Anal Canal Mucosa Research Articles

Clinicopathological features of primary mucosal CD30-positive T-cell lymphoproliferative disorders

Objective: To investigate the clinicopathological features and differential diagnosis of primary mucosal CD30-positive T-cell lymphoproliferative disorders (pmCD30+TLPD). Methods: Eight cases of pmCD30+TLPD diagnosed from 2013 to 2023 at the Department of Pathology, Beijing Friendship Hospital Affiliated to Capital Medical University and Beijing Ludaopei Hospital were retrospectively collected. The immunophenotype, EBV infection status and T-cell receptor (TCR) clonability of tumor cells were examined. The clinicopathological features were analyzed and related literatures were reviewed. Results: There were 5 females and 3 males, aged 28 to 73 years, without B symptoms, lack of trauma and autoimmune diseases. Seven cases occurred in oral mucosa and one in anal canal mucosa. Submucosal nodules with ulcerations were presented in all cases except one, which only submucosal nodule. Morphologically, there was different distribution of allotypic lymphocytes in inflammatory background. Four cases showed "kidney-shaped", "embryonic" and "horseshoe-shaped" cells, and one case resembled Hodgkin and Reed/Sternberg (HRS) cells. Allotypic lymphocytes expressed CD3 (7/8), CD4+/CD8-(7/8) and CD4-/CD8-(1/8). CD30 was uniformly strongly positive while ALK and CD56 were negative. In situ hybridization of EBER was negative in five cases (5/5). Clonal TCR gene rearrangement was positive in two cases. Four patients did not receive radiotherapy or chemotherapy. All the seven patients survived without disease except one died due to concurrent leukopenia. Conclusions: pmCD30+TLPD had a broad morphological spectrum and could be easily confused with primary cutaneous CD30+TLPD and systemic ALK-negative anaplastic large cell lymphoma involving mucosa, which may lead to misdiagnosis. Although the majority of the cases had a favorable prognosis, a few cases relapsed or progressed to lymphoma.

One-day surgery: treatment of grade 3–4 hemorrhoids in a day patient department

Introduction. “One-day surgery” expands the possibilities of providing surgical care in a polyclinic with hospitalization for just one day. This area of medicine allows you to use the most effective method of treating hemorrhoids in a polyclinic – the operation hemorrhoidectomy.Aim. To substantiate the effectiveness of performing hemorrhoidectomy surgery in patients with stage 3–4 hemorrhoids in a day hospital of a polyclinic under the program “One-day surgery” with accelerated recovery of patients.Materials and methods. The main principle for performing hemorrhoidectomy surgery in a day hospital is a careful selection of patients. Closed hemorrhoidectomy with restoration of the anal canal mucosa (by Parks – Milligan – Morgan’s in the second modification of the State Research Center of Coloproctology) under spinal or general anesthesia is the surgery of choice for hemorrhoids treatment in the day patient department of a clinic. 138 surgeries were performed in the day patient department during 2 years and 10 months. After surgery, patients were placed in the surgical day-patient department wards for 3–5 hours until full activation. Then they were allowed to go home without being accompanied by a medical worker. The satisfaction of patients with the program was analyzed by a survey with a 5-point scale.Results. The timing of scheduled operations for patients has been shortened. The number of complications after hemorrhoidectomy in the early postoperative period was decreased, without long-term postoperative complications. The treatment of such patients in the surgical day-patient department demonstrated a good economic effect. The overall satisfaction with the one-day surgery program was very high (4.82). The results confirmed the effectiveness of this area of medicine.Discussion. Our experience of performing hemorrhoidectomy operations in a day surgical hospital for 3 years confirms the existence of a number of advantages over treating patients in a 24-hour hospital.Conclusions. The “One-day Surgery” and accelerated patient recovery programs expand the possibilities for treating patients with stage 4 hemorrhoids directly in the polyclinic, and thus reduce the burden on the surgical hospital.

Accuracy of magnetic resonance imaging in defining dentate line in anal fistula

PurposeTo retrospectively assess the accuracy of magnetic resonance imaging (MRI) in defining dentate line in anal fistula.Materials and methodsSeventy patients with anal fistulas were assessed by dynamic contrast-enhanced MRI. The distance from the dentate line to the anal verge for all patients was measured by MRI. To mitigate interference, 35 patients with anal fistulas whose internal openings were located on the dentate line were excluded from this study. Two observers independently judged the positional relationship between the internal opening and the MRI-defined dentate line, and compared with the results observed by surgeon to assess the accuracy.ResultsThe distance between the MRI-defined dentate line and the anal verge depended on the location of the internal opening and the morphology of the anal canal mucosa. The distance based on the location the internal opening and the morphology of the anal canal mucosa was 18.2 ± 8.1 mm and 20.0 ± 5.3 mm on oblique coronal T2WI, respectively. Compared with the results observed by the surgeon, the accuracy of evaluating the positional relationship between the internal opening and the dentate line from the morphology of the anal canal mucosa on MRI exceeded 89.9%. Taking 18.2–20.0 mm as the distance between the dentate line and the anal verge on the MRI image, the accuracy of evaluating the relationship between the position of the internal opening and the dentate line was over 85.7%. Considering both the dentate line and the anal canal mucosa, the accuracy of evaluating the relationship between the internal opening and the dentate line was over 91.5%. The results of MRI-defined dentate line were in good agreement with the results of intraoperative surgeon evaluation, and the κ values were 0.70, 0.63, and 0.78, respectively.ConclusionMRI has high accuracy in defining the dentate line in anal fistulas.

Simple mucopexy and hemorrhoidal arterial ligation with and without Doppler guide: a randomized clinical trial for short-term outcome.

Hemorrhoids are the most common benign anorectal diseases. Mucopexy strengthens the anal canal mucosa, which can be performed alone or in combination with Doppler-guided hemorrhoidal artery ligation (DG-HAL). In this study, we compared the postoperative complications between simple mucopexy plus HAL with and without a Doppler guide. This study was performed as a single-blinded randomized clinical trial. Patients referred to a tertiary colorectal referral clinic with grades 3 and 4 hemorrhoids who were candidates for surgical intervention entered the study. Thirty-six patients were randomly divided into 2 groups. Group A including 18 patients underwent mucopexy and DG-HAL and the other 18 patients (group B) underwent standard mucopexy and HAL without a Doppler guide. Postoperative pain score and the duration of oral analgesic consumption were recorded. Additionally, postoperative symptoms and complications were recorded and compared between the 2 methods. There was no significant difference between the 2 groups in terms of pain score and the duration of postoperative analgesic consumption as well as the incidence of postoperative complications. Besides, the primary grade of hemorrhoids was not significantly associated with recurrence, but there was a significant association between body mass index and Wexner score (WS) with recurrence. The mean WS of patients showed a significant decrease in both groups postoperatively. However, the rate of WS reduction was not remarkably different between the 2 groups. Simple mucopexy with blind HAL (without Doppler guide) might be considered for the treatment of grades 3 and 4 hemorrhoids effectively.

Treatment of Haemorrhoidal Disease by Laser Haemorrhoidoplasty at Dakar Preliminary Study of 21 Patients.

Background:Surgical treatment of haemorrhoidal disease by laser haemorrhoidoplasty is a minimally invasive procedure that facilitates the postoperative course. Due to less aggression on the anoderm and the anal canal mucosa, it causes less significant postoperative pain and low morbidity compared with conventional excision according to the Milligan–Morgan or Fergusson procedure. We report, through a preliminary study, our data on laser haemorrhoidoplasty and discuss the indications and results.Materials and Methods:This is a descriptive prospective study carried out on 21 patients operated on for haemorrhoidal disease by laser haemorrhoidoplasty with or without mucopexy.Results:The series was composed of 17 men and 4 women with a male/female ratio of 4.25:1. The average age was 39.6 years with a range of 27–62 years. The symptomatology was rectal bleeding in 16 cases (76%) and anal swelling in 18 cases (85.7%). These include grade 2 haemorrhoids in 2 cases (9.5%), grade 3 in 12 cases (57%), and grade 4 in 7 cases (33%). It was associated with an anal fissure in four cases (19%) and an anal fistula in three cases (14.2%). Mucopexy and laser coagulation were performed therapeutically in 13 cases (61.9%) and laser coagulation without mucopexy was performed in 8 cases (38%). The energy delivered was on average 1488 or 496 J per pile. It was associated with skin tag excision in 18 cases (85.7%), fissurectomy, sphincterotomy, anoplasty in 4 cases (19.2%), and fistulectomy for low anal fistula in 2 cases (9.5%). Piles retraction was judged sufficient in 17 patients (81%). The postoperative course was simple with no notable complaints in 16 patients (76%). Complications consisted of minimal bleeding in six cases (28%), significant bleeding in two cases with readmission, residual skin tag in six cases (28.5%), and subcutaneous fistula in two cases (9.5%). No recurrence of the symptoms of the haemorrhoidal disease was noted.Conclusion:Laser haemorrhoidoplasty is a minimally invasive alternative for the treatment of haemorrhoidal disease, especially for grade 2 and 3 haemorrhoids without major prolapse. Postoperative pain is minimal, and the risk of stenosis or incontinence is almost non-existent.

Postoperative functional outcomes and complications of partially intraanal canal anastomosis in stapled ileal pouch anal anastomosis for ulcerative colitis.

For ulcerative colitis (UC), stapled ileal pouch anal anastomosis (IPAA) reportedly results in better bowel function than does IPAA with mucosectomy. However, a potential cancer risk in the remnant mucosa has been observed. The clinical results of IPAA by double stapling technique (DS-IPAA) in which the anastomotic line was on the dentate line at posterior wall and the top of anal canal at anterior wall ("Partially intraanal canal anastomosis": PICA) to reduce the remnant mucosa were evaluated. Clinical results of PICA were retrospectively compared with those by DS-IPAA with anastomosis at above the anal canal on 1year after open surgery. Of 211 UC cases that underwent DS-IPAA, 146 cases (69%) with PICA who were confirmed by the squamous epithelium on the posterior part of the distal donuts were included. Sixty-five cases with anastomosis above the anal canal were evaluated as the control. One stage surgery underwent in 95% of PICA and 93% of control. One year after surgery, each group had six bowel movements daily. Nighttime evacuation was found in 16% of PICA and in 20% of control. Soiling was found in 1% of PICA and 4.8% of control. After one stage operation, anastomotic leakage that needed ileostomy was observed in 0.7% of PICA and 3% of control. Partially intraanal canal anastomosis (PICA) can reduce anal canal mucosa with the same postoperative bowel function and complication rate as DS-IPAA above the anal canal. This procedure may be feasible for UC patients who can tolerate this procedure in terms of decreasing postoperative cancer risk.

Zika virus shedding in the stool and infection through the anorectal mucosa in mice

Zika virus (ZIKV) has elicited global concern due to its unique biological features, unusual transmission routes, and unexpected clinical outcomes. Although ZIKV transmission through anal intercourse has been reported in humans, it remains unclear if ZIKV is detectable in the stool, if it can infect the host through the anal canal mucosa, and what the pathogenesis of such a route of infection might be in the mouse model. Herein, we demonstrate that ZIKV RNA can be recovered from stools in multiple mouse models, as well as from the stool of a ZIKV patient. Remarkably, intra-anal (i.a.) inoculation with ZIKV leads to efficient infection in both Ifnar1 −/− and immunocompetent mice, characterized by extensive viral replication in the blood and multiple organs, including the brain, small intestine, testes, and rectum, as well as robust humoral and innate immune responses. Moreover, i.a. inoculation of ZIKV in pregnant mice resulted in transplacental infection and delayed fetal development. Overall, our results identify the anorectal mucosa as a potential site of ZIKV infection in mice, reveal the associated pathogenesis of i.a. infection, and highlight the complexity of ZIKV transmission through anal intercourse.

Sonographic Determination of Type in a Fetal Imperforate Anus.

The purpose of this study was to determine the type of an imperforate anus by using sonography in the prenatal period. This retrospective study evaluated the fetal anus in all pregnant women, including low- and high-risk populations, between February 2010 and November 2013. High-type imperforate anuses were diagnosed by prenatal sonography when the anal sphincter muscles and anal canal mucosa were not visible. Low-type imperforate anuses were prenatally suspected when at least 1 of the following was present: (1) a small anus; (2) no visible anal mucosa; or (3) close location of the genitalia by the anus without a visible perineal body, particularly in a female fetus. Among the 9499 fetuses, 41 were prenatally suspected of having an imperforate anus, and 32 were confirmed to have this disorder. During the same study period, there were 11 false-negative cases, for a diagnostic sensitivity rate of 74%. All 9 fetuses who were confirmed to have a normal anus were prenatally suspected of having a low-type imperforate anus. Among the 32 fetuses with a confirmed imperforate anus, 19 were confirmed to have a high or intermediate type and 13 to have a low type. The type in 3 fetuses was incorrectly determined prenatally. Although an imperforate anus is not always diagnosed prenatally, its type can be determined by prenatal sonography.

Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure

Anal fissure is a common benign condition. An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge. Chronic anal fissure is defined by a history of symptoms present for more than 2 months' duration and with a triad of external skin tags, namely, a hypertrophied anal papilla, an ulcer with rolled edges, and a base exposing the internal sphincter. Because complications such as incontinence are associated with surgical treatment, chemical sphincterotomy is currently favored. The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2% nitroglycerin ointment for the treatment of chronic anal fissure. This was a quasi-experimental study carried out between January 16, 2007 and January 15, 2008 in the Surgical Department of Jinnah Hospital, Lahore, Pakistan. Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study. All recruited patients met the study inclusion criteria and were randomly assigned to one of the two groups. Group A was managed conservatively using topical 0.2% nitroglycerin ointment, whereas Group B underwent open partial lateral anal sphincterotomy. Both groups were followed up at 1 week, 2 weeks, 4 weeks, and 6 weeks after the treatment. All the patients complained of pain. A total of 43 (71.7%) patients had pain with constipation, whereas 31 (51.7%) patients had bleeding per rectum. Upon clinically examining the anal area, tenderness was elicited in all 60 (100%) patients. Group A included 30 (11 females and 19 males) cases treated with topical 0.2% nitroglycerin ointment and Group B included 30 (11 females and 19 males) cases who underwent open partial lateral anal sphincterotomy. In Group A, only 15 patients with fissures were successfully treated (50%). By contrast, 28 (93%) patients with fissures in Group B were successfully treated, and only two (7%) remained uncured. These two patients (6.6%) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure. This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2% nitroglycerin application in the treatment of chronic anal fissure, with good symptomatic relief, high rate of healing, fewer side effects, and a very low rate of early continence disturbances.

The role of hemorrhoidectomy in rectocele complicated by grade 3–4 hemorrhoids

We read with great interest the article by Leal et al. [1] in which the authors concluded that the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) has satisfactory anatomic and functional results with a low incidence of postoperative pain and complications. A rectocele is an abnormal sac-like projection of the anterior rectum into the posterior vaginal wall. Women commonly complain of stool trapping, a form of obstructed defecation, and report requiring digital pressure through the vagina in order to pass stools. The diagnosis of rectocele can be easily made on rectal examination. Defecography can be used for diagnosis or surgical decision making [2]. Stool trapping requiring digital evacuation or vaginal support and large protruding rectoceles are the major criteria for operative intervention [3]. Rectocele can be treated with a variety of local surgical approaches including the technique used by authors for rectocele complicated by rectal mucosal prolapse. Rectocele can be complicated by other perianal pathologies like hemorrhoids. We would like to share our experience of patients with grade 3 and 4 hemorrhoids coexisting with symptomatic rectocele. Eight women presented with some complaint of stool trapping, constipation, anal swelling and bright red blood per rectum. Rectocele and grade 3–4 hemorrhoids were diagnosed based on the history, physical examination, colonoscopy and defecography. We planned a 3-quadrant hemorrhoidectomy with Liga-Sure as an initial treatment. After recovery, we saw that symptoms related to rectocele were improved in all of the patients, and defecography was normal. Postsurgical inflammation and fibrosis in 3-quadrant hemorrhoidectomy may increase the tightness in the anal mucosa and prevent bulging into the vagina. We think that a 3-quadrant hemorrhoidectomy rather than a circular mucosectomy causes more tightness in anal canal mucosa and better recovery for patients with coexisting rectocele.

Salivary gland choristoma in large bowel

The occurrence of heterotopic tissue in the large bowel is relatively rare. The most common type of tissue in such heterotopia is gastric mucosa, but rare cases of pancreatic and salivary tissue are also reported in literature. All cases of salivary choristomas reported in literature arose in the rectum–anal canal region [1–5]. Here we report a submucosal salivary gland choristoma in the sigma of a 55year-old woman who underwent largebowel endoscopy for colorectal carcinoma screening. At gross examination of the bowel we found a pedunculated polypoid lesion of 1cm situated at 19cm from the anal verge, resembling a submucosal lipoma without other mucosal alterations (● Fig.1). At histological examination we found a small aggregate of acinar glands with mixedmucous–serous features in the submucosa. In addition, we found an intercalated duct composed of a double layer of cells – epithelial and myoepithelial – that reached the mucosal surface (● Fig.2). Immunohistochemical staining was performed in order to confirm the nature of the lesion. The glands were positive for lysozyme antibody and negative for pancreatic amylase, S-100 protein, chromogranin, and synaptophysin. Themorphology of the glands and the immunostaining were consistent with the typical architecture of normal mixed salivary glands (● Fig.3). Only four other cases of salivary gland heterotopia in the large bowel have previously been reported in the literature; all were a histologically mixed type, all arose in the rectum–anal canal mucosa, and they were most prevalent in men. Two cases also showed gastric heterotopia, something that we have not found in the case reported here. Some authors explained the presence of heterotopic salivary gland tissue in the large bowel as anomalous differentiation of embryonic remnants or as metaplastic changes [1–3]. We think that the absence of other anatomic structures in the sigma, Fig.1 Endoscopic image of pedunculated yellowish polypoid lesion. Fig.2 Intercalated duct connected with the mucosal surface (hematoxylin and eosin; original magnification ×10).

Temperature gradient between the rectum and the anal canal: evidence against the role of temperature sensation as a sensory modality in the anal canal of normal subjects.

Temperature difference between the rectum and anal canal is a fundamental requirement for the hypothesis that temperature sensation is of physiological importance in discrimination of anorectal contents occurring during the 'sampling reflex'. The temperature gradient between the rectum and the anal canal was measured in 47 normal subjects (mean age 51.6 years +/- 16.8 s.d., 24 men). The maximum mean difference in temperature between the rectum and the anal canal was 0.13 degrees C (0.06-0.19, 95 per cent confidence intervals) and occurred 4 cm from the anal verge. This difference is too small to be detected by the anal canal mucosa. Under normal physiological circumstances the conscious appreciation of temperature of faeces passing from the rectum to the anal canal is impossible during the anorectal sampling reflex.

Anal canal mucosa in restorative proctocolectomy for ulcerative colitis.

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.

Anal transitional zone and columnar cuff in restorative proctocolectomy.

The popularity of double stapling the ileal pouch-anal anastomosis probably owes more to the technical ease it brings than to histological considerations or functional results. It is preservation of a 'columnar cuff' of mucosa, rather than the restricted site of the anal transitional zone, that should be the focus of research with respect to long-term risk of malignancy and inflammatory complications. If cancer is present in colon that has been removed for ulcerative colitis, there is a 25 per cent incidence of dysplasia in the columnar cuff in the short term. In other circumstances, those who are spared from carcinoma by colectomy are likely to have a similar risk of developing dysplastic change in the columnar cuff with longer follow-up. Double stapling the pouch-anal anastomosis and preserving the anal canal mucosa improves function, but long-term surveillance of the columnar cuff is then required, including biopsies.

Histopathology of stapled haemorrhoidectomy specimens: a cautionary note.

Stapled haemorrhoidectomy is a new technique with encouraging early results. The aim of this study was to examine the tissue removed during stapled haemorrhoidectomy, in particular to check on the presence or absence of transitional or squamous anal canal mucosa and internal anal sphincter muscle. Twenty-six consecutive patients undergoing stapled haemorrhoidectomy were studied. Resected tissue was examined histologically according to a standardized histological protocol. All 26 specimens contained columnar mucosa. Twelve specimens also contained anal transitional and stratified squamous epithelium. Two specimens contained columnar and transitional mucosa. Twenty-two of 26 specimens contained smooth muscle as well as mucosa (median maximum diameter 7.5 mm, range 2-20 mm). In 11 specimens this was circular muscle only; in 11 circular and longitudinal smooth muscle were present. In 10 specimens smooth muscle was seen to be lying beneath stratified squamous or transitional epithelium, suggesting that it was from the internal anal sphincter. Stapled haemorrhoidectomy results in resection of stratified squamous mucosa or part of the internal anal sphincter in a significant proportion of patients. Surgeons should be aware that this technique may result in damage to the internal anal sphincter.

New approaches to the treatment of anal fissure.

According to Antropoli, pathologies of the anal canal are extremely common. About 30 to 40 percent of the population suffers from proctologic pathologies at least once in their lives. In most cases they are more annoying than dangerous. Anal fissure (AF) was recognized as a clinical entity in 1934. It is a longitudinal defect of the anal canal mucosa and anoderm extending usually from the dentate line to the external verge of the anal canal. This defect exposes the lower half or even most of the fibres of internal anal sphincter. AF is almost always accompanied by extensive tension of this muscle. Anal fissures affect all age groups but predominantly occur in the 3rd and 4th decades of life (2, 8, 23). Gathright states that fissure disease causes from 6 to 15% of office visits and 10% of operative procedures in a colorectal practice. The etiology of anal fissure has only been partially explained and remains controversial although spasm of the internal anal sphincter has been recognized to play a main role in the pathogenesis of this disease. Recent studies have cast new light on the pathogenesis of anal fissures.

Giant Anal Condyloma Acuminatum in Childhood: A Case Report

The authors report a case of anal giant condyloma acuminatum present for 10 years in a 14 year old. The giant tumor was responsible for difficulty in the sitting and difficulty with defecation. Surgical excision was a little limited in order to conserve the anal sphincter. Cauterization with diathermy was done on the remaining small sized lesions at the level of the perineum and at the level of anal canal mucosa. Post-operative follow-up was marked by the recurrence of the tumor after 3 months. Giant ano-rectal condylomas are very rare. The treatment is surgical excision and chemotherapy. (Nig J Surg Res 2001; 3: 170 – 174) KEY WORDS: Giant Condyloma, Anus

A CASE OF FISTULA CANCER IN WHICH A FISTULA IN THE TUMOR WAS CONFIRMED

A 65-year-old man was seen at the hospital because of anal bleeding. There was a past history of a fistula-in-ano for about 30 years that was operated on at the age of 56. Postoperative course was uneventful except an operative hard scar. In March 1996, he had a symtom, anal bleeding, and a tumor on the left side of the anus was pointed out. The tumor had grown in the left ishiorectal fossa with an extraluminal growth by CT and MRI. By colonoscopy, the tumor had a submucosal-tumor like appearance, and the biopsy from the errosion of the anal canal mucosa led to the diagnosis of adenocarcinoma. An adomino-perineal resection of the rectum with D2 lymphadenectomy and extensive perineal skin resection was carried out. Histopathological findings of the resected specimen revealed a well differentiated adenocarcinoma at superificial mucosa of the anal canal and the fistula, and a mucinous adenocarcinoma at the deep portion of the fistula. The tumor was fistula-cancer after the operation for the fistula-in-ano.

Skin appendage involvement in anal intraepithelial neoplasia

High-grade anal intraepithelial neoplasia (AIN III) may be premalignant. Surgical excision of large areas of anal epithelium carries significant morbidity. Ablation treatments may carry less morbidity; however, the depth of ablation is uncertain and failure to ablate dysplasia in hair shafts and other skin appendages may lead to early recurrence. This study assesses morphometric aspects of skin appendages in perianal skin and anal canal mucosa in tissues from 30 patients with AIN III. Both normal and dysplastic epithelium was assessed in each patient. The depth to which AIN III involved skin appendages was measured using computerized image analysis. Both the perianal epidermis and anal canal mucosa affected by AIN III were significantly thicker than normal. Nineteen of 30 patients with AIN III had skin appendage involvement. Some 57 per cent of hair follicles (79 of 138), 16 per cent of sebaceous glands (11 of 69) and 25 per cent of sweat glands (24 of 96) observed beneath an abnormal epithelium had evidence of AIN. The median depth of AIN involvement of the hair follicle was 1.14 (range 0.44-1.67) mm, sebaceous glands 1.44 (range 0.96-1.90) mm, and sweat glands 0.94 (range 0.50-2.20) mm. These figures do not take into account tissue shrinkage due to histological processing. AIN III involvement of epithelial appendages is a significant problem. For disease eradication, tissue destruction or removal to a depth of at least 2.2 mm below the adjacent basement membrane is required. Surgical excision of high-grade AIN remains the treatment of choice.

Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano

The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a risk of fecal incontinence. We have assessed the functional impact of treating patients with a complex fistula-in-ano by a cutting seton fistulotomy technique that preserves the internal sphincter. The operative steps consisted of initial eradication of sepsis, identification of the internal and external openings of the fistula tract, excision of the fistula tract with anal canal mucosa, and insertion of a cutting silk seton around both the internal and external sphincters. In this way open drainage of the intersphincteric space was avoided, and integrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradication and effect on fecal continence was assessed in 27 patients (15 males) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery. The fistula was cured in 26 patients (96 percent) with no reports of altered continence at the time of discharge from outpatient review. Recurrence developed in one patient (4 percent) in whom hidradenitis suppurativa was subsequently diagnosed. All four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently undergone proctectomy for severe perianal and rectal Crohn's involvement. Long-term follow-up revealed three patients (19 percent, all rectovaginal fistulas) who experienced a deterioration in continence after discharge. Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are effective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.