Surgical treatment of anal stenosis

Table 1 Anoplasty for anal stenosis

Procedures	Indications	Advantages/Disadvantages
Partial lateral internal sphincterotomy	Functional stenosis; mild and low stricture in the anal canal	This technique is simple and safe. Use is limited to functional stenosis
Mucosal advancement flap	Middle or high localized stricture	Ectropion formation if the flap is sutured at the anal verge
Y-V advancement flap	Low and localized stricture below the dentate line	Proximal part of the flap is very narrow and will not allow for a significant widening of the stricture above the dentate line. Also, the tip of the V within the anal canal is subject to ischemic necrosis from lack of mobilization, tension of the flap or loss of vascularization
V-Y advancement flap	Mild to severe stricture at the dentate line. Middle or high localized strictures, associated with mucosal ectropion	The tip of the V is subject to ischemic necrosis
Diamond flap	Moderate to severe long stricture, localized or circumferential stricture above the dentate line, associated with mucosal ectropion	A diamond-shaped flap is designed so that it will cover the intra-anal portion of the defect. The flap is mobilized with minimal undermining to preserve the integrity of the subcutaneous vascular pedicle
House flap	Moderate to severe long stricture, localized or circumferential or diffuse, and stricture above the dentate line, associated with mucosal ectropion	It allows primary closure of the donor site and increases anal canal diameter along its length. Because of the wide base, it avoids the pitfall of having a narrow apex present inside the anal canal that may become ischemic
U flap	Moderate to severe stricture, localized or circumferential, associated with mucosal ectropion	This technique is particularly useful when there is need to excise a significant area of ectropion. The donor site is left open
C flap	Moderate to severe stricture, localized or circumferential, associated with mucosal ectropion	The donor site is left open
Rotational S flap	High severe stricture, circumferential or diffuse, associated with mucosal ectropion	It provides for adequate blood supply, avoids tension, and can be performed bilaterally if necessary for coverage of large areas of skin. Complex technique: high morbidity and longer hospital stay

Table 2 Experiences in literature

Authors	No. of cases	Procedure	Results			Healing rate (%)
			Good	Fair	Poor
Sarner et al[45]	21	Sarner’s flap	-	-	-	100
Nickell et al[46]	4	Advancement flap anoplasty	4	-	-	100
Oh et al[41]	12	C anoplasty	11	-	1	90
Khubchandani[40]	53	Advancement flap anoplasty	Nr	Nr	Nr	94
Milsom et al[6]	24	V-Y anosplasty and Sarner’s anoplasty	-	-	-	90
1Gingold et al[28]	14	Y-V anoplasty	9	5	-	64
Caplin et al[11]	23	Diamond flap anoplasty	23	-	-	100
Ramanujam et al[30]	21	Y-V anoplasty	18	2	1	95
Pearl et al[29]	25	Island flap anoplasty	16	7	2	92
2Angelchik et al[23]	19	Y-V anoplasty (12 cases)	8	4	0	100
		Diamond flap anoplasty (7 cases)	7	-	-	100
Pidala et al[42]	28	Island flap anoplasty	25		3	91
Eu et al[38]	9	Lateral internal sphincterotomy (5 patients) and anoplasty (4 cases)	9	-	-	100
Gonzalez et al[39]	17	S anoplasty (6 cases) and advancement flap anoplasty (11 cases)	16	-	1	92
Sentovich et al[32]	29	House advancement flap	26	-	3	90
Saldana et al[34]	1	Internal pudendal flap anoplasty	1	-	-	100
Aitola et al[25]	10	Y-V anoplasty with internal sphincterotomy	6	3	1	60
de Medeiros[47]	30	Sarner’s flap or Musiani’s flap	-	-	-	100
Maria et al[5]	42	Y-V anoplasty (29 cases)	26	-	3	90
		Diamond flap anoplasty (13 cases)	13	-	-	100
Stratmann et al[44]	3	-	-	-	-	100
Ettorre et al[26]	1	House advancement flap	1	-	-	100
Saylan[20]	3	Y-V anoplasty	-	-	-	100
3Rakhmanine et al[24]	95	Lateral mucosal advancement anoplasty	74	-	8	90
Carditello et al[36]	149	Internal sphincterotomy and mucosal flap anoplasty	Nr	Nr	Nr	97
Habr-Gama et al[15]	77	Sarner’s flap (58 patients) and Musiani’s flap (19 patients)	-	-	-	87
Filingeri et al[27]	7	Y-V anoplasty	-	-	-	100
Casadesus et al[1]	19	Y-V anoplasty (7 patients) and lateral mucosal advancement flap anoplasty (12 patients)	-	-	-	100
Alver et al[31]	8	House advancement flap (14 flaps: 1 flap for 2 patients, and 2 flaps for 6 patients)	6	-	-	100

Nr: Not reported.

¹No sphincterotomies were done;

²Not all patients underwent sphincterotomy, and some of the procedures were for anal ectropion;

³Depending on the degree of stenosis, patients initially underwent either unilateral (62%) or bilateral (38%) anoplasty. Thirteen patients with a follow up of less than 6 mo were excluded from the analysis for restenosis.