Anoplasty for anatomical anal stenosis: systematic review of complications and recurrences

Sclerotherapy with 3% polidocanol foam for the treatment of mucocutaneous bridges and/or residual piles after open excisional hemorrhoidectomy

Injection sclerotherapy is an effective and safe treatment in selected cases. It might be used as the first treatment for I-III degree hemorrhoidal disease (HD), but also as a bridge therapy for more severe cases not amenable to invasive treatments. However, concerning the long-term recurrence rate, open excisional hemorrhoidectomy remains the gold standard in cases of III- and IV-degree HD. In this context, it is recommended to perform the excision of no more than three piles and to preserve the muco-cutaneous bridges to avoid post-operative anal stenosis. The aim of this study is to evaluate surgical outcomes and efficacy of the combined treatment of open excisional hemorrhoidectomy and the use of ST on the remnant muco-cutaneous bridges/residual piles. This was a single-center retrospective study and a total of 18 patients with IV-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification, were enrolled between January 2023 and June 2023 and their follow-up continued until October 2023 after reaching 3 months of follow-up. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey Incontinence Score were used to assess symptoms and their impact on quality of life and continence. A total of 77.8% (14/18) of the patients were symptom-free (hemorrhoidal disease symptom score (HDSS) score = 0) after 3 months. Moreover, a statistically significant decrease in the median HDSS and short health scale for HD (SHS-HD) score was registered from 16 preoperatively (T0) to 2 at 3-month follow-up (T3). Neither post-operative bleeding nor any type of complications occurred. The use of sclerotherapy in combination with the traditional open excisional hemorrhoidectomy has shown promising results. Further structured studies are needed and greater dissemination and education of the general surgeon on the subject is necessary.

Bilateral Transposition Flap for Postoperative Anal Stenosis after Reconstruction for Paget Disease

One of the complications of anal surgery or disease is anal stenosis. To release the tension of the anus, a tension-releasing incision in the perianal skin and various anoplasty procedures are usually considered. The aim of this article is to describe a straightforward technique with local flaps for severe anal stenosis after anal reconstruction. A 57-year-old man presented to the clinic with diverticulitis secondary to severe anal stenosis, and reported difficulty with defecation after perianal skin resection around the anus and surgery to create a V-Y advancement flap for perianal primary Paget disease 9 months previously. After improvement of the diverticulitis using antibiotics, bilateral transposition flaps were transferred to release the anal stenosis. The surgical treatment for severe anal stenosis has been known to entail several complications, including infection, incontinence, anal mucosal ectropion, pruritus, wound dehiscence, and restenosis. In this severe case, because the scars were situated at the 6 o'clock and 12 o'clock positions on the anus due to the previous V-Y advancement flap, bilateral rotation flaps were transferred from the 3 o'clock and 9 o'clock positions of the anus to prevent wound dehiscence and partial flap necrosis. Three months later, the size of the anus was unchanged, but additional surgery was performed at the patient's request. A bilateral transposition flap procedure was used, with flaps designed and elevated from the 6 o'clock and 12 o'clock positions. The postoperative course was uneventful, and the anal stenosis was improved.