Diamond Versus V-Y Advancement Flaps for Management of Anal Stenosis: Efficacy and Outcomes (2025)

Background: Anal stenosis is a weighty complication after anal and rectal surgery. Moderateand severe cases mostly require surgery.
Patients and Methods: This study included 45 patients with post-hemorrhoidectomy analstenosis; 23 patients underwent diamond flap anoplasty (group I), and 22 had V-Y flapanoplasty (group II). Patients were monitored for post-operative complications and followedup at 1, 3 and 6 months postoperatively for symptomatic improvement, pain visual analoguescale (VAS) and Wexner score for continence level.
Results: 31 patients were males and 14 were females. Age was 34.13±4.32 years. 13patients had severe anal stenosis, while 32 patients had moderate anal stenosis.Preoperative VAS score ranged between 5 and 10. There was no statistically significantdifference between both groups regarding operative time and post-operative complications.Follow up at 1, 3 and 6 months showed a highly significant drop in VAS score withsignificant improvement of symptoms with no significant difference in both groups.
Conclusion: Diamond and V-Y flap anoplasty are easy, safe and successful options formanagement of moderate and severe post-hemorrhoidectomy anal stenosis with markedimprovement of patient symptoms and low complication rate. Both techniques had nearlysimilar outcomes and choice of procedure depends on surgeon’s preference.Key words: anoplasty, diamond flap, V-Y, post-hemorrhoidectomy, anal stenosis

INTRODUCTION

Anal stenosis is a serious disabling condition. It can be anatomical orfunctional. In anatomical stenosis, the normal anoderm is replaced with avarying degree of restrictive non-elastic cicatrized tissue, while in functionalstenosis, there is a hypertonic internal anal sphincter (1). It has been reportedthat aggressive hemorrhoidectomy accounts for about 90% of anal stenosiscases (2). It may be due to inflammatory process as in ulcerative colitis andCrohn’s disease. Some venereal diseases, post radiotherapy, tuberculosis andchronic abuse of laxatives may be also involved (3).Some patients may cope quite well in spite of the stenosis, while otherscomplain of symptoms such as decreasing stool caliber, constipation, fecal incontinence, difficulty in evacuation, anal pain,bleeding or diarrhea (4).
The severity of postoperative anal stenosis isclassified into three degrees; mild stenosis, in whichthere is tight anal canal which can admit a mediumsized Hill–Ferguson anal retractor or lubricated indexfinger, moderate stenosis which can admit them onlyafter forceful dilatation of the anus and severe stenosisin which neither the small sized Hill–Ferguson retractornor lubricated little finger can be admitted (5). The levelof anal stenosis may be low (distal to at least 0.5 cmbelow the dentate line), middle (0.5 cm above and 0.5cm below the dentate line), high (proximal to 0.5 cmabove the dentate line) and diffuse affecting the wholeanal canal (6). Furthermore, The level of anal stenosismay be low (distal to at least 0.5 cm below the dentateline), middle (0.5 cm above and 0.5 cm below thedentate line), high (proximal to 0.5 cm above the dentateline) and diffuse affecting the whole anal canal (4).
The best treatment is prevention via adequateanorectal surgical technique (7). Conservative treatmentis advised for mild cases and initially for themoderate ones. Plenty of fluids with the use of fibersupplements and stool softeners are the basis ofconservative management in addition to anal dilatationwhich can be performed digitally or with graduatedmechanical dilators (8). Lots of surgical techniques arewell-known for management of moderate and severecases of anal stenosis. The simplest procedure iis partiallateral internal sphincterotomy, while classic anoplastyshould be performed for more severe cases to restorethe pliability of the anal canal. Many types of flaps canbe performed and the selection of the appropriatesurgical procedure depends on many factors alocation, type, extension of stenosis and surgeon'sexperience (3).

Aim of the work

To evaluate the efficacy and outcomes of twodifferent techniques of anoplasty (diamond versusV-Y advancement flaps) for management of posthemorrhoidectomyanal stenosis.

Patients and methods

This retrospective cohort study was carried out on45 patients with anal stenosis over a period of threeand half years from May 2017 to October 2020 at AinShams University hospitals after approval by theMedical Ethical Committee. Written informed consentwas obtained from all patients prior to surgery.Inclusion criteria consisted of patients with moderateand severe anal stenosis due to complications ofMilligan–Morgan’s open hemorrhoidectomy and theaverage duration of their symptoms was 1–2 years withfailure of conservative management. Patients with mildanal stenosis or those with history of inflammatorybowel disease (IBD), TB, previous radiotherapy, analmalignancy and previous anoplasty were excluded fromthe study. Patients were divided into two groupsaccording to the type of anoplasty; group (I) had 23patients who underwent diamond flap anoplasty, andgroup (II) had 22 patients with V-Y flap anoplasty.Data collected included age, sex, degree of analstenosis according to Milsom and Mazier (5), preoperativesymptoms and assessment of anal pain using avisual analogue scale (VAS) score on a 10-cm linerepresenting 0 for “no pain” and 10 for “worst pain” inaddition to assessment of the level of continence usingClevland Clinic Incontinence Score (Wexner Score, WS).Operative details included the side performed eitherunilateral or bilateral, operative time and immediatepost-operative complications. All patients were followedup at 1, 3 and 6 months postoperatively for assessmentof level of symptomatic improvement on a scale of 1 to5, where 1 is worse, 2 is the same, 3 is slight, 4 isgood and 5 is excellent improvement (4) in addition toassessment of VAS score for anal pain, Wexner scoreand any complications.

Operative details

Because of the very much tight anal orifices, nopreoperative enemas were possible, however, stoolsofteners were prescribed to all patients 5 days beforesurgery. Just prior to surgery, all patients received intravenousantibiotic (cephazoline and metronidazole) thatwas continued for 5 days postoperatively (6). Surgerywas done under general or spinal anesthesia, and allprocedures were done in the lithotomy position. Afterantiseptic cleaning of the area and draping, theanal verge was inspected, palpated and dilated using amedium sized Hill-Ferguson anal retractor.
For diamond flap anoplasty, incision of the scarredtissue is done leaving a diamond-shaped raw area.Then, a diamond-shaped flap is designed to cover theraw area. Adequate mobilization of the flap should bedone to be tension free and preserve an adequateblood supply (9). For the V-Y flap anoplasty, afterincising the scar tissue, the base of the V flap is suturedto the top of the raw area. The skin is then closedbehind the V from outside pushing it inside the anal canal (10) as shown in figs. 1 and 2.

The size of the flaps was tailored according to theraw area after performing stricturotomy in all patientsand the decision of performing bilateral anal flaps isconsidered after assessment of the anal diameterfollowing unilateral anoplasty. After the operation, allpatients were maintained on analgesics in addition tothe antibiotic with dressing twice daily till healing; thefirst dressing was done after 24 hours to excludeischemia of the flap. They were also advised for NPOfor 24 hours followed by clear oral fluids for 48 hoursthen soft diet for 1 week. High-fiber diet and bulklaxatives were prescribed to all patients for the earlypostoperative period

Statistical analysis

The collected data was revised, coded, tabulatedand introduced to a PC using Statistical package forSocial Science (SPSS 20). Data was presented andsuitable analysis was done according to the type of dataobtained for each parameter. Descriptive statisticsincluded mean, standard deviation and range forparametric. Frequency and percentage were used fornon-numerical data.Analytical statistics included Friedman test forassessment of statistical significance of the differencebetween more than two study variables. Chi-Squaretest was used for the relationship between two qualitativevariables and Mann Whitney Test for statisticalsignificance of the difference of a non-parametricvariable between two study groups. P-value >0.05represents non- significant, < 0.05 for significant onesand <0.01 for highly significant results.

RESULTS

Most of the patients were males (n=31, 68.9%) and14 (31.1%) were females. Their age ranged from 25 – 40years with a mean ± SD of 34.13 ± 4.32. There was nostatistically significant difference between patients inboth groups regarding their sex or age. The main preoperativesymptoms of all patients were anal pain,constipation, difficult evacuation and narrow stool. 19patients (54.3%) had additional symptoms of perianalitching, while 12 (34.3%) had recurrent attacks ofbleeding and only 3 (8.6%) had symptoms of mild fecalincontinence (FI) as shown in table 1. Upon examination,13 out of the 45 patients (28.9%) had severe analstenosis (7 in group I and 6 in group II), while 32patients (71.1%) had moderate anal stenosis.

Assessment of anal pain revealed that all the patientshad a VAS score ranging between 5 and 10 (mean ± SD;7.09 ± 1.77) and assessment of the continence levelshowed that only 3 patients had symptoms of mild fecalincontinence, while 42 patients had no symptomsincontinence with WS ranging from 0-9 (mean ± SD;1.02 ± 2.09).There was no statistically significant differencebetween both groups regarding the operative time as itranged from 40-70 minutes (mean ± SD; 52.17 ± 8.90)in group I and from 40 – 65 minutes (mean ± SD; 50.00± 9.26) in group II. 11 patients (24.4%) with severe analstenosis needed performing the same shape anoplastyin the contralateral side (5 in group I and 6 in group II).All patients remained in the hospital for 2-3 days postoperativelyfor follow up and dressing during which, nosignificant immediate post-operative complicationswere reported apart from 2 patient in group I and 1 ingroup II who developed transient urine retention,which was successfully managed by Foley’s catheter.

Follow up of the patients at 1, 3 and 6 months aftersurgery showed a highly significant drop in VAS scorefor anal pain and a highly significant improvement oftheir symptoms over time as shown in table 2 andfigs. 3 and 4 with no significant difference betweenpatients in both groups regarding their post-operativeoutcomes at 1,3 and 6 months as shown in table 3.Post-operative Wexner score revealed improvement ofthe continence level of the 3 patients who had preoperativemild fecal incontinence (WS 4 Vs 9). Amongthe remaining 42 patients, only 2 patients in group Iand 3 patients in group II developed mild occasionalincontinence to flatus and liquid stool postoperatively(WS 3 to 4). Regarding post-operative wound complications,there was no statistical difference between both groups regarding the complication rate. At one monthfollow up, 4 patients developed wound dehiscence and2 patients had delayed wound healing in group I, whilein group II, 5 patients had wound dehiscence andanother 3 patients had delayed wound healing. Allthese complications were completely resolved at 3months follow up apart from one patient in group IIwho developed a picture suggestive of restenosis at 3months that eventually resulted in recurrence of analstenosis by the 6th month giving a healing rate of 100%in group I and 95.5% in group II.

DISCUSSION

Many procedures have been described for managementof anal stenosis as Y–V, V–Y, diamond, house,U-shaped, C-shaped advancement flaps and rotationalS-flap (11). The principle of anoplasty consists ofincreasing the dimension of the anal outlet by internalsphincterotomy and removal of cutaneous scarring andmaintaining correction by proximal advancement ofskin flaps or distal advancement of mucosa (4).
No single procedure fits all, and the choice of theoperation depends both on the surgeon’s experienceand on the severity of stenosis (7). Despite the reportedgood results of these procedures (60–100% healing rate),many complications have been reported like analmucosal ectropion, seepage of mucus or liquid stools,pruritus, suture dehiscence, flap retraction, ischemicnecrosis especially at the corners of the flaps, infection,incontinence, and recurrence. The best technique hasto be simple with no morbidity and restoring the analfunction giving the best long-term results (3).
In our study, we preferred to study and compare theoutcomes of two different techniques of anoplastywhich are diamond and V-Y flap anoplasty as wehypothesized that they both have good long-termresults and low complications, beside that they may beperformed bilaterally in patients with severe analstenosis.
All cases of anal stenosis in our study were complicationsof Milligan–Morgan’s open hemorrhoidectomywhich is going well with the literature as the commonestcause of anal stenosis. Its rate has been reportedfrom 1.2 - 10% after overzealous hemorrhoidectomy(9). Excision of large areas of rectal mucosa sacrificingthe muco-cutaneous bridges during hemorrhoidectomyleads to massive scarring ending in chronic stricture (10).Patients with other causes of anal stenosis as IBD, TB,previous radiotherapy or anal malignancy were notincluded in the study to exclude the possibility of recurrenceas a pathological result of these original diseases.
In our study, both techniques resulted in significantimprovement of the preoperative symptoms asevidenced by marked drop of the VAS score for analpain and a significant increase of the symptomimprovement score of the patients with their follow upat 1, 3 and 6 months after surgery with over all healingrate of 97.8%. This was in agreement with Milsom andMazier (5) who advocated V-Y anoplasty for managementof severe low anal stenosis over a five-yearperiod and documented excellent results with 90%healing rate after the operation. Sheikh and hiscolleagues (12) also documented successful results ofV-Y flap anoplasty for management of severe cases ofanal stenosis in a series of 5 patients.
100% healing rate was documented in study ofCaplin et al in which 23 patients with anal stricture andmucosal ectropion were operated using diamond flapanoplasty (13). The same healing rate (100%) was alsodocumented in many studies using diamond flap formanagement of anal stenosis (9,14).
Comparing both techniques in our study showedthat they were similarly successful in management ofthe condition with no significant difference betweenboth techniques regarding operative time and postoperativeoutcomes. Prospective trials were notperformed quietly enough in the literature, so it isdifficult to compare the results of the various anoplastictechniques. However, in the comparative prospective randomized study by Farid et al (15), thehouse advancement flap resulted in longer operativetime but was associated with fewer complications andbetter clinical improvement, patient satisfaction, andquality of life compared to Y-V and diamond flaps forthe treatment of anal stenosis. In another comparativestudy of 10 patients who underwent different flapsurgery for anal stenosis (V-Y, house, diamond anddufourmental), they were nearly similar in their outcomewith no preference of single technique (16).
Few patients in our study developed minimal postoperativecomplications at one month follow up aswound dehiscence and delayed wound healing mostlyrelated to wound infection. They were managedconservatively and completely resolved by the 3rdmonth apart from one patient who developedrestenosis. This was in accordance with many studiesthat reported occurrence of minimal post-operativesymptoms that were treated conservatively and did notneed any further surgical interventions (1,4,5).

CONCLUSION

Diamond and V-Y flap anoplasty are easy, safe andsuccessful options for management of moderate andsevere post-hemorrhoidectomy anal stenosis withmarked improvement of patient symptoms and lowcomplication rate. Both techniques had nearly similaroutcomes and choice of procedure depends onsurgeon's preference.

Conflict of interest

The authors declare no conflict of interest.

Ethical approval

Institutional ethical approval was obtained priorto the study.

REFRENCES

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