Proctology Blog

Pilonidal Sinus Disease

“Now Permanent Cure Possible With Minimally Invasive Laser Therapy & Epsit”

VeinCure_Pilonidal_Sinus

What is a PILONIDAL SINUS or Cyst ?

Pilonidal disease was originally described by Herbert Mayo in 1833.
The Latin pilus, meaning “hair,” and nidus, meaning “nest.”
So it is a nest of hair in the deeper tissues of lower back in the upper part of inter-gluteal fold which plays
a central role in the pathogenesis of this disease. The incidence of disease is approximately 26 per 100,000
population.and is more common in Young hirsute men.
What are the risk factors to develop this condition. ?
First of all it is an Acquired condition .Two most important factors which play the role is 1) Hairy body & 2) deep gluteal cleft. Other risk factors include obesity, local trauma, sedentary lifestyle, and family history.

Hairs become detached from the skin of the back and behave like darts. It is speculated that the cleft creates a suction that draws hair into the midline pits of moist skin when a patient is sittting as well as due to action of rubbing of the gluteal skin with each other during movements . These ingrown hairs act like a foreign body , and form a pseudo cyst with infection and abscess formation.

How do I know whether I am suffering from this condition.?

Pilonidal sinus disease in acute stage presents as a painful fluctuant swelling or foul smelling draining infected sinus or openings in the midline of gluteal cleft .
The pain and swelling might subside after the pus has drained out or after a course of antibiotics .
The same process usually repeats after a pause of few days.
It can also present as chronic persistent discharging sinuses in the midline of inter-gluteal fold. Keen Observer can also notice tufts of hair protruding out of the sinus openings( ‘Pits’)

Socioeconomic impact of the disease

Because pilonidal disease is a debilitating illness, causing daily discomfort , limiting activity & affecting people in their most productive years, the socioeconomic effect of the disease is great . This is because patients spend significant amount of time away from school or work.

How to get my PILONIDAL sinus infection treated ?

Seek early advice from an experienced surgeon. In an acute stage it must be drained as early as possible before pressure builds inside it and gets complicated
The abscess can be drained under local anesthesia ,as an office based procedure or under a short general anesthesia in a daycare setting if the patient is apprehensive . This is followed by a short course of antibiotics and in 80% of cases this leads to cure . The surrounding skin should be shaved weekly to prevent the
reintroduction of hair.

Surgical Management Of Chronic Pilonidal Sinus Disease

Chronic Pilonidal Sinus with Midline Pits and Deep Tracts

Pilonidal Abscess

However the infection recurs in the remaining cases after few weeks and leads to chronic discharging openings known as sinuses ( shown below ) which form branching tubes deep to the skin.

Traditional surgery involved wide excision of the infected tissues with either primary closure or keeping the wound open allowing slow natural healing.
This involves few days hospitalization, limitation of day to day activities, 2 weeks absence from work and daily painful dressings till the wound healing , which happens in 3 weeks approximately.

However this surgery does not guarantee permanent cure and recurrence happens in 10% of cases.
In patients with recurrent disease who have undergone multiple prior surgical interventions, flap-based procedures, such as a V-Y advancement flap, rhomboid flap, Z-plasty, Bascom cleft lip repair, or Karydakis flap, may be beneficial.

However this surgery does not guarantee permanent cure and recurrence happens in 10% of cases.
In patients with recurrent disease who have undergone multiple prior surgical interventions, flap-based procedures, such as a V-Y advancement flap, rhomboid flap, Z-plasty, Bascom cleft lip repair, or Karydakis flap, may be beneficial.

The BASCOM cleft lip repair has been verypopular . This surgery removes all the infected tissues , provides off-midline closure , and obliterates the deep gluteal cleft as well.

However the drawbacks are again hospitalisation for few days, a painful procedure with limitation of activities and few days off from work.

EPSiT - Endoscopic Pilonidal Sinus Treatment & LASER.

Novel Minimally Invasive Procedures For Cure Of Pilonidal Sinus Disease.

Invented by Piercarlo Meinero MD, the EPSiT procedure is a new video-assisted technique for the treatment of the pilonidal sinus disease and its recurrences.
Direct vision using a fistuloscope allows the surgeon to see perfectly not only the pilonidal sinus, but also any possible fistula tracts or abscess cavities. The destruction can be modulated and there is the certainty of the complete removal of the infected area.

In our clinic , We have added LASER to EPSit which guarantees very high success rates.
The aesthetic result is excellent , it is painless procedure, and the patient’s quality of life is better compared with traditional techniques. There is no need for painful dressings and healing occurs within two to three weeks. The EPSiT procedure is performed in day surgery (the patient is admitted and discharged the same day of surgery). He can resume his work the very next day.
Till date we have cured hundreds of cases with Pilonidal sinus disease by this novel technique combined with LASER.

Does Cancer Happens In Pilonidal Sinus ?

Yes. There is a rare chance of squamous cell cancer developing in long standing pilonidal sinus disease. Cancer is confirmed by biopsy and needs wide local excision down to the sacrococcygeal fascia. . A large flap is usually required to close the defect. Adjuvant chemotherapy or radiation
therapy should be guided by the pathologic features and the general recommendations for squamous cell carcinoma.

For Further Advice Kindly Consult Our Team Of Dedicated Surgeons.

Written by: Dr.Shashikant Jadhav

Proctology Blog

Anal Fissures

Anal fissure is the most common cause of severe anal pain. It is seen in all age groups and may affect infants and children too. The pain of anal ulcer is intolerable. It may be so severe that patients may avoid defecation for days together until it becomes inevitable. This leads to hardening of the stools, which further tear the anoderm during defecation, setting a vicious cycle. The fissures can be classified into
1] Acute or superficial
2] Chronic fissure in ano
An anal fissure (fissure-in-ano) is a small, elliptical tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common in the general population, but are often confused with other causes of pain and bleeding, such as haemorrhoids.

chronic-anal-fissure

Most (85-90%) fissures occur in the posterior (back) midline of the anus with about 10-15% occurring in the anterior (front) midline. A small number of patients may actually have fissures in both the front and the back locations
CAUSES OF ANAL FISSURE
It has been proved that constipation is the primary and sole cause of initiation of a fissure. Passage of hard stool, low fibre diet, consumption of spicy and pungent food, faulty bowel habits such as sitting on the commode for a long time, and lack of local hygiene can contribute for initiation of the pathology. In females, the ailment is usually triggered during pregnancy and following childbirth. It occurs as a superficial split in the anoderm that may heal by itself or may progress to a chronic fissure
TREATMENT OF SUPERFICIAL FISSURES:
It has long been recognized that superficial fissures can be cured conservatively.
1. Warm water sitz bath with or without addition of Betadine and rock salt. This treatment soothes the pain and relaxes the spasm of the internal sphincter for some time. This should be carried out several times a day and after each bowel movement.
2. Stool softening is essential as soft and formed stools negotiate the rectum and anal canal in non-traumatic physiologic way. Plenty of oral fluids also help in keeping the stools soft.
3. High-fibre-diet and bulk-forming agents such as Isaphgula; green leafy vegetables and fibrous fruits go a long way in increasing the bulk of stool leading to a smooth and swift act of defecation.
4. Reassurance and encouragement for not resisting the urge for defecation help prevent hard stools. Later the patient could be encouraged to acquire and maintain a regular bowel habit of once or twice a day.
5. Application of local anesthetic cream or gel may help avoid the torture experienced in passage of stools in the patients with acute fissures. Ointments containing xylocaine, and soothing agents can help in relieving pain. These mixtures are introduced on the finger instead of using as suppositories.

TREATMENT OF CHRONIC OR COMPLICATED FISSURES:
The above mentioned approaches do not prove effective in the chronic variety of fissures. These chronic or complicated fissures are not amicable to the simple conservative line of treatment. A definitive therapy is needed to tackle this stubborn problem. The fissure is labelled as chronic or complicated if it does not respond to conservative treatment, if it has associated sentinel skin tag, if the fissure is indurated and associated with fibrous polyp and if internal sphincter fibres are visible in the base of fissure.
Treatment of chronic fissures could be operative or non-operative.
Non-operative techniques
1] Injection of Botulin Toxin: Botulin toxin (Botox) is known to cause paresis of the sphincter. This causes sphincter relaxation for about 3 months, a period which is sufficient for healing of a chronic uncomplicated anal fissure. It is well tolerated and can be administered on an outpatient basis. The healing rate reported is about 79%.
2] Local application of vasodilators: Voasodilator creams such as nitro-glycerine and Diltiazem cause internal anal sphincter relaxation and thereby improving blood flow to the ulcer and promoting healing. It has been proved that chronic anal fissure is ischemic in origin due to poor blood supply and spasm of internal anal sphincter. Headaches during the treatment is major drawback.

OPERATIVE TECHNIQUES
1] Stretching of anal sphincter [Lord’s anal dilatation]:
This was one of the most favoured and accepted methods of treating the anal fissures. The primary cause of attraction for the procedure is its extreme simplicity. Anal dilatation helps in healing of the fissure by reducing the anal canal pressure. If performed with due care by avoiding excessive manipulation, it does not cause any damage to the external anal sphincter as feared. In experienced hands, incontinence of stools or flatus is seldom seen.
2] Division of internal anal sphincter:
Division of internal sphincter fibres to relieve the sphincter spasm is presently considered the preferred therapy for chronic, recurrent and non-healing fissures. Division of internal sphincter could be open sphincterotomy or closed sphincterotomy.
Lateral internal sphincterotomy is the most favoured procedure due to the simplicity of the procedure, minimal anaesthesia requirement and good results.
RECENT ADVANCES:
Recently with advent of surgical Lasers, the CO2 or Diode Lasers are used to vaporize the base of fissure and carry out the sphincterotomy together offer promising results, quick recovery and minimal post-operative pain.

CONCLUSION:
Revisiting the trends of treatment of anal fissures, it can be concluded that conservative treatments with nitro-glycerine, and botulin toxin are effective methods that may reduce the need for anaesthesia and surgery in many of the patients. These could always be offered to the patients who are not willing for operative procedure. Surgical manipulation should be sought in case of recurrence or failure of conservative treatment. However Laser fissurectomy with sphincterotomy should remain the treatment of choice when available.

Proctology Blog

Anal Fistulas

Anal fistulas are recently becoming frequent mainly due to poor dietary habits and poor intake of fluids this leads to attacks of severe constipation which is the main cause of anal fistulas. Other causes of anal fistulas include inflammatory bowel disease like Crohn’s disease, trauma, sexually transmitted disease tuberculosis and cancer.
Inside the anus there are a number of small glands that make mucus that help in stool passage during defecation. Occasionally, these glands get blocked by hard stool particles and can become infected leading into an abscess. About 50% of these abscesses may develop into an anal fistula which is a small canal that opens internally in the ano-rectal area and externally around the anus.
The signs and symptoms of an anal fistulas include frequent anal abscesses with pain and swelling around the anus. These abscesses either self-drain or are surgically drained with the formation of a perianal draining sinus opening that may drain continuously or on and off with bloody or foul-smelling pus drainage. The pain usually decreases after the fistula drains. This is associated with irritation of the skin around the anus from the drainage.
There are 4 types of anal fistulas:
-Intersphincteric fistula where the tract pierces the internal anal sphincter, passes in the space between the internal and external anal sphincter muscles and opens close to the anal opening.
-Transphincteric fistula where the tract passes through the internal and external sphincter muscles and opens usually within few centimetres from the anal opening. These fistulas can go around the anal canal with multiple external openings on both sides of the anus (so called a horseshoe fistula).
-Suprasphincteric fistula where the tract turns upward to a point above the puborectal muscle and then goes down to open away from the anus.
-Extrasphincteric fistula where the tract usually begins at the recto-sigmoid colon and extends downward to pass through the levator ani muscle and opens around the anus. These fistulas are usually caused by inflammatory bowel disease like Crohn’s disease and can be multiple.

Anal fistula are diagnosed on anal digital rectal exam and anoscopy which reveal the external opening of the fistula and may even detect the internal opening. A pelvis MRI with contrast is almost always mandatory to delineate the fistula tract type, its relation to the anal sphincters and any branching or deep abscesses. Colonoscopy may be advisable if Crohn’s disease is suspected.

Treatment of anal fistulas varies with its type and complexity. For simple low type fistulas, laying open of the fistula tract by laser and radiofrequency followed by curettage and leaving the wound to heal by itself in a couple of weeks is advisable.
More advanced or complex fistulas especially with the presence of an abscess may however need staged procedure with usually lasering of the fistula tract and insertion of a draining seton being the first step. This will help to resolve the infection and inflammation and downgrade the fistula. The second stage (final stage) will be done in 2-3 months depending on the clinical follow up and it consists of different advanced minimally invasive, sphincter preserving and minimally painful procedures depending on the fistula type.
– Laser anal fistulectomy (FiLaC)
– FiLaC with VAAFT (video assisted anal fistula treatment) with or without mucosal advancement flap closure of internal fistula opening.
– FiLaC with LIFT (ligation of intersphincteric fistula tract)
– FiLaC with SLOFT (submucosal ligation of fistula tract)
Permacol paste may be added to the above in case of wide fistula tract to help in the closure or in case where an internal opening is not detected in some high complex anal fistulas.
We at Veincureclinic/Emirates health group are specialized and pioneered in treating anal fistulas complex and simple with excellent results using the latest technology and with minimal pain and a day surgery setting where the patient can go back to his normal life immediately after surgery with no alteration in his life style.

Written by Dr. Luay Hajjar

Proctology Blog

Anorectal problems associated with pregnancy.

Pregnancy is a condition associated with a lot of changes in a woman’s body. Gastrointestinal symptoms like nausea, vomiting, reflux, and constipation affect majority of pregnant women. Almost two thirds of women during pregnancy and in post partum period suffer from anal problems like haemorrhoid and fissure. The most important cause of which is constipation.
Constipation during pregnancy is due to the various physiological and anatomical changes taking place in the body of a pregnant lady. For example the increased levels of progesterone reduces the bowel motility and increases transit time of stool. This leads to more water absorption from the gut making the stool dry and hard. Decreased physical activity, use of vitamin and iron supplement further contributes to constipation. In later stages of pregnancy, the bulky uterus compresses the colon. All these factors predispose to anal problems like haemorrhoid and anal fissure mostly either ignored or diagnosed inaccurately by the patients’ themselves or by their primary physician.
Haemorrhoids are dilated tortuous veins in the rectum or anal canal. First degree haemorrhoids maybe asymptomatic or can cause bleeding. Whereas the second and third degree, along with bleeding, prolapse out of the anal canal. In this condition they can become thrombosed and infected leading to severe pain.
Anal fissure is described as a vertical cut, wound or ulcer in the anoderm usually in the posterior midline. There is associated spasm of the internal anal sphincter leading to severe pain. In fact acute anal fissure is the commonest cause of painful rectal bleeding.
Both conditions can easily be diagnosed by a rectal examination and proctoscopy.
The mainstay of managing these conditions is treatment of constipation. Therefore it is imperative for pregnant women to increase their fluid intake add more fibre to their diet, be physically active and exercise regularly. As a second line of treatment various stool softeners, laxatives and bulk forming agents maybe prescribed which are safe to use in pregnancy. Although osmotic and stimulant laxatives should be used with caution.
The symptoms associated with first, second degree haemorrhoids and acute anal fissure are significantly relieved by these measures. Besides some locally applied creams and ointments can be used for their treatment .However thrombosed haemorrhoids and chronic anal fissure may require some surgery. Minimally invasive procedure using laser are available but ideally any surgical procedure is deferred during pregnancy unless it is an emergency .Therefore the patients should seek expert medical advice at the earliest when the problems can be managed conservatively.

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