Classification and management of postsurgical anal stenosis

Abstract

Postoperative anal stenosis is a serious complication of anal operations. To date, ideal management of this problem has not been well defined. We reviewed the experience with this entity in 212 patients admitted over a five year period to a hospital specializing in colonic and rectal diseases. Etiology of the stenosis was secondary to hemorrhoid operations in 186 patients (87.7 per cent), anorectal surgical procedures associated with Crohn's disease in seven (3.3 per cent) and multiple other causes in the remaining 19 (9.0 per cent). A treatment plan based upon the cause, severity and level of stenosis of the anal canal (lower, middle and upper part of the canal) is proposed. Anal stenosis associated with Crohn's disease was treated with dilation with the patient under anesthesia with good results in six of seven patients. Severe lower anal canal stenosis was best treated by V-Y anoplasty (18 of 20 patients [90 per cent] with good results), although a simple sphincterotomy or multiple anal sphincterotomies achieved a good result in 75 of 111 patients (67 per cent). The middle, upper and entire anal canal stenoses were treated effectively by single or multiple internal anal sphincterotomies (34 of 42 patients [83 per cent] with good results), although advancement flap anoplasty procedures (simple advancement flap and V-Y anoplasty) worked well when indicated (nine of ten patients with good results). We advocate simple or multiple internal anal sphincterotomies for mild to moderate low anal stenoses, V-Y anoplasty for severe low anal stenoses and initial simple or multiple anal sphincterotomies through the stenotic area for middle, high or entire anal canal stenoses. Surgical judgement will dictate when lack of anoderm mandates advancement flap anoplasty with the sphincterotomy for the higher stenoses.