Anal pathology in pediatric surgery with Dr. Nelson Rosen

The anal verge is defined as the mucocutaneous junction where tissue stops being pink and wet and starts being skin.

Anal fissures are exquisitely painful.

A sentinel pile (heaped up lump of granulation covered with regular skin) is a sign of chronic inflammation in the area of a fissure.

Chemical sphincter relaxation for anal fissures started coming into vogue in the late 1990s.

Nitroglycerin allows for sphincter relaxation and healing in about 80% of patients but has a fairly high rate of causing headaches.

Diltiazem gel has been used for the past 20 years with pretty reasonable results for anal fissure treatment.

Stooling physiology is complex, and it's not always the stool consistency that generates the push and the degree of pressures.

Dr. Rosen receives about 12 children referred per year for hemorrhoids, and maybe 1 to 2 of them might actually be hemorrhoids.

Hemorrhoids are one of the least common anal pathologies Dr. Rosen gets called about in pediatric patients.

The mainstay of hemorrhoid management is good constipation management.

Wet cleansing (bidets, washlets, wet wipes) is more efficient and less traumatic to perianal skin than dry paper wiping.

A rectal exam is essential to make sure you're not missing an intussusception, which can be from an anatomic lead point like a polyp in the upper rectum or distal sigmoid.

In a prolapse, a finger will go nowhere when trying to stick it around the prolapsed tissue, but in an intussusception, it will go right next to it between the anal canal and the prolapse.

In the era of universal cystic fibrosis screening, the yield of picking up a child with no history or concern for CF based solely on rectal prolapse is in the 3 to 3.5% range.

Injection sclerotherapy can be highly effective for recurrent rectal prolapse.

Laparoscopic rectopexy is a very effective procedure for rectal prolapse.

Pelvic floor physical therapy is beneficial for older patients with rectal prolapse because pelvic floor laxity won't improve with surgery but will improve with physical therapy.

Dr. James Warden, a highly respected pediatric surgeon from California, stopped draining perianal abscesses in infants because they all went away on their own.

Most infants with perianal abscess don't need to go to the operating room for a fistulotomy, and the abscess should not be drained; instead, try to cool off the abscess with antibiotics because doing so will dramatically decrease the likelihood of forming a fistula in ano.

If an infant persists with a fistula to age 2 and there are no other concerns, Dr. Rosen will do a fistulotomy.

The reason for avoiding surgery in infant perianal abscess is to avoid the anesthetic, not because surgery doesn't work.

Dr. Rosen is a big fan of the cruciate incision for draining perianal abscesses because it helps facilitate ongoing drainage.

Dr. Rosen is a big fan of not packing abscess cavities; he places just the corner of a 4x4 for initial hemostasis, tells patients to soak in the tub so it falls off, then use a top dressing.

Goodsall's rule is a generalization that is often true, but there are plenty of patients whose fistulas do not follow this rule.

In children under 18 who presented with a fistula, 12% developed Crohn's disease; 5% of those with abscesses and 2% of those with fissures developed Crohn's.

Children over 10 years of age presenting with perianal symptoms had a 13% likelihood of Crohn's disease, and if that symptom was a fistula, that group had a 35% likelihood of having Crohn's.

Looking back at children eventually diagnosed with Crohn's disease, 64% of them had abdominal symptoms that could be paired with their perianal symptom to identify high-risk patients.

The standard adult pathway is fistulotomy for superficial fistulas, but suprasphincteric or intersphincteric fistulas need a different treatment plan to avoid causing incontinence.

For complex fistulas, a bioprosthetic plug (Cook brand) is used by scrubbing the tract, placing the plug, and stitching it in place on the inside and outside, with about a 60-70% likelihood of healing.

The eye only sees what the mind suspects; clinicians must keep pilonidal disease in their thoughts at all times when evaluating perianal pathology.