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SCORE School Benign Anorectal, Part 1 of 2
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SCORE School Benign Anorectal, Part 1 of 2
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Segment:0 .
AMIT JOSHI: Hi, everyone. Welcome to SCORE school. I'm delighted to introduce Dr. Michael Kwiatt who'll be taking us through the benign anorectal part 1 of 2. He'll be covering 4 modules which he's going to introduce. Dr. Kwiatt is the program director of the General Surgery Residency at Cooper University Hospital in Camden, New Jersey. He attended medical school at Washington University in St. Louis and then did his training at Cooper in Camden followed by a Colorectal Surgery Fellowship at the Cleveland Clinic in Ohio.
AMIT JOSHI: Dr. Kwiatt is a specialist in colonorectal cancer, IBD, diverticular disease, and benign anorectal disease. And it's a pleasure to welcome him to SCORE school. Thanks Dr. Kwiatt and please go ahead.
MICHAEL KWIATT: Thanks Dr. Joshi and thanks for having me. You can use the question and answer feature with this QR code throughout the presentation. As Dr. Joshi mentioned, the topic this week for this week in SCORE is a benign anorectal part 1 of 2. So it's a two weeks covering in anorectal disease. This week's topics, there's eight modules in total, but there's some overlap between the two. So we'll be discussing some anorectal anatomy just before we get started, to help guide our conversation.
MICHAEL KWIATT: Then, we'll delve into anorectal abscesses and fistula, anal fissures, and pilonidal disease. So just real briefly some anorectal anatomy before we get started. First of all, the dentate line is the division between the rectal columnar epithelium and the anal squamous epithelium. So embryologically, approximately comes to the embryonic and endoderm which makes up the rectal columnar epithelial and distally, you have the embryonic ectoderm which makes up the anal squamous epithelium.
MICHAEL KWIATT: The anal verge, when we talk about the anal verge, that's the border between the anoderm and the skin. An anoderm lacks hair and sweat glands, that's what makes up the anoderm different from just the skin. And then in terms of the anal canal, anatomically, if you'll get Netters or your anatomy textbook, they discuss the anatomic anal canal as the dentate line to the anal verge. So from that dentate line all the way down to the border between the hairy and the non hairy skin.
MICHAEL KWIATT: But surgically, we typically talk about the anal canal as incorporated in the anorectal ring which is the upper portions of the sphincter complex and the tubal rectalis muscle, all the way down to the anal verge that's a little bit longer. The surgical anal canal is a little bit longer. We make that distinction because when you're talking about a cancer resection, you can't take that sphincter complex and still perform an anastomisis.
MICHAEL KWIATT: So surgically, when we talk about the anal canal, we talk about that longer segment going all the way up to the anal rectal ring. And then the internal anal sphincter itself, it's important to note as a continuation of the rectal and the circular smooth muscle. So it's a smooth muscle complex. And then the external anal sphincter is a continuation of the levator ani.
MICHAEL KWIATT: You can see that coming down here. So the internal sphincter and the external sphincter right here. We'll go ahead and move on to anorectal abscesses. So the etiology of anorectal abscesses is believed to be blockage within the anal glands. You have anal glands sitting at the dentate line at the bottom of the crypts of Morgagni.
MICHAEL KWIATT: In all there's estimated everyone has between about 6 to 8. And the classification of anal abscesses which form after clogging or blockage of the anal canal or of the anal glands is classified by the potential space that the abscess is located. So we'll go ahead and go through that briefly. So first, we often talk about a perianal abscess. You can see that right here.
MICHAEL KWIATT: And that's located in the perianal space, which is defined as superficially at the anal verge and is in continuation with the ischioanal fossa laterally. So this can be very, very close to the anal verge and this area right here. An ischioanal abscess is going to be further out. It's located in the ischioanal space which superiorly is bordered by the levator ani, medially by the external anal sphincter, and then laterally by the pelvic side wall.
MICHAEL KWIATT: So this area here, we'll call an ischioanal or an ischiorectal abscess. And then an intersphincterical abscess, this can be located in the intersphincteric plane. So that's going to be the space between the internal and the external sphincter muscles, that's very easy to understand. That's the intersphincteric abscess.
MICHAEL KWIATT: And then lastly, well let's talk about a supralevator abscess which is extraperitoneal in nature. It's in the supralevator space which is found medially by the rectum, laterally by the pelvic sidewall, and it's above the levators. So in terms of a patient presentation for an anorectal abscess, generally patients will present to the clinic talking about gradually worsening anal rectal pain, swelling in the inner rectal area, and they may develop fevers and chills.
MICHAEL KWIATT: So anytime a patient is in the office coming to you with anorectal complaints, a lot of times you can get a good sense of what's going on, just based by their history alone. In a classic with anorectal abscess is that they'll feel some swelling and some achy pain that's going to gradually become worse over time. And if not seeking out treatment, will develop to chills or fevers.
MICHAEL KWIATT: Kind of the main thing you want to distinguish it between, clinically, would be hemorrhoids which are also going to kind of have that gradual anal pain. But an anorectal abscess can be more acute, whereas, hemorrhoidal diseases can be more insidious and kind of a long lasting process. Physical exam findings are really going to depend on the location of the abscess, like we had discussed previously.
MICHAEL KWIATT: Perianal and ischiorectal abscesses are usually the easiest to distinguish on physical exam. In general, you'll see erythema, tenderness, or fullness over the perianal or the ischiorectal area. Intersphincteric abscess are a little more difficult to diagnose because they're within the intersphincteric groove. Often, you don't see external findings on physical exam, but they'll typically have very extreme tenderness, if you perform a digital rectal exam on these patients.
MICHAEL KWIATT: And thus in your differential, you might be trying to distinguish between an intersphincteric abscess versus a fissure. Postanal space abscesses, I wish we didn't go over on the previous classification system, but that's going to sit behind the rectum in the post anal space. And those are the ones that on digital rectal exam, you'll feel some bogginess in the anal canal.
MICHAEL KWIATT: So when you're examining these patients, when you're doing that exam to see if there's anything within the anal canal, you're really checking for there is a post anal space abscess. Then again, the supralevator abscesses given their extraperitoneal location, and they can be a little bit more difficult to diagnose. These patients typically, their presentations can be a little bit different.
MICHAEL KWIATT: And more typically, they'll have pelvic or back pain, a very common urinary symptoms. We'll talk about urinary frequency or inability to urinate, and these patients can have systemic signs of an infection like high fevers, chills, and such of that nature. In terms of imaging, potentially, you can image these abscess with a CAT scan and MRI, [INAUDIBLE] it an endorectal ultrasound.
MICHAEL KWIATT: But this really is only needed if the diagnosis is unclear. If you're seeing a patient and they have an obvious area of an abscess, that that's typically, ischiorectal again or perianal abscess. You're going to be able to pick that up on a physical exam. And unless the diagnosis is unclear, you typically don't need any further imaging. Generally though someone with a supralevator abscess, that is going to require further imaging.
MICHAEL KWIATT: And usually, a CT scan is sufficient to detect those. Or if you have someone who's got complex abscesses, so they have abscesses in multiple locations, or you're concerned about something such as like Fourniere's gangrene or a necrotizing soft tissue infection. In terms of treatment, I can't say enough that drainage is the mainstay of treatment and anorectal abscesses need to be drained.
MICHAEL KWIATT: Antibiotics, themselves are rarely effective unless a patient's drained first. So often, these patients would be seeing an urgent care center and discharged home on antibiotics. And that's never been shown to be an effective treatment for anorectal abscesses. And in fact, if anything, it just delays the drainage which can lead to a greater increased risk of fistula formation.
MICHAEL KWIATT: So these patients need to have the abscess drained. You can consider the use of antibiotics, in addition to drainage. Again, that is also not typically needed, but you may consider it in an immunosuppressed patients, so someone who's a brittle diabetic, someone who's on chemotherapy, as you often see anorectal abscesses in patients receiving treatment. Or if they fail to improve after adequate drainage that might be another time to consider addition of antibiotics.
MICHAEL KWIATT: But typically, the treatment of choice is to drain the abscess and antibiotics only in special circumstances. Some considerations when treating an anorectal abscess. First thing to consider is setting. Often, if it's a superficial ischiorectal rectal abscess or a perianal abscesses, this can be drained in the office just under a local anesthetic. When you're anesthetizing these patients in the sensitive areas, you generally want to anesthetize away from the abscess first, and then slowly inject a local anesthetic into the area.
MICHAEL KWIATT: And if it's superficial, they can be trained right there in the office. If there's a risk of inadequate drainage, bedside or in the office setting, then you want to consider taking these patients to the operating room. In terms of your incision, this is where you kind of want to think about what could happen down the road.
MICHAEL KWIATT: The big complication from an incorrect abscess or can even be considered as part of the natural disease process is the development of fistula tract. And it's easier to treat a short fistula tract. So when you're making your incision, you want to try to place the incision as close to the anal verge as possible in order to reduce the length of that possible fistula tract.
MICHAEL KWIATT: Still, you want to make that incision in an area where you can feel fluctuance. You can feel the abscess, but if it's a large cavity, you want to try to make it as close to the anal verge as possible. And you also want the incision to run parallel to the fibers of the external sphincter. So essentially, it's going to be radial incision around the anus.
MICHAEL KWIATT: And you can use an elliptical or a cruciate incision, either one. As we'll talk about more momentarily, about 40% to 50% of these patients, 11 associated fistula will develop a fistula. And it is OK to gently probe for a fistula after initially draining, especially if you're in the operating room. It's typically not tolerated in the office, but you can gently probe. But the key here is that in the setting of active inflammation, there is the risk of developing a false passageway.
MICHAEL KWIATT: So you want to be careful with that. And I wouldn't worry too much about trying to find a fistula after initially draining an abscess, but it is OK to look if there's an obvious one that's easy to find. Some other things to consider with a large abscess cavity, rather than opening up a large perirectal wound that would be hard to care for, you can consider using counterincisions.
MICHAEL KWIATT: And with the use of Penrose drains or Setons to keep the cavity open. One thing that I corporate a lot of my practice is the use of a drainage catheter. You can place a mushroom catheter within the abscess cavity itself. I usually use a malachite catheter, usually a 12 or 14 french looks nice. Works nicely for this.
MICHAEL KWIATT: You insert it into the cavity and then you can secure it to the skin and leave it in place. This can be in lieu of packing because the area can be very difficult to pack, unless the patient has a lot of support at home. It's difficult to get adequate wound care in that area. And typically, in terms of how long to leave a catheter in, general recommendations is until the abscess is no longer draining.
MICHAEL KWIATT: And this will be typically over the course of 1 to 2 weeks. You just want to be careful not to leave these in too long because you can get ingrowth, and then they become difficult to remove. Then for an intersphicteric abscess, you want to open the internal sphincter. So you're going to be opening and draining the abscess within the anal canal itself. And you have to open up the internal anal sphincter along the length of the abscess.
MICHAEL KWIATT: So for most of these abscesses, you're going to drain them externally. But for an intersphincteric abscess, you're going to want to drain that internally as well. Then briefly about fistulotomy, traditionally, there's always been a lot of hesitance to perform a fistulotomy at the time of abscess drainage because of fear of increased risk of incontinence of performing a fistulotomy in that setting.
MICHAEL KWIATT: However, multiple studies have shown that a fistulotmy at the time of abscess drainage may result in faster wound healing and reduced rate of recurrences. So it has not been shown to show an increased risk of incontinence, but despite this, due to these historical fears, it's often avoided at the time of initial diagnosis even though it may in fact, be safe and beneficial to the patient.
MICHAEL KWIATT: The one entity we should also discuss lastly with anorectal abscesses is a horseshoe abscess. And this is typically a bilateral abscess arising from the postanal space so it involves the post anal space behind the rectum and then bilaterally into the ischiorectal fossa. So these patients have an abscess in their postanal space and bilateral ischiorectal fossa. And the traditional procedure for treating these is called the Hanley procedure.
MICHAEL KWIATT: And there's three parts of this procedure. And you want to drain it. Drain the abscess posteriorly through the anococcygeal ligament. So you're going to behind the rectum pop into the anococcygeal ligaments in order to get into that postanal space and drain the abscess. You also want to make a midline incision over the internal anal sphincter at the level of the abscess.
MICHAEL KWIATT: So that's going to be in the posterior midline and you would drain that just as you would a intersphincteric abscess by opening up the internal anal canal. And then lastly, you're going to drain the bilateral ischiorectal fossa. So these horseshoe abscesses can be difficult to control the perianal sepsis due to needing to widely drain these.
MICHAEL KWIATT: And the only way to do that is to open up the bilateral ischiorectal fossa and then performing the incision at the internal anal sphincter at the midline. Sometimes people perform what they call a modified Hanley procedure. And in that case, you don't do the additional drainage through the anococcygeal ligament. You just open up the bilateral ischiorectal fossa and then at the internal anal sphincter and the posterior midline.
MICHAEL KWIATT: We'll go ahead and move on to anorectal fistulas then.
AMIT JOSHI: Dr. Kwiatt, let me just let me just ask you a question.
MICHAEL KWIATT: Sure.
AMIT JOSHI: Sorry to interrupt you.
MICHAEL KWIATT: OK.
AMIT JOSHI: So give me a sense of post-operative instructions for patients who let's say we took care of a straightforward abscess, maybe even required a I and D in the operating room. But what do you tell them in terms of discharge instructions of how to care for that wound? Whether if, let's if not packing, maybe you put them out and cut in or just draining openly, what are your recommendations?
MICHAEL KWIATT: Yes. I'll typically leave a malachite in. They'll usually have a kind of a gauze dressing. I tell him that evening they can go home, take the gauze off, and I typically recommend that they do it Sitz bath or take a shower or bath after every bowel movement. And at the minimum twice a day. So I recommend that the shower kind of before they go to bed or when they get up in the morning. And then for post-operative care, I typically will see those patients in the office in about a week to remove that drain.
MICHAEL KWIATT: If I do pack it at the initial operation, typically, I'll tell them that evening to go ahead and get in the shower and remove the packing in the shower and then just leave a clean gauze over the wound at that point.
AMIT JOSHI: OK. And when you're counseling them about the risk of fistula occurrence and recurrent abscess, what's the general timeline, you may get a little bit into this in the next section. After that in indexed abscess, when you do see a fistula or remove an abscess, how long is it typically?
MICHAEL KWIATT: In terms of a fistula, generally what we often see is that the incision just never really heals. So usually after that first visit about a week after when we remove the drain, usually I tell them to come back in about a month to take a look at the wound. And at that point really, it should have healed at that point. So if there's a non-healing wound there, that's when I'm going to start being concerned about a fistula.
MICHAEL KWIATT: And talk to them about potentially doing an examination under anesthesia again to look for the fistula. Like we talk about, it's usually about a 40-50% chance of a fistula formation. Once they've healed, a recurrent abscess, generally if it's going to recur, it's going to recur sometime in the next about three months or so. They're going to see it come back, if it's the same anal gland.
AMIT JOSHI: And when you do the modified Hanley procedure, do you use Penrose to connect those three separate [INAUDIBLE]?
MICHAEL KWIATT: Usually, if I do the full Hanley, I'll use a Penrose through the postanal space into the ischiorectal fossa. And then place a Seton from the postanal space. And then if I don't do that, that posterior incision which I'll be honest, usually in patients I found that I've had to. But if I don't in that case, I usually just put a Seton through both areas. That way you don't open it up quite as much.
SPEAKER 1: OK. Thank you.
MICHAEL KWIATT: All right. So a fistula is an abnormal connection between two epithelial lined surfaces. So then an anorectal fistula connects an anal crypt to the perianal skin. So again, an anal gland can become clogged to which they sit at the bottom of the anal crypts. And that can lead to an infection. The best way to think of this is that an infection is going to flow to the path of least resistance.
MICHAEL KWIATT: So they're going to form a tract to the perianal skin. And just like our anal abscesses, their classification can be based on their location. In terms of the etiology, so 90% of cases result from cryptoglandular disease. And all that means is that 90% of the cases come from a preceding perianal abscess. So the overwhelming majority are from cryptoglandular disease or just benign abscesses.
MICHAEL KWIATT: It's not from IBD. That's what a lot of, I find a lot of residents get tripped up on it. They'll see someone in their 20s with an anal fistula and they think, oh, they must have IBD. And most likely, it's just going to be from a prior abscess. In terms of the remaining causes, typically it could be trauma, IBD, or an infection. And it's about 3% for each of those.
MICHAEL KWIATT: So those are all about equal. So even though we often think anorectal disease, perianal Crohn's disease, kind of one-to-one it, that's not the most common cause. And as we mentioned earlier, about 30% to 50% of anorectal abscesses would go on to develop a fistula. In terms of risk factors, the biggest risk for performing an anorectal fistula after an abscess has been found to prolonged time to drainage.
MICHAEL KWIATT: So the longer that a patient goes without having their abscess drained, that's going to be the most likely reason to develop a fistula, or biggest risk factor I should say. And they're more common with ischiorectal and intersphincteric abscesses than just benign perianal disease. Again in terms of classification, it's based on where the fistula goes. So an intersphincteric fistula involves a portion of the internal sphincter.
MICHAEL KWIATT: So it's going to go from the anal crypt, as you can see here. And then course through the intersphincteric plane between the internal and external sphincters, with an opening in the perianal skin. So it's a short tract and it does not involve any of the external sphincter. A transphincteric fistula is going to go ahead and cross a cross, that's going to go through both the internal sphincter and the external sphincter.
MICHAEL KWIATT: And we often classify these as high transphincteric or low. In low ones, cross at the lower one-third of the external sphincter so they don't involve much of the sphincter complex. Whereas, high cross over the upper 2/3s and involve a large portion of the external sphincter complex. And that classification will become important when we start talking about treatment.
MICHAEL KWIATT: And then suprasphincteric fistulas track through the anal crypt and encircle the entire external sphincter muscle and come out to the ischiorectal fossa. So these are fairly complex. And as you can see, these go up and involve the entire external sphincter complex. And then lastly, is an extrasphincteric fistula which begin high in the anal canal, and then they encircle the internal and the external sphincter, and then they come out onto the buttocks.
MICHAEL KWIATT: And these typically are not cryptoglandular in origin. You may see these in IBD, or after radiation damage, or probably most commonly, they're iatrogenic in nature. And then fortunately, these are the least common fistulas that we see. Another way we often classify fistulas is just based on simple versus complex. So a simple fistula typically involve minimal amounts of the external sphincter.
MICHAEL KWIATT: So simple fistulas are going to include your inner sphincteric fistulas and your low transphincteric fistulas. And these are typically managed with just fistulotomy. Complex fistulas are going to be your high transphincteric fistulas, fistulas that are formed from Crohn's disease, malignancy, or radiation and your suprasphincteric fistulas. And generally speaking, these are ones that we cannot safely manage with a fistulotomy.
MICHAEL KWIATT: In terms of presentation, like we said, 90% of these cases will have a preceding anorectal abscess. Often it drains by a surgeon in the office, or in the emergency department, or the operating room, or they may drain spontaneously. Sometimes patients will say they soaked in a tub and pop an abscess in the past. But they get either recurrent abscesses or persistent drainage after resolution of the abscess.
MICHAEL KWIATT: So if the tract becomes well epithelialized, a lot of times I'll just get some bloody drainage or some serious drainage afterwards that just persists and goes on. So a lot of times, I'll say, that I'm having blood back there. Other times you can get leakage of stool back there or even just benign serous fluid. And then a recurrent abscess can happen when you get stool stuck within that tract and that causes a localized infection and a recurrence of the abscess.
MICHAEL KWIATT: On physical examination, you're just going to look for an opening, kind of a non-healing wound. Often, these characteristically have a lot of hypergranulation tissue at the surface. And it's typically going to be seen on the skin at the anal margin or you're going to see some drainage when you examine the patient.
MICHAEL KWIATT: In terms of operative considerations, when deciding what procedure to perform in these patients, you're going to think of the location of the sphincter tract, the amount of sphincter involved, you wanted to consider the patient's preoperative continence. So you want to know about the patients if they've had prior anorectal surgery, have they had a prior sphincterotomy for a fissure, if they already had a fistulotomy.
MICHAEL KWIATT: And in women that have had vaginal deliveries, you're going to want to take a thorough obstetric history, to find out if at any time during their delivery where there's a use of forceps, did they have an episiotomy, were there any fourth degree lacerations. And those things would kind of alert you that this patient at baseline, may have issues with continence or just be at higher risk for complications of incontinence due to their prior anorectal or anovaginal procedures.
MICHAEL KWIATT: So you want to take that into consideration of what to perform. Often, especially old the attendings, all colorectal surgeons like to ask students and residents about Goodsall's rule. So this rule says that when you draw a transverse line across the anus, fistulas with internal openings, interior typically have a fistula tract that comes back in in a radial fashion.
MICHAEL KWIATT: So it's going to be a straight line on that tract. Whereas, in the posterior line it's a curvilinear course, going back to the fistula. But in reality, it's only accurate in about 60% of cases. So it's not a terribly hard fast rule. A fistulotomy is kind of the typical and the most often described procedure for treatment of the anorectal fistula.
MICHAEL KWIATT: And just simply, you place a probe through the fistula tract from the external opening into the internal opening. You want to be very careful when probing this area because if you're too aggressive, you can make an iatrogenic injury, which is going to be even more difficult to repair than just a cryptoglandular fistula. And all you do is you just unroof the fistula for its entire tract.
MICHAEL KWIATT: So this may involve cutting through a portion of the internal sphincter and the external sphincter as well. This is the treatment of choice for we'd classified as simple fistulas. These are going to be the low transphincteric fistulas and the intersphincteric fistulas that you can typically safely perform a fistulotomy with a risk of incontinence less than 1%.
MICHAEL KWIATT: In terms of the risk, typically patients will report some mild about 10% incontinence following a fistulotomy in the short term. And usually what they discuss is some seepage afterwards or some difficulty controlling gas, but most of these patients will have resolution of their symptoms by about a month postop. So I typically tell the patients in the initial post-operative period after a fistulotomy, you may have some seepage or a little slight incontinence of gas, but this typically will go away once everything heals.
MICHAEL KWIATT: Setons are frequently used and it can be used to drain an anorectal abscess. I'm sorry it could be used after the drainage of anorectal abscess to try to cause fibrosis of the fistula tract. And that can be useful to help control the drainage and then I often use them as a bridge to a more definitive procedure. Typically, you use a non-absorbable suture or vessel loops.
MICHAEL KWIATT: And like I mentioned, could be a bridge to a definitive treatment in the future. Or even occasionally, someone with a very complex fistula with advanced Crohn's disease, they will live with a long term Seton. With the Seton in place, what that does is that prevents them having recurrences of an abscess and we might be able to get them down with biologics to have a minimal amount of drainage.
MICHAEL KWIATT: In terms of other procedures to do for your transphincteric fistulas, a one that's commonly described is the LIFT procedure, which is the location of the intersphincteric fistula tract. The fistula tract, the steps for this procedure is you want to identify that fistula tract between the and the the external sphincter, and then ligate that area.
MICHAEL KWIATT: So the idea is that rather than opening up the entire tract, which could potentially have a greater risk for incontinence due to the large volume of the sphincter complex involved, with this you're just ligating that portion between the internal and the external sphincter. With the idea being that if the internal hole is able to close, the internal opening of the fistula, the external opening will close on its own because the internal area's really the source of your disease.
MICHAEL KWIATT: So the steps for that is you're going to feel for the intersphincteric plane, and then make a curvilinear incision along the intersphincteric plane. Usually you have to open that up about 2 to 3 centimeters in order to get adequate exposure. And then you're going to dissect within the intersphincteric groove and then identify that portion of the tracks. Usually I'll leave the fistula probe in and then dissect around the probes so that I know that I've found that portion of the tract between the internal and the external sphincter.
MICHAEL KWIATT: And then use a suture ligation of the tract, usually you can use an absorbable suture like a Vicryl and you're going to ligate the tract, right at the internal sphincter, and then also ligate it a second time right at the external sphincter, and then divide your sutures in between. And then after that's done, recommend that you probe the tract once more to make sure that you successfully closed it from the outside.
MICHAEL KWIATT: And then just curette the external opening and then close up your incision just with an absorbable suture. And then like we said by removing that internal portion, the external portion that can close up on its own. Reports of success with it are highly variable in the literature, but overall typically you see about a 75% success rate with a LIFT procedure.
MICHAEL KWIATT: Some other things that you often hear discussed, but not used as much anymore. There was a lot of hope for Fibrin glue and Fistula plugs. And kind of the principle between both these is that if you could just fill in the fistula tract with a synthetic material and a bioabsorbable material, and by plugging it up that would lead to healing of the fistula. There's been a few institutions that have reported a lot of success with that, but most other institutions haven't been able to replicate their success.
MICHAEL KWIATT: It happens a lot of times is that if it doesn't form these patients end up with a quick recurring abscess. Then, of course, we should discuss the endorectal advancement flap, which again, can be used for complex diseases. This is very commonly used in patients with Crohn's disease. It's what often used for treatment of a rectovaginal fistual as well.
MICHAEL KWIATT: And the idea here is like the LIFT procedure, you're going to close up the internal opening to allow the fistula to heal. Historically, people tried to suture, ligating the internal opening closed, but we find that over time that breaks down. And the idea between an advancement flap is by doing a layered closure, you'll be able to heal. So for this procedure, you make a wide curvilinear incision at the internal opening, and then dissection is performed in the submucosal plane to raise a flap of rectal tissue for about 4 to 6 centimeters proximally.
MICHAEL KWIATT: The key here is you have to make a wide incision of about 2 to 3 centimeters to have a wide base for your flap. And after you've made that incision, you close the defect within the internal sphincter with suture, and then advanced the flap over that area to close it up. And again with that layered closure, you can lead to a greater healing rate. A 60% to 90% success rate is reported in these instances.
MICHAEL KWIATT: So before we move on, I did want to mention, I don't think was necessary in the reading material with Perianal Crohn's disease in fistulas, just some key things to keep in mind in someone who's got well controlled perianal disease and they haven't had procedures. A Crohn's patient with a simple perianal fistula can undergo a fistulotomy.
MICHAEL KWIATT: It is reasonable to offer someone who hasn't had multiple anorectal procedures and has well controlled disease a fistulotomy performed. But with more advanced disease, you're going to want to consider something like an endorectal advancement flap. And typically with those patients, I'll place Setons in to control the perianal sepsis. And then generally, I recommend that they get on biologic treatment for about 3 months to see how their disease responds.
MICHAEL KWIATT: And if they are able to get control of their perianal disease, you're going to look for no mucosal friability and healthy appearing anorectal mucosa for Crohn's patients. I typically offer those patients an endorectal advancement flap as the procedure of choice in that instance.
AMIT JOSHI: Thanks for that clarification on the Crohn's disease. A couple questions for you. Do you routinely use a perineal block like either a superficial diamond block intersphincteric blocks with local anesthetic. Do you use a pudendal block? And describe some of the anesthetic considerations for any of these anorectal procedures.
MICHAEL KWIATT: It's a good question. So my go to is that I anesthetize with-- I use a 50/50 mixture of [INAUDIBLE] marcaine and 1% lidocaine with epi because they're generally performed under a MAC anesthetic, if you want that short acting anesthetic. And I'll generally anesthetize them superficially circumferential around the anus. The way I learned was to pretty much use 10 cc on each side of the anal canal and then radially anesthetize that area.
MICHAEL KWIATT: They are awake. So typically, I try to do one needle stick on each side and move my needle that way. And then once that's done, I use the remaining local intersphincterically to numb them up, to get a little more deeper. And generally, I tell my anesthesiologists, they're going to move until I inject the lidocaine and I'm fine with that.
MICHAEL KWIATT: Once you get numbed up, generally they're fine for the case and you really don't [INAUDIBLE] these patients real deep, especially if you're good if you're going to do the procedure in the prone jackknife position. Another option is you can do a pudendal block as another option as well.
AMIT JOSHI: I've been in this situation before where I'm exploring someone for a fistula and I can find the external os, but I can't locate the internal os. Any tips or tricks for that?
MICHAEL KWIATT: Yeah, I think the biggest tip is don't force the issue. So with gentle probing you can't find it. In terms of finding it, is there actually an internal os? What I'll do is I'll use a hydrogen peroxide. So I'll fill a 20 cc syringe with hydrogen peroxide and use a 14 gauge angiocatheter on the end, and then insert that into the external opening and then inject. And then with a retractor in the anal canal, you can look for the extravasation of hydrogen peroxide in the anal canal.
MICHAEL KWIATT: And that'll typically give you a good idea, is there actually an internal opening? Other thing that has been described, people often use too is methylene blue, which can be nice. The big disadvantage with that is if you spill it, everything gets stained. So it can be difficult. So I find that hydrogen peroxide a little more forgiving. But say you get the situation that you do inject, you find an opening, but despite all your probing, you can't find anyone.
MICHAEL KWIATT: And in that case I usually stop and what I'll do is I usually send the patient for a rectal MRI. In general, if you document that you've tried in the UA, you can't find the opening that can be one way to give you a better idea of the anatomy. It can give you an idea. Is this is a suprasphincteric fistula or a high transphincteric? It's going to be a little bit more difficult to find.
MICHAEL KWIATT: And then generally bring it back.
AMIT JOSHI: I also loved your emphasis on a comprehensive obstetric history. So important and something probably a lot of people miss.
MICHAEL KWIATT: Yeah, it often gets missed in the initial assessment.
AMIT JOSHI: Yes. Thank you. We go on to the next module.
MICHAEL KWIATT: OK. So we're going to move on to anal fissure. So an anal fissure is a tear in the distal anal canal. So what you'll have is a cut in that area. About 90% of them are going to occur in the posterior midline. And then about another 9% are going to occur in the anterior midline. So you're typically going to see these in the midline. If it's off midline, that's an atypical presentation.
MICHAEL KWIATT: And that's when you really want to start thinking about Crohn's disease. I know that's going to be a very common presentation of IBD. You can also see it rarely with patients with poorly controlled HIV. And occasionally in your leukemia or neutropenic patients. It's also been described in tuberculosis as well. But really, you're going to look to think that this is going to be in the midline.
MICHAEL KWIATT: One thing to note is that we know we often associate fissures with constipation. That's kind of the most common traditional understands bad episode of constipation leads to a fissure, but you can also see it after a real severe diarrhea illness. So not just constipation, you can also see it after diarrhea. And there's kind of two prevailing theories that kind of explain why the posterior midline is the most common area.
MICHAEL KWIATT: One's the Mechanical theory. And the idea is that the posterior midline, when you're having a bowel movement is the area of the greatest stress and that's due to the anorectal angle on that area. And when you're having a bowel movement, it leads to the most stress in that area. So with a hard stool, you're going to stress that area, and lead to the formation of a fissure. Or the other explanation is the Ischemic theory is that basically, the posterior midline is a watershed territory and because of this, blood flow is limited.
MICHAEL KWIATT: So in the setting of a hypertonic anal sphincter, the blood flows can be even more severely compromised and that can lead to fissure formation. Symptoms, like we talked about, you're going to get a lot from the history of what's actually causing this anorectal issue. So for an anal fissure, you're going to see sharp or tearing anal pain that's worse with bowel movement. Classically, these patients will show up in the office, complaining of rectal pain or anal pain, and when you ask them describe it, they'll say that every time I feel like I'm having a bowel movement or every time I go to the bathroom it feels like it like knives are coming out or that I'm passing pieces of glass or shards of glass.
MICHAEL KWIATT: That's very typical. I hear that, anal fissure is number one on my diagnosis. And that's almost always the case. Occasionally they may see bright red blood typical what they're going to describe those is a little bit of spotting on the toilet paper. You typically don't get heavy bleeding with an anal fissure. But the big thing is it's very severe anal pain with bowel movements.
MICHAEL KWIATT: So diagnosis, typically you're going to see a tear in the anal skin on a physical exam. Occasionally, you'll see a sentinel tag. That's going to be kind of a tag on the outside of the tip of the fissure. Or you may see a hypertrophic anal papilla. So one of the anal glands on the internal anal canal would be dilated and almost look like a tiny hyperplastic polyp in that area.
MICHAEL KWIATT: Generally, just by inspection, external you're going to be able to see this. And typically these patients aren't going to even let you perform a digital rectal or an endoscopic exam due to the severe pain. In terms of treatment, I like to think of a stepwise approach. So typically, you start with conservative measures. And this is what you're going to use for an acute anal fissure. So typically, in acute anal fissure is something that you're going to have less than 6 weeks.
MICHAEL KWIATT: So for these patients, typically, I recommend a topical anesthetic. Something like a lidocaine gel usually about a 2% or 5% lidocaine, even just over the counter at their pharmacy. You recommend they can do sitz baths to help with that area, increase your dietary fiber intake. The general recommendation is to recommend patients get up to 25 to 30 grams of fiber a day. Typically, that's going to require the use of a fiber supplement something like Metamucil, Citrucel.
MICHAEL KWIATT: I particularly like the powders because that forces them to take enough water with it. And you can also consider certain stool softeners. And with just those measures, typically about 50% of them will heal over that time. So usually I'll see those patients, counsel them on that, tell them to come back in 6 weeks and see how they're doing. If they haven't healed at this point.
MICHAEL KWIATT: At this point, we usually talk about a chronic anal fissure. And those typically, when you exam those patients, a lot of times you'll see exposed internal sphincter at that point. You'll see the white fibers exposed in the bed or they'll have rolled edges. And in that case, there are multiple topical agents that you can use in that situation. And the general theory behind those agents is that they increase the blood flow to the area to allow the fissure to heal.
MICHAEL KWIATT: The two main categories of agents we use are nitroglycerin or calcium channel blockers something like diltiazem or nifedipine. Nitroglycerin, about 70% of patients will report severe headaches. So that's a disadvantage to using nitroglycerin. So residents often ask why would you ever give someone that? And the reason is that's what's commercially available. If you go to your local pharmacy, you can generally write a prescription for them to get nitroglycerin and they can fill that at their local pharmacy.
MICHAEL KWIATT: Something like a calcium channel blocker, if you want to put someone on a 2% diltiazem ointment that has to come from a compound pharmacy. So they can't take that prescription to a regular pharmacy, you have to have a compound pharmacy so that they can fill that out. So that that's why that's typically not done. And the other issue is with the calcium channel blockers, just logistically, that they're typically not covered by insurance.
MICHAEL KWIATT: So patients are going to spend $50 to $100 out of pocket in order to fill that prescription. But with these chronic anal fissures for those that didn't respond to the conservative measures, about 50% to 70% of these will heal with the use of the topical agents. And there's been multiple studies comparing, but none have definitively shown that that nitroglycerin or any of the calcium channel blockers are superior.
MICHAEL KWIATT: Another thing that's been used more frequently, probably, at least recently in the last 10 years is botox injections. So the theory behind this is that botulinum toxin inhibits release of acetylcholine into the neuromuscular junction, which then blocks contraction of the internal anal sphincter, and then allows the sphincter to relax. So the idea is that you're getting rid of the hypertonicity of the anal sphincter. I kind of like to consider it almost like a chemical sphincterotomy.
MICHAEL KWIATT: So you're going to give someone the sphincterotomy, we'll get to is kind of the gold standard. A tried and true treatment without having to perform the actual sphincterotomy. And these have been shown to have about 70% success in healing chronic fissures. Just things to keep in mind, it's a temporary effect. So botox typically lasts last for 3 months. If you have botox elsewhere, a lot of times people get repeated injections.
MICHAEL KWIATT: So it's the same with an anal fissure. So it's only going to last for about a few months. So because of that, recurrence is possible. One of the big advantages is with fistulotomy and just like with a chemical, I'm sorry with a sphincterotomy or it's a chemical sphincterotomy, there is a risk of incontinence because botox is temporary. If a patient does have an adverse reaction and leads to incontinence, it's going to be a temporary thing that'll wear off over time.
MICHAEL KWIATT: In terms of being able to perform this on a patient, in order to get this coverage, typically, insurance companies will want you to try one of the topical agents first. A lot of times you don't have the option of going right to botox. You kind of have to go through the stepwise progression. And the last is the lateral internal sphincterotomy, which has been used for decades for the treatment of an anal fissure.
MICHAEL KWIATT: And the idea is cutting a portion and division of the sphincter leads to a release of the hypertonicity, and allows the finger to heal. I do want to make a plug that a lateral internal sphincterotomy is one of the core procedures listed in the school curriculum. So it's considered fair game by the American Board of Surgery. So I do recommend that you really kind of get in a sense of how this procedure is performed.
MICHAEL KWIATT: We're going to spend some time going over that right now. So some key things is you're dividing the internal sphincter. It's a lateral internal sphincterotomy. And the division's done in the lateral area of the anal canal. And the reason being as we discussed earlier, if you do a fistulotomy in the posterior midline, kind of going back to that ischemia or watershed theory that the posterior midline is a poor area for wound healing.
MICHAEL KWIATT: And what happens is that you won't heal that wound fully and you'll get almost like a divot back there or what we call a keyhole deformity if you don't perform it at the area of the fissure, you're going to go lateral where the blood supply is better. And there's two techniques that are better described in open or closed technique. They both have six similar success rates and they both have similar risks of fecal incontinence.
MICHAEL KWIATT: In terms of the closed technique, we'll go over it and describe the steps how to do that. Simply what you're going to want to do is you want to locate the intersphincteric groove. So I generally do these in lithotomy and they can also be done in the prone jackknife position. Like Dr. Joshi mentioned before, you'll want to anesthetize the area with a local anesthetic. And with a retractor, I like the Hill-Ferguson retractor, I'll place that in the anal canal.
MICHAEL KWIATT: Do an exam to make sure there's no pathology. Sometimes an anal cancer can masquerade as symptoms of as a fissure. And a lot of times, you're not able to do an endoscopy in the office or digital rectal exams. You want to make sure that you take the time to do a thorough examination under anesthesia before you start. But with that retractor and that's going to put some stretch on the sphincter and that's going to really allow you to palpate the intersphincteric groove, you're going to be able to feel the two bands touching just proximal of the anal verge.
MICHAEL KWIATT: You can feel the two bands and be able to help in the internal and the external sphincter. Or you can do that as I'm taking an 11 blade scalpel, insert it into the intersphincteric groove, and then turn the scalpel medially, and then divide the internal sphincter. And you can see that at the bottom here, you're going to divide the lower portion of the internal sphincter by turning the blade medially and cutting that way.
MICHAEL KWIATT: Classically this is described as to do the division without the retractor in the anal canal, and with one finger in the anal canal and then perform the sphincterotomy, you can actually feel the sphincter loosen and lose that hypertonicity. So that's the closed technique. Other technique is the open technique.
MICHAEL KWIATT: So with that again, can be done in prone jackknife or in the lithotomy, adequate anesthesia, and do a thorough exam. And then with the retractor and again, you're going to find the intersphincteric groove. But this time, you're going to make a radial incision over the intersphincteric groove. So it's radial incision. This is different than what you would do for a LIFT procedure where you make a circular one which is right over the groove.
MICHAEL KWIATT: And then using just like a hemostat, you can dissect out and expose the internal sphincter. I would show the medical students when I'm doing this that the internal sphincter is white, that sounds very easily-- obviously could be more medial, and it's white in appearance. That's how you can identify the internal sphincter. And then you just divide it. I typically just use electric cautery and then close up the incision.
MICHAEL KWIATT: Just a couple other things to consider. Traditionally, they talk about cutting the internal sphincter for a sphincterotomy up to the dentate line. That's a classic definition. More often, people perfom what's called a Tailored sphincterotomy. And in that case, you're not going to make quite as large of a sphincterotomy.
MICHAEL KWIATT: In that case, typically, they talk about doing your sphincterotomy that's the same length of your fissure. So that's about how large your fissure is. It's about how much sphincter you have to divide with your sphincterotomy. And then the other thing to consider, in the case that you're doing a patient with a repeat sphincterotomy, you'll want to do the opposite sides of patients who have had a sphincterotomy in the left.
MICHAEL KWIATT: If you find that it's unsuccessful, and in that case, you have to go back and do another sphincterotomy, typically you go to the other side.
AMIT JOSHI: Really nice algorithm and view also of a fissure. Are there any circumstances where you would go, let's say you-- I mean I'm sure you'll always do a conservative, no topical, no botox, but is there any reason why you would ever skip over, topical skip over botox and go straight to sphincterotomy. What are those circumstances?
MICHAEL KWIATT: If you're examining the patient and you find that they have clearly a chronic fissure, something's got the rolled edges exposed sphincter. And you find out that they're in severe pain, a lot of times, sometimes especially in a young man and you examine and they have a really tight sphincter complex. You know those patients that is often gone right to the fissure. And a lot of times at the initial discussion when they see me in the office, I kind of lay out for them this is how this goes down and that these are the things that we can try.
MICHAEL KWIATT: And you have the occasional patient that says like, this is driving me nuts. I can't go through all of this. Let's go let's go right to the sphincterotomy. And if you do think it's truly a chronic fissure with a hypertonocity problem, and you have a lot of reason to think that they'd be at increased risk for incontinence. Those patients, I will occasionally, jump right to the sphincterotomy.
AMIT JOSHI: And do you personally ever do a closed one or do you always do an open one?
MICHAEL KWIATT: I should do both. I usually like to show the residents both. And I actually think when you're first learning to show them the open just because I think it gives you kind of a sense of what you're doing. And then when they've done that and kind of move on to the closed one.
AMIT JOSHI: I was going to ask you what rate of incontinence do you quote forced entorotomy. I guess it's part of the patient's preop.
MICHAEL KWIATT: But no. I mean-- So it's a wide range of what people quote. Some say as high as 40%, some say it can be as low as 2% to 3%. I mean, I usually say about 10%. And I explain to them with that generally, what they're talking about is patients talking about having leakage of gas or a little bit of seepage. And the risk of actually having full incontinence of solid or liquid stoll is well less than 1% in the average patient.
AMIT JOSHI: And even when there's some gas and liquid, it's usually temporary. Correct?
MICHAEL KWIATT: Correct. Yes. So like we mentioned, like with the fistulotomy before. They will say, it's tense and that goes back to, it depends on a lot of times how you study it. If you survey patients within the first couple of weeks, you're going to see a much higher risk of incontinence. Whereas, usually after about a month, a lot of times the temporary incontinence will resolve.
MICHAEL KWIATT: OK. All right. And then lastly, pilonidal disease will be a little shorter. So pilonidal diseases is acute or chronic infection in the sacrococcygeal region. So really at the tip of the tailbone. It's typically seen in patients in their 20s and 30s and more common in men than women.
MICHAEL KWIATT: So kind of the stereotypical patient for pilonidal disease is going to be a young man with a deep natal cleft with a lot of hair. So those are the what you kind of see as a typical pilonidal disease patient. However, can be seen in women as well. So the pathogenesis, we used to believe that Pilonidal sinuses were congenital openings in the sacrococcygeal region in the midline.
MICHAEL KWIATT: But now the leading idea is that you can have a hair follicle in that area that ruptures from stretching or becoming clogged with keratin and that leads to the creation of this environment that causes abscesses. So the area is moist, it's anaerobic, and this causes abscess, and prevents the area to healing. And that leads to the formation of a midline pit. So a midline pit is almost going to be like a pinpoint opening in the sacrococcygeal region right in the midline.
MICHAEL KWIATT: And the idea is that hair gets drawn into the area of the natal cleft and a pit forms and that causes an enlarging abscess. So these areas keep getting hair sucked in there. And then the body attempts to eradicate the infection. And that leads to the formation of all these sinuses that you'll see laterally on the skin. In terms of non-surgical management, you can counsel patients that have had a pilonidal abscess to reduce their sitting time.
MICHAEL KWIATT: If they're overweight, you can counsel them with weight loss. You can discuss improved hygiene. Some patients, especially teenagers, you may need to tell them that they need to shower every day. And then you can also discuss weekly shaving, which we often counsel our patients on to remove the hair in the area, but won't really prevent the formation of an abscess that's already there. What shaving will do is it will decrease the number of surgical procedures required to get rid of an abscess or decrease the length of stay of hospital stay or time to healing.
MICHAEL KWIATT: And after the healing of an abscess, it might prevent a recurrence. One of the interesting things to note is that we talk about shaving, but they've actually found that there's a lot of theories that it's not necessarily your hair from your gluteus cleft that ends up in this area. And the reasoning behind that is that there there's an increase of risk of pilonidal disease we've seen in hairdressers and in sheep shearers.
MICHAEL KWIATT: People that shear sheep or dress hair can often have a higher risk of pilonidal disease. So it may not be even their own hair. An acute Pilonidal abscess, it presents as a painful, fluctuant abscess over the intergluteal cleft. So the patients come in and say, I have swelling and pain in my tailbone area. And just like your perianal abscess, the treatment's incision and drainage.
MICHAEL KWIATT: All these need to be drained. A lot of times, primary care physicians will send these patients home on antibiotics. And really, what will happen is eventually they'll burst on their own. And what they really need done is an I and D. Typically, like in a fissure the midline area of your sacrococcygeal area is a watershed area, not a great area for wound healing.
MICHAEL KWIATT: So typically, you recommend you place the incision off midline about a centimeter to improve healing. You can use elliptical or cruciate incision. And like your perianal abscess, antibiotics typically aren't needed. Chronic pilonidal sinus can form after multiple abscesses. And what happens is they get openings on the external skin. Occasionally, patients will have these, but not have much symptoms.
MICHAEL KWIATT: And that's the patient that you talked about hair removal to prevent further flare ups and another abscess. And your procedure options include incisional and excisional procedures. So you can think of incisional procedures where you're going to just open up the area versus an excisional where you're going to cut all the tissue away and then with or without primary closure.
MICHAEL KWIATT: So a midline excision that's the longest known entity for treating these. And with that is that's going to be en block excision of the entire pilonidal sinus is that you're going to go ahead and core out that area. Traditionally, what's been described is going all the way down to the presacral fascia. What they did historically was a wide local excision of the area.
MICHAEL KWIATT: And commonly, we talk about that pilonidal disease is called Jeep's driver's disease because they found that during the World War II, there is an increased risk of it. And the idea being is there's a lot of men in their 20s and 30s that were hairy. And it was such a problem that at one point during World War II, there were 80,000 soldiers during the course of the war that were hospitalized for pilonidal disease.
MICHAEL KWIATT: And their average length of stay after a wide local excision was 55 days in the hospital. So they had so many men off the battlefield that the surgeon general actually came out and put a ban on performing excision of pilonidal cysts in the military towards the end of the war. So again, we don't do quite as wide of an excision these days. You just remove the inflamed tissue to include the sinus in the midline cyst.
MICHAEL KWIATT: And you can't consider closing these primarily. That will lead to a faster closure. They've shown that if leaving it open and letting it to heal into out, that's going to be about two weeks, I'm sorry two months to closure versus about two weeks. But that does increase your risk of recurrence or infection. Unroofing with secondary healing that's going to be rather than taking out the whole area and cutting and removing all that tissue, the sinuses just unroof and curetted clean.
MICHAEL KWIATT: And then what this does is that creates a much smaller wound without an excision. And this can be useful in the setting of an acute abscess when you can't close the wound. So someone comes in with an abscess and associated sinus, you can just open up that whole area and curette it clean, and let it heal from the inside out. Along those lines, we talk about the Bascom I which is just the midline pit excision.
MICHAEL KWIATT: And then this is another open it up and let it drain. What you could do in this procedure is you make an incision off the midline as you would for an abscess and then using a curette, you curette towards the midline and clean out all the sinus cavities and tracts, but you don't excise any tissues. Except for in the midline, where you can use an 11 blade scalpel or my pediatric colleagues have almost like a punch biopsy that they use to just remove the midline pits in the middle and then close that usually with an absorbable suture.
MICHAEL KWIATT: It usually takes one simple stitch. So you're not excising anything, you're pretty much removing the pits and then draining off midline for a Bascom I. There's also a lot of flaps that you can use to control if you have to do a large excision. I personally got to say I don't have a whole lot of experience with these and when it gets this bad, I usually refer this to my plastic surgery colleagues.
MICHAEL KWIATT: But they discuss a Karyadakis flap which is really just the mobilization of the skin from one side of the tissue, one side of the gluteal cleft to the other. So you just mobilize the opposite side that your excised and then advance it across the midline and suture closed. Or they talk about the Limberg flap which is just a rhomboid rotational flap. And in this case you just do a diamond shaped excision of the tissue.
MICHAEL KWIATT: And then using a counter incision, you make a rhomboid flap that you can then rotate into the wound. And then the most advanced you may hear of is the Bascom II which is the cleft lift procedure. The principles behind this is you undermine and obliterate the gluteal cleft. So what you do is you raise the skin off the gluteal cleft leaving the subcutaneous tissues in place.
MICHAEL KWIATT: And then just curette chronic wound, excise the diseased skin, and then you just perform just a skin flap across the midline to the wound. So in pilonidal disease, there's a lot of treatment options and this is really going to be tailored to the individual case depending on the severity of the disease. And I think that that concludes everything I have for you guys today.
AMIT JOSHI: That's great. A little military history. The anecdotes about the sheep shearers and the hairdressers, it was a mildly disturbing to me.
MICHAEL KWIATT: Yes.
AMIT JOSHI: It's fascinating. Also it's so important to talk about prevention of recurrence and so all the non-operative management of pilonidal with hygiene and hair control. You can do a great procedure and then if the patient is not complying with those things, six weeks, six months later, they're back in the office with the same problem. So important to set those expectations at the beginning. This is great Dr. Kwiatt.
AMIT JOSHI: These procedures are so central to not just colorectal surgeons but general surgeons across the country. And certainly important to residents in training. So this is a great review of all four of these conditions. Thank you so much for all your expertise in this week of SCORE school.
MICHAEL KWIATT: Right. Well thank you for having me.
Segment:0 .
AMIT JOSHI: Hi, everyone. Welcome to SCORE school. I'm delighted to introduce Dr. Michael Kwiatt who'll be taking us through the benign anorectal part 1 of 2. He'll be covering 4 modules which he's going to introduce. Dr. Kwiatt is the program director of the General Surgery Residency at Cooper University Hospital in Camden, New Jersey. He attended medical school at Washington University in St. Louis and then did his training at Cooper in Camden followed by a Colorectal Surgery Fellowship at the Cleveland Clinic in Ohio.
AMIT JOSHI: Dr. Kwiatt is a specialist in colonorectal cancer, IBD, diverticular disease, and benign anorectal disease. And it's a pleasure to welcome him to SCORE school. Thanks Dr. Kwiatt and please go ahead.
MICHAEL KWIATT: Thanks Dr. Joshi and thanks for having me. You can use the question and answer feature with this QR code throughout the presentation. As Dr. Joshi mentioned, the topic this week for this week in SCORE is a benign anorectal part 1 of 2. So it's a two weeks covering in anorectal disease. This week's topics, there's eight modules in total, but there's some overlap between the two. So we'll be discussing some anorectal anatomy just before we get started, to help guide our conversation.
MICHAEL KWIATT: Then, we'll delve into anorectal abscesses and fistula, anal fissures, and pilonidal disease. So just real briefly some anorectal anatomy before we get started. First of all, the dentate line is the division between the rectal columnar epithelium and the anal squamous epithelium. So embryologically, approximately comes to the embryonic and endoderm which makes up the rectal columnar epithelial and distally, you have the embryonic ectoderm which makes up the anal squamous epithelium.
MICHAEL KWIATT: The anal verge, when we talk about the anal verge, that's the border between the anoderm and the skin. An anoderm lacks hair and sweat glands, that's what makes up the anoderm different from just the skin. And then in terms of the anal canal, anatomically, if you'll get Netters or your anatomy textbook, they discuss the anatomic anal canal as the dentate line to the anal verge. So from that dentate line all the way down to the border between the hairy and the non hairy skin.
MICHAEL KWIATT: But surgically, we typically talk about the anal canal as incorporated in the anorectal ring which is the upper portions of the sphincter complex and the tubal rectalis muscle, all the way down to the anal verge that's a little bit longer. The surgical anal canal is a little bit longer. We make that distinction because when you're talking about a cancer resection, you can't take that sphincter complex and still perform an anastomisis.
MICHAEL KWIATT: So surgically, when we talk about the anal canal, we talk about that longer segment going all the way up to the anal rectal ring. And then the internal anal sphincter itself, it's important to note as a continuation of the rectal and the circular smooth muscle. So it's a smooth muscle complex. And then the external anal sphincter is a continuation of the levator ani.
MICHAEL KWIATT: You can see that coming down here. So the internal sphincter and the external sphincter right here. We'll go ahead and move on to anorectal abscesses. So the etiology of anorectal abscesses is believed to be blockage within the anal glands. You have anal glands sitting at the dentate line at the bottom of the crypts of Morgagni.
MICHAEL KWIATT: In all there's estimated everyone has between about 6 to 8. And the classification of anal abscesses which form after clogging or blockage of the anal canal or of the anal glands is classified by the potential space that the abscess is located. So we'll go ahead and go through that briefly. So first, we often talk about a perianal abscess. You can see that right here.
MICHAEL KWIATT: And that's located in the perianal space, which is defined as superficially at the anal verge and is in continuation with the ischioanal fossa laterally. So this can be very, very close to the anal verge and this area right here. An ischioanal abscess is going to be further out. It's located in the ischioanal space which superiorly is bordered by the levator ani, medially by the external anal sphincter, and then laterally by the pelvic side wall.
MICHAEL KWIATT: So this area here, we'll call an ischioanal or an ischiorectal abscess. And then an intersphincterical abscess, this can be located in the intersphincteric plane. So that's going to be the space between the internal and the external sphincter muscles, that's very easy to understand. That's the intersphincteric abscess.
MICHAEL KWIATT: And then lastly, well let's talk about a supralevator abscess which is extraperitoneal in nature. It's in the supralevator space which is found medially by the rectum, laterally by the pelvic sidewall, and it's above the levators. So in terms of a patient presentation for an anorectal abscess, generally patients will present to the clinic talking about gradually worsening anal rectal pain, swelling in the inner rectal area, and they may develop fevers and chills.
MICHAEL KWIATT: So anytime a patient is in the office coming to you with anorectal complaints, a lot of times you can get a good sense of what's going on, just based by their history alone. In a classic with anorectal abscess is that they'll feel some swelling and some achy pain that's going to gradually become worse over time. And if not seeking out treatment, will develop to chills or fevers.
MICHAEL KWIATT: Kind of the main thing you want to distinguish it between, clinically, would be hemorrhoids which are also going to kind of have that gradual anal pain. But an anorectal abscess can be more acute, whereas, hemorrhoidal diseases can be more insidious and kind of a long lasting process. Physical exam findings are really going to depend on the location of the abscess, like we had discussed previously.
MICHAEL KWIATT: Perianal and ischiorectal abscesses are usually the easiest to distinguish on physical exam. In general, you'll see erythema, tenderness, or fullness over the perianal or the ischiorectal area. Intersphincteric abscess are a little more difficult to diagnose because they're within the intersphincteric groove. Often, you don't see external findings on physical exam, but they'll typically have very extreme tenderness, if you perform a digital rectal exam on these patients.
MICHAEL KWIATT: And thus in your differential, you might be trying to distinguish between an intersphincteric abscess versus a fissure. Postanal space abscesses, I wish we didn't go over on the previous classification system, but that's going to sit behind the rectum in the post anal space. And those are the ones that on digital rectal exam, you'll feel some bogginess in the anal canal.
MICHAEL KWIATT: So when you're examining these patients, when you're doing that exam to see if there's anything within the anal canal, you're really checking for there is a post anal space abscess. Then again, the supralevator abscesses given their extraperitoneal location, and they can be a little bit more difficult to diagnose. These patients typically, their presentations can be a little bit different.
MICHAEL KWIATT: And more typically, they'll have pelvic or back pain, a very common urinary symptoms. We'll talk about urinary frequency or inability to urinate, and these patients can have systemic signs of an infection like high fevers, chills, and such of that nature. In terms of imaging, potentially, you can image these abscess with a CAT scan and MRI, [INAUDIBLE] it an endorectal ultrasound.
MICHAEL KWIATT: But this really is only needed if the diagnosis is unclear. If you're seeing a patient and they have an obvious area of an abscess, that that's typically, ischiorectal again or perianal abscess. You're going to be able to pick that up on a physical exam. And unless the diagnosis is unclear, you typically don't need any further imaging. Generally though someone with a supralevator abscess, that is going to require further imaging.
MICHAEL KWIATT: And usually, a CT scan is sufficient to detect those. Or if you have someone who's got complex abscesses, so they have abscesses in multiple locations, or you're concerned about something such as like Fourniere's gangrene or a necrotizing soft tissue infection. In terms of treatment, I can't say enough that drainage is the mainstay of treatment and anorectal abscesses need to be drained.
MICHAEL KWIATT: Antibiotics, themselves are rarely effective unless a patient's drained first. So often, these patients would be seeing an urgent care center and discharged home on antibiotics. And that's never been shown to be an effective treatment for anorectal abscesses. And in fact, if anything, it just delays the drainage which can lead to a greater increased risk of fistula formation.
MICHAEL KWIATT: So these patients need to have the abscess drained. You can consider the use of antibiotics, in addition to drainage. Again, that is also not typically needed, but you may consider it in an immunosuppressed patients, so someone who's a brittle diabetic, someone who's on chemotherapy, as you often see anorectal abscesses in patients receiving treatment. Or if they fail to improve after adequate drainage that might be another time to consider addition of antibiotics.
MICHAEL KWIATT: But typically, the treatment of choice is to drain the abscess and antibiotics only in special circumstances. Some considerations when treating an anorectal abscess. First thing to consider is setting. Often, if it's a superficial ischiorectal rectal abscess or a perianal abscesses, this can be drained in the office just under a local anesthetic. When you're anesthetizing these patients in the sensitive areas, you generally want to anesthetize away from the abscess first, and then slowly inject a local anesthetic into the area.
MICHAEL KWIATT: And if it's superficial, they can be trained right there in the office. If there's a risk of inadequate drainage, bedside or in the office setting, then you want to consider taking these patients to the operating room. In terms of your incision, this is where you kind of want to think about what could happen down the road.
MICHAEL KWIATT: The big complication from an incorrect abscess or can even be considered as part of the natural disease process is the development of fistula tract. And it's easier to treat a short fistula tract. So when you're making your incision, you want to try to place the incision as close to the anal verge as possible in order to reduce the length of that possible fistula tract.
MICHAEL KWIATT: Still, you want to make that incision in an area where you can feel fluctuance. You can feel the abscess, but if it's a large cavity, you want to try to make it as close to the anal verge as possible. And you also want the incision to run parallel to the fibers of the external sphincter. So essentially, it's going to be radial incision around the anus.
MICHAEL KWIATT: And you can use an elliptical or a cruciate incision, either one. As we'll talk about more momentarily, about 40% to 50% of these patients, 11 associated fistula will develop a fistula. And it is OK to gently probe for a fistula after initially draining, especially if you're in the operating room. It's typically not tolerated in the office, but you can gently probe. But the key here is that in the setting of active inflammation, there is the risk of developing a false passageway.
MICHAEL KWIATT: So you want to be careful with that. And I wouldn't worry too much about trying to find a fistula after initially draining an abscess, but it is OK to look if there's an obvious one that's easy to find. Some other things to consider with a large abscess cavity, rather than opening up a large perirectal wound that would be hard to care for, you can consider using counterincisions.
MICHAEL KWIATT: And with the use of Penrose drains or Setons to keep the cavity open. One thing that I corporate a lot of my practice is the use of a drainage catheter. You can place a mushroom catheter within the abscess cavity itself. I usually use a malachite catheter, usually a 12 or 14 french looks nice. Works nicely for this.
MICHAEL KWIATT: You insert it into the cavity and then you can secure it to the skin and leave it in place. This can be in lieu of packing because the area can be very difficult to pack, unless the patient has a lot of support at home. It's difficult to get adequate wound care in that area. And typically, in terms of how long to leave a catheter in, general recommendations is until the abscess is no longer draining.
MICHAEL KWIATT: And this will be typically over the course of 1 to 2 weeks. You just want to be careful not to leave these in too long because you can get ingrowth, and then they become difficult to remove. Then for an intersphicteric abscess, you want to open the internal sphincter. So you're going to be opening and draining the abscess within the anal canal itself. And you have to open up the internal anal sphincter along the length of the abscess.
MICHAEL KWIATT: So for most of these abscesses, you're going to drain them externally. But for an intersphincteric abscess, you're going to want to drain that internally as well. Then briefly about fistulotomy, traditionally, there's always been a lot of hesitance to perform a fistulotomy at the time of abscess drainage because of fear of increased risk of incontinence of performing a fistulotomy in that setting.
MICHAEL KWIATT: However, multiple studies have shown that a fistulotmy at the time of abscess drainage may result in faster wound healing and reduced rate of recurrences. So it has not been shown to show an increased risk of incontinence, but despite this, due to these historical fears, it's often avoided at the time of initial diagnosis even though it may in fact, be safe and beneficial to the patient.
MICHAEL KWIATT: The one entity we should also discuss lastly with anorectal abscesses is a horseshoe abscess. And this is typically a bilateral abscess arising from the postanal space so it involves the post anal space behind the rectum and then bilaterally into the ischiorectal fossa. So these patients have an abscess in their postanal space and bilateral ischiorectal fossa. And the traditional procedure for treating these is called the Hanley procedure.
MICHAEL KWIATT: And there's three parts of this procedure. And you want to drain it. Drain the abscess posteriorly through the anococcygeal ligament. So you're going to behind the rectum pop into the anococcygeal ligaments in order to get into that postanal space and drain the abscess. You also want to make a midline incision over the internal anal sphincter at the level of the abscess.
MICHAEL KWIATT: So that's going to be in the posterior midline and you would drain that just as you would a intersphincteric abscess by opening up the internal anal canal. And then lastly, you're going to drain the bilateral ischiorectal fossa. So these horseshoe abscesses can be difficult to control the perianal sepsis due to needing to widely drain these.
MICHAEL KWIATT: And the only way to do that is to open up the bilateral ischiorectal fossa and then performing the incision at the internal anal sphincter at the midline. Sometimes people perform what they call a modified Hanley procedure. And in that case, you don't do the additional drainage through the anococcygeal ligament. You just open up the bilateral ischiorectal fossa and then at the internal anal sphincter and the posterior midline.
MICHAEL KWIATT: We'll go ahead and move on to anorectal fistulas then.
AMIT JOSHI: Dr. Kwiatt, let me just let me just ask you a question.
MICHAEL KWIATT: Sure.
AMIT JOSHI: Sorry to interrupt you.
MICHAEL KWIATT: OK.
AMIT JOSHI: So give me a sense of post-operative instructions for patients who let's say we took care of a straightforward abscess, maybe even required a I and D in the operating room. But what do you tell them in terms of discharge instructions of how to care for that wound? Whether if, let's if not packing, maybe you put them out and cut in or just draining openly, what are your recommendations?
MICHAEL KWIATT: Yes. I'll typically leave a malachite in. They'll usually have a kind of a gauze dressing. I tell him that evening they can go home, take the gauze off, and I typically recommend that they do it Sitz bath or take a shower or bath after every bowel movement. And at the minimum twice a day. So I recommend that the shower kind of before they go to bed or when they get up in the morning. And then for post-operative care, I typically will see those patients in the office in about a week to remove that drain.
MICHAEL KWIATT: If I do pack it at the initial operation, typically, I'll tell them that evening to go ahead and get in the shower and remove the packing in the shower and then just leave a clean gauze over the wound at that point.
AMIT JOSHI: OK. And when you're counseling them about the risk of fistula occurrence and recurrent abscess, what's the general timeline, you may get a little bit into this in the next section. After that in indexed abscess, when you do see a fistula or remove an abscess, how long is it typically?
MICHAEL KWIATT: In terms of a fistula, generally what we often see is that the incision just never really heals. So usually after that first visit about a week after when we remove the drain, usually I tell them to come back in about a month to take a look at the wound. And at that point really, it should have healed at that point. So if there's a non-healing wound there, that's when I'm going to start being concerned about a fistula.
MICHAEL KWIATT: And talk to them about potentially doing an examination under anesthesia again to look for the fistula. Like we talk about, it's usually about a 40-50% chance of a fistula formation. Once they've healed, a recurrent abscess, generally if it's going to recur, it's going to recur sometime in the next about three months or so. They're going to see it come back, if it's the same anal gland.
AMIT JOSHI: And when you do the modified Hanley procedure, do you use Penrose to connect those three separate [INAUDIBLE]?
MICHAEL KWIATT: Usually, if I do the full Hanley, I'll use a Penrose through the postanal space into the ischiorectal fossa. And then place a Seton from the postanal space. And then if I don't do that, that posterior incision which I'll be honest, usually in patients I found that I've had to. But if I don't in that case, I usually just put a Seton through both areas. That way you don't open it up quite as much.
SPEAKER 1: OK. Thank you.
MICHAEL KWIATT: All right. So a fistula is an abnormal connection between two epithelial lined surfaces. So then an anorectal fistula connects an anal crypt to the perianal skin. So again, an anal gland can become clogged to which they sit at the bottom of the anal crypts. And that can lead to an infection. The best way to think of this is that an infection is going to flow to the path of least resistance.
MICHAEL KWIATT: So they're going to form a tract to the perianal skin. And just like our anal abscesses, their classification can be based on their location. In terms of the etiology, so 90% of cases result from cryptoglandular disease. And all that means is that 90% of the cases come from a preceding perianal abscess. So the overwhelming majority are from cryptoglandular disease or just benign abscesses.
MICHAEL KWIATT: It's not from IBD. That's what a lot of, I find a lot of residents get tripped up on it. They'll see someone in their 20s with an anal fistula and they think, oh, they must have IBD. And most likely, it's just going to be from a prior abscess. In terms of the remaining causes, typically it could be trauma, IBD, or an infection. And it's about 3% for each of those.
MICHAEL KWIATT: So those are all about equal. So even though we often think anorectal disease, perianal Crohn's disease, kind of one-to-one it, that's not the most common cause. And as we mentioned earlier, about 30% to 50% of anorectal abscesses would go on to develop a fistula. In terms of risk factors, the biggest risk for performing an anorectal fistula after an abscess has been found to prolonged time to drainage.
MICHAEL KWIATT: So the longer that a patient goes without having their abscess drained, that's going to be the most likely reason to develop a fistula, or biggest risk factor I should say. And they're more common with ischiorectal and intersphincteric abscesses than just benign perianal disease. Again in terms of classification, it's based on where the fistula goes. So an intersphincteric fistula involves a portion of the internal sphincter.
MICHAEL KWIATT: So it's going to go from the anal crypt, as you can see here. And then course through the intersphincteric plane between the internal and external sphincters, with an opening in the perianal skin. So it's a short tract and it does not involve any of the external sphincter. A transphincteric fistula is going to go ahead and cross a cross, that's going to go through both the internal sphincter and the external sphincter.
MICHAEL KWIATT: And we often classify these as high transphincteric or low. In low ones, cross at the lower one-third of the external sphincter so they don't involve much of the sphincter complex. Whereas, high cross over the upper 2/3s and involve a large portion of the external sphincter complex. And that classification will become important when we start talking about treatment.
MICHAEL KWIATT: And then suprasphincteric fistulas track through the anal crypt and encircle the entire external sphincter muscle and come out to the ischiorectal fossa. So these are fairly complex. And as you can see, these go up and involve the entire external sphincter complex. And then lastly, is an extrasphincteric fistula which begin high in the anal canal, and then they encircle the internal and the external sphincter, and then they come out onto the buttocks.
MICHAEL KWIATT: And these typically are not cryptoglandular in origin. You may see these in IBD, or after radiation damage, or probably most commonly, they're iatrogenic in nature. And then fortunately, these are the least common fistulas that we see. Another way we often classify fistulas is just based on simple versus complex. So a simple fistula typically involve minimal amounts of the external sphincter.
MICHAEL KWIATT: So simple fistulas are going to include your inner sphincteric fistulas and your low transphincteric fistulas. And these are typically managed with just fistulotomy. Complex fistulas are going to be your high transphincteric fistulas, fistulas that are formed from Crohn's disease, malignancy, or radiation and your suprasphincteric fistulas. And generally speaking, these are ones that we cannot safely manage with a fistulotomy.
MICHAEL KWIATT: In terms of presentation, like we said, 90% of these cases will have a preceding anorectal abscess. Often it drains by a surgeon in the office, or in the emergency department, or the operating room, or they may drain spontaneously. Sometimes patients will say they soaked in a tub and pop an abscess in the past. But they get either recurrent abscesses or persistent drainage after resolution of the abscess.
MICHAEL KWIATT: So if the tract becomes well epithelialized, a lot of times I'll just get some bloody drainage or some serious drainage afterwards that just persists and goes on. So a lot of times, I'll say, that I'm having blood back there. Other times you can get leakage of stool back there or even just benign serous fluid. And then a recurrent abscess can happen when you get stool stuck within that tract and that causes a localized infection and a recurrence of the abscess.
MICHAEL KWIATT: On physical examination, you're just going to look for an opening, kind of a non-healing wound. Often, these characteristically have a lot of hypergranulation tissue at the surface. And it's typically going to be seen on the skin at the anal margin or you're going to see some drainage when you examine the patient.
MICHAEL KWIATT: In terms of operative considerations, when deciding what procedure to perform in these patients, you're going to think of the location of the sphincter tract, the amount of sphincter involved, you wanted to consider the patient's preoperative continence. So you want to know about the patients if they've had prior anorectal surgery, have they had a prior sphincterotomy for a fissure, if they already had a fistulotomy.
MICHAEL KWIATT: And in women that have had vaginal deliveries, you're going to want to take a thorough obstetric history, to find out if at any time during their delivery where there's a use of forceps, did they have an episiotomy, were there any fourth degree lacerations. And those things would kind of alert you that this patient at baseline, may have issues with continence or just be at higher risk for complications of incontinence due to their prior anorectal or anovaginal procedures.
MICHAEL KWIATT: So you want to take that into consideration of what to perform. Often, especially old the attendings, all colorectal surgeons like to ask students and residents about Goodsall's rule. So this rule says that when you draw a transverse line across the anus, fistulas with internal openings, interior typically have a fistula tract that comes back in in a radial fashion.
MICHAEL KWIATT: So it's going to be a straight line on that tract. Whereas, in the posterior line it's a curvilinear course, going back to the fistula. But in reality, it's only accurate in about 60% of cases. So it's not a terribly hard fast rule. A fistulotomy is kind of the typical and the most often described procedure for treatment of the anorectal fistula.
MICHAEL KWIATT: And just simply, you place a probe through the fistula tract from the external opening into the internal opening. You want to be very careful when probing this area because if you're too aggressive, you can make an iatrogenic injury, which is going to be even more difficult to repair than just a cryptoglandular fistula. And all you do is you just unroof the fistula for its entire tract.
MICHAEL KWIATT: So this may involve cutting through a portion of the internal sphincter and the external sphincter as well. This is the treatment of choice for we'd classified as simple fistulas. These are going to be the low transphincteric fistulas and the intersphincteric fistulas that you can typically safely perform a fistulotomy with a risk of incontinence less than 1%.
MICHAEL KWIATT: In terms of the risk, typically patients will report some mild about 10% incontinence following a fistulotomy in the short term. And usually what they discuss is some seepage afterwards or some difficulty controlling gas, but most of these patients will have resolution of their symptoms by about a month postop. So I typically tell the patients in the initial post-operative period after a fistulotomy, you may have some seepage or a little slight incontinence of gas, but this typically will go away once everything heals.
MICHAEL KWIATT: Setons are frequently used and it can be used to drain an anorectal abscess. I'm sorry it could be used after the drainage of anorectal abscess to try to cause fibrosis of the fistula tract. And that can be useful to help control the drainage and then I often use them as a bridge to a more definitive procedure. Typically, you use a non-absorbable suture or vessel loops.
MICHAEL KWIATT: And like I mentioned, could be a bridge to a definitive treatment in the future. Or even occasionally, someone with a very complex fistula with advanced Crohn's disease, they will live with a long term Seton. With the Seton in place, what that does is that prevents them having recurrences of an abscess and we might be able to get them down with biologics to have a minimal amount of drainage.
MICHAEL KWIATT: In terms of other procedures to do for your transphincteric fistulas, a one that's commonly described is the LIFT procedure, which is the location of the intersphincteric fistula tract. The fistula tract, the steps for this procedure is you want to identify that fistula tract between the and the the external sphincter, and then ligate that area.
MICHAEL KWIATT: So the idea is that rather than opening up the entire tract, which could potentially have a greater risk for incontinence due to the large volume of the sphincter complex involved, with this you're just ligating that portion between the internal and the external sphincter. With the idea being that if the internal hole is able to close, the internal opening of the fistula, the external opening will close on its own because the internal area's really the source of your disease.
MICHAEL KWIATT: So the steps for that is you're going to feel for the intersphincteric plane, and then make a curvilinear incision along the intersphincteric plane. Usually you have to open that up about 2 to 3 centimeters in order to get adequate exposure. And then you're going to dissect within the intersphincteric groove and then identify that portion of the tracks. Usually I'll leave the fistula probe in and then dissect around the probes so that I know that I've found that portion of the tract between the internal and the external sphincter.
MICHAEL KWIATT: And then use a suture ligation of the tract, usually you can use an absorbable suture like a Vicryl and you're going to ligate the tract, right at the internal sphincter, and then also ligate it a second time right at the external sphincter, and then divide your sutures in between. And then after that's done, recommend that you probe the tract once more to make sure that you successfully closed it from the outside.
MICHAEL KWIATT: And then just curette the external opening and then close up your incision just with an absorbable suture. And then like we said by removing that internal portion, the external portion that can close up on its own. Reports of success with it are highly variable in the literature, but overall typically you see about a 75% success rate with a LIFT procedure.
MICHAEL KWIATT: Some other things that you often hear discussed, but not used as much anymore. There was a lot of hope for Fibrin glue and Fistula plugs. And kind of the principle between both these is that if you could just fill in the fistula tract with a synthetic material and a bioabsorbable material, and by plugging it up that would lead to healing of the fistula. There's been a few institutions that have reported a lot of success with that, but most other institutions haven't been able to replicate their success.
MICHAEL KWIATT: It happens a lot of times is that if it doesn't form these patients end up with a quick recurring abscess. Then, of course, we should discuss the endorectal advancement flap, which again, can be used for complex diseases. This is very commonly used in patients with Crohn's disease. It's what often used for treatment of a rectovaginal fistual as well.
MICHAEL KWIATT: And the idea here is like the LIFT procedure, you're going to close up the internal opening to allow the fistula to heal. Historically, people tried to suture, ligating the internal opening closed, but we find that over time that breaks down. And the idea between an advancement flap is by doing a layered closure, you'll be able to heal. So for this procedure, you make a wide curvilinear incision at the internal opening, and then dissection is performed in the submucosal plane to raise a flap of rectal tissue for about 4 to 6 centimeters proximally.
MICHAEL KWIATT: The key here is you have to make a wide incision of about 2 to 3 centimeters to have a wide base for your flap. And after you've made that incision, you close the defect within the internal sphincter with suture, and then advanced the flap over that area to close it up. And again with that layered closure, you can lead to a greater healing rate. A 60% to 90% success rate is reported in these instances.
MICHAEL KWIATT: So before we move on, I did want to mention, I don't think was necessary in the reading material with Perianal Crohn's disease in fistulas, just some key things to keep in mind in someone who's got well controlled perianal disease and they haven't had procedures. A Crohn's patient with a simple perianal fistula can undergo a fistulotomy.
MICHAEL KWIATT: It is reasonable to offer someone who hasn't had multiple anorectal procedures and has well controlled disease a fistulotomy performed. But with more advanced disease, you're going to want to consider something like an endorectal advancement flap. And typically with those patients, I'll place Setons in to control the perianal sepsis. And then generally, I recommend that they get on biologic treatment for about 3 months to see how their disease responds.
MICHAEL KWIATT: And if they are able to get control of their perianal disease, you're going to look for no mucosal friability and healthy appearing anorectal mucosa for Crohn's patients. I typically offer those patients an endorectal advancement flap as the procedure of choice in that instance.
AMIT JOSHI: Thanks for that clarification on the Crohn's disease. A couple questions for you. Do you routinely use a perineal block like either a superficial diamond block intersphincteric blocks with local anesthetic. Do you use a pudendal block? And describe some of the anesthetic considerations for any of these anorectal procedures.
MICHAEL KWIATT: It's a good question. So my go to is that I anesthetize with-- I use a 50/50 mixture of [INAUDIBLE] marcaine and 1% lidocaine with epi because they're generally performed under a MAC anesthetic, if you want that short acting anesthetic. And I'll generally anesthetize them superficially circumferential around the anus. The way I learned was to pretty much use 10 cc on each side of the anal canal and then radially anesthetize that area.
MICHAEL KWIATT: They are awake. So typically, I try to do one needle stick on each side and move my needle that way. And then once that's done, I use the remaining local intersphincterically to numb them up, to get a little more deeper. And generally, I tell my anesthesiologists, they're going to move until I inject the lidocaine and I'm fine with that.
MICHAEL KWIATT: Once you get numbed up, generally they're fine for the case and you really don't [INAUDIBLE] these patients real deep, especially if you're good if you're going to do the procedure in the prone jackknife position. Another option is you can do a pudendal block as another option as well.
AMIT JOSHI: I've been in this situation before where I'm exploring someone for a fistula and I can find the external os, but I can't locate the internal os. Any tips or tricks for that?
MICHAEL KWIATT: Yeah, I think the biggest tip is don't force the issue. So with gentle probing you can't find it. In terms of finding it, is there actually an internal os? What I'll do is I'll use a hydrogen peroxide. So I'll fill a 20 cc syringe with hydrogen peroxide and use a 14 gauge angiocatheter on the end, and then insert that into the external opening and then inject. And then with a retractor in the anal canal, you can look for the extravasation of hydrogen peroxide in the anal canal.
MICHAEL KWIATT: And that'll typically give you a good idea, is there actually an internal opening? Other thing that has been described, people often use too is methylene blue, which can be nice. The big disadvantage with that is if you spill it, everything gets stained. So it can be difficult. So I find that hydrogen peroxide a little more forgiving. But say you get the situation that you do inject, you find an opening, but despite all your probing, you can't find anyone.
MICHAEL KWIATT: And in that case I usually stop and what I'll do is I usually send the patient for a rectal MRI. In general, if you document that you've tried in the UA, you can't find the opening that can be one way to give you a better idea of the anatomy. It can give you an idea. Is this is a suprasphincteric fistula or a high transphincteric? It's going to be a little bit more difficult to find.
MICHAEL KWIATT: And then generally bring it back.
AMIT JOSHI: I also loved your emphasis on a comprehensive obstetric history. So important and something probably a lot of people miss.
MICHAEL KWIATT: Yeah, it often gets missed in the initial assessment.
AMIT JOSHI: Yes. Thank you. We go on to the next module.
MICHAEL KWIATT: OK. So we're going to move on to anal fissure. So an anal fissure is a tear in the distal anal canal. So what you'll have is a cut in that area. About 90% of them are going to occur in the posterior midline. And then about another 9% are going to occur in the anterior midline. So you're typically going to see these in the midline. If it's off midline, that's an atypical presentation.
MICHAEL KWIATT: And that's when you really want to start thinking about Crohn's disease. I know that's going to be a very common presentation of IBD. You can also see it rarely with patients with poorly controlled HIV. And occasionally in your leukemia or neutropenic patients. It's also been described in tuberculosis as well. But really, you're going to look to think that this is going to be in the midline.
MICHAEL KWIATT: One thing to note is that we know we often associate fissures with constipation. That's kind of the most common traditional understands bad episode of constipation leads to a fissure, but you can also see it after a real severe diarrhea illness. So not just constipation, you can also see it after diarrhea. And there's kind of two prevailing theories that kind of explain why the posterior midline is the most common area.
MICHAEL KWIATT: One's the Mechanical theory. And the idea is that the posterior midline, when you're having a bowel movement is the area of the greatest stress and that's due to the anorectal angle on that area. And when you're having a bowel movement, it leads to the most stress in that area. So with a hard stool, you're going to stress that area, and lead to the formation of a fissure. Or the other explanation is the Ischemic theory is that basically, the posterior midline is a watershed territory and because of this, blood flow is limited.
MICHAEL KWIATT: So in the setting of a hypertonic anal sphincter, the blood flows can be even more severely compromised and that can lead to fissure formation. Symptoms, like we talked about, you're going to get a lot from the history of what's actually causing this anorectal issue. So for an anal fissure, you're going to see sharp or tearing anal pain that's worse with bowel movement. Classically, these patients will show up in the office, complaining of rectal pain or anal pain, and when you ask them describe it, they'll say that every time I feel like I'm having a bowel movement or every time I go to the bathroom it feels like it like knives are coming out or that I'm passing pieces of glass or shards of glass.
MICHAEL KWIATT: That's very typical. I hear that, anal fissure is number one on my diagnosis. And that's almost always the case. Occasionally they may see bright red blood typical what they're going to describe those is a little bit of spotting on the toilet paper. You typically don't get heavy bleeding with an anal fissure. But the big thing is it's very severe anal pain with bowel movements.
MICHAEL KWIATT: So diagnosis, typically you're going to see a tear in the anal skin on a physical exam. Occasionally, you'll see a sentinel tag. That's going to be kind of a tag on the outside of the tip of the fissure. Or you may see a hypertrophic anal papilla. So one of the anal glands on the internal anal canal would be dilated and almost look like a tiny hyperplastic polyp in that area.
MICHAEL KWIATT: Generally, just by inspection, external you're going to be able to see this. And typically these patients aren't going to even let you perform a digital rectal or an endoscopic exam due to the severe pain. In terms of treatment, I like to think of a stepwise approach. So typically, you start with conservative measures. And this is what you're going to use for an acute anal fissure. So typically, in acute anal fissure is something that you're going to have less than 6 weeks.
MICHAEL KWIATT: So for these patients, typically, I recommend a topical anesthetic. Something like a lidocaine gel usually about a 2% or 5% lidocaine, even just over the counter at their pharmacy. You recommend they can do sitz baths to help with that area, increase your dietary fiber intake. The general recommendation is to recommend patients get up to 25 to 30 grams of fiber a day. Typically, that's going to require the use of a fiber supplement something like Metamucil, Citrucel.
MICHAEL KWIATT: I particularly like the powders because that forces them to take enough water with it. And you can also consider certain stool softeners. And with just those measures, typically about 50% of them will heal over that time. So usually I'll see those patients, counsel them on that, tell them to come back in 6 weeks and see how they're doing. If they haven't healed at this point.
MICHAEL KWIATT: At this point, we usually talk about a chronic anal fissure. And those typically, when you exam those patients, a lot of times you'll see exposed internal sphincter at that point. You'll see the white fibers exposed in the bed or they'll have rolled edges. And in that case, there are multiple topical agents that you can use in that situation. And the general theory behind those agents is that they increase the blood flow to the area to allow the fissure to heal.
MICHAEL KWIATT: The two main categories of agents we use are nitroglycerin or calcium channel blockers something like diltiazem or nifedipine. Nitroglycerin, about 70% of patients will report severe headaches. So that's a disadvantage to using nitroglycerin. So residents often ask why would you ever give someone that? And the reason is that's what's commercially available. If you go to your local pharmacy, you can generally write a prescription for them to get nitroglycerin and they can fill that at their local pharmacy.
MICHAEL KWIATT: Something like a calcium channel blocker, if you want to put someone on a 2% diltiazem ointment that has to come from a compound pharmacy. So they can't take that prescription to a regular pharmacy, you have to have a compound pharmacy so that they can fill that out. So that that's why that's typically not done. And the other issue is with the calcium channel blockers, just logistically, that they're typically not covered by insurance.
MICHAEL KWIATT: So patients are going to spend $50 to $100 out of pocket in order to fill that prescription. But with these chronic anal fissures for those that didn't respond to the conservative measures, about 50% to 70% of these will heal with the use of the topical agents. And there's been multiple studies comparing, but none have definitively shown that that nitroglycerin or any of the calcium channel blockers are superior.
MICHAEL KWIATT: Another thing that's been used more frequently, probably, at least recently in the last 10 years is botox injections. So the theory behind this is that botulinum toxin inhibits release of acetylcholine into the neuromuscular junction, which then blocks contraction of the internal anal sphincter, and then allows the sphincter to relax. So the idea is that you're getting rid of the hypertonicity of the anal sphincter. I kind of like to consider it almost like a chemical sphincterotomy.
MICHAEL KWIATT: So you're going to give someone the sphincterotomy, we'll get to is kind of the gold standard. A tried and true treatment without having to perform the actual sphincterotomy. And these have been shown to have about 70% success in healing chronic fissures. Just things to keep in mind, it's a temporary effect. So botox typically lasts last for 3 months. If you have botox elsewhere, a lot of times people get repeated injections.
MICHAEL KWIATT: So it's the same with an anal fissure. So it's only going to last for about a few months. So because of that, recurrence is possible. One of the big advantages is with fistulotomy and just like with a chemical, I'm sorry with a sphincterotomy or it's a chemical sphincterotomy, there is a risk of incontinence because botox is temporary. If a patient does have an adverse reaction and leads to incontinence, it's going to be a temporary thing that'll wear off over time.
MICHAEL KWIATT: In terms of being able to perform this on a patient, in order to get this coverage, typically, insurance companies will want you to try one of the topical agents first. A lot of times you don't have the option of going right to botox. You kind of have to go through the stepwise progression. And the last is the lateral internal sphincterotomy, which has been used for decades for the treatment of an anal fissure.
MICHAEL KWIATT: And the idea is cutting a portion and division of the sphincter leads to a release of the hypertonicity, and allows the finger to heal. I do want to make a plug that a lateral internal sphincterotomy is one of the core procedures listed in the school curriculum. So it's considered fair game by the American Board of Surgery. So I do recommend that you really kind of get in a sense of how this procedure is performed.
MICHAEL KWIATT: We're going to spend some time going over that right now. So some key things is you're dividing the internal sphincter. It's a lateral internal sphincterotomy. And the division's done in the lateral area of the anal canal. And the reason being as we discussed earlier, if you do a fistulotomy in the posterior midline, kind of going back to that ischemia or watershed theory that the posterior midline is a poor area for wound healing.
MICHAEL KWIATT: And what happens is that you won't heal that wound fully and you'll get almost like a divot back there or what we call a keyhole deformity if you don't perform it at the area of the fissure, you're going to go lateral where the blood supply is better. And there's two techniques that are better described in open or closed technique. They both have six similar success rates and they both have similar risks of fecal incontinence.
MICHAEL KWIATT: In terms of the closed technique, we'll go over it and describe the steps how to do that. Simply what you're going to want to do is you want to locate the intersphincteric groove. So I generally do these in lithotomy and they can also be done in the prone jackknife position. Like Dr. Joshi mentioned before, you'll want to anesthetize the area with a local anesthetic. And with a retractor, I like the Hill-Ferguson retractor, I'll place that in the anal canal.
MICHAEL KWIATT: Do an exam to make sure there's no pathology. Sometimes an anal cancer can masquerade as symptoms of as a fissure. And a lot of times, you're not able to do an endoscopy in the office or digital rectal exams. You want to make sure that you take the time to do a thorough examination under anesthesia before you start. But with that retractor and that's going to put some stretch on the sphincter and that's going to really allow you to palpate the intersphincteric groove, you're going to be able to feel the two bands touching just proximal of the anal verge.
MICHAEL KWIATT: You can feel the two bands and be able to help in the internal and the external sphincter. Or you can do that as I'm taking an 11 blade scalpel, insert it into the intersphincteric groove, and then turn the scalpel medially, and then divide the internal sphincter. And you can see that at the bottom here, you're going to divide the lower portion of the internal sphincter by turning the blade medially and cutting that way.
MICHAEL KWIATT: Classically this is described as to do the division without the retractor in the anal canal, and with one finger in the anal canal and then perform the sphincterotomy, you can actually feel the sphincter loosen and lose that hypertonicity. So that's the closed technique. Other technique is the open technique.
MICHAEL KWIATT: So with that again, can be done in prone jackknife or in the lithotomy, adequate anesthesia, and do a thorough exam. And then with the retractor and again, you're going to find the intersphincteric groove. But this time, you're going to make a radial incision over the intersphincteric groove. So it's radial incision. This is different than what you would do for a LIFT procedure where you make a circular one which is right over the groove.
MICHAEL KWIATT: And then using just like a hemostat, you can dissect out and expose the internal sphincter. I would show the medical students when I'm doing this that the internal sphincter is white, that sounds very easily-- obviously could be more medial, and it's white in appearance. That's how you can identify the internal sphincter. And then you just divide it. I typically just use electric cautery and then close up the incision.
MICHAEL KWIATT: Just a couple other things to consider. Traditionally, they talk about cutting the internal sphincter for a sphincterotomy up to the dentate line. That's a classic definition. More often, people perfom what's called a Tailored sphincterotomy. And in that case, you're not going to make quite as large of a sphincterotomy.
MICHAEL KWIATT: In that case, typically, they talk about doing your sphincterotomy that's the same length of your fissure. So that's about how large your fissure is. It's about how much sphincter you have to divide with your sphincterotomy. And then the other thing to consider, in the case that you're doing a patient with a repeat sphincterotomy, you'll want to do the opposite sides of patients who have had a sphincterotomy in the left.
MICHAEL KWIATT: If you find that it's unsuccessful, and in that case, you have to go back and do another sphincterotomy, typically you go to the other side.
AMIT JOSHI: Really nice algorithm and view also of a fissure. Are there any circumstances where you would go, let's say you-- I mean I'm sure you'll always do a conservative, no topical, no botox, but is there any reason why you would ever skip over, topical skip over botox and go straight to sphincterotomy. What are those circumstances?
MICHAEL KWIATT: If you're examining the patient and you find that they have clearly a chronic fissure, something's got the rolled edges exposed sphincter. And you find out that they're in severe pain, a lot of times, sometimes especially in a young man and you examine and they have a really tight sphincter complex. You know those patients that is often gone right to the fissure. And a lot of times at the initial discussion when they see me in the office, I kind of lay out for them this is how this goes down and that these are the things that we can try.
MICHAEL KWIATT: And you have the occasional patient that says like, this is driving me nuts. I can't go through all of this. Let's go let's go right to the sphincterotomy. And if you do think it's truly a chronic fissure with a hypertonocity problem, and you have a lot of reason to think that they'd be at increased risk for incontinence. Those patients, I will occasionally, jump right to the sphincterotomy.
AMIT JOSHI: And do you personally ever do a closed one or do you always do an open one?
MICHAEL KWIATT: I should do both. I usually like to show the residents both. And I actually think when you're first learning to show them the open just because I think it gives you kind of a sense of what you're doing. And then when they've done that and kind of move on to the closed one.
AMIT JOSHI: I was going to ask you what rate of incontinence do you quote forced entorotomy. I guess it's part of the patient's preop.
MICHAEL KWIATT: But no. I mean-- So it's a wide range of what people quote. Some say as high as 40%, some say it can be as low as 2% to 3%. I mean, I usually say about 10%. And I explain to them with that generally, what they're talking about is patients talking about having leakage of gas or a little bit of seepage. And the risk of actually having full incontinence of solid or liquid stoll is well less than 1% in the average patient.
AMIT JOSHI: And even when there's some gas and liquid, it's usually temporary. Correct?
MICHAEL KWIATT: Correct. Yes. So like we mentioned, like with the fistulotomy before. They will say, it's tense and that goes back to, it depends on a lot of times how you study it. If you survey patients within the first couple of weeks, you're going to see a much higher risk of incontinence. Whereas, usually after about a month, a lot of times the temporary incontinence will resolve.
MICHAEL KWIATT: OK. All right. And then lastly, pilonidal disease will be a little shorter. So pilonidal diseases is acute or chronic infection in the sacrococcygeal region. So really at the tip of the tailbone. It's typically seen in patients in their 20s and 30s and more common in men than women.
MICHAEL KWIATT: So kind of the stereotypical patient for pilonidal disease is going to be a young man with a deep natal cleft with a lot of hair. So those are the what you kind of see as a typical pilonidal disease patient. However, can be seen in women as well. So the pathogenesis, we used to believe that Pilonidal sinuses were congenital openings in the sacrococcygeal region in the midline.
MICHAEL KWIATT: But now the leading idea is that you can have a hair follicle in that area that ruptures from stretching or becoming clogged with keratin and that leads to the creation of this environment that causes abscesses. So the area is moist, it's anaerobic, and this causes abscess, and prevents the area to healing. And that leads to the formation of a midline pit. So a midline pit is almost going to be like a pinpoint opening in the sacrococcygeal region right in the midline.
MICHAEL KWIATT: And the idea is that hair gets drawn into the area of the natal cleft and a pit forms and that causes an enlarging abscess. So these areas keep getting hair sucked in there. And then the body attempts to eradicate the infection. And that leads to the formation of all these sinuses that you'll see laterally on the skin. In terms of non-surgical management, you can counsel patients that have had a pilonidal abscess to reduce their sitting time.
MICHAEL KWIATT: If they're overweight, you can counsel them with weight loss. You can discuss improved hygiene. Some patients, especially teenagers, you may need to tell them that they need to shower every day. And then you can also discuss weekly shaving, which we often counsel our patients on to remove the hair in the area, but won't really prevent the formation of an abscess that's already there. What shaving will do is it will decrease the number of surgical procedures required to get rid of an abscess or decrease the length of stay of hospital stay or time to healing.
MICHAEL KWIATT: And after the healing of an abscess, it might prevent a recurrence. One of the interesting things to note is that we talk about shaving, but they've actually found that there's a lot of theories that it's not necessarily your hair from your gluteus cleft that ends up in this area. And the reasoning behind that is that there there's an increase of risk of pilonidal disease we've seen in hairdressers and in sheep shearers.
MICHAEL KWIATT: People that shear sheep or dress hair can often have a higher risk of pilonidal disease. So it may not be even their own hair. An acute Pilonidal abscess, it presents as a painful, fluctuant abscess over the intergluteal cleft. So the patients come in and say, I have swelling and pain in my tailbone area. And just like your perianal abscess, the treatment's incision and drainage.
MICHAEL KWIATT: All these need to be drained. A lot of times, primary care physicians will send these patients home on antibiotics. And really, what will happen is eventually they'll burst on their own. And what they really need done is an I and D. Typically, like in a fissure the midline area of your sacrococcygeal area is a watershed area, not a great area for wound healing.
MICHAEL KWIATT: So typically, you recommend you place the incision off midline about a centimeter to improve healing. You can use elliptical or cruciate incision. And like your perianal abscess, antibiotics typically aren't needed. Chronic pilonidal sinus can form after multiple abscesses. And what happens is they get openings on the external skin. Occasionally, patients will have these, but not have much symptoms.
MICHAEL KWIATT: And that's the patient that you talked about hair removal to prevent further flare ups and another abscess. And your procedure options include incisional and excisional procedures. So you can think of incisional procedures where you're going to just open up the area versus an excisional where you're going to cut all the tissue away and then with or without primary closure.
MICHAEL KWIATT: So a midline excision that's the longest known entity for treating these. And with that is that's going to be en block excision of the entire pilonidal sinus is that you're going to go ahead and core out that area. Traditionally, what's been described is going all the way down to the presacral fascia. What they did historically was a wide local excision of the area.
MICHAEL KWIATT: And commonly, we talk about that pilonidal disease is called Jeep's driver's disease because they found that during the World War II, there is an increased risk of it. And the idea being is there's a lot of men in their 20s and 30s that were hairy. And it was such a problem that at one point during World War II, there were 80,000 soldiers during the course of the war that were hospitalized for pilonidal disease.
MICHAEL KWIATT: And their average length of stay after a wide local excision was 55 days in the hospital. So they had so many men off the battlefield that the surgeon general actually came out and put a ban on performing excision of pilonidal cysts in the military towards the end of the war. So again, we don't do quite as wide of an excision these days. You just remove the inflamed tissue to include the sinus in the midline cyst.
MICHAEL KWIATT: And you can't consider closing these primarily. That will lead to a faster closure. They've shown that if leaving it open and letting it to heal into out, that's going to be about two weeks, I'm sorry two months to closure versus about two weeks. But that does increase your risk of recurrence or infection. Unroofing with secondary healing that's going to be rather than taking out the whole area and cutting and removing all that tissue, the sinuses just unroof and curetted clean.
MICHAEL KWIATT: And then what this does is that creates a much smaller wound without an excision. And this can be useful in the setting of an acute abscess when you can't close the wound. So someone comes in with an abscess and associated sinus, you can just open up that whole area and curette it clean, and let it heal from the inside out. Along those lines, we talk about the Bascom I which is just the midline pit excision.
MICHAEL KWIATT: And then this is another open it up and let it drain. What you could do in this procedure is you make an incision off the midline as you would for an abscess and then using a curette, you curette towards the midline and clean out all the sinus cavities and tracts, but you don't excise any tissues. Except for in the midline, where you can use an 11 blade scalpel or my pediatric colleagues have almost like a punch biopsy that they use to just remove the midline pits in the middle and then close that usually with an absorbable suture.
MICHAEL KWIATT: It usually takes one simple stitch. So you're not excising anything, you're pretty much removing the pits and then draining off midline for a Bascom I. There's also a lot of flaps that you can use to control if you have to do a large excision. I personally got to say I don't have a whole lot of experience with these and when it gets this bad, I usually refer this to my plastic surgery colleagues.
MICHAEL KWIATT: But they discuss a Karyadakis flap which is really just the mobilization of the skin from one side of the tissue, one side of the gluteal cleft to the other. So you just mobilize the opposite side that your excised and then advance it across the midline and suture closed. Or they talk about the Limberg flap which is just a rhomboid rotational flap. And in this case you just do a diamond shaped excision of the tissue.
MICHAEL KWIATT: And then using a counter incision, you make a rhomboid flap that you can then rotate into the wound. And then the most advanced you may hear of is the Bascom II which is the cleft lift procedure. The principles behind this is you undermine and obliterate the gluteal cleft. So what you do is you raise the skin off the gluteal cleft leaving the subcutaneous tissues in place.
MICHAEL KWIATT: And then just curette chronic wound, excise the diseased skin, and then you just perform just a skin flap across the midline to the wound. So in pilonidal disease, there's a lot of treatment options and this is really going to be tailored to the individual case depending on the severity of the disease. And I think that that concludes everything I have for you guys today.
AMIT JOSHI: That's great. A little military history. The anecdotes about the sheep shearers and the hairdressers, it was a mildly disturbing to me.
MICHAEL KWIATT: Yes.
AMIT JOSHI: It's fascinating. Also it's so important to talk about prevention of recurrence and so all the non-operative management of pilonidal with hygiene and hair control. You can do a great procedure and then if the patient is not complying with those things, six weeks, six months later, they're back in the office with the same problem. So important to set those expectations at the beginning. This is great Dr. Kwiatt.
AMIT JOSHI: These procedures are so central to not just colorectal surgeons but general surgeons across the country. And certainly important to residents in training. So this is a great review of all four of these conditions. Thank you so much for all your expertise in this week of SCORE school.
MICHAEL KWIATT: Right. Well thank you for having me.
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