Ambulatory Anorectal Surgery

Surgeon-administered conscious sedation and local anesthesia for ambulatory anorectal surgery
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Diminished squeezing tone can originate from many circumstances such as defects of the external sphincter secondary to birth trauma, previous operations, or neurological defects. With the patient straining, a rectocele can be diagnosed [ 5 , 6 ], whereas intussusception is difficult to diagnose by means of DRE [ 7 ]. DRE is mandatory in rectal cancer where it discloses location of the tumor, displacement which is a good parameter for depth of invasion , and the relationship to the anal sphincter. This simple examination still determines today whether the patient can have a sphincter-preserving operation or not.

A standardized recording of the DRE in form of the DRESS digital rectal examination scoring system score has an excellent correlation with anal manometry [ 10 ]. The strength of this scoring is defined by the standardization of the examination but its role in surgical treatment evaluation has not been proven yet. Regarding anal incontinence, DRE has a good sensitivity but low specificity [ 11 ], meaning that a normal DRE does not rule out incontinence. Regarding postoperative examination, DRE can reveal anastomotic dehiscence of a low rectal anastomosis or a colo-anal or an ileal pouch-anal anastomosis.

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The water holding procedure is a simple, non-invasive examination for evaluation of the sphincter function. A very good indication for the water holding procedure is testing continence in a patient with a loop ostomy before restauration of bowel continuity. A standardized approach is important for the water holding procedure which can be done by the nurses on the ward.

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The patient is asked to hold the water for 20 min while wearing a sanitary pad. During this time, the patient is allowed to move as usual. The water holding procedure is positive when the sanitary pad is dry and the patient was able to hold the water. Interestingly, it is unknown who has invented and introduced this simple test in the clinical routine. It has been described earlier and it is still sometimes being done with liquids other than water.

The ease of the method with the possibility to repeat it is a major advantage. In our setting, it corresponds well with rectal manometry and even predicts clinical outcome unpublished results. Endosonography EUS can be very helpful in diagnosing perianal fistulas or sphincter defects [ 11 , 12 , 13 ]. EUS is often done in patients with perianal manifestation of Crohn's disease. However, complex anal fistulas, especially with supralevatoric extension, can be difficult to detect [ 14 ]. In these cases, magnetic resonance imaging MRI should be performed.

In the German guideline for perianal fistulas, EUS and MRI are judged as equivalent and are suggested for complex or repeat fistulas [ 15 ]. Injection of peroxide into the fistula opening can enhance visualization of the fistula tract [ 16 ]. Ideally, the surgeon will perform the EUS examination intraoperatively in order to correlate the pre- and intraoperative findings directly.

EUS is mandatory for the diagnosis of rectal carcinoma and differentiation between carcinoma and rectal adenoma [ 17 ]. It detects depth of infiltration of the rectal wall and visualizes locally enlarged lymph nodes. Routine repeat EUS can be done after neoadjuvant chemoradiotherapy to prove downsizing [ 18 ]; however, it is not done after surgery for routine follow-up. Anal manometry measures pressure in the anal canal under resting and squeeze conditions. Resting pressure assesses function of the internal anal sphincter while squeeze pressure estimates external anal sphincter function.

The capacity of the puborectalis sling is also measured during manometry. There is a wide range of measuring probes that can be used for anorectal manometry. The most frequently applied technique is perfusion manometry.

Perirectal block for out-patient anorectal surgery: A new technique

The manometry probe is inserted and positioned with the tip in the ampulla of the rectum. During manometry the sphincter pressure is continuously measured. The first result is the pressure at rest followed by assessment of the pressure at maximum sphincter contraction. Additionally, the patient can be requested to cough which allows the documentation of this stress reaction. The last measurement includes the anorectal inhibition reflex fig. The shorter female anal canal does not result in reduced pressure per se. However, women have lower especially resting pressures compared to men.

Furthermore, a reduced pressure combined with full continence has no clinical relevance. Manometry was done to underline anal continence before ileostomy takedown. Anal manometry measures basal resting pressure of the anal sphincter 1 and then pressure under squeezing 2 and with coughing 3. RAIR 4 denotes for rectal anal inhibitory reflex. A balloon is inflated with 20 ml water simulating distention of the rectal reservoir and leading to relaxation of the internal anal sphincter.

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He underwent low anterior resection for rectal cancer after neoadjuvant radiotherapy. Digital rectal examination before ileostomy takedown demonstrated a poor anal function with low resting and reduced squeezing pressure. Anal manometry was done to confirm the clinical impression. Ileostomy takedown resulted in severe incontinence. Spontaneous relaxation of the anal canal has been observed in healthy subjects before awakening in the morning and also in patients with an ileoanal pouch during overnight studies associated with leakage [ 20 ].

A diminished squeeze pressure can result from muscular or neurological damage which can be further distinguished via EUS. Muscular atrophy of the external sphincter has not been described [ 20 ]. Manometry is helpful in various clinical situations since it can be used to evaluate treatment results. Biofeedback for low anterior resection syndrome LARS after rectal cancer surgery is a good example [ 21 , 22 , 23 ]. Patients with rectal resection show reduced anal pressure up to 1 year after surgery. The level of incontinence correlates with reduced resting pressure levels [ 24 , 25 ].

Recovery of this function can be monitored via manometry [ 26 ]. Manometry can also be helpful in some cases of redo surgery such as hemorrhoidectomy. Although incontinence after hemorrhoidal surgery should be rare, objectivation can be helpful since specific surgical treatments result in distinct postoperative manometric outcome [ 27 ].

Rarely, resection of the sensitive anoderm can result in sensory anal incontinence. Advantages of anal manometry are easy feasibility, low cost, and no exposure to radiation. Protective ileostomy is done in low rectal anastomosis with and without previous radiotherapy, in most cases of proctocolectomy, and in some cases of emergency colonic surgery such as sigmoid perforation. Ileostomy is done to protect the anastomosis and to prevent leak. A standard diagnostic workup before ileostomy takedown has not been defined [ 29 ], and its usefulness is questioned in general [ 30 ].

Depending on the type of surgery and the anastomosis performed, DRE, rectoscopy or proctoscopy, and water-soluble contrast enema are often employed before ileostomy takedown. Contrast enema are administered by the radiologist. The focus of the examination is the opacification of the anastomosis. A Foley catheter is introduced just above the anastomosis, where the contrast material, usually Gastrografin, is inflated via hydrostatic pressure.

Clinical Practice Guideline for Ambulatory Anorectal Surgery.

In most cases a post-evacuation picture is taken. Most studies do not routinely display the whole colon and only very few depict the passage up to the ileostomy [ 31 ].

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Occasionally, the examination is done in an anterograde way via opacification of the descending part of the ileostomy [ 32 ]. A systematic review on the utility of contrast enema evaluated 1, enemas and reported abnormalities in cases, such as leaks, strictures, or fistulas [ 31 ]. In 16 out of 1, cases, the enema was normal but stoma reversal was complicated. Therefore, it is rare that a patient will develop a leak at the previous anastomosis if they had a normal enema [ 33 , 34 ].

Side-to-end anastomoses have been shown to be an alternative to a pouch anastomosis [ 35 ]. Since this end represents the most distal part, clinically inapparent fistulas or leaks due to impaired perfusion can theoretically occur. In these cases, contrast enema can be helpful.

A Multimodal Enhanced Recovery Program in Anorectal Surgery

Ileostomy closure can be performed even in the presence of a leak identified by contrast enema, but the outcome is uncertain. In most cases, ileostomy reversal is postponed [ 19 ] and a repeat contrast enema is performed.

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In 11 cases of persistent leak or sinus formation, only 1 patient developed pelvic sepsis after stoma reversal [ 31 ]. In general, bowel function in patients with a postoperative leak is poorer compared to non-leak cases, and the oncological outcome is also impaired [ 36 ].

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Strictures can also be detected via contrast enema especially after proctocolectomy [ 37 ]. Your email address will never be sold or distributed to a third party for any reason. Due to the high volume of feedback, we are unable to respond to individual comments. Sorry, but we can't respond to individual comments. Recent searches Clear All.

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