioning and injection of local anesthetic. Good light and an
assistant are important to the patient's comfort and the procedure's success. Either 0.5%
lidocaine with 1:200,000 epinephrine or 0.25% bupivacaine with 1:200,000 epinephrine can be
used to produce a eld block at the site of the thrombosis. An ellipse of skin overlying the
thrombus is excised, with the axis of the ellipse beginning on the perianal skin and proceeding
toward the anal canal (Fig 7). A small tenotomy scissor is ideal to excise the cluster of small clots;
effort should be made to excise all the small clots that can be removed without excessive
anodermal undermining. Bleeding should be minimal because the feeding vessels should be
clotted off; the epinephrine in the local anesthetic also helps. The skin can be left open or closed
per surgeon's preference. The patient is instructed to avoid hard stools and straining. Sitz baths
provide comfort. Nonopiate pain medications are usually sufcient after clot removal as most of
the pain is owing to the acutely stretched skin.
Nonoperative management is indicated when patients are not candidates for excision, such as
when the tissue is generally edematous but no clot is present, or if the clot is in the process of
resolution, or if the patient is anticoagulated. Patients are instructed to use a bulking ber
supplement with appropriate water intake; a stool softener may also be helpful. Sitz baths
provide comfort and local anesthetic creams may be used for a short time as well. Patients can
be told that a skin tag may result after resolution, which may or may not require attention.
Further investigation, including anoscopic examination and exible endoscopy, as indicated,
should be done at some point after resolution to rule out proximal pathology.
Hemorrhoidal skin tags and broepithelial polyps

Patients often complain of symptoms that they relate to external skin tags and broepithelial
polyps, which may be the residua of previous hemorrhoidal episodes. It can be challenging to
determine if the related symptoms are in fact caused by these ndings. In the author's
experience, rm broepithelial polyps are more likely to cause symptoms of soiling and
discomfort than more bland-appearing external skin tags. Patients should be examined carefully
for additional pathology. Excision of these entities can be performed safely in the outpatient
116
setting. Discussion with the patient should cover potential complications, including but not
limited to bleeding, infection, and scarring that may alter stooling and sensation, and unresolved
symptoms.
Special situations
Strangulated hemorrhoids
Strangulated hemorrhoids are internal hemorrhoids that have prolapsed and become
incarcerated owing to internal sphincter spasm. Thrombosis of the external hemorrhoids often
accompanies this condition. The incarcerated internal hemorrhoids may be beefy red, or
ulcerated and necrotic, depending on the length of time of incarceration. If not necrotic,
circumferential injection of local anesthetic and reduction of the strangulated hemorrhoids can
be accomplished, followed by bed rest. One small randomized trial published in 1991 compared
reduction followed by banding of the internal component and excision of the external
thromboses with excisional hemorrhoidectomy; 13.5% patients treated with reduction and
banding went on to require excisional hemorrhoidectomy.72 Unless the patient has prohibitive
operative risk, the best option for strangulated hemorrhoids is expeditious excisional
hemorrhoidectomy; in the presence of necrosis, excision is a necessity. Either an open or a
closed technique can be used. If tissues are very edematous, or if devitalized tissue is present,
one may consider leaving the wounds open to prevent abscess. Postoperative care is as usual
after excisional hemorrhoidectomy. The outcomes are good.
Hemorrhoids in pregnancy
Engorgement of the internal hemorrhoids and edema of the external hemorrhoids are
common during pregnancy, possibly related to impaired venous return, constipation, and
pressure on the pelvic oor. However, hemorrhoidal issues almost always resolve after delivery.
The usual recommendations of ber, stool softeners, water intake, and sitz baths should be
offered. Surgical intervention for hemorrhoids in pregnancy is reserved for strangulated
hemorrhoids, or occasionally a very symptomatic external thrombosis. When necessary,
operation should be performed using local anesthesia with the patient positioned in the left
lateral position to avoid compression of the inferior vena cava.
Hemorrhoids, varices, and portal hypertension
Rectal varices and hemorrhoids are distinct and different. Incidence of hemorrhoidal
symptoms in patients with portal hypertension is similar to that in the general population.
Although rectal varices are common in patients with portal hypertension, they bleed much less
commonly than esophageal varices. In the rare instance of bleeding from rectal varices,
multimodal treatment should be considered, including medical management of portal
hypertension, direct control methods such as sclerotherapy and suture ligation, to transjugular
intrahepatic portosystemic shunt and surgical portosystemic shunts.
Hemorrhoids in Crohn disease
As many patients with Crohn disease have loose stools, engorged hemorrhoids may
occasionally be seen. In the background of rectal inammation, conservative management is
indicated. Older literature describes a high rate of poor wound healing and complications with
hemorrhoidectomy in Crohn disease, and many patients with anorectal Crohn disease describe a
hemorrhoidectomy with poor outcome as immediately preceding their inammatory bowel
disease diagnosis. However, in appropriately selected patients who are well controlled medically
and have no rectal inammation or other anorectal disease, a good outcome can be attained.
117
Wolkomir and Luchtefeld73 reported healing in 15 of 17 patients with Crohn disease with
ileocolic disease after hemorrhoidectomy. Karin reported on a group of 13 patients with Crohn
disease without rectal involvement who had symptomatic grade 3 hemorrhoids. All underwent
transanal hemorrhoidal dearterialization. There were no deaths, new incontinence, fecal
impaction, or persistent pain. At 18 months, 10 patients were without hemorrhoid-related
symptoms.74
Hemorrhoids in the immunocompromised patient
Anorectal pathology is increasingly seen in immunocompromised patients, including those
with medically induced immunosuppression, such as solid organ transplant recipients and
patients receiving steroids or chemotherapy, as well as those with disease-induced immunosuppression, including HIV. One must recall that this population is heterogeneous. For those in
whom the immunocompromise can be expected to resolve, conservative management should be
pursued aggressively until immunity is normal or nearly so. For those with an ongoing degree of
immunocompromise, medical management should be the primary approach, reserving direct
intervention only after medical failure and with careful consideration of the implications of
complications in this population. RBL and excisional hemorrhoidectomy have been shown to be
safe in HIV-positive patients on highly active antiretroviral therapy with acceptable CD4
counts.35,75
Summary
Symptoms thought related to hemorrhoids must be carefully considered before intervention.
The rst line of therapy for any hemorrhoidal complaint remains conservative management
with increased uid and ber intake and appropriate modication of toileting behavior. Bleeding
in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely
managed with ofce-based therapies; some grade 3 hemorrhoids would also respond to this,
though more treatment sessions would likely be required. Operative therapy is the best choice
for management of persistently symptomatic grade 2 disease and for grades 3 and
4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with
a familiarity with instrumentation and techniques, good results can be obtained with newer
operative interventions for internal hemorrhoids. Outcomes must always be compared with
those obtained with classic excisional hemorrhoidectomy.
Fistula in Ano
Introduction
Familiarity with anorectal anatomy and the pathogenesis and classication of stula is
essential to successful stula management. At its simplest, the pelvic oor consists of 2 funnelshaped structures, 1 within the other. The inner structure is the lower end of the circular
muscle of the rectum, which becomes thick and rounded as it condenses into the structure
known as the internal anal sphincter. Surrounding this is a funnel of pelvic oor muscle formed
by the levator ani, the puborectalis, and the external anal sphincter. The intersphincteric space
lies between these 2 funnels and is continuous inferiorly with the perianal space and superiorly
with the rectal wall. The perianal space is located in the area of the anal verge and becomes
continuous with the ischioanal space laterally. The ischioanal space extends from the levator
superiorly to the perineum inferiorly and is bound anteriorly by the transverse perinei
muscles and posteriorly by the gluteus maximus and sacrotuberous ligament. In the midportion
of the anal canal at the level of the dentate line, the ducts of the anal glands empty into the anal
crypts.
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Etiology
Fistula in ano, the most common form of perineal sepsis, is an abnormal communication between the anal canal or rectum and the perianal skin. Most arise because of
cryptoglandular infection. Anal crypt glands penetrate the anal sphincter complex to varying
depths. Obstruction of these glands leads to suppuration, which tends to track toward the skin;
the path taken determines the abscess location, and hence the type of stula that may develop
(Fig 8). Fistula is twice more common in men, and the mean age of diagnosis is approximately 40
years. There is approximately a 50% chance of developing an anal stula after a perianal abscess
is drained. An internal opening is infrequently identiable at the time of abscess drainage,
possibly owing to inammation and edema. In a study of 1023 patients with anal abscess, the
internal opening was identied in 34.7%.76 Another study followed up 232 patients after anal
abscess drainage for up to 13 years, reporting development of stula in ano in 66% of the
cohort.77 Most surgeons would drain a perianal abscess without acutely searching for a stula.
Vigorous probing can cause iatrogenic stulas, and those who would develop a stula would
present in due time. Etiologies that should be considered in the differential diagnosis of
cryptoglandular stula are listed below. Here, we consider primarily the diagnosis and
management of cryoptoglandular stulas.
Crohn disease
Fistula in ano is the most common perianal manifestation in patients with Crohn disease,
seen in 6%-34% of patients.78 Perineal stulas are present in most patients with rectal Crohn
disease and are commonly seen with Crohn colitis as well. Multiple or recurrent stulas or those
with secondary openings more than 3 cm forming the anal verge should raise suspicion for
Crohn disease. Some patients with Crohn disease that is medically well managed may become
candidates for directed stula management.
Pilonidal disease
The gluteal cleft should always be carefully examined when seeing someone with a
presumed perianal stula. Fewer than 5% of pilonidal sinuses track caudad, but if this rare
occurrence is misdiagnosed as an anal stula, complex iatrogenic stulas that are difcult to
manage may result.
Fig. 8. Cryptoglandular suppuration: (A) anal crypt with suppuration and (B) pathways along which the abscess may
extend.
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Lymphogranuloma venereum
Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis. Multiple complex
perineal stulas can be seen in longstanding LGV. Recent outbreaks of LGV in the developed
world are due to sexual transmission among men having sex with men. Most of these patients
will have associated proctitis and many are also HIV positive.79 LGV should be considered in a
patient with stula in ano, proctitis, and inguinal bubos. Response to medical management
determines if any surgical treatment is feasible.
Actinomycosis and tuberculosis
These diseases are rare in the general population but can be seen in immunocompromised
individuals; these etiologies should be considered in patients with a stula that is stubbornly
recurrent or unusually complex.80 As in LGV, response to medical management will dictate if
surgical intervention is indicated.
Hidradenitis suppurativa
Hidradenitis results from inammation of apocrine sweat glands, which abound in the
perineum, groins, and axilla, and can mimic stula in ano. Patients typically give a history of
repeated abscesses and drainage. Physical examination shows associated scarring. Although
hidradenitis may involve perianal skin distal to the dentate line owing to apocrine glands in the
area, there cannot be an involvement of the anus at or above the dentate line or the rectum.
Classication
The most widely accepted classication of stula in ano is proposed by Parks and
colleagues,81 which describes the stula track in relation to anal sphincter complex. This is
integral to selecting appropriate treatment options. There are 4 general types of stulas
according to Parks' classication (Fig 9).
Fig. 9. Types of anal stulas: (A) intersphincteric; (B) transsphincteric; (C) suprasphincteric; and (D) extrasphincteric.
See text for discussion.
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Intersphincteric stula
Comprising approximately 70% of all perianal stulas, this type usually results from a
perianal abscess. The track passes within the intersphincteric space to the perineum with a
variable amount of internal sphincter involved. The external opening, if present, is in the anal
canal. No external sphincter is involved, or this would be a transsphincteric stula. The
suppuration may pass into the intersphincteric plane and terminate as a blind track with no
perineal opening. Suppuration may also spread cranially in the intersphincteric plane to lie
above the levator or may originate as a pelvic abscess that tracks along the intersphincteric
plane to manifest in the perineal area.
Transsphincteric stula
Accounting for roughly 25% of stulas, these usually arise from an ischioanal abscess. The track
traverses portions of both the internal and external sphincters into the ischioanal fossa and then to
the perineum. A high blind track may pass toward the apex of the ischioanal fossa or extend
through the levator into the pelvis. A rectovaginal stula is a type of transsphincteric stula.
Suprasphincteric stula
This results from a supralevator abscess and accounts for approximately 5% of anal stulas.
The track arises in the intersphincteric space and tracks cranially, passing above the puborectalis
muscle into the ischioanal fossa and then to the perianal skin. A high blind track may occur and
result in a horseshoe extension.
Extrasphincteric stula
The track passes from the rectum above the levators and to the perianal skin through the
ischioanal fossa. This is the rarest type of stula. Common causes include iatrogenic through
inadvisable vigorous probing during stula surgery, penetrating injury to the perineum or
rectum, Crohn disease, or carcinoma and its treatment.
Fistula in ano may also be categorized as simple or complex. Simple stulas, which include
intersphincteric and low-lying transsphincteric stulas, involve a minimum of external
sphincter muscle, and when otherwise uncomplicated are mainly treated by primary
stulotomy.
Complex stulas are considered to include suprasphincteric and extrasphincteric stulas;
stulas involving more than 30% of the external sphincter; stulas with multiple tracks; anterior stula in a woman; rectovaginal stulas; stulas in patients with impaired continence;
recurrent stulas; or stulas secondary to inammatory bowel disease, infectious diseases
including tuberculosis and HIV, radiation, or neoplasm.
History
Patients with stula often give a history of episodic drainage near the anus that may or may
not be related to a lump or opening. Many give no history of having had an abscess, though
patients with anorectal abscess have approximately a 50% risk of developing a stula. The nature
of the drainage may be bloody, purulent, or clear. The drainage may be associated with relief of
pain, although many patients with stula do not report pain. The differential diagnosis includes
Crohn disease, anorectal neoplasms, caudad-draining pilonidal abscess, sexually transmitted
infections including HIV and LGV, inammatory infections such as actinomycosis or tuberculosis
(unusual in the United States), or other unusual neoplasms such as invasive squamous cell
cancer, lymphoma, or melanoma.
Physical examination
The physical examination begins with inspection of perianal area and gluteal cleft. Although
only 4% of pilonidal cysts drain in a caudad direction, misidentication of this as stula in ano
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Fig. 10. Goodsall's rule.
can lead to complex iatrogenic stulas that are difcult to treat. The external, or secondary,
opening can often be identied in the perianal region draining uid or harboring granulation
tissue. The location and number of external openings help to identify the internal opening.
Goodsall's rule states that a stula with the external opening lying posterior to a line drawn
transversely across the perineum between the ischial spines has a curved track that originates
from an internal opening in the posterior midline, whereas a stula with an external opening
anterior to this line usually originates from a radially located anal crypt with a straight track
(Fig 10). The accuracy of Goodsall's rule is reported to vary. One retrospective study reported that
90% of posterior external openings had curved tracks with the primary opening in the posterior
midline, whereas 71% of anterior openings tracked to an opening in the anterior midline (90% of
women, 62% of men).82 Another study found that the predictive accuracy of Goodsall's rule was
71% for anterior external openings but only 41% for posterior openings.83 A Belgian study
suggested that the accuracy of Goodsall's rule was not affected by Crohn disease, while noting
that stulas with anterior external openings were seen more commonly in women and patients
with Crohn disease.84 Goodsall's rule also states that if the distance between the external
opening and the anal margin exceeds 3 cm, there is an increased chance of complicated
extensions of the stula track through surrounding tissues. A simple yet elegant Israeli study
measuring the distance between external opening and anal verge reported that distance
correctly predicted whether a stula was simple (mean 2.8 cm) or complex (mean 4.4 cm,
P o 0.0001). The authors also found that 80% of the anterior external openings had a straight
track and 56% of posterior external openings had a curved track, conrming the validity of
Goodsall's rule.85
Digital rectal examination should pay special attention to resting tone and voluntary squeeze,
because pretreatment continence factors prominently in recommendations regarding treatment
options and anticipated outcomes. Induration or scarring in the anal canal is noted. Bidigital
examination of the anal canal and perianal area notes any lateral asymmetry. An indurated
cordlike structure may be palpable extending from the external opening toward the anus.
Investigations
Anoscopy and proctoscopy or exible sigmoidoscopy may be performed in the outpatient
clinic as part of the ofce examination, or in the outpatient procedure setting. Anoscopy can
sometimes identify the internal, or primary, opening of the stula track. Proctoscopy or
sigmoidoscopy can be performed to exclude other pathology such as proctitis or neoplasm. Any
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patient with symptoms suggestive of inammatory bowel disease, including multiple or

recurrent stulas, should undergo colonoscopy and small bowel imaging such as CT or MR
enterography. Although a good sense of sphincter adequacy can be gained on digital rectal
examination, anal manometric studies may be useful as an adjunct in management planning for
patients with Crohn disease, diabetics, women with anterior stulas, or anytime there is a
concern for pretreatment impaired continence. Preoperative imaging is generally reserved for
denition of complex stula anatomy or demonstration of clinically undetected sepsis to serve
as a guide to surgical intervention and decrease recurrence rates. Imaging modalities include
stulography, endoanal ultrasonography, and CT and MRI scans.
Fistulography
Classic radiographic stulography involves insertion of a small caliber catheter into the
external opening of a stula and injection of radiographic contrast material directly into the
stula track. Radiographs from different angles are then obtained to determine the stula type
and anatomy. Previously used in evaluation of recurrent stulas, this modality became much less
common owing to several drawbacks. Debris in secondary tracks often prevents their
identication, and excessive injection force can disrupt previously uninvolved tissues. The level
of the internal opening and location of sphincters may be difcult to see owing to absence of
precise radiopaque landmarks. In 1 study of 25 patients, stulography was accurate in only 16%
and produced false-positive ndings in 10% when compared with operative ndings.86 Another
study of 27 patients reported that information obtained from stulogram revealed unexpected
pathology or directly altered surgical management in 48%.87 These results led to the
development of methods of enhanced stulography techniques, including endoanal ultrasound
(EAS) with hydrogen peroxide (H2O2) injected into the track, CT scan with stulography, and MR
stulography.
Endoanal ultrasound
The aims of using EAS in the evaluation of perianal stula disease are to establish the
relationship of the track to the sphincters and determine the complexity and number of tracks. A
prospective study of 38 patients comparing physical examination and endoanal ultrasonography
found no difference between expert physical examination and EAS in identication of
intersphincteric and transsphincteric tracks; however, EAS was unable to correctly identify
primary supercial, intersphincteric, and extrasphincteric tracks or secondary supralevator and
infralevator tracks.88 A prospective study of 21 patients comparing physical examination,
conventional EAS, and H2O2-enhanced EAS reported that H2O2-enhanced EAS was superior to
clinic examination and standard EAS in identifying anatomical stula course, though it was less
successful than physical examination at identication of primary opening.89 H2O2 EAS also
identied secondary extensions in 7 patients; 5 of these had the secondary extension found at
surgery. The 2 patients whose secondary extensions were not identied at surgery developed
recurrent stulas, leading the authors to conclude that H2O2-enhanced EAS had value in
planning the operative strategy.89 Two prospective studies with 143 and 151 patients compared
H2O2-enhanced EAS and ndings at surgery. These studies showed high rates of concordance
with internal opening identication: 63% concordance overall, and 77% with transsphincteric
stulas in 1 study and 93% in the other.90,91 However, a study comparing physical examination
and EAS in 401 patients treated for acute or chronic stula noted that EAS was signicantly more
accurate in identifying the primary opening in chronic stula as compared with acute stula
(89.5% vs 76.8%; P o 0.0001).92 A prospective study of 19 patients with recurrent or complex
stula compared 3-dimensional EAS reconstructions done before and after H2O2 enhancement
with MR and surgical ndings. Results showed that EAS was more accurate in detection of
primary tracks and internal openings than in detection of extensions, and although H2O2enhanced EAS helped identify some tracks and internal openings, and may have been helpful in
difcult cases, no overall benet was demonstrated.93 EAS can be performed rapidly and is well
tolerated, but it is operator-interpreter dependent. Scars or defects from previous surgery or
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trauma can complicate interpretation. The addition of H2O2 as a contrast medium allows better
identication of internal openings and tracks, reducing the risks of recurrence and potentially
also incontinence.89
CT scan
CT scan with IV and rectal contrast is used in the assessment of the perirectal spaces, often to
identify abscess or differentiate abscess from pelvic cellulitis.94 A retrospective study of 113
patients who had a CT scan less than 48 hours before surgical drainage of an anorectal abscess
revealed an overall sensitivity for CT scan detecting perirectal abscess of 77%, but noted that CT
lacked sensitivity in immunocompromised patients.95 The limited resolution of CT makes it
difcult to differentiate between inammatory soft tissue streaking and a stula tract.96 CT is
inconsistently able to identify a track's relationship to the pelvic oor muscles. CT stulography
has been considered as a method of extending the usefulness in the stula disease. However,
owing to radiation exposure concerns, this method has largely been replaced by EAS and MRI.
Magnetic resonance imaging
MRI with body coil, endorectal coil, and phase array has been evaluated for its utility in the
assessment of complex and recurrent stula disease and in the previously operated patient with
disruption of normal anatomy. Multiplanar views clarify differentiation of supralevator from
infralevator lesions.97 MRI has been shown to be valuable in identication of the primary track
as well as the presence, position, and course of secondary extensions. A prospective study
comparing MR ndings with blinded operative ndings showed concordance of 86% for the
presence and course of primary track, 91% for the presence and site of secondary extension or
abscess, and 97% for the presence of horseshoeing.98 The authors note that the 9% rate of failure
to heal was related to pathology identied on MRI but missed at surgery98 (Fig 11). Results of a
subsequent study in which the surgeon was blinded to preoperative MR results were less
striking, showing that MRI detected 50% of tracks, 74% of internal openings and 46% of external openings, and 33% of abscesses.99 Interpretation of MR images can be challenging because
scars and neurovascular structures may be mistaken for stulas, and image artifacts may
simulate a uid-lled track.100,101 A learning curve has been demonstrated in interpretation
of these images.99 Adjuncts for improving image resolution include saline instillation into
stulas, gadolinium rectal instillation, use of an endorectal coil, and IV contrast agents. Saline
injected into stula tracks was noted to improve delineation of stula extent and make
uid collections more conspicuous, improving visualization of stulas and the relationship to
normal anatomical structures.102 Use of the endorectal coil showed correct identication of the
internal opening in 80%103 and has been shown superior to external MRI in demonstration of
sphincter anatomy, although denition lessens outside the sphincters and tracks that extend
Fig. 11. MR image showing abscess distant from stula. (Color version of gure is available online.)
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beyond this may not be fully evaluated.102 MR images obtained before and after the rectal
administration of gadolinium were compared with surgical ndings in 50 patients with
cryptoglandular stula disease. Overall, 54 of 68 tracks detected at surgery were correctly
identied by noncontrast short T1 inversion recovery (STIR) sequences and postcontrast STIR
images, with postcontrast T2 images correctly identifying 58 of 68 tracks. The authors concluded
that both noncontrast STIR and postcontrast T2-weighted sequences were adequate for stula
classication, but postcontrast T2-weighted images were superior in complex recurrent stula
disease.104 MR stulography employing IV gadobenate dimeglumine in a study of 36 patients
with anal stula or abscess reported complete concordance of MR and surgical ndings in 32
patients (89%). The 4 patients in whom there was no concordance had complex anal Crohn
disease.105
A study comparing the diagnostic ability of endoanal MRI, H2O2-enhanced EAS, and surgical
exploration in 21 patients with cryptoglandular stula and a visible external opening noted
excellent agreement among modalities for classication of primary track and location of internal
opening (81%-90%), and good agreement for secondary tracks, noting agreement was higher for
linear tracks (71%-81%) than curved tracks (57%-71%).106 Another study compared the relative
accuracy of physical examination, EAS, and MRI in 104 patients suspected of having stula in
ano. Both EAS and MR were found superior to physical examination in correct classication of
primary track and abscess (P o 0.001), horseshoe extension (P 0.003), and identication of
internal opening (P o 0.001). Authors reported that EAS correctly identied internal opening
location in 91% vs 97% with MRI, noting that although MR was superior overall in imaging, EAS is
a viable alternative for identication of internal opening location.107 MRI in expert hands
provides superiority in denition of complex anal and perineal stula disease, and owing to the
cost and limited availability of specialized MRI, EAS remains a low cost, widely available and
useful tool in the evaluation of complex and recurrent stula disease.
Operative management
General considerations
The goals of stula management are elimination of the stula with preservation of sphincter
function and prevention of recurrence. Any preoperative discussion must include all these
outcomes, clearly outlining the risks related to the planned intervention. Identication of the
primary and secondary openings is the rst step in stula classication, which is integral to
choosing the proper operative management option. The long-term functional outcomes of
primary and staged stulotomy have led to the search for alternative management methods.
The external opening is commonly readily apparent. Identication of the internal opening
can be more challenging. There are number of ways to accomplish this. Examination under
anesthesia may be all that is needed to clearly identify the internal opening. A probe can then be
passed carefully and gently through to the external opening, thereby dening the track. This
direction, from internal to external, is preferred because it is less likely to cause a false track.
However, when the internal opening is not readily apparent, the probe may be passed carefully
from the external opening toward the area thought to harbor the internal opening. Goodsall's
rule (Fig 10) can be used to guide this maneuver, always being mindful of its pitfalls. Diluted dye
such as methylene blue, H2O2, or milk can be injected into the external opening, watching for its
appearance at the dentate line. Following the granulation tissue present in the stula track
always helps identify the internal opening, although this requires tissue division before the
internal opening is claried. Grasping the track and noting the puckering of the anal crypt when
traction is placed on the stula track is useful in simple stulas, but openings may be missed in
complex stula disease.
Most stula procedures can be performed easily and safely with the patient in prone
jackknife position and buttocks taped apart for exposure. Local anesthesia, (0.5% lidocaine or
0.25% bupivacaine with 1:200,000 epinephrine injected circumanally and submucosally) with IV
sedation as adjunct is commonly used, although general anesthesia may be used in select cases
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for airway control issues. Although regional anesthesia can be used, caudal blocks have lost
popularity, and spinal anesthesia has a relatively high rate of postoperative urinary retention.
Low, simple stula
Lay open technique
This is used chiey for simple intersphincteric and low transsphincteric stulas. This is
dened in the Practice Parameters for the Treatment of Perianal Abscess and Fistula-in-Ano
prepared by the Standards Task Force of the American Society of Colon and Rectal Surgeons as
including a single, nonrecurrent track crossing less than 30%-50% of the external sphincter, not
an anterior stula in women, in subjects with unimpaired continence and no history of Crohn
disease or pelvic radiation.108 A probe is inserted into the track; the tissue overlying the probe is
divided and the track curetted of epithelial and granulation tissue. If there is any concern for
neoplasia, the curettings can be sent for pathologic evaluation, although in general the yield is
low. The wound is most commonly allowed to heal by secondary intention, but marsupialization
is sometimes done. The wound is generally too saucerlike to pack effectively.
Recurrence and rates of fecal incontinence are low with proper patient selection. A review of
624 patients treated for stula reported that recurrence was associated with complex or
horseshoe stula, failure to identify the internal opening or lateral location of the internal
opening, and previous stula surgery. Alterations in continence were associated with female
gender, high stula, type of stula surgery, and prior stula surgery.109 van Koperen and
colleagues reported on patients treated surgically for stula with median 76-month follow-up.
Of 109 patients with low stula treated by stulotomy, the 3-year recurrence rate was 7%;
however, soiling was reported at 40%.110 Tyler and colleagues reported that 38 patients with
submucosal stulas healed after primary stulotomy with no recurrence.111 A prospective study
of 148 patients with intersphincteric stula managed by stulotomy reported postoperative
soiling in 6, incontinence to atus in 27, and incontinence to liquid stool in 4 patients. The
authors also noted decreases in maximum resting pressure and length of high-pressure zone,
but no change in voluntary contraction pressure.112 Multivariate analysis revealed low voluntary
contraction pressure and multiple previous operations to be independent risk factors for
postoperative continence disturbance.112
High or complex stula
Staged stulotomy with seton
Preservation of continence is more challenging when managing high transsphincteric
stulas, as simple laying open of the involved muscle produces a high rate of fecal incontinence.
These procedures are often performed in a staged fashion with use of a seton. The seton may be
any nonabsorbable loop passed through the track; commonly used materials include silk or
other nonabsorbable suture, soft drains, rubber bands, or silastic vessel loops. The external and
internal openings of the stula track are identied; skin, anal mucosa, and other non-muscle
tissues are divided to expose the sphincter; and the seton is passed through the track and
secured. Silk setons are tied to themselves; other materials can be secured with 2 silk sutures.
Sufcient room is left between the knot and the tissues to allow manipulation of the seton via
the long knot. Situations considered for seton use are shown in Table 3. Any seton used as a drain
or to prevent abscess collection, or both, should be nonreactive such as a silastic vessel loop.
Use of a silk suture as a seton promotes inammation and brosis, with the aim of allowing a
second-stage stulotomy to divide the remaining sphincter muscle when the divided ends will
be kept in close proximity by the brosis.113 Tying the seton tightly about the tissues to promote
tissue ischemia and allow the seton to cut through the tissue is painful for patients and has
been associated with a high rate of incontinence, ranging from a gas incontinence rate of 9.5% at
1 year114 to an average rate of 12% incontinence reported in a 2009 review.115 The Practice
Parameters for the Treatment of Perianal Abscess and Fistula-in-Ano prepared by the Standards
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Table 3
Indications for seton use
A.
B.
C.
D.
E.
F.
Identication or promotion of brosis at complex stula encircling all or much of sphincter mechanism
Mark stula track in setting of extensive sepsis with distortion of normal anatomy
Anterior transsphincteric stula in female patient
High transsphincteric stula in patient with expected poor healing (HIV, Crohn, and other immunosuppression)
Promote drainage or prevent abscess in anorectal Crohn disease
Other situations with concern that sphincter division would result in incontinence: previous anorectal procedures
involving sphincters, multiple stulas, and elderly patients
Task Force of the American Society of Colon and Rectal Surgeons note rates for minor
incontinence as 34%-63% and major incontinence as 2%-26% after seton use.108 The Association
of Coloproctology of Great Britain and Ireland has recommended that cutting setons be used
only for low transsphincteric stula.116
High transsphincteric stulas involve the entire external sphincter complex as well as the
puborectalis; laying open the entire tract would certainly produce incontinence. Several
alternatives have been used to manage this type of stula. Parks described division of the
internal sphincter and the supercial portion of the external sphincter to the external opening,
placing a seton around the remaining external sphincter, with 63% healing reported.117 A
modication in which no external sphincter is divided reported 66% healing in posterior and 88%
in anterior stulas.118 Rates of healing and continence are often inversely related, particularly for
complex or recurrent stula disease.
Horseshoe stulas are suprasphincteric stulas with complete sphincter involvement, and
often have multiple external openings that are at a signicant distance from the internal opening.
Treatment requires identication of the internal opening and proper drainage of the postanal
space. This is classically accomplished by unroong the postanal space starting at the internal
opening and dividing the internal sphincter. Some surgeons prefer to unroof the deep postanal
space through a skin incision and place a seton through the internal opening in the posterior
midline. Although complete opening of the lateral extensions has been described, most surgeons
now prefer the Hanley technique of management, consisting of postanal space drainage with or
without a seton, and counterincisions to drain the lateral extensions (Fig 12). Tracks are curetted,
and some surgeons place penrose or other drains through the lateral extensions for several days of
drainage. With the inciting cryptoglandular source obliterated, the lateral tracks should heal
secondarily; however, the recurrence rate is as high as 18% and disturbance in continence as high
as 40%. Anterior horseshoe stulas are very uncommon and can be difcult to manage. One must
remember that there is no puborectalis muscle anteriorly, and the abscess or stula track may lie
deep to the transverse perinei muscle. Immediate stulotomy would guarantee incontinence.
Anterior drainage is provided by division of the inferior half of the internal sphincter and seton
drainage. Counterincisions may be performed for lateral tracks.
There are several small series in the literature of patients with high stulas treated by
completely laying open the stula with division of internal and external sphincters, excision of
accessory tracks, and repair with overlapping sphincteroplasty.119,120 Preoperative continence
disturbance was present in 30%-50% of patients; most of the patients showed improved
continence scores postoperatively. However, 8%-25% of patients with no preoperative
continence disturbance reported new continence alterations postoperatively. The stula
recurrence rate was reported as 5.7%-6.3%. These are small nonrandomized studies of extremely
complex surgical management. Randomized comparison with other methods of stula
management would help to clarify the role of this type of approach.
Continence-preserving procedures
The risk of incontinence with classic stula management led to the development of various
procedures designed to preserve continence while obliterating the stula. These include dermal
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Fig. 12. Horseshoe stula; modied Hanley treatment.
or endorectal advancement ap, brin glue, stula plug, ligation of intersphincteric stula tract
(LIFT) procedure, and several investigational procedures. However, sphincter-preserving
procedures are associated with a recurrence rate of 30%-50% overall.121
Dermal or endorectal advancement ap
The aim of advancement ap procedures is obliteration of the internal opening, while
avoiding division of any sphincter muscle, leaving the track and external opening to drain and
close by secondary intention. If the internal opening is at the dentate line, a dermal ap is
preferred to avoid a wet anus postoperatively. If the internal opening is higher, an endorectal
ap may be employed (Fig 13). Large stulas may require combined dermal and endorectal
aps.122 Patients are prepared with mechanical bowel preparation and IV antibiotics. Both
internal and external openings and the track must be identied. The external opening is
saucerized to allow curettage of debris and irrigation; the internal opening is carefully excised of
brous tissue that would hamper healing. A ap of well-vascularized tissue (skin and
subcutaneous tissue for dermal aps; mucosa, submucosa, and some muscle for endorectal
aps) is raised to allow tension-free coverage of the internal opening. The ap base should be
twice the width of the tip to maintain good blood supply. Thicker aps are associated with lower
recurrence.123,124 Recurrence rates range from 23%-40%.122,123,125,126 Separate closure of the
internal sphincter was associated with lower recurrence,122 and this became part of the plug
procedure, discussed later in this section; however, later studies of internal sphincter closure
with ap or as a stand-alone technique did not show improved healing, reporting essentially
identical recurrence rates of 23%.127,128
Two studies noted poorer outcomes of aps in patients with Crohn disease.125,126 In 1 study,
patients with Crohn disease had fewer recurrences identied.122 A 2010 review showed success
and incontinence rates of 80.8% and 13.2%, respectively, for cryptoglandular disease and 64% and
9.4%, respectively, for Crohn-related stulas.129 Reasonable success can be expected for
advancement aps in Crohn disease if there is no active rectal inammation.
Fibrin glue
The use of brin glue for therapeutic purposes dates back to World War I, but was
discontinued owing to hazards of virus transmission. Improvements in virus-elimination
technology allowed the Food and Drug Administration to reapprove its use in 1972.
This modality involves plugging the entire stula track with brin glue, which is thought to
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Fig. 13. Endorectal advancement ap. (A) Anatomy of track. (B) Track curettage. (C) Endorectal ap raised. (D) Flap
advancement and securing; distal tip harboring stula opening has been excised.
help healing by stimulating the migration of broblasts and pluripotent endothelial cells
into the stula tract. The use of brin glue for anal stula is appealing owing to its simplicity and avoidance of continence disturbance. The procedure can be repeated in the case
of failure with very low risk. As with stulotomy, both the internal and external openings
of the stula track must be clearly identied, and the track is brushed or curetted to
remove debris. A commercially available preloaded double-barrel syringe is introduced into
the tract until the tip is seen through the internal opening. The syringe is emptied slowly
and steadily, allowing the components of the glue to mix while steadily withdrawing the
syringe outwards to ll the stula tract from the internal opening out, avoiding any gaps in
lling the track. The injection is followed by a 10-minute wait to allow the reaction to stabilize
the clot.
Early results of brin glue in anal stula were promising. A pilot study of 26 patients using
autologous brin tissue adhesive reported with 81% initial closure rate at 3.5 months.130
However, follow-up revealed that recurrences became apparent as late as 11 months after the
procedure using autologous or commercial brin sealant.131 Subsequent studies reported
success for rst-time treatment ranging between 38% and 74%.132-135 A review of 12 studies of
anal stula treated with brin glue noted the studies were widely variable in stula etiology and
complexity, and in quality of data. Overall healing rate was 53%, with a range of 10%-78%.136
Factors associated with poorer healing rates included stula complexity and shorter track
length.132,136
Dislodgement of the brin plug is considered to be a cause of early failure. Inadequate stula
tract curettage, unresolved sepsis, and postoperative infection have been proposed as other
potential causes of failure. To address these concerns, Singer and colleagues performed a
prospective randomized trial comparing outcomes of brin glue containing cefoxitin, closure of
stula internal opening, or both, with mean 27-month follow-up. The initial healing rate was
21% with intra-adhesive antibiotic, 40% with internal opening closure, and 31% with combined
treatment. One patient in each group was retreated successfully, bringing the nal healing rates
129
to 25%, 44%, and 35%, respectively; these differences were not statistically signicant (P
0.38).137 A study comparing outcomes of seton or brin glue for transsphincteric stula showed
signicantly better healing in the seton group (87.5% vs 39.5%, P 0.0007) but worsening of anal
manometry and fecal continence issues; patients treated with glue had less pain and no
deterioration of continence.138 A randomized controlled trial that sought to compare the
outcome of mucosal or anodermal advancement ap alone with ap plus brin glue for
transsphincteric stula found a recurrence rate after ap was 20%, whereas the recurrence rate
after ap plus glue was 46.4%.139 A case-control study that evaluated ap alone and ap plus
glue for high perianal stulas had similar results; the recurrence rate after ap was 13%, and
recurrence after ap plus glue was 56%.140 A multicenter randomized controlled trial using brin
glue in patients with Crohn stulas showed that those treated with brin glue had a remission
rate of 38% compared with 16% in the group which did not receive brin glue treatment
(P 0.04).141 Although the sample was small and the success modest, this can be a meaningful
improvement in this patient group.
Despite the inconsistent success rates, most studies showed that brin glue can achieve
30%-60% success rates in properly selected patients. The technique is simple, does not affect
continence, can be repeated, and in case of failure, does not preclude the patient from receiving
other methods of treatment.
Anal stula plug

The anal stula plug was conceived as another sphincter-preserving treatment option for
stula in ano. The biologic plug (Surgisis Anal Fistula Plug, Cook Surgical, Belington, IN, USA) is
manufactured from porcine small intestinal submucosa. The synthetic plug (GORE BIO-A Fistula
Plug, W. L. Gore and Associates, Flagstaff, AZ, USA) is a polyglycolic acid-trimethylene carbonate
bioabsorbable polymer. The plug is intended to be passed through the track and xed into place,
allowing ingrowth of normal tissues that would obliterate the track. This form of treatment has
appeal similar to brin glue in its simplicity of technique and preservation of continence. The
results are variable. Early enthusiasm was tempered by lower success rates in long-term studies,
and plug dislodgement and perianal sepsis have been consistently reported.
Preoperative bowel preparation and perioperative antibiotics are preferred by most surgeons.
The prior use of a seton is suggested to allow sepsis to resolve, as well as to make the wall of the
track more brotic, and facilitate the procedure by identifying the stula anatomy. The details of
plug placement vary according to manufacturer and also experience published in the literature.
A prospective cohort study compared the outcome of anal stula plug with brin glue in
patients with high transsphincteric or more complex stulas. Ten patients were treated with
glue and 15 were treated with the plug. At 3 months, there was 40% healing in the glue group
compared with 87% healing in the plug group.142 Subsequent studies reported less encouraging
results. Most studies are small and nonrandomized; healing rates range between 24% and 62% in
most studies. Failure was associated with more external sphincter involvement,143 shorter
tracks,144 posterior stula,145 tobacco smoking,145,146 diabetes,146 and previous failed attempts at
repair.145,147,148 The reported rate of postprocedural sepsis is 5%-29%.149-151 Plug dislodgment
occurs in somewhere between 3.3% and 9.7% of patients.146,148,150-152 The data for plug
treatment of anal stulas in Crohn disease is sparse; the studies are small, with the largest
including 20 patients.153 Reported success ranges widely from 9%-80%.153-156
Two retrospective studies compared the outcome of advancement ap and stula plug with
nearly identical ndings. Success rates after ap procedures for stulas classied as complex or
transsphincteric were 62% and 63%, respectively. Success rates after stula plug in these studies
were 34% and 32%, respectively.157,158 A randomized trial in Spain was closed prematurely when
it was noted that 12 of 15 patients treated with plug had recurred after 1 year, compared with
2 of 16 ap patients (P o 0.001).159 A Dutch multicenter randomized trial reported 48% success
after ap procedure compared with 29% after stula plug with 11-month follow-up.160
Most of the studies currently in the literature are small, and few are randomized. It appears
that technique may play an important role in success with the stula plug. Whether the type of
130
plug also plays a role is not clear. Although the stula plug healing rates are lower than initially
reported, and postoperative sepsis remains a concern, these issues do not impair function, and
use of the stula plug in selected patients with concern for continence seems a safe alternative.
LIFT procedure
The LIFT procedure is a relatively new sphincter-sparing approach with promising results.
As with the stula plug, sepsis must rst be controlled; placement of a seton for a few weeks
before operation is also recommended to allow the track to mature for best results. The
procedure begins with a curvilinear incision in the intersphincteric groove; the stula track is
then identied and dissected out (Fig 14). The track is ligated next to the internal opening with a
3-0 absorbable suture. The lateral track is curetted, then suture ligated externally to the rst site;
the track is then divided. Track division must be conrmed by injection or probing. Fecal
continence is preserved in almost all of the studies reported. The initial report showed healing in
94% (17/18 patients) at 4 weeks.161
Longer follow-up seemed to reveal later failures, as well as a range in success rates. Success
when LIFT was performed as the primary stula procedure ranges from 40%-90%.162-164 For
patients with recurrent stulas, success rates are somewhat lower, at 57%-82%.162,165-168 The
time to diagnosis of failure generally ranges from 7-20 weeks.165,166,168 Liu and colleagues168
noted that 80% of failures noted occurred within 6 months of the LIFT procedure.
LIFT procedures fail in 3 ways. Type 1 failures are residual sinus tracks without an internal
opening. Type 2 failures are represented by a downstaged tract, with healing having occurred
from the external opening to the intersphincteric incision. This produces a less complex
intersphincteric stula. Type 3 failures, the least common, are complete failures that extend
from a previous internal opening to 1 or more external skin openings. One may consider type
2 failure as still a benet, as a high transsphincteric stula is converted to an intersphincteric
stula.163,164 Tan and colleagues169 followed up patients after LIFT for 4 years to analyze reasons
for failure and recurrence. Seven of 93 patients (7.5%) failed, with discharge noted at the
intersphincteric wound. Four of these also had an unhealed internal opening, and these were
treated with stulotomy. Three patients with discharge at the intersphincteric wound
underwent ultrasound, which showed no demonstrable track, and had the intersphincteric
wound treated with silver nitrate only. Six of 93 (6.5%) recurred, with a demonstrable track
extending from the previous internal opening to an external opening, and healing of the
intersphincteric wound. These were treated successfully with stulotomy, repeat LIFT, or ap
closure.169 Some surgeons have added interposition of a bioprosthetic mesh at the
Fig. 14. Ligation of intersphincteric stula track.
131
intersphincteric site. A retrospective series of 31 patients managed in this way revealed a clinical
healing rate of 94%, with no complications that required intervention; the minimum follow-up
was 1 year.170 A second, smaller study reported healing a rate of 68.8% (8/13) with a median
follow-up of 26 weeks. The 5 failures had isolated discharge at the intersphincteric wound; at
press time, 2 had undergone successful stulotomy.171
A study combining LIFT with a ap procedure performed concomitantly, based on the
rationale that ap failures may be due to ongoing sepsis in the persistent stula track, failed to
show improved outcomes. Primary healing was seen in 51% (21/41 patients). Of the 20 patients
who failed, the original transsphincteric stula persisted in 12; in the remaining 8 patients, the
stula was converted into an intersphincteric stula, and these successfully underwent
stulotomy.172 A small randomized study designed to compare LIFT and ap in complex stulas
reported a similar failure rate: 8% after LIFT (2/25 patients) and 7% after ap (1/14 patients). LIFT
was 30 minutes swifter, and patients returned to work earlier.173 However, a retrospective
comparison of LIFT and ap outcomes found a lower rate of success after LIFT. The LIFT
success rate was 62.5% (15/24 patients) compared with ap success rate of 93.5% (29/31
patients).174
The LIFT procedure appears to be a safe and effective sphincter-sparing management option
for complex stulas, with a very acceptable rate of success, even in recurrent disease. Failure is
higher in anterior175 and longer168 stulas, but repeat procedures remain feasible. Downstaged
tracks may be amenable to stulotomy. Longer-term results of the bioprosthetic mesh at the
intersphincteric site variant would be of interest.
Newer modalities under investigation
Stem cells. Adipose-derived stem cells (ASCs) have emerged as a promising therapy for wound
healing. Experimental studies have shown that ASCs have a number of effects that signicantly
accelerate wound closure, including increasing epithelialization and granulation tissue
deposition, spontaneous site-specic differentiation into epithelial and endothelial lineages,
and increasing neovascularization.176 A phase II study of expanded ASCs in the treatment of
complex perianal stulas reported 71% healing in patients treated with brin glue plus ASCs
compared with 16% healing in those treated with brin glue alone (P o 0.001). Healing rates
were similar in cryptoglandular and Crohn stulas.177 A phase III randomized trial performed by
the same investigators compared ASC treatment alone with ASC plus brin glue and to brin
glue with internal opening closure. Healing rates at 26 weeks were equivalent: 39.1%, 43.3%, and
37.3%, respectively. Although healing was noted to increase to approximately 50% at 1 year in the
2 groups treated with ASCs, it was not statistically improved over healing in the brin glue
group.178 Long-term follow-up showed that 58% of ASC-treated patients remained recurrencefree after 3 years.179
Summary
The most important step in the management of stula in ano is identication of the track;
without proper and correct anatomical denition, success is unattainable. The next most
important consideration is discussion of the risks with the patient; a realistic understanding of
the anticipated outcome is imperative. Low simple stulas can safely be treated with a lay open
technique. For tracks incorporating no muscle, effect on continence should be nil in the absence
of complication. Intersphincteric tracks and some low transsphincteric tracks can safely be
managed with stulotomy in most patients as well. Exceptions include those with preexisting
sphincter compromise, any anterior stula in a woman, and recurrent disease.
Complex and recurrent stulas should be managed with sphincter-sparing techniques,
understanding that success rates may be lower than those seen after stulotomy, but continence
would be less affected. Outcomes tend to be better after a track has matured with a seton in
place; this temporizing measure burns no bridges when appropriately managed. If a patient has
a complex stula with an abscess, the abscess can be drained and a seton placed; the patient can
132
be denitively managed at a later date. Fibrin glue and anal stula plug may be considered in
select patients; there is little risk, the procedure can be repeated, and though sepsis may be seen,
it is easily managed. Endorectal or dermal advancement aps can be used safely when the
underlying principles are well understood and adhered to; failure can preclude subsequent
attempts at aps owing to the scarring involved. The LIFT procedure is becoming more widely
used. The initial excellent results have matured to more sober outcomes, but these are still very
acceptable. Some LIFT failures can even be considered advantageous, as when a type 2 failure
downstages a transsphincteric stula to an intersphincteric stula that can be safely managed
with stulotomy.
ASCs are being studied in several diseases, including stula in ano; although results from the
use of these seem to be equivalent to brin glue at this time, future data may provide clues as to
how stem cells might boost healing in this persistent disease.
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Current Problems in Surgery 51 (2014) 98137

Contents lists available at ScienceDirect

Current Problems in Surgery

Hemorrhoids and Fistulas: New Solutions to

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Etiology and epidemiology

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Nomenclature and classication

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

pulmonary disease, immunocompromise, liver disease, or coagulopathy or use of anticoagulants.

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Fig. 3. Various types of anoscopes used in the clinic setting.

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Benzocaine, dibucaine, dyclonine, lidocaine, and tetracaine

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Rubber band ligation

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Fig. 4. McGivney (left) and O'Regan (right) rubber band appliers.

Fig. 5. Hemorrhoid banding with McGivney bander.

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

reason RBL is relatively contraindicated in patients on anticoagulation or those who have an

Energy methods of xation

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Surgical management of internal hemorrhoids

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Open hemorrhoidectomy (Milligan-Morgan technique)

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Historical note: Whitehead hemorrhoidectomy

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Transanal hemorrhoidal dearterialization

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Hemorrhoidal skin tags and broepithelial polyps

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Fig. 10. Goodsall's rule.

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

patient with symptoms suggestive of inammatory bowel disease, including multiple or

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Fig. 12. Horseshoe stula; modied Hanley treatment.

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Anal stula plug

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

Fig. 14. Ligation of intersphincteric stula track.

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

J. Rakinic and V.P. Poola / Current Problems in Surgery 51 (2014) 98137

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