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Proctology Hemorrhoids Anal - Fissure Fistula - Ani

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Presentation on theme: "Proctology Hemorrhoids Anal - Fissure Fistula - Ani"— Presentation transcript:

1 Proctology Hemorrhoids Anal - Fissure Fistula - Ani
Constipation (Obst. Defacation Syndroms) Incontinence Tumors (Benign & Malignant) Infections (Viral, Bacterial, Fungi, Chemical, Allergic, Others) Yehiel Ziv, MD, Assaf-Harofe Med. Ctr. Chairman, The Isreal Society of Colon & Rectal Surgeons

2 Levator ani muscle anal columns Int. anal sphincter Anal canal Ext. anal sphincter

3 Levator ani muscle Int. anal sphincter Ext. anal sphincter rectum
deep part superficial part Anal canal subcutaneus part

4 anal column tributaries of superior rectal vein ANAL SINUS conjoint longitudinal muscle anal valve pecten external anal sphincter intermuscular groove [white line of Hilton] internal anal sphincetr tributaries of inferior rectal vein

5 Levator ani muscle Ano-rectal line anal gland

6

7 levator ani muscle external anal sphincer ischioanal fossa fibrous septum of ischioanal fossa internal anal sphincter conjoint longitudinal muscle

8 Hemorrhoids

9 Hemorrhoids Normal components (sub-mucosal vascular tissue) of human anatomy External (Inf. Hem. Plexus, Somatic Nerve) Internal (Sup. Hem. Plexus, Above DL, Senseless) Mixed 2 – Right Side, Anterior & Posterior 1 – Left Side M = F, Peak = 45-65y

10 Hemorrhoids Pathogenesis : Hypothesis: Hypertrophy or - Increased age
- Ch. diarrhea or constipation - Increased Intra - Abdominal Pressure (prolonged sitting, pregnancy etc.) Hypothesis: Hypertrophy or Increased Muscle Tone

11 Hemorrhoids Internal Hem. Classification
1st deg : project into lumen & bleed. 2nd deg : protrude – spont. reduction 3rd deg : protrude – manual reduction 4th deg : irreducibly prolapsed.

12 Hemorrhoids Diagnosis Medical History Physical Examination Inspection
Digital Exam. Rectoscopy

13 Hemorrhoids Symptoms : Ext, Hem. Pain, bleed, swelling Int, Hem.
Bleed, swelling, soilage, itching, pain, discharge, protrusion.

14 Hemorrhoids Medical Treatment : Sitz baths, Diet, Hygiene,
Stool modifiers, Topical creams, Suppositories.

15 Minimally Invasive Treatment :
Hemorrhoids Minimally Invasive Treatment : Int, Hemorrhoids (Grade 2-3) RBL IRC Sclerotherapy Cryo

16 Hemorrhoids Surgical Treatment : Ext, Hem. Int, Hem.
Thrombectomy (Emergency) Excision (Failed Med. Treat.) Int, Hem. Excision or Resection with Anopexy or DHL (Failed Med. or Invasive Treat. 4th degree, Association with other anal disease)

17 Hemorrhoids Surgical Treatment : Anal Dilatation (rarely used)
Excision: - Open (Milligen-Morgan) - Closed (Fergusson) - Semiclosed Resection with Anopexy (Longo Proc.) Trans Anal Ligation of Hem. Arteries

18 Hemorrhoids Surgical Options : Scissors & Scalp Ligasure
Harmonic Scalpel Laser Stapler DHL

19 Hemorrhoids Surgical Treatment : Complications :
Incontinence, Stenosis, Bleeding, Urinary Retention Infection (absc., fistula) > Sepsis Persistent Hemorrhoids

20 Hemorrhoids (Rest, Magnesium Sulphate 30%, Incarcerated Hemorrhoids
Treat Medically !!! (Rest, Magnesium Sulphate 30%, Suppsitories, Stool-softeners) Avoids Complications Rate

21 Hemorrhoids Hemorrhoids in Pregnancy Surgery
Treat Medically or Minimally Invasive Failure Surgery

22 Anal Fissure Vertical tear in squamous epihelial lining of the anal canal between the anal verge and the dentate line Location : Post – 85%, Ant - 10%, Lat – 5%

23 Anal Fissure Acute Chronic Symptoms > 50% Secondary changes
No secondary changes Chronic > 30d Symptoms > 50% Secondary changes

24 Anal Fissure Secondary changes: Sentinel tag (sometimes w fistula)
Hypertrophied anal papilla Indurated edges Exposed Int. Sphincter fibers

25 Anal Fissure Etioligy : - Trauma - Spec. underlying Disease :
Chlamidia, Gonorrhea, Herpes, Syphillis, Aids, TB, Neoplasia, Crohn, Ulcerative Colitis.

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

27 Anal Fissure Symptoms : Diagnosis : swelling, itching.
Pain, bleeding, discharge, swelling, itching. Diagnosis : Inspection, palpation Anoscopy/rectoscopy (not recom.)

28 Anal Fissure Treatment Acute AF Chronic AF Sitz baths, Topical creams.
Medical : Diet, Bulk laxatives, Sitz baths, Topical creams. Chronic AF Medical, Surgery

29 Anal Fissure Medical Treat. of Chronic AF
- Diet, Bulk lax., Sitz baths, Creams. “Chemical” Sphincterotomy - NTG, ISDN NO transmitor - Nifedipine Ca Channel Blocker - Botolinum A - ACE Inhibitor - Alpha-1 adrenoceptor blockade

30 Anal Fissure Surgical Treat. of Ch AF
- Open / Closed LIS - Anal Dilatation (only in special cases) - Fissurectomy - Advancement Flap (from inside or outside)

31 Surgical Treat. of Recurrent Ch AF
Anal Fissure Surgical Treat. of Recurrent Ch AF - Open / Closed LIS (other side, after TRUS) - Anal Dilatation (only in special cases) - Fissurectomy - Advancement Flap (from inside or outside)

32 Anal Fissure Complications Stenosis Dilatation, Surgery
Incontinence Conservative, Surgery Stenosis Dilatation, Surgery Hemorrhage Hemostasis Infection, Ab, Drainage Urin. Reten. Cateterization

33 Anal Fistula Pathogenesis : Infected Anal Glands
(open to Dentate Line) Ductal Obstruction lead to ; Stasis, Infection, Abscess. 50% develop Fistula

34 Anal Fistula Signs & Symptoms : Ano-rectal Pain & High Temp.
Pain, Pruritus, Bleeding, Discharge. Pressure (evacution, cough, sitting) Swelling Fever Ano-rectal Pain & High Temp. = Abscess, until proven otherwise !

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

36 Anal Fistula Park’s Classification: Trans - Sphincteric
Inter - Sphincteric Supra - Sphincteric Extra - Sphincteric

37 Anal Fistula Other Classification: Special Fistulas
Simple Vs Compound (horseshoe) Low, Middle, High (Anal Canal) Small, Large (Int. opening) Special Fistulas Recto - Vaginal Fistula, Associated with Underlying Disease (TB, IBD, Irradiation, Infections)

38 Anal Fistula Asymptomatic Fistulas Require No Therapy !!!
Medical Treatment May Cure Simple Mild Symptomatic Fistulas (sitz-baths, antibiotics)

39 Anal Fistula Surgical Treatment : Fistulotomy or Fistulectomy
Fibrin Glue Anal Plage Seton Placement (Loose, Tight) RAF (Mucosal or Full Thickness) Colostomy Anterior resection Patches (Omentum, Muscles)

40 ODS Obstructive Defacation Syndroms
מצב שבו החולה אינו מסוגל להתרוקן באופן רגיל ונאלץ להשתמש במשלשלים, חוקנים או אמצעים אחרים. כאבים בזמן יציאה צורך במאמץ חריג על מנת להתרוקן ישיבה ממושכת בשירותים מרווחים ארוכים בין היציאות 5-10 ימים אי נוחות באזור חייץ הנקבים בזמן עמידה תחושה מתמדת של חוסר התרוקנות Tenesmus = התרוקנות לא רציפה Incomplete Evac = הפרעות בשליטה = Incontinence 40

41 אבחנה של ODS הופעה קבועה ביותר מרבע היציאות ב-12 השבועות האחרונים של:
מאמץ מוגבר ביותר ביציאה צואה קשה וגושית הרגשה של חוסר התרוקנות הרגשה של הפרעה או חסימה ביציאה שימוש ביד לצורך יציאה- לחץ וגינאלי, רקטלי, לחץ על חיץ הנקבים פחות משלוש יציאות לשבוע 41

42 הברור הקליני לפני הניתוח על החולה לעבור סדרה של בדיקות אשר יגדירו האם הוא מתאים ליפול שמרני או ניתוח דפקוגרפיה מנומטריה בדיקת EMG אלקטרומיוגרפיה בדיקת זמן מעבר TTI בדיקת TRUS 42

43 גורמים ל ODS Intussusceptions (rectal invagination) Rectocele
Genital Prolapse Enterocele 43

44 Thank You !


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