Is anoplasty superior to scar revision surgery for post-hemorrhoidectomy anal stenosis? Six years of experience

BACKGROUND Anal stenosis is a rare but frustrating condition that usually occurs as a complication of hemorrhoidectomy. The severity of anal stenosis can be classified into three categories: mild, moderate, and severe. There are two main surgical treatments for this condition: scar revision surgery and anoplasty; however, no studies have compared these two approaches, and it remains unclear which is preferrable for stenoses of different severities.AIM To compare the outcomes of scar revision surgery and double diamond-shaped flap anoplasty.METHODS Patients with mild, moderate, or severe anal stenosis following hemorrhoidectomy procedures who were treated with either scar revision surgery or double diamond-shaped flap anoplasty at our institution between January 2010 and December 2015 were investigated and compared. The severity of stenosis was determined via anal examination performed digitally or using a HillFerguson retractor. The explored patient characteristics included age, sex, preoperative severity of anal stenosis, preoperative symptoms, and preoperative adjuvant therapy; moreover, their postoperative quality of life was measured using a 10-point scale. Patients underwent proctologic follow-up examinations one, two, and four weeks after surgery.RESULTS We analyzed 60 consecutive patients, including 36 men(60%) and 24 women(40%). The mean operative time for scar revision surgery was significantly shorter than that for double diamondshaped flap anoplasty(10.14 ± 2.31 [range: 7-15] min vs 21.62 ± 4.68 [range: 15-31] min; P < 0.001). The average of length of hospital stay was also significantly shorter after scar revision surgery than after anoplasty(2.1 ± 0.3 vs 2.9 ± 0.4 d; P < 0.001). Postoperative satisfaction was categorized into four groups: 45 patients(75%) reported excellent satisfaction(scores of 8-10), 13(21.7%) reported good satisfaction(scores of 6-7), two(3.3%) had no change in satisfaction(scores of 3-5), and none(0%) had scores indicating poor satisfaction(1-2). As such, most patients were satisfied with their quality of life after surgery other than the two who noticed no difference due owing to the fact that they experienced recurrences.CONCLUSION Scar revision surgery may be preferable for mild anal stenosis upon conservative treatment failure. Anoplasty is unavoidable for moderate or severe stenosis, where cicatrized tissue is extensive.