B. Strittmatter

Leitlinie: Analfissur : AWMF Reg.-Nr. 013/061, Entwicklungsstufe 1 (Leitlinie)

Die chronische Analfissur zeigt sich als ein längliches, manchmal schmierig belegtes Ulkus, auf dessen Grund u.U. die quer verlaufenden Fasern des M. sphincter ani internus sichtbar sind. Im Verlauf können sich sekundäre Veränderungen entwickeln: hypertrophe Analpapille (histologisch: Fibrom) am proximalen Fissurrand in Höhe der Linea dentata, Vorpostenfalte (sekundäre Mariske, Wachposten) am distalen Fissur-ende, narbig aufgeworfene Ränder (kallös, unterminiert), frei liegende und evtl. fibrosierte Internusfasern.

German S3 guidelines: anal abscess and fistula (second revised version)

BackgroundThe incidence of anal abscess and fistula is relatively high, and the condition is most common in young men.MethodsThis is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature.ResultsCryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate.ConclusionIn this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

Erratum zu: Leitfaden und Empfehlungen für die Hygiene in der Koloproktologie – Teil 1@@@Erratum to: Guidelines and recommendations for hygiene in coloproctology – Part 1: Herausgegeben vom Berufsverband der Coloproktologen Deutschlands (BCD) und der Deutschen Gesellschaft für Koloproktologie (DGK)@@@Published by the Professional Association of Coloproctologists Germany (BCD) and the German Society for Coloproctology (DGK)

coloproctology 2017 · 39:111–120 DOI 10.1007/s00053-017-0149-0 Online publiziert: 21. Februar 2017

Leitlinie: Hämorrhoidalleiden : (AWMF Reg.-Nr. 081/007, Entwicklungsstufe 1) (Leitlinie)

Der anatomische Plexus haemorrhoidalis superior (Hämorrhoidalplexus bzw. Corpus cavernosum recti) ist ein zirkulär in der Submukosa des distalen Rektums bis unmittelbar oberhalb der Linea dentata breitbasig aufsitzendes, schwammartiges Gefäßpolster. Er ist ein wichtiger Bestandteil des analen Kontinenzorgans und verantwortlich für die Feinabdichtung des Afters [17]. Erst bei einer Vergrößerung spricht man von Hämorrhoiden. Nur wenn die Hämorrhoiden Beschwerden verursachen, handelt es sich um ein Hämorrhoidalleiden (symptomatische Hämorrhoiden).

Leitlinie Pilonidalsinus : (AWMF Reg.-Nr. 013/022, Entwicklungsstufe 2, Version: 01.08.2008) (Leitlinie)

Der Pilonidalsinus oder Sinus pilonidalis (pilus = Haar, nidus = Nest) ist eine akut oder chronisch verlaufende Entzündung im subkutanen Fettgewebe, überwiegend im Bereich der Steißbeinregion. Der Begriff wurde 1880 von Hodges [16] geprägt. Synonyme sind Haarnestgrübchen, Haarnestfistel und „Jeep disease“; unzutreffend sind die Bezeichnungen Steißbeindermoid, Sakraldermoid, Dermoidzyste, Steißbeinfistel, Raphefistel, Pilonidalzyste und Sakrokokzygealzyste.

Erratum zu: Leitfaden und Empfehlungen für die Hygiene in der Koloproktologie – Teil 2

excision versus non-resectional methods in the treatment of acute and chronic pilonidal disease. Br J Surg 82: 752–753 19. McCallum IJ, King PM, Bruce J (2008) Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ 336: 868–871 20. Mentes O, Bagci M, Bilgin T et al (2008) Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Arch Surg 393: 185–189 21. Muller XM, Rothenbuhler JM, Frede KE (1992) Sacro-coccygeal cyst: surgical techniques and results. Helv Chir Acta 58: 889–892 22. Ortiz H, Marzo J (2000) Endorectal flap advancement repair and fistulectomy for high transsphincteric and suprasphincteric fistulas. Br J Surg 87: 1680–1683 23. Ortiz H, Marzo J, Ciga MA et al (2009) Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. Br J Surg 96: 608–612 24. Petersen S, Wietelmann K, Evers T et al (2009) Long-term effects of postoperative razor epilation in pilonidal sinus disease. Dis Colon Rectum 52: 131–134 25. Ritchie RD, Sackier JM, Hodde JP (2009) Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis 11: 564–571 26. Rushfeldt C, Bernstein A, Norderval S, Revhaug A (2008) Introducing an asymmetric cleft lift technique as a uniform procedure for pilonidal sinus surgery. Scand J Surg 97: 77–81 27. Soll C, Hahnloser D, Dindo D et al (2008) A novel approach for treatment of sacrococcygeal pilonidal sinus: less is more. Int J Colorectal Dis 23: 177–180 28. Sondenaa K, Andersen E, Nesvik I, Soreide JA (1995) Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 10: 39–42 29. Subasinghe D, Samarasekera DN (2010) Comparison of preoperative endoanal ultrasonography with intraoperative findings for fistula in ano. World J Surg 34: 1123–1127 30. Tang CL, Chew SP, Seow-Choen F (1996) Prospective randomized trial of drainage alone vs. drainage and fistulotomy for acute perianal abscesses with proven internal opening. Dis Colon Rectum 39: 1415–1417 31. Tepes B, Cerni I (2008) The use of different diagnostic modalities in diagnosing fistula-in-ano. Hepatogastroenterology 55: 912–915 32. Thornton M, Solomon MJ (2005) Long-term indwelling seton for complex anal fistulas in Crohn’s disease. Dis Colon Rectum 48: 459–463 33. Toyonaga T, Matsushima M, Kiriu T et al (2007) Factors affecting continence after fistulotomy for intersphincteric fistula-in-ano. Int J Colorectal Dis 22: 1071–1075 34. Uribe N, Millan M, Minguez M et al (2007) Clinical and manometric results of endorectal advancement flaps for complex anal fistula. Int J Colorectal Dis 22: 259–264 35. Westerterp M, Volkers NA, Poolman RW, Tets WF van (2003) Anal fistulotomy between skylla and charybdis. Colorectal Dis 5: 549–551

Die häufigsten Gründe für Stuhlinkontinenz

ZusammenfassungDie Ursachen anorektaler Kontinenzstörungen reichen vom Entbindungstrauma bis hin zum Tumor. Entsprechend den verschiedenen an der Kontinenzleistung beteiligten Faktoren empfiehlt unser Autor eine modifizierte Klassifizierung zur besseren diagnostischen und therapeutischen Orientierung. Dabei ist auch der Leidensdruck des Patienten für das weitere Vorgehen entscheidend.

Kommentar von B. Strittmatter zu P.J. Gupta et al. Closed Lateral Internal Sphincterotomy Versus Anal Sphincterolysis for Chronic Anal Fissure. A Prospective, Randomized, Controlled Trial

Purpose: The aim of this randomized, prospective study was to compare the results of closed lateral internal sphincterotomy with the authors’ innovative approach of finger fragmentation of internal sphincter fibers, termed sphincterolysis, in the treatment of chronic anal fissure. Patients and Methods: Adult patients with chronic anal fissures were randomly assigned to undergo closed lateral sphincterotomy or sphincterolysis. The patients were reexamined at 4 and 54 weeks. Postoperative pain, complications, and fissure healing were prospectively assessed. Results: Of the 85 patients randomly assigned, four were lost to follow-up leaving behind 40 sphincterotomy and 41 sphincterolysis patients for assessment. At 4 weeks postoperatively, fissures were healed in 95% of patients in both groups. At the 4-week follow-up, three patients from the closed sphincterotomy group and two patients from the sphincterolysis group reported deterioration in continence. Of these five patients, four had recovered at the 54-week follow-up, while the remaining patient from the sphincterotomy group continued to have a defective continence. Both groups had significantly lower anal resting pressures compared with their corresponding preoperative levels (p = 0.005 and p = 0.004) at the last follow-up. Conclusion: The procedure of sphincterolysis seems to be equally effective when compared with closed sphincterotomy. It is safe and easy to perform having less incidences of postoperative complication with no significant continence defect.