Stenosis Of Anal Canal Research Articles

Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn’s disease

In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon. A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates. A total of 63 patients were included; mean age was 47years (SD 15years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n=56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n=54; 85.7%) versus neoplasia (n=9; 14.3%). The median length of long-term follow-up was 17.7months (IQR: 4.72, 38.7months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon. Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.

When Radiation Proctitis Gets Way Complicated

Radiotherapy is an essential treatment modality for prostate cancer. However, radiation proctitis (RP) is a common complication, with 40% developing rectal hemorrhage. Previous successful experiences in treating cystitis has led to the use of formalin as a treatment modality. Although there have been few published reports of formalin use for RP in the literature, most results show that it is safe and effective. Unusual complications such as fistulae, anal stenosis and colitis have been rarely reported. A 61-year-old man with medical history of prostate cancer status-post radiation therapy completed 6 months ago presented with a 2-week history of rectal bleeding and tenesmus. He denied fever, use of antibiotics, weight loss or previous GI bleeding. Digital rectal exam was painful and with evidence of blood clots. Initial labs showed iron deficiency anemia. Patient underwent colonoscopy which showed a large erythematous ulcerated lesion that extended from anal verge up to 10cm and covered 70% of diameter (Figure 1). Histologic exam was consistent with RP and negative for rectal carcinoma. Initially, patient was provided with supportive management with hydration and steroid enemas. However, he developed progression of symptoms with intractable rectal bleeding requiring multiple blood transfusions as well as severe rectal pain. Pelvic MRI showed bilaterally myositis of the obturator internus and pectineus muscles suggestive of radiation induced myositis. Given severity of symptoms, General Surgery proceeded with rectal instillation of 4% formalin which was unsuccessful for which diverting Loop Colostomy was performed. Patient showed improvement of symptoms until a few days later when he developed hematochezia, fever and leukocytosis. Abdominal CT revealed inflammatory colitis suggestive of formalin-induced colitis which resolved with antibiotics and hydration. Follow up colonoscopy was performed for possible re-connecting surgery which showed anal canal stenosis with 99% of lumen occluded (Figure 2). Patient was referred to Colorectal surgeon whom performed multiple dilations with resolution of stenosis. In this case, anal stenosis and colitis were a complication of formalin instillation as therapy for RP. Both complications are very rare and few cases have been published in which a clinical scenario mirroring our patient presentation and outcome are described. Awareness of rarely described complications is essential for early recognition and treatment.Figure: Large erythematous ulcerated lesion.Figure: Anal canal stenosis.

Usefulness of 3D transperineal ultrasound in severe stenosis of the anal canal: preliminary experience in four cases

BackgroundOrganic or functional anal canal stenoses are uncommon conditions that occur in the majority of cases as a consequence of anal diseases. A proper assessment is fundamental for decision making; however, proctological examination and endoanal ultrasound are often unfeasible or very difficult to perform even under local or general anesthesia. We therefore began to use 3D transperineal ultrasound to assess patients. The aim of this study was to compare the results of evacuation proctography and 3D transperineal ultrasound in patients with severe anal canal stenosis.MethodsFour consecutive patients with high-grade anal canal stenosis were evaluated using both proctography and 3D transperineal ultrasound with a micro-convex transducer between March and June 2011.ResultsIn all cases, 3D transperineal ultrasound provided detailed information on the length and level of stenosis and on the integrity of the anal sphincters.ConclusionsOur preliminary experience suggests that 3D transperineal ultrasound makes it possible to plan optimal surgical treatment.

2:10 PM Abstract No. 211 - Transrectal ultrasound-guided prostate fiducial marker placement for prostate localization during external beam radiotherapy: a safe and reliable procedure

Purpose Fiducial markers may be used to localize the prostate during radiotherapy using portal film and/or cone-beam CT. The purpose of this study is to describe the technique, efficacy, and complications of transrectal ultrasound (TRUS)-guided prostate fiducial marker placement by interventional radiology. Materials and Methods With IRB approval, medical records of patients who underwent TRUS-guided prostate fiducial marker placement between 1/2011 and 8/2012 were reviewed. Three gold markers, Visicoil (IBA, Bartlett, TN) or AnchorMarker (Biocompatibles, Oxford, CT), were placed, 1 each in the right and left prostate base as well as right apex (1). Post-procedure frontal and lateral radiographs confirmed placement. An additional marker was placed if malposition was noted. Complications of fiducial placement and need for additional localization modality at radiotherapy were recorded. Results In total 111 men with mean age 69 years (range 52—90), mean PSA 11 (range 1—106), mean Gleason score 7 (range 6—9), and clinical stage T1c—T3b underwent marker placement. Prior TURP was noted in in 6 (5.4%), and cryotherapy in 1 (0.9%). Mean prostate volume was 31.5 mL (range 2—130). In 60 (54%), 1% lidocaine was injected into the neurovascular bundle; 51 (46%) received no lidocaine. Moderate sedation due to anxiety was used in 1 (0.9%) and general anesthesia due to anal canal stenosis was used in 1 (0.9%). Malposition of 1 marker was recognized at US in 4 (3.6%) and on radiograph in 2 (1.8%), necessitating additional fiducial placement. In all cases, the fiducials were still used during radiotherapy. Poor visualization of the fiducial markers required additional prostate localization in 3 patients (2.7%) using B-mode acquisition and targeting US. Post-procedure urinary tract infection requiring oral antibiotics occurred in 1 (0.9%). Urosepsis requiring admission and IV antibiotics occurred in 1 (0.9%). Conclusion TRUS-guided prostate fiducial marker placement is a safe and reliable technique that may be performed by the interventional radiologist for subsequent prostate localization during radiotherapy. Reference 1. Shinohara K, Roach M, 3rd. Technique for implantation of fiducial markers in the prostate. Urology. 2008 Feb;71:196–200.

Mayer-Rokitansky-Kuster-Hauser syndrome and anal canal stenosis: case report and review of literature

Mayer-Rokitansky-Kuster-Hauser (MRKH) is a characteristic syndrome in which the mullerian structures are absent or rudimentary. It is also associated with anomalies of the genitourinary and skeletal systems. There are very few cases reported regarding its association with anorectal malformations, particularly perineal fistulas. To the best of our knowledge, there have not been any reported cases of anal canal stenosis in patients with MRKH. We describe a very rare association of MRKH with anal canal stenosis and multiple renal calculi. The patient underwent corrective surgery for the anomalies and removal of renal calculi. She has been under regular follow-up for the last few months and is doing well.

Efficacy evaluation of intersphincteric resection during anus-preserving operation for ultralow rectal carcinoma

To evaluate anorectal dynamics, function and efficacy of ultralow rectal carcinoma patients undergone intersphincteric resection(ISR). From January 2004 to August 2007, 30 patients with ultralow rectal carcinoma(2.5-4.0 cm distance from anal edge) underwent ISR. All the patients received anorectal manometry before and after operation. The postoperative anal function was evaluated by Williams continence standard and the treatment outcome was followed up. After ISR operation, anal resting pressure, maximum squeeze pressure and maximum tolerance volume of the rectum decreased significantly (all P<0.01) and restored gradually, but not to normal. The rectal anal inhibitory reflex disappeared in 27 patients(90.0%) and was not improved. According to Williams continence standard, 86.7%, 93.3% and 96.7% of patients obtained acceptable anal function in 3, 6, and 12 months after operation respectively. During follow-up of 12 to 44 months, all the patients were still alive and no patient developed pelvis or local recurrence, distant metastasis and anastomotic leakage. Fecal eczema of anus occurred in 10 patients, colonic mucosa prolapse in 2 patients and stenosis of anal canal in one patient. ISR for ultralow rectal carcinoma can not only attain radical treatment outcome, but also preserve anal sphincter.

Three-dimensional transperianal and transvaginal sonography in diagnostics of anal canal stenosis

Three-dimensional transperianal and transvaginal sonography in diagnostics of anal canal stenosis

Albumin-glutaraldehyde bioadhesive ("Bioglue") for prevention of postoperative complications after stapled hemorrhoidopexy: a randomized controlled trial

Hemorrhoidopexy using the circumferential stapler is an established method for surgical treatment of patients with prolapsing hemorrhoids. Despite its advantages, complications such as anal canal stenosis, hemorrhage and anastomosis leak with eventual intrapelvic sepsis can cause serious postoperative problems. The aim of this study was to evaluate the utility of a surgical adhesive, the biological albumin-glutaraldehyde glue "Bioglue", in reduction of these postoperative complications. Between January 2002 and November 2004, 200 patients undergoing stapled hemorrhoidopexy were enrolled in a prospective, randomized clinical trial. One hundred patients were randomly assigned to the control group; the study group consisted of 100 patients who received Bioglue in the mucosa anastomosis area. All patients received standardized postoperative analgesic, laxative and antibiotic treatment. We then evaluated the two groups for postoperative complications (after surgery and 6 months postoperatively). From the control group (no Bioglue application), two patients presented with anal stenosis, two with hemorrhage, three had anastomosis leak and one had thrombosis, whereas none of the patients from the Bioglue group had any of these complications. Both groups had patients with severe postoperative pain (3 each) and fecal incontinence (1 patient each). The overall difference in the number of complications in the two groups was statistically significant (p < 0.05). In this first study using Bioglue in patients undergoing circumferential stapled hemorrhoidopexy we have shown that application of the glue is effective in reducing postoperative complications.

Perianal Crohn Disease

Fissures, fistulas, abscesses, and anal canal stenosis are manifestations of perianal Crohn disease (CD). There are no known predictors of which patients will fail sphincter-sparing surgical therapy and ultimately require fecal diversion. Of 356 consecutive patients with CD, 24% (86) had perianal CD (age range, 14-83 years), and women were slightly more frequently affected. Clinical variables were examined for factors predictive of the need for permanent fecal diversion. CD associated with perianal CD was limited to the small bowel and/or ileocolic area in 23% of patients; the remainder had colorectal CD. Eighty-six patients underwent 344 operations. Forty-two patients (49%) ultimately required permanent diversion; among them were 21 of 32 patients (66%) with anal stricture and 12 of 20 women (60%) with rectovaginal fistula. Univariate analyses of clinical variables were performed with respect to need for permanent fecal diversion. Significant univariate predictors were the presence of colonic CD (P = 0.0045, odds ratio [OR] 5.4), avoidance of ileocolic resection (P = 0.0147, OR 0.4), and the presence of an anal stricture (P = 0.0165, OR 3.0). In multivariate logistic regression, the presence of colonic disease and anal canal stricture were predictors of permanent diversion. The OR associated with the risk of permanent diversion in the presence of colonic disease and in the absence of anal stricture was 10 (P = 0.0345). In the presence of both colonic disease and anal canal stenosis, the OR associated with permanent stoma was 33 (P = 0.0023). The management of perianal CD continues to be challenging. Roughly half of patients required permanent fecal diversion, which was even more frequently true for patients with colonic CD and anal stenosis. Recognizing these tendencies will assist both patients and surgeons in planning optimal treatment.

Feasibility of perineal sagittal approaches in patients without anorectal malformations

Perineal sagittal approaches (posterior sagittal anorectoplasty and anterior and posterior sagittal transanorectal approaches) allow complete anatomic exposure of the perineum and lower pelvis. Moreover, they reduce the risk of damaging important structures because the incision is led in the midline. Therefore, many surgeons have used these approaches to treat diseases other than anorectal malformations (ARM), including intestinal dysganglionosis, trauma, pseudohermaphroditism, presacral mass, and rectal duplication. The aim of this study was to describe a small series of patients operated on via these approaches at Gaslini Children's Hospital over a 5-year period. We retrospectively evaluated 10 patients consecutively operated on via a perineal sagittal approach, with or without sphincteric structure involvement, between January 1997 and December 2001. All of these patients were without ARM. Indications included retrorectal abscesses (two), iatrogenic anal canal stenosis (one), postinflammatory anal canal stenosis (one), internal anal sphincter neurogenic achalasia (one), female pseudohermaphroditism (one), benign sacrococcygeal teratomas (two), malignant sacrococcygeal teratoma (one), and perineal rhabdomyosarcoma (one). Protective colostomy was used in four patients. The parameters that we analysed included technical details, possible complications, perineal cosmetic appearance, and outcome. No complications were experienced. The postoperative cosmetic perineal appearance was excellent in all patients, and continence, when assessed, was always considered satisfactory. All tumours underwent complete gross resection. However, one patient with malignant sacrococcygeal teratoma died as a result of the malignant process 2 years after surgery. Although our study was carried out on a small series of patients, it confirmed that perineal sagittal approaches can be used not only for ARM but also for other conditions involving perirectal pouches, presacral space, and urogenital structures, as these approaches are safe and provide excellent cosmetic results as well as satisfactory functional outcome. Although tumours can be treated via these approaches, outcome remains related to the nature and malignancy of the disease itself.

Anal canal stenosis and pseudo‐obstruction

Mechanical large bowel obstruction and pseudo-obstruction can be difficult to differentiate because clinical symptoms and signs are often misleading. Although plain abdominal radiographs showing diffuse gaseous distension, no shut-off point and gas in the rectum are very suggestive of pseudo-obstruction, incomplete clinical examination with over-reliance on the abdominal radiographs may lead to large bowel mechanical obstruction being misdiagnosed as pseudo-obstruction. We report a rare case of large bowel obstruction occurring secondary to anal canal stenosis.