Outcomes of V-Y Anoplasty Technique in The Management of Moderate to Sever Post Hemorrhoidectomy Anal Stenosis

Abstract

Introduction

Anal stenosis is a very annoying complication after anorectal surgery. Moderate and severe cases often need surgery.

Objectives

The aim of the study is to evaluate the efficacy and outcomes of an anoplasty technique (V-Y advancement flap) for management of moderate to severe post- hemorrhoidectomy anal stenosis.

Methods

This is a randomized clinical study that was performed on 25 patients with post- hemorrhoidectomy anal stenosis and treated with anoplasty (V-Y advancement flaps) technique in the department of general surgery in a well specialized center from December 2023 to December 2024. Patients were monitored for Pain levels scoring and postoperative complications were analyzed.

Results

The mean age of the study contributors was 36.4 ± 5.25. The gender distribution showed a higher number of males (16) as compared to females (9). 5 patients had severe anal stenosis, while 20 patients had moderate anal stenosis. Mean preoperative VAS score was 6.2 ± 1.4. Follow up at 1, 3 and 6 months showed decrease in VAS score with significant improvement of symptoms. As regards post-operative complications, there was only one patient (4.0%) who presented with postoperative mild bleeding, also one patient (4.0%) suffered from urine retention, two patients (8.0%) had wound dehiscence, one patient (4.0%) patient presented by transient gas incontinence and one patient (4.0%) presented by mild restenosis.

Conclusion

V-Y flap anoplasty is a safe, simple and effective procedure for management of moderate and severe post-hemorrhoidectomy anal stenosis with marked improvement of patient symptoms and low complication rates.

 

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Keywords

anal stenosis - anoplasty - V-Y advancement flap

Introduction

Anal stenosis is a condition that hinders daily life. It can be anatomical or functional. In anatomical stenosis, the anoderm is replaced with a varying degree of restrictive non-elastic cicatrized tissue, while in functional stenosis, there is a hypertonic internal anal sphincter.[1]

Anatomical anal stenosis usually results from anal surgery, inflammation of the anus in Crohn's disease, ulcerative colitis, radiation therapy, venereal disease, tuberculosis and chronic laxative abuse. 90% of anal stenosis is caused by radical imputative hemorrhoidectomy.[2]

Anal stenosis post hemorrhoidectomy is thoroughly debilitating for the patients. Symptoms include constipation, pain and bleeding with defecation and a reduction of the caliber of stools. Prevention of post-surgical stenosis is based on the surgical technique and on the repeated careful follow up.[3]

Diagnosis is usually straight forward after careful history and local inspection with digital rectal examination, history of anal procedure especially hemorrhoidectomy is strong evidence of anal stenosis.[4]

The level of anal stenosis may be low (distal to at least 0.5 cm below the dentate line), middle (0.5 cm above and 0.5 cm below the dentate line), high (proximal to 0.5 cm above the dentate line) or diffuse affecting the whole anal canal.[5]

The severity of postoperative anal stenosis can be classified into three degrees; mild stenosis, in which there is tight anal canal which can admit a medium sized Hill–Ferguson anal retractor or lubricated index finger, moderate stenosis which can admit them only after forceful dilatation of the anus and severe stenosis in which neither the small sized Hill–Ferguson retractor nor lubricated little finger can be admitted.[6]

Although conservative strategies including bulking agents alone or in combination with anal dilation or lateral internal sphincterotomy are helpful in mild to moderate AS, surgery still represents the mainstay of treatment for moderate to severe AS refractory to conservative treatment.[7]

Various surgical plastic techniques have been described to treat severe anal stenosis including mucosal advancement flap, Y-V flap, V-Y flap, C flap, house flap, Diamond flap, rotational flap, etc.[4]

The role of anoplasty is to restore the normal function of the anus by dividing the stricture leading to widening the anal canal, thus decreasing the symptoms and relief pain.[8]

The study at hand presented that our experience in using (V-Y advancement flap) technique for management of moderate to severe post- hemorrhoidectomy anal stenosis and evaluating the postoperative outcome and complications.

This study aims to evaluate the efficacy and the outcomes of anoplasty technique (V-Y advancement flap) for management of moderate to severe post- hemorrhoidectomy anal stenosis.

 

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Methods

A randomized clinical study was carried out on 25 patients, all presented with moderate to severe post- hemorrhoidectomy anal stenosis and treated with anoplasty (V-Y advancement flap) technique

This study was carried out in the Department of General Surgery from December 2023 to December 2024.

Patients of both sexes aged ≥ 18years old with moderate to severe post- hemorrhoidectomy anal stenosis were included after failure of conservative management and occurrence of symptoms within 1–2 years.

Patients with mild anal stenosis, co-existing perianal disease inflammatory bowel disease (IBD), TB, prior radiotherapy or anoplasty were excluded. Pregnant females and patients with bleeding tendency, cancer or other serious diseases, inability to cooperate with the requirement of the study, those with recent history of alcohol or drug abuse, current therapy of any anticonvulsant or immunosuppressive were also excluded.

All patients were subjected to the following:

A Full History as Personal history name, age, sex, residence, admission date, telephone number, and other habits of medical interest, history as surgical anal procedure especially hemorrhoidectomy is strong evidence of anal stenosis.

A Full clinical assessment was carried out including presenting symptoms as painful or difficult defecation, difficulty in initiating evacuation, incomplete evacuation. Other symptoms included narrow stool, rectal bleeding and constipation. Signs as moderate to severe anal stenosis detected by digital rectal examination.

Routine pre-operative investigations such as CBC, coagulation profile (PT, PTT&INR), liver and kidney function tests, random blood sugar, and ECG.

Informed consent was taken from the patients after receiving adequate information about the study (the characters of the study, benefits, and possible side effects). The study was approved by the local ethical committee approval ID #11393-17-12-2023. This study is adherent to CONSORT guidelines. This study was conducted in accordance with the principles set forth in the Helsinki Declaration.

The patient was kept NPO for 6 hours before surgery. Prophylactic antibiotics (I.V 500 mg of metronidazole and ceftriaxone 1 gm) were given with the anesthesia induction and continued for five days. Patients were admitted to the hospital the day before surgery and received a Fleet enema before the operation.

All patients fulfilled the criteria of the American Society of Anesthesiology (ASA) for fitness for surgery and anesthesia. Surgery was done under either spinal anesthesia technique or general anesthesia according to the preference of the anesthetist.

All patients were placed in the lithotomy position. The procedure includes making incision across the fibrotic stricture to dilate the anus and make V flap defect then equivalent V flap was made adjacent and lateral to the defect with good mobilization of skin and subcutaneous fat to ensure suturing to the defect without tension then the resultant defect lateral to the flap was sutured Y shaped with interrupted 4-0 vicarly suture. Lateral sphincterotomy done for all patients ([Fig. 1]).

Fig. 1 Steps of V-Y advancement flap (A,B).

Postoperatively patients received laxatives for two weeks to aid evacuation and daily sitz path. Postoperative variables such as bleeding, pain, and urine retention were monitored.

Pain was evaluated postoperatively by a visual analogue scale[8] that was explained to the patients. Pain was evaluated by a score of 0 (painless) to 10 (very painful).

Patients were asked about their pain both preoperatively and on days; one, three, seven, 14 days postoperatively for any early complications and assessment of pain using Visual Analogue Scale VAS (from 0-10), and then after 3 and 6 months to evaluate the result of the procedure and patients' satisfaction also using the visual analogue scale (VAS). Follow up was done in the surgical outpatient clinic and by the one need. NSAIDs (Diclofenac Sodium, DS) administered postoperatively. The required analgesic doses were recorded and analyzed as a marker for pain severity. All patients complete the study till the end. The mean pain scores is followed up for each day using Wilcoxon's rank-sum test.

 

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Results

This study involved twenty-five patients; their age ranged from 25 to 60 years with a mean age of (36.4 ± 5.25) years. There were 9 (36.0%) females and 16 (64.0%) males ([Table 1]).

Table 1 Age and sex distribution in the study group

Demographic		Group
		Count	(%)
Sex	Female	9	(36.0%)
	Male	16	(64.0%)
Total		25	(100.0%)
Age	Range Mean ± SD	(25–60) 36.4 ± 5.25

Abbreviation: SD, Standard Deviation.

As regards preoperative symptoms in the study group. [Table 2] shows that all patients (100.0%) are presented by constipation, 20 patients (80.0%) presented by obstructed defecation and Anal Pain, 15 patients (60.0%) presented by anal Bleeding, 10 patients (40.0%) presented by itching, 2 patients (8.0%) presented by soiling and one patient (4.0%) presented by abdominal pain. Mean Preoperative VAS score was 6.2 ± 1.4.

Table 2 Clinical picture in the study group

Clinical picture		Group
		Count	(%)
	Constipation	25	(100.0%)
	Obstructed defecation	20	(80.0%)
	Anal Pain	20	(80.0%)
	Anal Bleeding	15	(60.0%)
Symptoms	Itching	10	(40.0%)
	Soiling	2	(8.0%)
	Abdominal pain	1	(4.0%)
	Preoperative VAS score	6.2 ± 1.4

In [table 3], there were five patients (20.0%) presented with severe anal stenosis and 20 patients (80.0%) presented with moderate anal stenosis.

Table 3 Degree of anal stenosis in the study group

Clinical picture
			Count	(%)
Degree of anal stenosis	severe	5	(20.0%)
	moderate		20	(80.0%)
Total		25		(100.0%)

[Table 4] shows that the mean operative time in the study group was 60.51 ± 6.3 min and ranged from 50-75 min.

Table 4 Operative time distribution in the study

Intraoperative	Group
Operative time (min) Range (min)	60.51 ± 6.3 50-80 min

Abbreviation: Min, minutes.

This study shows that there is a patient (4.0%) who is presented by postoperative mild bleeding that was managed by anal packing, one patient (4.0%) presented by urine retention, two patients (8.0%) presented by wound dehiscence seven days postoperatively, one patient (4.0%) patient presented by transient gas incontinence resolved within 2 months postoperatively. One patient (4.0%) presented with Flap necrosis and one patient (4.0%) presented with mild re-stenosis that was managed by conservative treatment ([Table 5]).

Table 5 Postoperative Complications in the study group

Postoperative Complications	Count	(%)
Bleeding	1	(4.0%)
urinary retention	1	(4.0%)
Wound dehiscence	2	(8%)
Incontinence	1	(4.0%)
Flap necrosis	1	(4.0%)
Restenosis	1	(4.0%)

[Table 6] shows marked improvement of postoperative visual analogue scale. There was a marked decrease of the pain score in the six months of the postoperative follow-up.

Table 6 Postoperative pain in the study group

Pain score (VAS)	Mean ± SD
1st month	2.8 ± 1.5
3rd month	1.4 ± 0.6
6th month	0.7 ± 0.5

Abbreviation: VAS, visual analogue score.

[Table 7] shows that the required Diclofenac sodium doses needed to control the pain in the study group were decreased by time.

Table 7 Postoperative Mean dose of diclofenac sodium analgesics in the study

Mean dose of diclofenac sodium	(dose/mg)
3rd day	100
7thday	50
14th day	25

This study shows that the mean hospital stay was 1.4 ± 0.6 days and ranged from 1-2 days, the mean wound healing (the coaptation of the edges of the wound) was 5 ± 1.3 weeks and ranged from (4-7 weeks) ([Table 8]).

Table 8 Postoperative Outcome in the study group

OUTCOME	Group
Hospital stay (day) Range (day)	1.4 ± 0.6 1-2
Wound healing(week) Range (week)	5 ± 1.3 4-7

 

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Discussion

The causes of anal stenosis can vary among anorectal surgery, inflammatory bowel disease (e.g., Crohn's disease), venereal disease, radiation therapy, and long-term laxative abuse. The main cause of anal stenosis is overzealous hemorrhoid operation. It can also be caused by application of local drugs.[9]

No doubt, prevention is the best treatment of anal stenosis, especially after hemorrhoidectomy. Adequate preservation of mucocutaneous junction is the key preventing factor in avoiding anal stenosis.[10]

The management for AS is based on the etiology and severity of the condition. As a result, many treatments ranging from non-operative therapy to advanced surgery may be undertaken. Mild stenosis can be managed with stool softener or fibers supplements. A cautious manual or mechanical dilatation or a partial lateral internal sphincterotomy can also be done in some situations of persistent symptoms, requiring caution to avoid possibly irreparable injury to the internal anal sphincter.[5]

Many procedures were tried for management of anal stenosis as Y–V, VY, diamond, house, U-shaped, C-shaped advancement flaps and rotational S-flap.[11]

The principle of anoplasty consists of increasing the dimension of the anal outlet by internal sphincterotomy and removal of cutaneous scarring and maintaining correction by proximal advancement of skin flaps or distal advancement of mucosa.[8]

All the techniques have their advantages and disadvantages, and it all depends on the type of stenosis. The type of the flap to be used is based on the expertise of the surgeon in particular flap, as well as the patient's anatomy and the availability of adequate perianal skin.[3]

No single procedure fits all, and the choice of the operation depends both on the surgeon's preference and on the severity of stenosis.[9]

Although there are several techniques for anal stenosis, no technique is superior to another.[5]

As stated by Brisida et al.[12] ‘the ideal procedure should be simple, should lead to no or minimal early and late morbidity, and should restore anal function with good long-term outcome’.

In our study, we preferred to evaluate the efficacy and outcomes of anoplasty technique (V-Y advancement flap) for management of moderate to severe post- hemorrhoidectomy anal stenosis.

As regard this study all cases of anal stenosis were complications of Milligan–Morgan's open hemorrhoidectomy which is going well with Maria G et al that found as the commonest cause of anal stenosis. Its rate has been reported from 1.2 - 10% after hemorrhoidectomy.[13] Excision of wide areas of rectal mucosa sacrificing the muco-cutaneous bridges during hemorrhoidectomy leads to massive scarring ending in chronic stricture.[14] Patients with other causes of anal stenosis as IBD, TB, previous radiotherapy or anal malignancy were not included in the study to exclude the possibility of recurrence as a pathological result of these original diseases.[1]

Peri-operative preparation of patients included rectal enema in line with current clinical practice guidelines.[7]

In the current study Prophylactic antibiotics (I.V 500 mg of metronidazole and ceftriaxone 1 gm) were given with the anesthesia induction and continued for five days.

A total of 14 studies on 250 (45.0%) patients preferred antibiotic prophylaxis. Apart from one study,[15] this was routinely given either peri-or postoperative for five days. Cephalosporins and metronidazole were the most popularly prescribed medications.[7]

In the current study, all patients were placed in the lithotomy position.

Patient positioning was described in 18 studies, for a total of 314 (56.5%) patients. Lithotomy was the most used position, with 258 (82.2%) patients. Prone jack-knife position was preferred in 48 (15.3%) patients. Either position was described in one study on eight patients.[7]

Patient positioning is determined by surgeon preference and/or the orientation of the pathology within the anal canal. Given the horizontally oriented operative field in most cases (i.e. Y–V, rhomboid/ diamond or house flap), the former reason has probably represented the main driver for the choice.[7]

In the current study, Surgery was done under either spinal anesthesia or general anesthesia decided by the anesthesiologist. Spinal anesthesia was an alternative to general anesthesia in some cases. Several factors (e.g. patient choice, fear of the alternative technique, stress/anxiety) have been identified as the main drivers for a patient's choice of short-acting local anesthesia or general anaesthesia.[16]

This study involved twenty-five patients; their age ranged from 25 to 60 years with mean age was (36.4 ± 5.25) years. There were 9 (36.0%) females and 16 (64.0%) males.

This agreed with Yabanoğlu[17] study where 90% of the patients were males and 10% were females with the mean age of the patients was 54 (27-81) years.

While Tahamtan et al[2] study that involved 25 patients presented with anal stenosis, most of the patients were females (n = 15, 60.0%) mean age 48.1 ± 2.9 (St. Error), range 23–73, underwent anoplasty.

As regards preoperative symptoms in the study group. All patients (100.0%) presented by constipation, 20 patients (80.0%) presented by obstructed defecation and Anal Pain, 15 patients (60.0%) presented by anal Bleeding, 10 patients (40.0%) presented by itching, 2 patients (8.0%) presented by soiling and 1 patient (4.0%) presented by abdominal pain. Mean Preoperative VAS score was 6.2 ± 1.4. Five patients (20.0%) presented severe anal stenosis, and 20 patients (80.0%) presented moderate anal stenosis.

Omar [18] has found that post-operative constipation was found in 30% of patients, anal pruritis in 10%, 20% incontinence to gas or liquid.

In Darwish et al.[1] study, 19 patients (54.3%) had additional symptoms of perianal itching, while 12 (34.3%) had recurrent attacks of bleeding and only 3 (8.6%) had symptoms of mild fecal incontinence (FI) and VAS score ranging between 5 and 10 (mean ± SD; 7.09 ± 1.77. Upon examination, 13 out of the 45 patients (28.9%) had severe anal stenosis (7 in group I and 6 in group II), while 32 patients (71.1%) had moderate anal stenosis.

In this study, mean operative time was 60.51 ± 6.3 min and ranged from 50-75 min.

Another study[1] also documented that the operative time of V-Y flap anoplasty was ranged from 40–65 minutes (mean ± SD; 50.00 ± 9.26).

This study shows that there is one patient (4.0%) presented by postoperative mild bleeding that was managed by anal packing, one patient (4.0%) presented by urine retention, two patients (8.0%) presented by wound dehiscence seven days postoperatively, one patient (4.0%) patient presented by transient gas incontinence which was resolved within 2 months postoperatively. one patient (4.0%) presented by Flap necrosis and one patient (4.0%) presented by mild restenosis that was managed by conservative treatment

This agrees with another study[1] that documented, no significant immediate post-operative complications of V-Y flap anoplasty apart from 1 patient (4.5%) who developed transient urine retention, which was successfully managed by Foley's catheter. 5 patients (22.7%) had wound dehiscence, and another 3 patients (13.6%) had delayed wound healing. All these complications were completely resolved at 3 months follow up apart from one patient (4.5%) who developed a picture suggestive of restenosis at 3 months that eventually resulted in recurrence of anal stenosis by the 6th month giving a healing rate of 95.5%. 3 patients (13.6%) developed mild occasional incontinence to flatus and liquid stool postoperatively. Post-operative Wexner score revealed improvement of the continence level of the 3 patients who had preoperative mild fecal incontinence.

Omar[18] found in his study that 10% of patients developed flap dehiscence and 20% developed ischemic contracture. The patients were managed conservatively.

The study showed marked improvement of postoperative visual analogue scale. There was a marked decrease in the pain score within six months postoperatively. Also, the mean hospital stay was 1.4 ± 0.6 days and ranged from 1-2 days, the mean wound healing (the coaptation of the edges of the wound) was 5 ± 1.3 weeks and ranged from (4-7 weeks).

This agreed with Milsom and Mazier[6] who advocated V-Y anoplasty for management of severe low anal stenosis over a five-year period and documented excellent results with 90% healing rate after the operation. Darwish A and his colleagues.[1] also documented Follow up of the patients at 1, 3 and 6 months after surgery showed a highly significant drop in VAS score for anal pain and a highly significant improvement of their symptoms over time and documented that All patients remained in the hospital for 2-3 days postoperatively for follow up and dressing.

Carditello A, et al. conducted a study from January 1990 to December 2000, to evaluate the efficacy of anoplasty by mucosal advancement combined with internal sphincterotomy for the treatment of iatrogenic anal stenosis post-hemorrhoidectomy. The patients had mild postoperative pain. No significant complications were seen. The mean hospital stay was two days. Ninety-seven percent of patients were well satisfied with the surgical result one year after operation.[19]

 

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Conclusions

V-Y flap anoplasty is safe, simple and effective procedure for management of moderate and severe post-hemorrhoidectomy anal stenosis with marked improvement of patient symptoms and low complication rate.

 

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Conflict of Interest

The authors declare that there is no conflict of interest.

Recommendations

We recommend a long-term prospective study to prove the role of the V-Y flap anoplasty in anal stenosis surgery outcomes.

IRB approval ID: 11393-17-12-2023.

Clinical trial registration ID: NCT06860906 at ClinicalTrials.gov.

Authors' Contributions

RZ: study conception and design, material preparation, data collection and analysis, writing – original draft; AMM: material preparation, data collection; YHH: study conception and design; YAO: study conception and design, material preparation, data collection, data analysis. All authors read and approved the final manuscript.

Data Availability Statement

The data that support the findings of this study are available from the authors upon reasonable request.

ORCID IDs

Reham Zakaria – https://orcid.org/0000-0002-3708-5840

Abd-Elrahman M. Metwalli – https://orcid.org/0009-0006-6325-8959

Yasmine Hany Hegab – https://orcid.org/0009-0003-3433-755X

Yasser A. Orban – https://orcid.org/0009-0008-1343-7275

• References

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Publication History

Received: 08 April 2025

Accepted: 16 July 2025

Article published online:
07 October 2025