Anus and Rectum

SAM GRASSO 2019

CARA REITZ 2018
JOSHUA DILDAY 2017
JAKE SWANN 2016
 Begins at anorectal
ring – insertion of
levatorani
 Ends at anal verge
– junction of
anoderm and skin
 Dentate line is 2cm
from anal verge
 Anoderm –
hairless, squamous
epithelium
Anatomy

 A supply – inferior rectal a.

 V drainage –
 above dentate internal hemorrhoid
plexus
 Below dentate- external hemorrhoid
plexus
 Nodal drainage –
 Superior and middle rectum – IMA
 Lower rectum IMA, internal iliac
 Anal canal internal iliac and
inguinal
 Anal margin- inguinal
 Hemorrhoids

 Internal and External

 Internal
 Grade I: no prolapse
 Grade II: prolapse with spontaneous reduction
 Grade III: prolapse with manual reduction
 Grade IV: non-reducible
 Treatment
 Medical
 Thrombosed
 <72hr surgical excision, >72hr lance only
 Surgical indications
 Recurrent bleeding, multiple thrombosis, large external component,
moderat to severe pain
 Urinary retention MCC
 Rectal Prolapse

 Starts 6-7cm from anal verge

 Pudendal neuropathy and laxity of anal sphincters

 Full thickness – entire rectum protrudes through

anus
 Mucosal prolapse – solitary rectal ulcer syndrome
 Internal intussusception
 High fiber diet, stool softeners, hydration, avoid
laxitives
 Surgery for full thickness prolapse only, have to
manualy reduce or cannot reduce
 Anal Fissure

 Painful mucosal tear

 90%posterior midline
 Due to local ischemia

 Medical management (90% heal)

 Fiber, sitz baths

 Topical nitrogylcerine and botox (refractory –dilt)

 Lateral internal sphincterotomy
 Surgical treatment of choice

 If not in posterior midline need to biopsy

 Cancer, HIV, Crohns
 Anoperineal Abscess

 Perianal: soft-tissue
overlying sphincter complex
 Intersphincteric: between
internal and external
 Ischioanal: in the ischioanal
space
 Supralevator: between
levators
 Treatment is I&D
 Not antibiotic alone
 Fistula formation is likely
Fistula-In-Ano

 Abnormal connection
between anus/rectum and
skin
 History of Crohns, abscess,
radiation, cancer
 Parks Classification
 Intersphincteric
 Transsphincteric
 Suprasphincteric
 Extrasphincteric
 Goodsall Rule
 Anterior opening is radial,
straight line
 Posterior opening is curvilinear
 Fistula-In-Ano

 Fistulotomy
 Used for low, simple fistula

 Not in Crohns

 Seton
 LIFT
 Rectovaginal Fistula

 OB trauma is the most common cause

 Crohns, radiation, prior surgery, infection

 Intervention is delayed for 6 months

 50% will heal

 Rectal mucosa advancement flap

 Unless rectal ischemia from Crohns

 Full thickness fistulotomy with layered closure

 Condyloma Acuminatum

 HPV-related
 Pink or white papillary lesion
 Risk factors
 HIV, MSM, anal receptive intercourse, cervical dysplasia

 May develop into anal intraepithelial neoplasia

(AIN) and squamous cell carcinoma
 Eradication is warranted
 Podophyllin, imiquimod, fulguration
 Verrucous (Buschke-Lowenstein) carcinoma
 Non-mets squamous cell carcinoma
 WLE
 Squamous Cell Carcinoma

 80% of anal cancer

 Nigro protocol
 Radiation and 5-FU/mitomycin
 75-90% cure rate
 APR is indicated if recurrence of failure
 Metastasis is to inguinal lymph nodes

Above Dentate Nigro protocol

Below dentate
<5cm WLE
>5cm, sphincter involved, +nodes, recurrence Nigro
 Other Anal Cancers

 Adenocarcinoma
 Treated similarly to rectal

 Melanoma
 Resistant to XRT/chemo

 WLE or APR

 Poor prognosis

 Basal Cell
 3mm margins

 WLE
 Rectal Adenocarcinoma

T
 T1: submucosa
 T2: muscularis propria
 T3: Subserosa
 T4: Adjacent structure
 Stage
 1: T1-2 no nodes

 2: T3-3 no nodes

 3: N1-2

 4 M1
 Rectal Adenocarcinoma

 Stage with CT, MRI, U/S, CEA, LFT

 Neoadjuvant XRT/Chemo for Stage 2-3
 Sphincter preservation

 Transanal excision
 T1N0M0

 APR
 Sphincter within 1-2cm

 TME
 Rectal Carcinoid

 <1cm can be treated with excisional biopsy

 Larger need radical resection
 May need APR

 Not associated with carcinoid syndrome

 Rectal Trauma

 Extra-peritoneal injuries need colostomy

 Explore if associated pelvic injury

 Intra-peritoneal injuries are treated like colon

 Primary repair

 Diversion

 Colostomy
 Rectocele

 Anterior invagination of rectovaginal septum

 Diagnosis
 Defecacography

 Anorectal manomety

 Rectal volume studies

 Patient history (vaginal pressure needed for defecation)

 Surgery only for obstruction

 Anus and Rectum

JACOB A. SWANN, MD, FS

CPT, MC, USA
GENERAL SURGERY RESEARCH RESIDENT
WILLIAM BEAUMONT ARMY MEDICAL
CENTER
 All are true regarding anorectal disease except
___?

 A. The dentate line marks the transition point

between columnar and squamous mucosa
 B. The presacral fascia separates the rectum from
the presacral venous plexus and the pelvic nerves
 C. The Waldeyer fascia attaches to the fascia
propria at the anorectal junction
 D. In men, Denonvilliers’s fascia separates the
rectum from the prostate and seminal vesicles
 The surgical anal canal is longer in females than in
males
 All are true regarding anorectal disease except
___?

 A. The dentate line marks the transition point

between columnar and squamous mucosa
 B. The presacral fascia separates the rectum from
the presacral venous plexus and the pelvic nerves
 C. The Waldeyer fascia attaches to the fascia
propria at the anorectal junction
 D. In men, Denonvilliers’s fascia separates the
rectum from the prostate and seminal vesicles
 The surgical anal canal is longer in females
than in males
 Anal Anatomy (Gross and Micro)

 “The surgical anal canal is 2-4cm in length and is longer in men. It

spans the area from the anorectal junction to the anal verge. The
anal transition zone is just proximal to the dentate line and has
features of columnar and squamous epithelium as well as cuboidal
epithelium. Cancers above this area are usually adenocarcinomas,
whereas those distal to this line are squamous or cloacogenic. It is
approximately 1-2cm in length. In women, Denonvilliers’s fascia
separates the rectum from the vagina. Morgagni columns are found
at the dentate line. Anal crypts empty in this area and are the
source of abscesses.”
 It’s a transition zone; it is not composed of transitional cells
 The Waldayer fascia (aka the presacral fascia) does the stuff listed
 Denonvilliers’s fascia (aka the rectoprostatic fascia) in men
corresponds to the rectovaginal fascia (aka the rectovaginal septum
or fascia of Otto) in the female
A 40 y/o M presents with rectal pain and bleeding. He
reports a history of prolapsing hemorrhoids with
straining for several years that he is simply able to
manually reduce. However, he states that this time he is
unable to do so. On physical exam, a large mass of
edematous hemorrhoidal tissue is evident that you are
unable to reduce. Management consists of:

A. Urgent hemorrhoidectomy
B. Urgent rubber band ligation
C. Stab incision and drainage with the patient under
local anesthesia in the emergency department
D. Elliptical excision of the skin and drainage with the
patient under local anesthesia in the emergency
department
E. Rectal examination with the patient under general
anesthesia with incision and drainage
A 40 y/o M presents with rectal pain and bleeding. He
reports a history of prolapsing hemorrhoids with
straining for several years that he is simply able to
manually reduce. However, he states that this time he is
unable to do so. On physical exam, a large mass of
edematous hemorrhoidal tissue is evident that you are
unable to reduce. Management consists of:

A. Urgent hemorrhoidectomy
B. Urgent rubber band ligation
C. Stab incision and drainage with the patient under
local anesthesia in the emergency department
D. Elliptical excision of the skin and drainage with the
patient under local anesthesia in the emergency
department
E. Rectal examination with the patient under general
anesthesia with incision and drainage
 Hemorrhoid Tx

 Internal hemorrhoids are classified into four degrees.

First degree bleed with no prolapse. Second degree
bleed, prolapse, and spontaneously reduce. Third degree
bleed, prolapse, and reduce with manual/digital
reduction. Fourth degree bleed, prolapse, and can’t be
reduced.

 The key with this question is that the hemorrhoids are

acutely larger, edematous, and nonreducible. This
elevates concern for hemorrhoidal strangulation. The
natural history of this leads to hemorrhiodal necrosis,
pain, urinary retention, and sepsis.
Twelve hours after the intervention you performed, you
are paged by the patient’s floor nurse. She reports that
the patient has worsening rectal pain, new low
abdominal pain, and has not urinated since the
operation. His temperature is 102˚ F and heart rate is
110 beats per minute. Management consists of:

A. Placement of a Foley catheter

B. Broad-spectrum IV antibiotics
C. Broad-spectrum antibiotics and rectal examination
with the patient under anesthesia
D. Stool softeners and oral antibiotics
E. In and out catheterization of the bladder and stool
softeners
Twelve hours after the intervention you performed, you
are paged by the patient’s floor nurse. She reports that
the patient has worsening rectal pain, new low
abdominal pain, and has not urinated since the
operation. His temperature is 102˚ F and heart rate is
110 beats per minute. Management consists of:

A. Placement of a Foley catheter

B. Broad-spectrum IV antibiotics
C. Broad-spectrum antibiotics and rectal
examination with the patient under anesthesia
D. Stool softeners and oral antibiotics
E. In and out catheterization of the bladder and stool
softeners
 Hemorrhoid Surgery Complications
 Urinary retention (33%) and rectal pain (100%) are
common after hemorrhoidectomy. If these symptoms had
occurred independently, placing a Foley would be
appropriate.
 However, the patient is 2/4 SIRS criteria (fever and HR >
90); therefore, must rule out pelvic sepsis. This is a rare
condition, but it is life threatening.
 The patient will typically present within 12 hours after a
procedure (banding, sclerotherapy, or hemorrhoidectomy).
Pain, fever, and urinary retention are the hallmarks of this
disease.
 Initial treatment are ICU admission, fluid resuscitation, and
IV antibiotics to cover anaerobes and Gram-negative rods.
Surgery is mandatory to rule out a necrotizing soft tissue
infection that may require surgical debridement.
 Which of the following anorectal findings would
least likely raise concern for a more serious
underlying pathology?

 A. Acute lateral anal fissure

 B. Chronic posterior anal fissure
 C. Recurrent perianal fistulas
 D. Multiple perianal fistulas
 E. A perianal fistula with multiple tracts
 Which of the following anorectal findings would
least likely raise concern for a more serious
underlying pathology?

 A. Acute lateral anal fissure

 B. Chronic posterior anal fissure
 C. Recurrent perianal fistulas
 D. Multiple perianal fistulas
 E. A perianal fistula with multiple tracts
 Anal Fissure Underlying Pathophysiology

 Test pearl: “RTFQ”

 Chronic anal fissures are most commonly located in
the posterior midline. Fissures in any other location,
such as lateral ones, should raise suspicion for other
underlying diseases such as Crohn’s disease, sexually
transmitted diseases, and hidradenitis suppurative.
Likewise, recurrent or complex fisulas should raise
concern for Crohn’s disease.
 A 58 y/o WM practicing homosexual presents to
clinic with CC: of “[p]ain in [his] bottom and
bleeding.” On examination, an ulcerated lesion is
noted in his anal canal that is TTP. Biopsy reveals
squamous cell carcinoma. Tx?

 A. Abdominal Perineal Resection (APR)

 B. Wide local excision
 C. Wide local excision with regional lymph node
dissection
 D. Radiation therapy
 E. Radiation therapy and chemotherapy
 A 58 y/o WM practicing homosexual presents to
clinic with CC: of “[p]ain in [his] bottom and
bleeding.” On examination, an ulcerated lesion is
noted in his anal canal that is TTP. Biopsy reveals
squamous cell carcinoma. Tx?

 A. Abdominal Perineal Resection (APR)

 B. Wide local excision
 C. Wide local excision with regional lymph node
dissection
 D. Radiation therapy
 E. Radiation therapy and chemotherapy
 The patient undergoes the Nigro protocol. After
three months of therapy, the patient has failed to
resolve his lesion. He is referred back to you by his
medical oncologist and radiation oncologist for
further management. Tx?

 A. Abdominal Perineal Resection (APR)

 B. Total Mesorectal Excision (TME)
 C. Low Anterior Resection (LAR)
 D. Wide local excision with regional lymph node
dissection
 E. Wide local excision
 The patient undergoes the Nigro protocol. After
three months of therapy, the patient has failed to
resolve his lesion. He is referred back to you by his
medical oncologist and radiation oncologist for
further management. Tx?

 A. Abdominal Perineal Resection (APR)

 B. Total Mesorectal Excision (TME)
 C. Low Anterior Resection (LAR)
 D. Wide local excision with regional lymph node
dissection
 E. Wide local excision
 Anal Cancer

 Anal cancer comes in many varieties (anal basal cell

carcinoma, anal carcinoid, anal melanoma), but the most
common (~80%) is squamous cell carcinoma
 SSC is associated with HPV (esp. serotypes 16 and 18),
immunocompromised individuals, and
 It has multiple eponyms (Bowen disease (SCCa in situ),
verrucous carcinoma aka Buschke-Lowenstein tumor (giant
condyloma accuminata)
 Treatment is the Nigro protocol (5-FU, mitomycin-C, and
external beam radiation)
 Treatment failures are managed with APR due to inability to
perform wide local excision because of cancers are locally
advanced and likely involvement of anal sphincters in
specimen.
 Which of the following is true regarding the blood
supply to the rectum?

 A. The superior and middle rectal arteries arise

from the inferior mesenteric artery
 B. The middle rectal veins drain into the internal
iliac veins
 C. The inferior rectal veins drain into the inferior
mesenteric vein
 D. The superior rectal veins drain into the inferior
vena cava
 E. There is poor collateralization between the
superior and inferior rectal arteries
 Which of the following is true regarding the blood
supply to the rectum?

 A. The superior and middle rectal arteries arise

from the inferior mesenteric artery
 B. The middle rectal veins drain into the
internal iliac veins
 C. The inferior rectal veins drain into the inferior
mesenteric vein
 D. The superior rectal veins drain into the inferior
vena cava
 E. There is poor collateralization between the
superior and inferior rectal arteries
 Rectal Anatomy

 Superior artery and vein = IMA/V and then to portal

vein
 Middle and inferior artery and vein = internal iliac
A&V and IVC
 Rich collaterals exist; low chance of ischemia

 Lymph drainage is similar for rectal cancer

 Of note, anal cancer drains to the inguinal lymph
nodes if below the dentate; therefore, it is critical to
perform an inguinal exam for anal cancers
 Assuming the patient is in the OR within 1 hour of
injury, minimal contamination is present, and no
hemodynamic instability is occuring, which of the
following patients requires colostomy?

 A. 45 y/o F s/p arrow to R colon

 B. 39 y/o M construction worker s/p through and
through injury to L colon after falling 4’ on rebarb
 C. 23 y/o M s/p .22 round to sigmoid colon
 D. 19 y/o F s/p knife wound to transverse colon
 E. 25 y/o M s/p .30-06 round to mid rectum
 Assuming the patient is in the OR within 1 hour of
injury, minimal contamination is present, and no
hemodynamic instability is occuring, which of the
following patients requires colostomy?

 A. 45 y/o F s/p arrow to R colon

 B. 39 y/o M construction worker s/p through and
through injury to L colon after falling 4’ on rebarb
 C. 23 y/o M s/p .22 round to sigmoid colon
 D. 19 y/o F s/p knife wound to transverse colon
 E. 25 y/o M s/p .30-06 round to mid rectum
 Rectal Trauma: Who needs diversion

 Low velocity and stab wounds may not require

diversion if there is no gross contamination
 Simple suture repair is acceptable if <50% of the
circumference is damaged and no necrosis noted

 Extraperitoneal rectal injuries (below the splaying of

the tenia OR below the peritoneal reflection OR the
mid or low rectum) are a different animal
 Diverting colostomy, washout of the distal rectal
stump, and wide presacral drainage are mandatory
 50 y/o M is diagnosed with rectal CA that is 6cm
from the dentate line. LAR is planned. What is the
distance required from the anal verge for this
operation and what would the margin of resection
be?

 A. 4cm from the anal verge and 2cm margins

 B. 6cm from the anal verge and 4cm margins
 C. 12cm from the anal verge and 6cm margins
 D. 8cm from the anal verge and 2cm margins
 E. 2cm from the anal verge and 4cm margins
 50 y/o M is diagnosed with rectal CA that is 6cm
from the dentate line. LAR is planned. What is the
distance required from the anal verge for this
operation and what would the margin of resection
be?

 A. 4cm from the anal verge and 2cm margins

 B. 6cm from the anal verge and 4cm margins
 C. 12cm from the anal verge and 6cm margins
 D. 8cm from the anal verge and 2cm
margins
 E. 2cm from the anal verge and 4cm margins
 Rectal Cancer

 Anal verge to dentate = 2-4cm

 Dentate to acceptable depth for LAR = 6cm
 Thus, 2+6 = 8

 Need 2cm margins for LAR and stand off from the
sphincter complex
 If can’t get 2cm margins or cancer involves sphincter
complex, APR mandatory
 An 80 y/o F presents with rectal prolapse. She has
a history of chronic constipation. Colonoscopy
findings are negative. Treatment would be best
achieved via:

 A. Fixation of the rectum with prosthetic sling

(Ripstein repair)
 B. Anterior resection with rectopexy
 C. Thiersch anal encirclement
 D. Resection of the perineal hernia and closure of
the cul-de-sac (Moschowitz procedure)
 E. Perineal rectosigmoidetomy (Altemeier
procedure)
 An 80 y/o F presents with rectal prolapse. She has
a history of chronic constipation. Colonoscopy
findings are negative. Treatment would be best
achieved via:

 A. Fixation of the rectum with prosthetic sling

(Ripstein repair)
 B. Anterior resection with rectopexy
 C. Thiersch anal encirclement
 D. Resection of the perineal hernia and closure of
the cul-de-sac (Moschowitz procedure)
 E. Perineal rectosigmoidetomy (Altemeier
procedure)
 Rectal Prolapse (aka procidentia)

 W >> M
 Adults require surgery, children nonop tx
 Two operations: abdominal and perineal repairs
 Abdominal are associated with lower recurrence, but higher
complication rates
 For young patients, abdominal approaches are best
 Abdominal rectopexy with possible sigmoidectomy
 For elderly, the perineal rectosigmoidectomy (Altemeier) is
the “minimally invasive” rectal prolapse repair and preferred
 15% recurrence rate
 The Delorme Procedure is another perineal operation
 Rectal mucosa is stripped, rectal muscle is plicated together to reduce
the prolapse (for less significant prolapse)
 Summary

 Anorectal anatomy is key

 Hemorrhoids are low hanging fruit (… see what I did
there?...)
 Fissures are high yield too
 Nigro protocol, Nigro protocol, Nigro protocol
 Who to divert in trauma
 Rectal prolapse (abdominal vs. perineal)
 APR vs. LAR vs. TME
 Extra points for workup, staging, and neoadjuvant/adjuvant
chemotherapy regimens and side effects for rectal cancer
 Butthole surgeons are buttholes and have 1,000 names
for stuff (aka know eponyms)