DepartmentofSurgeryDepartmentofSurgeryRuijinClinicalMedicalCollegeRuijinClinicalMedicalCollegeShanghaiJiaoTongUniversityShanghaiJiaoTongUniversityAnatomyLevatoranimuscleDeepexternalsphincterandPuborectalismuscleConjoinedlongitudinalmuscleSubcutaneousexternalsphincterAnorectalringArterialsupplyoftherectum•Superiorrectalartery•Middlerectalartery•InferiorrectalarteryVenousdrainageoftherectum•Internalhemorrhoidalplexus•ExternalhemorrhoidalplexusSensoryComponentsNeuropathways•Sympathetic+parasympatheticpathwaystointernalsphincter(hypogastric)•Somatictoexternalsphincter(pudendal)SphincterfactorsBasaltone•Pressurezone•analcanal25–120mmHg•rectum5–20mmHg•Continuoustoneofint.andext.sphincterincreaseswithincreasedabdominalpressureMechanismofAnalContinenceStructuralconsiderations•Anorectalanglebetweenrectumandanalcanal•Flapvalveangleoftheanteriorrectalmucosacausedbypuborectaliscausesocclusion•InternalsphincterincontinuoustonicstatewithexternalsphincterengagedduringVasalvaAnalFissure•Ulcerinthelowerportionoftheanalcanal•Acute/chronicprimary/secondary•Sx:analpain,duringandafterBM’sAnalFissureTriadeofanalfissure•analpapillahypertrophy•fissureinano•sentinelpileAcuteFissureTreatment•inspection,usuallyincreasedanaltonecanbeappreciatedonrectalexamiftolerated•cleansingmeasurestypicallyresolvein6weekswithoutsurgicalinterventionChronicFissure•sentineltag,ulcer,hypertrophiedanalpapilla•Formbecauseofswelling,edema,andlowgradeinflammationmaygoontofibrosis•ExtendsfromthedentatelinetotheanalvergeChronicFissureTeatment•nitroglycerinointment0.2%-0.4%BID•Topicaldiltiazem(50%resolutionat6weeks)•BotulinumtoxinAinjection–42%recurrenceat42months–sideeffects•Surgery:lateralinternalsphincterotomyLateralinternalsphincterotomySecondaryanalfissure•Crohn’sdisease•Non-midlineorabnormalappearingfissureshouldundergomarginbiopsy•Avoidsurgeryinneutropenicpatients–treatwithperinealhygineandpainreliefAnorectalAbscessAnorectalAbscess•Infectioninoneoftheanalglands•Maybeasymptomaticorcauseseverethrobbingpainthatresemblesafissure•AbscessshouldbedrainedwhendiagnosedAnorectalAbscess•Sx:severepain(aggravatedbywalking,straining)•SwollenmassmaybeappreciatedAnorectalAbscessTreatment•drainage,avoidpacking,noabscesstypically•Crohn’sdiseaseoralmetronidazoleorciprofloxacinseemstohaveamitigatingeffectFistula•Chronicformofperianalabscess•Evaluationwithanoscopy,endoanalultrasound•ClassificationFistulaintersphincterictranssphinctericsuprasphinctericextraspinctericGoodsall’sruleFistulaTreatment•Unroofingthefistula,eliminatingtheinternalopening,andestablishingadequatedrainage•OlderpatientsuselooselytiedsetonstoallowforadequatedrainageAnalfistulotomyThread-drawingHemorrhoidsHemorrhoids•Varicesofhemorrhoidalplexus•A-Vcommunicationinanalmucosa•Vascularcushions–thicksubmucosawithbloodvessels,smoothmuscle,elasticandconnectivetissueHemorrhoidClassification•Externalskintags•Externalhemorrhoids(belowthedentateline)•InternalhemorrhoidsInternalhemorrhoidsTreatment•Bulkingagentsforfirstandseconddegreehemorrhoids•Sclerotherapy•InfraredPhotocoagulation•Banding2–3ligationsat4to6week•Hemorrhoidectomy•StapledCircularHemorrhoidectomyforprolapsedhemorrhoidsProcedureforprolapsedhemorrhoidsCircumciseforhemorrhoidsNeoplasmsoftheAnalCanal•Squamouscellcarcinoma•BasaloidCarcinoma•MucoepidermoidCarcinomas•AdenocarcinomasThankyou
