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Ambulatory Care

in
Colorectal
Surgery

Division of Colorectal Surgery


UP - PGH
LEARNING OBJECTIVES
• Enumerate the common anal diseases
among Filipinos seen at the OPD.
• Discuss the etiology, surgical anatomy
and classification of these conditions.
• Discuss the signs and symptoms,
diagnosis and treatment modalities of
the common anal conditions.
Diseases of the Anus
COMMON UNCOMMON
Anal Warts
• Hemorrhoids
Anal TB
• Fistula in Ano Rectal Prolapse
• Anal Fissure Anorectal Tumors
Pilonidal Sinus
Hidradenitis Suppurativa
Symptomatology of Anal
Conditions
• Rectal bleeding
• Peri-anal discharge
• Prolapsing mass
• Pain on defecation
• Pruritus
• Feeling of incomplete evacuation
Rectal Examination
DIAGNOSTIC TESTS
Adult and Pediatric Proctosigmoidoscope; Anoscope
Flexible Colonoscope
Normal
Colonoscopy
Polyp w/ stalk

Colon Cancer

Sessile polyp

Abnormal Colonoscopy
DIAGNOSTIC TESTS

Barium enema
Endorectal and Endoanal Ultrasonography
Recurrent fistula-in-ano with posteriorly
located tract and internal openning
Recurrent Fistula in Ano with posteriorly located track
visualized after instillation of hydrogen peroxide
Hemorrhoids
Recommended Treatment
for Hemorrhoidal Disease
Grade I - Conservative treatment
Grade II - Conservative or
Rubber band ligation
Grade III - Rubber band ligation or
Hemorrhoidectomy
Grade IV - Hemorrhoidectomy
(excision or stapled)
• Mostly outpatient except for
complicated cases
RUBBER BAND LIGATION
Banded Internal Hemorrhoid
Infrared
Photocoagulation
STAPLED
HEMORRHOIDECTOMY
STAPLED
HEMORRHOIDECTOMY
HARMONIC SCALPEL
hemorrhoidectomy
Harmonic scalpel – Ultrasonic activated instrument
(Ultracision)

-Vibrates at 55,000/sec
-Minimal lateral thermal injury
< 1:5 mm
Ligasure Hemorrhoidectomy
•Vessel Sealing System Sutureless Closed
Hemorrhoidectomy

Reduces lateral extent of


thermal injury
(1.5mm vs > 2.5mm)
Anal fissures
Chronic Anal Fissure
Recommended Treatment
for
Anal Fissure
Acute fissure - Conservative treatment
Nitroglycerine ointment

Chronic fissure - Lateral internal


sphincterotomy
with or without excision of the anal
fissure
Open sphincterotomy
Open sphincterotomy
Open sphincterotomy
Closed Sphinterotomy
Cryptoglandular
Infections
• Anal Abscesses
– Perianal
– Ischiorectal / Deep Post-Anal
– Intersphincteric
• Fistula-in-Ano
Perianal Abscess
Perianal Abscess
Complicated Abscess
Fournier’s Disease
Recommended Treatment
of Anorectal Abscess and
Fistula
Anorectal abscesses - Emergency I and D

Simple fistula-in-ano - Fistulotomy or


fistulectomy on out-patient basis

Complicated fistula - Referral to senior


resident/fellow for possible admission or
more complex procedure (Seton, flap,
colostomy)
General Care for
Anorectal Conditions
• High fiber diet or fiber supplements
• Avoid constipation
• Perianal hygiene
• Warm sitz baths
• Analgesics as indicated
• Generally no antibiotics required
• Avoid rectal exam in patients with severe
pain!
Postop Care for Anal
Conditions
• High fiber diet or fiber supplements
• Avoidance of constipation
• Perianal hygiene
• Warm sitz baths
• Analgesics RTC for 2-3 days then PRN there-
after
• Watch for bleeding, unusual discharge, progres-
sion of pain
• Follow-up 1 week postop then every month till
resolution of condition
Other Anal Diseases
Rectal Prolapse
Condyloma Acuminata
Fibroepithelial
pseudopolyp
Anal Stricture
Pilonidal Sinus
Hidradenitis Suppurativa
Perianal
Rhabdomyosarcoma
Thank You