Annals of Coloproctology

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Case Report

Bilateral Rotational S Flap Technique for Preventing Restenosis in Patients With Severe Circular Anal Stenosis: A Review of 2 Cases: Yuda Handaya, Mukhamad Sunardi; Ann Coloproctol. 2019;35(4):221-224. Published online February 19, 2019; DOI: https://doi.org/10.3393/ac.2017.10.16

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Anal stenosis is a late hemorrhoidectomy complication. Sphincterotomy and various anoplasty techniques are used for treatment severe anal stenosis, such as the C flap, House flap, U flap, and rotational S flap, but no procedure is ideal for every patient. We review 2 cases of severe circular anal stenosis. Their complaints included narrow caliber of the stool and feeling unsatisfied defecation. Excision of scar tissue using the circular technique was followed by reconstruction using the bilateral rotational S flap procedure. At the 1-year follow-up, the patient had complaints about neither defecation nor pain, and no longer needed laxative agents. In conclusion, the bilateral rotational S flap technique should be considered as a viable treatment because it can also prevent the occurrence of restenosis, especially given the consideration of adequate blood supply.

Citations

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Is anoplasty superior to scar revision surgery for post-hemorrhoidectomy anal stenosis? Six years of experience
Yu-Tse Weng, Kuan-Jung Chu, Kuan-Hsun Lin, Chun-Kai Chang, Jung-Cheng Kang, Chao-Yang Chen, Je-Ming Hu, Ta-Wei Pu
World Journal of Clinical Cases.2022; 10(22): 7698. CrossRef
Anoplasty for anatomical anal stenosis: systematic review of complications and recurrences
Gaetano Gallo, Arcangelo Picciariello, Gian Luca Di Tanna, Patrizia Pelizzo, Donato Francesco Altomare, Mario Trompetto, Giulio Aniello Santoro, Franco Roviello, Carla Felice, Ugo Grossi
Colorectal Disease.2022; 24(12): 1462. CrossRef

Original Articles

Prevalence of Anatomic Anal Stenosis in Patients with Chronic Anal Fissure and Results of Lateral Internal Sphincterotomy.: Cho, Dong Yoon , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 2002;18(1):7-9.

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Abstract PDF: PURPOSE
The aim of this study was to estimate the prevalence of anatomic anal stenosis in patients with chronic anal fissure (CAF) and ascertain the results of lateral internal sphincterotomy (LIS) using a new calibrator.
METHODS
Ninety-eight adults with CAF and a control group of 40 normal adults underwent anal calibration under spinal anesthesia. The calibrator was a conical design and the diameter was scaled in increments of 1 mm. The calibration was standardized and the reliability of it was assessed by two independent examiners for the same group (n=45). Confounding effects of age, sex, body weight, and height on the anal caliber were studied. The internal sphincter was divided to the level of the dentate line during LIS.
RESULTS
The anal caliber was 34.6 +/- 1.4 mm (mean +/- SD) in the control group and 28.7 +/- 3.0 mm (mean +/- SD) in patients with CAF. Excellent correlation was obtained between the two examiners (r=0.958). The confounding effects of age, sex, body weight, and height were not significant. Therefore, anal stenosis was defined as when the measurement was 31 mm or below (mean-2SD of control value). Stenosis was present in 82 of 98 patients (84%) with CAF. Patients with stenosis had an anal caliber of 27.9 +/- 2.5 mm, with a range of 21 to 31 mm. Following LIS, 91 of 98 patients (93%) with CAF attained the normal range, two patients still had stenosis, and five patients had an anal caliber exceeding the normal value.
CONCLUSIONS
Anatomic anal stenosis was found in 84% of the patients with CAF. Ninety three percent of these patients attained a normal anal caliber, 2 percent of the patients still had stenosis and 5 percent of the patients had an anal caliber exceeding the normal value after LIS.

Comparison of C-anoplasty and House Shaped Advancement Flap in Anal Stenosis.: Yang, Hyung Kyu , Kim, Sang Hee , Ryu, Kwang Seok , Choi, Jai Pyo , Na, Jai Woong , Ban, Jai Min; J Korean Soc Coloproctol. 2001;17(2):76-83.

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Abstract PDF: PURPOSE
The surgical treatment of anal stenosis includes internal sphincterotomy, rotaton flap and advancement flap according to the stenosis degree, recently, Christensen performed house shaped advancement flap and reported fair results. We compared and analyzed the surgical methods and results in patients with moderate and severe anal stenosis who underwent house shaped advancement flap and C-anoplasty.
METHODS
We have performed this study with 6 cases using the house shaped advancement flap and 6 cases using the C-anoplasty. The out come was assessed by clinical characteristics, surgical method, operation time, duration of hospitalization, healing time, postoperative complications, results.
RESULTS
The average operation time was 38 min in those house shaped advancement flap cases and 63 min in C-anoplasty cases. The average time of hospitalization was 6 days and 9 days, respectively, and the average time of healing was 28 days and 46 days, respectively. In those house advancement flap cases, surgery could be done in 2 directions at the same time in 4 cases and 3 directions in 2 cases; as for those C-anoplasty cases, surgery could be done in 1 direction in 4 cases and 2 directions in 1 case. Two complications were observed in C-anoplasty, one flap infection and one flap necrosis, and in house shaped advancement flap, no complication was observed.
CONCLUSIONS
House shaped advancement flap have several advantages compared to the C-anoplasty, and since house shaped advancement flap could be performed in 2 to 3 directions or even 4 directions at the same time, the anus could sufficiently expanded in severe anal stenosis patients. The house shaped advancement flap might be one of the good method in treating anal stenosis.

Surgical Managements of Anal Stricture.: Lee, Chul Ho , Park, Won Kap , Lee, Kwang Real , Yoo, Jung Jun , Park, Se Yong; J Korean Soc Coloproctol. 1997;13(3):473-480.

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Abstract PDF: Anal stricture is a mechanical narrowing of the anal canal due to contracture of the epithelial lining which has been supplanted by fibrous connective tissue. We reviewed 82 patients with anal strictures who were admitted at Song-Do Colorectal Hospital from Jan. 1994 to Dec. 1996. The etiology of the strictures were injection therapy with necrotizing agent in 62 patients(78%), secondary to hemorrhoid and fistular operations in 13 patients(17%), and other causes in 7 patients(8.5%). The degree of anal stricture was mild in 40 patients, moderate in 33 patients, and severe in 9 patients. The operation methods used to treat the anal strictures were infernal sphincterotomy in 27 patients, local advancement flap in 42 patients, and rotational flap in 13 patients; the selection of the operation method was based on the cause, severity and level of the stricture. During the local advancement or rotational flap operation, a concurrent internal sphincterotomy was also employed in selected patients who had a fibrotic muscular component contributing to the stricture. We preferred to use a sliding skin graft in the advancement flap operation and a C-flap in rotational flap operation. According to a follow-up study with an average follow-up of 20 months, 24 of the 27 patients with mild stricture, 19 of the 24 patients with moderate stricture, and 7 of the 8 patients with severe stricture had good results, and remained 3 patients with mild stricture, 5 patient with moderate stricture, and 1 patient with severe stricture had fair results. Mild anal strictures were effectively treated by sphincterotomy or one or two sliding skin grafts, moderate to severe anal strictures with diaphragmatic type were treated by anorectoplasty, and moderate to severe low anal stoictures with annular type were effectively treated by two or three sliding skin grafts. Based on these results, sliding skin grafts should be effective in most cases of moderate to severe anal canal stricture, although occasionally a rotational flap may be indicated in cases of severe lack of the anoderm.

A Clinical Study on Sliding Skin Graft for the Treatment of Anal Stenosis.: Huh, Moo Ryang; J Korean Soc Coloproctol. 1997;13(2):239-246.

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Abstract PDF: Twenty five patients with moderate to severe anal stenosis were treated with sliding skin graft during the period of time from April 1987 to March 1996. And a follow-up study was carried out on 18 cases among them. The original causes of the anal stenosis were previous necrotherapy in 14, hemouhoidectomy in 3, and cryotherapy in one. Postoperatively, partial disruption of the suture line developed in 2 cases and perianal fistula in one. Long term clinical results were good in 12 cases, fair in 4, and poor in 2. As a result, sliding skin graft is thought to be a simple and effective method for the treatment of moderate to severe anal stenosis.

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