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Zen Anorectal Unit (Fistula,
Fissure, pilonidal Sinus, Piles)

Niranjan-Agarwal

Anorectal refers to the conditions related to the rectum or the anus. Most of the conditions are mainly caused due to some abnormal growth of the tissues in the rectal region. A proctologist, also known as a colon and rectal surgeon or coloproctologist, is a surgical specialist who diagnoses and treats diseases of the colon, rectum or anus.

Some of the most common anorectal disorders include faecal incontinence, pelvic floor dyssynergia, anal fissures, pruritus ani, proctalgia fugax, and solitary rectal ulcer syndrome.

Zen Hospital has a highly specialized team of proctologists who use state-of-the-art equipment and the latest procedures to get you the best treatment possible. The procedures aim to provide quick recovery time and pain-free results.

President: The Association of Colon & Rectal Surgeons of India

Executive Board Member :International Society of University of Colon & Rectal Surgeons

Managing Trustee & Past President : Association of Medical Consultants Mumbai

Trustee : Colorectal Foundation Trust. Mumbai

Chairman: AMC NOAH

Vice President : Mumbai Surgical Society

Ex Treasurer : The Indian Association of Day Surgery

Ex Committee Member : Indian Medical Association Mira Bhayandar Branch Bhayandar Medical Association Parmarth Seva Samity Agrawal Seva Samity Ram Ratna Interational

  • Consultant Colorectal Surgeon

Bombay Hospital. Wookhardt Hospital Salasar Nursing Home

  • Fellowship of the ACRSI
  • Awarded international travelling Fellowship ACRSI (2009)
  • Member Board of Examiner of FACRSI
  • Delivered many Creations lectures at National & laternational Conferences
  • Invited as Faculty p various medical schools
  • Authored meny scientific papers and textbook chapters
  • Conducted many health camps interviewed by radio channel for public awareness program and participated in many social events

Treatments

What is fistula?
An anal fistula is a small tunnel that develops between the end of the rectum and the skin near the anus.Anal fistulas can cause unpleasant symptoms, such as boil, pain, discharge leading to discomfort and skin irritation, and will not usually get better on their own.

Treatments for an anal fistula
Surgery is usually necessary to treat an anal fistula as they usually do not heal by themselves. There are many procedures available but best option will depend on the position of fistula and whether it’s a single channel or branches off in different directions which can be assessed by doing MRI scan of rectum.
The aim of surgery is to heal the fistula while avoiding damage to the sphincter muscles.
Surgery offered at Zen hospital are mentioned below-
Fistulotomy- procedure involves cutting along the whole length of the fistula to open it up so it heals as a flat scar.

Seton techniques- If your fistula passes through a significant portion of anal sphincter muscle, the surgeon may initially recommend inserting a seton which is a piece of surgical thread that’s left in the fistula for several weeks to keep it open.
This allows it to drain and helps it heal, while avoiding the need to cut the sphincter muscles.

LIFT procedure- The ligation of the intersphincteric fistula tract (LIFT) procedure is a treatment for fistulas that pass through the anal sphincter muscles, where a fistulotomy would be too risky.
In this, a cut is made in the skin above the fistula and the sphincter muscles are moved apart. The fistula is then sealed at both ends and cut open so it lies flat.

Laser surgery- Laser treatment for fistula-in-ano, also known as FiLaCR (fistula laser closure) or LAFT (laser ablation of fistula tract), has gained increasing attention in the last decade.
The procedure consists of delivering laser energy at 360° within the lumen of fistulas by means of a radial fiber which is slowly withdrawnacross the fistula tract.Laser ablation is limited to the lumen of fistulas making the technique ‘sphincter-saving’. The advantage of this procedure is that it is minimally invasive and safe procedure;hence chances of loosing control of stools are minimum and since no big wounds are made for the surgery, healing is faster and pain is minimal. However, the recurrence rates are high as in any complex fistula.
Other procedures used for treatment of fistula includes use of Fibrin glue for tract closure, Bioprosthetic plug, Advancement flap procedure, Endoscopic ablation, though results are not very promising.

What anal fissures?

An anal fissure is a tear or open sore (ulcer) that develops in the lining of the large intestine, near the anus.

Treatment for anal fissure
Avoid constipation and regular exercise may help in prevention
Plenty of fibre in diet, such as fruit and vegetables and staying well hydrated by drinking plenty of fluids
Avoiding dehydration
Soaking your bottom in a warm bath several times a day, particularly after a bowel movement, to relax the muscles in your anus

Medicines –
Laxatives
Painkillers
Glyceryl trinitrate
Topical anaesthetics
Calcium channel blockers

Surgery –
Surgery may be recommended if other treatments haven’t worked.
It is generally considered to be the most effective treatment for anal fissures, with more than 90% of people experiencing good long-term results.
Commonest procedure performed is Fissurectomy with Lateral sphincterotomy
In This procedure- Fissure is either excised or scrapped and a lateral sphincterotomy done making a small cut in the ring of muscle surrounding the anal canal (sphincter) to help reduce the tension in your anal canal. This allows the anal fissure to heal and reduces your chances of developing any more fissures.
Most people will fully heal within 2 to 4 weeks.
Advancement anal flaps
Advancement anal flaps involve taking healthy tissue from surrounding area of the anus to cover the diseased area. This is specifically used for patient whose sphincters are already lax.

Laser Surgery for fissure –
Sphincterotomy as described above can be also achieved using Laser energy. The bleeding with Laser is definitely less, however there are no other great advantages of laser in anal fissure.

A pilonidal sinus is caused by migration of hairs into the skin leading to formation of a hole which may get filled with fluid or pus there by resulting in a cyst or abscess at the top of the buttocks, where they divide (the cleft). It does not always cause symptoms and only needs to be treated if it becomes infected.

Causes of pilonidal sinus –
Exact cause is unknown. Though excess hair growing around the buttock area, or loose hair shed from the buttocks or elsewhere that gathers around the buttock cleft and enters the pilonidal sinus and later infect them. Pilonidal sinus is seen more in males with excess hair. Sitting for long periods can also increase your chances of getting a pilonidal sinus.

Symptoms-
Recurring episodes of pain or swelling in the area of the tailbone.
Yellowish pus-like or bloody discharge from the tailbone area which may be foul smelling
Painful lump under the skin in that area
Certain activities like riding a bicycle, doing sit-ups may be very uncomfortable.
Fever

Treatment
In case of acutely infected sinus,Minor operation to drain pus from sinus will be most helpful before planning conventional surgery.
Incision and drainage- Here small incision is taken to remove pus from infected sinus. Follow up dressing is required and usually wound heals in 4 to 6 weeks.
Surgery to remove sinusOptions
1- Wide excision and open healing- Here the sinus is cut out and some surrounding skin removed. The wound is left open to heal naturally but takes long time to heal.

2- Excision and wound closure, often with flattening of the groove between the buttocks- The sinus is removed and by doing plastic surgery wound is closed. This heals faster and much easier to manage for patient.

3- LASER Ablation (SiLAT)– This is a minimally invasive procedure done using laser. In this procedure, small cut is made on the skin and all the pus is drained out. The entire sinus tract is then sealed with the laser fibre.
Advantages of this procedure includes- Usually patient is discharged on same day and wound heals within4-6 weeks and thus recovery is much faster as compared to conventional Wide excision.

4- MODIFIED KARYADAKIS– Complete sinus is excised andby plastic surgery cleft is flattenedso the gathering of loose hair is less likely, so infection is avoided.Wound is closed and generally wound heals in 6-8 wks.

5- LIMBERG FLAP / GLUTEAL FLAP-This procedure is offered in patients with extensive Pilonidal disease. Here sinus is widely excised a flap of skin and thick fat is mobilised from the buttock beside and below the cavity. The flap is swung into the centre and the edges are sutured.

What to do after your operation ?
Do’s
keep the affected area cleanand shaved
wear comfortable, loose-fitting cotton underwear

Don’t
do not ride a bike for 6 to 8 weeks
do not go swimming until your wound has completely healed

What are Piles (hemorrhoids)?
Piles or hemorrhoids are dilated blood vessels presenting like lumps in and around your bottom (anus). They are one of the most common ailments known.

What arethe treatmentoptions at Zen hospital?
Correct diagnosis is very crucial when treating piles as there are other dangerous conditions such as ulcerative colitis, crohn’s disease or cancer of thelarge intestine which may present with bleeding per rectum and the only way to diagnose is by doing a colonoscopy.
Initially we offer conservative treatment using medicines and ointments and most of the patients respond to treatment and do not require surgery.
For patients who do not respond to medicines and have smaller piles (Grade I and II), we can offer procedures like Sclerotherapy (a medicine is injected into your piles to make them shrink) or banding (a medicated elastic band on the bleeding piles)
For larger piles (Grade III & IV), surgery is required and surgical option includes removal of piles (Hemorrhoidectomy) by either open technique or using specialized stapler or Laser
We are also one of few centers offering most advanced laser treatment for piles.

What are advantages of piles treatment with laser as compared to other treatment options?
Laser surgery can be performed on an Daycare basis. By using laser, the surgeon can pinpoint the exact tissue that needs to be treated thus injury to surrounding tissue is minimal which leads to faster healing. The procedure is minimally invasive; hence either no pain or minimal pain and patient can be discharged on same day. Since the blood vessels in the anal region are sealed off by the laser, minimum bleeding is caused during the procedure.
In brief, Piles, a common problem can be successfully managed with proper diagnosis, preventive measures and different available treatment options. People should become aware and should not ignore any bleeding through rectum.