Anal Disease Research Articles

Abdominoperineal resection for severe perianal Crohn's disease

Despite the high incidence of involvement of the perianal region in Crohn's disease, excisional surgery seldom is required for perianal disease alone. Nine patients are presented who had severe perianal Crohn's disease, which eventually required abdominoperineal excision of the anorectum. In all nine patients, it was secondary manifestations of anal Crohn's disease that precipitated proctectomy, such as high fistulas, strictures, and rectovaginal fistulas. These secondary phenomena, especially fistulas caused by cavitating ulceration, become self-perpetuating by the mechanical effect of feces being forced into the tract. During the same period, 17 patients required rectal excision by abdominoperineal resection, where perianal disease was incidental to severe colorectal disease. There is a tendency for excessive delay before advising surgery for severe perianal disease. An attempt should be made to identify patients with a poor prognosis to avoid unnecessarily prolonged morbidity. Assessment of the exact nature of the anal lesion and assessment of Crohn's disease activity are important in making this decision.

Anal carcinoma

Although epidermoid cancer of the anus is an uncommon tumor, it has served well as a model for several disciplines within oncology. Advances in understanding the epidemiology and the definitive therapeutic role of combined radiation therapy and chemotherapy for anal tumors have encouraged many investigators to study similar applications in the more common epithelial malignancies. In this monograph, the anatomy of the anal area is reviewed emphasizing the differences in natural history and prognosis between anal margin and anal canal cancers. Treatment does not depend on the specific histologic variant of the epidermoid tumors which arise in this region. The roles of viruses, of immunodeficiency syndromes, and of a history of benign anal disease and trauma in the etiology and epidemiology of this tumor are discussed. Current staging will be critically reviewed stressing that invasive (pathologic) staging by surgery is not indicated, but noninvasive staging has definite limitations. Small superficial tumors may be definitively treated with either limited surgery or radiation. While regional treatments such as surgery and radiation offer cure to between 45% and 60% of nonselected patients, initial treatment with combination radiation and chemotherapy produces cure rates between 65% and 85% for similar groups of patients. The rationale for combined for therapy by stage of the cancer are made. Finally, we present questions that remain for future research in the clinic and laboratory regarding epidermoid tumors of the anus.

A Manometric Study of Anal Fissure Treated by Subcutaneous Lateral Internal Sphincterotomy

A prospective, manometric trial of anal fissure treated by subcutaneous lateral internal sphincterotomy (SLIS) was designed to elucidate the pathophysiology of this condition. Anorectal manometry with a closed, precalibrated, water-filled microballoon using the station pull-through technique was performed on 13 patients with anal fissure before, and at one and 150 days after SLIS. The results were compared with 13 control subjects, matched for age and sex, who had no history of anal disease. Both resting pressure (RP) and maximum voluntary contraction pressure (MVCP) were measured at centimeter intervals of the anal canal. At all levels RP was significantly higher in the preoperative patients compared with controls (p less than 0.0001). After operation RP fell significantly at all levels with the result that there was no significant difference in RP between postoperative patients and controls, except at 4 cm from the anal verge, where there remained a significant elevation in RP in the postoperative group. There was no significant difference in the two sets of postoperative manometric results. All patients underwent rapid healing and resolution of their symptoms. MVCP did not change significantly after operation, nor did it differ from the control values. This suggests that the increase in RP is due to activity of the internal anal sphincter. This over-activity is present throughout the entire length of the internal anal sphincter and sphincterotomy of its lowest portion returns RP to normal values throughout most of the anal canal.

Treatment of Anal Disease in Infants and Children

Treatment of Anal Disease in Infants and Children

Anal condylomas in men. 1. Histopathological and virological assessment.

A series of 128 biopsy specimens from anal condylomas in 73 homosexual or bisexual and 38 heterosexual men (mean (SD) age 31.8 (9.6) years) were subjected to histological assessment and human papillomavirus (HPV) typing by in situ DNA hybridisation with 35S-labelled HPV 6, 11, 16, 18, 31, and 33 probes. Most patients were also tested serologically for antibodies to human immunodeficiency virus (HIV). As evaluated on light microscopy, most (74%, 95/128) of the lesions were exophytic (papillary) acuminate warts, 15% (19) were flat, and 11% (14) were pigmented papulous lesions. No signs of anal intraepithelial neoplasia (AIN) were seen in 70% (90) of the 128 biopsy specimens (NAIN), 27% (35) were classified as showing AIN I, and another 2% (three) as AIN II. AIN was significantly (p less than 0.05) more often associated with papulous lesions, only 43% (6/14) of which showed NAIN compared with 72% (68/98) of acuminate condylomas. The duration of disease was directly related to the presence and severity of AIN in the lesions; thus in 47 lesions that had been present for more than 12 months, NAIN was found in 31 (66%), AIN I in 14 (30%), and AIN II in two (4%). HPV DNA of at least one of the six types tested for was detected in 109/125 (87%) lesions. HPV 6 and HPV 11 were the two most common types, comprising 57% (62) and 37% (40), respectively, of the 109 HPV DNA positive cases. Only seven (6%) biopsy specimens were associated with any of HPV types 16, 18, 31, or 33, which carry a high risk of potential malignant transformation. No association was found between sexual preferences of patients and the incidence of any of the various HPV types. Neither did the distribution of the various HPV types differ between men with antibody to HIV and those without antibody. All the men with antibody to HIV were homosexual or bisexual. On microscopy, 93% (38) of 41 lesions containing HPV 11 and 75% (48/64) of HPV 6 lesions were of the acuminate wart type; in comparison, the remaining 16 HPV 6 lesions were equally either flat or papulous (eight, 13% each). Of the 64 HPV 6 and 41 HPV 11 associated lesions, 73% (47) and 63% (26), respectively, were classified as NAIN. Only two lesions were associated with HPV 16, and both showed mild dysplasia. On the other hand, two HPV 6 induced lesions were associated with AIN II. No differences were found between HPV 6 and HPV 11 in duration of disease; (39%, and 27% respectively, had been present for more than 12 months). The results showed that overt anal wart disease was associated with HPV types 6 and 11 in most cases. Although HPV types considered as being of higher oncogenic potential were detected relatively rarely, the associated AIN in a relatively high proportion (31% 32/105) of HPV 6 or 11 induced lesions indicated that a malignant potential, even for HPV 11 associated anal warts, cannot be excluded.

Carcinoma in Anal Crohn's Disease: Discussion Paper

Carcinoma in Anal Crohn's Disease: Discussion Paper

Local depot methylprednisolone injection for painful anal Crohn's disease

Treatment, by local depot methylprednisolone injection, of severe anal pain in Crohn's disease not associated with overt sepsis is reported. It has given dramatic relief in 5 patients, but has not been successful in 2 patients where anal disease was in continuity with severe rectal involvement. Treatment has been effective for >1 yr, and no complication of the technique has been found on regular follow-up. When compared with previous attempts at treatment, the beneficial results attained with methylprednisolone injection suggest that the effect is more than a placebo response. Careful patient selection to exclude overt sepsis or severe rectal disease is recommended before proceeding to steroid injection.

Penile/anal condylomas and squamous cell cancer. A HPV DNA hybridization study.

Acuminate condylomas from the penis (n = 17) and anus (six cases), three anal/penile giant condylomas, anal Bowen's disease (four cases), and intraanal squamous cell carcinomas with associated condylomatous changes (10 cases) including two verrucous carcinoma were studied for human papillomavirus (HPV) infections with nick translated, biotinylated cDNA probes for HPV 6, 11, 16 and 18. In addition, six cases of flat white penile lesions designated as lichen sclerosus et atrophicus were examined. Reannealed complementary DNA strands were detected in situ with either immunoenzyme or immunogold protocols. The in situ hybridizations resulted in 1/6 positive penile lichenoid lesions, 12/17 positive penile acuminate condylomas, 6/6 positive anal acuminate condylomas (including two condylomas with cellular atypias), 2/3 positive giant condylomas, 1/4 positive anal bowenoid lesions, and 4/10 positive keratinized squamous cell carcinomas, two of them being verrucous carcinomas. All penile/anal condylomas and two giant condylomas harboured HPV 6 and/or 11 DNA. The five positive carcinomas (carcinoma in situ/invasive cancer) contained HPV 6 and/or 11 in two cases (including the verrucous carcinomas), and HPV 16 and/or 18 in three cases (one carcinoma in situ, two invasive carcinomas). Recurrent malignancies were seen in one case to harbour the same HPV type as the primary lesions (HPV 16). In one particular patient, a double infection with HPV 16 and HPV 18 was demonstrated in distantly located malignant tumours. Our study confirms the restrictions and the value of non-isotopic hybridization methods applied to archival tissues, and extends the knowledge on the presence and distribution of HPV infections at anogenital sites.

Canine cryptorchism and subsequent testicular neoplasia: case-control study with epidemiologic update.

A retrospective study of 2,912 cryptorchid dogs identified 14 breeds with significantly high risk. Among six distinct closely interrelated breed groups (e.g., toy, miniature, and standard poodles), the risk in the smaller breed was always greater than that in the larger relative, suggesting that genetically influenced maldescent could be, in part, related to physical size or the rate of growth of the involved structures. Testicular tumors were diagnosed in 5.7% of the cryptorchid dogs; half had only Sertoli cell tumors, one-third had only seminomas. The relative risk for Sertoli cell tumor or seminoma was not directly related to a familial risk for cryptorchism. Using the health experience of a control population composed of male dogs with anal sac disease (N = 4,184), there is an estimated relative risk of 9.2 in cryptorchid dogs to develop a testis tumor (95% confidence interval, 5.9-14.3) and 4.2 in dogs with inguinal hernia (95% confidence interval, 1.8-9.5). Considering that the anatomical development of the genital tract, testis descent, and tunic relationships in dog are very similar to that in man, and that the associations of cryptorchism and inguinal hernia with testis neoplasms are also similar, the dog should be an excellent model system to further investigate the causes of human cryptorchism.

Management of perianal Crohn's disease.

Symptomatic anal disease (excluding skin tags) was observed in 49 out of 151 successive patients treated for Crohn's disease. Two main types of anal disease were encountered: anal ulceration (23 patients) and anal abscesses and fistulae (26 patients). The ulcer group rarely required local surgical treatment. In the fistula group, a low tract was demonstrated and laid open in 20 patients. The healing times after operation in these patients were compared with those of 18 patients with non-Crohn's fistula-in-ano treated by the same method. No significant difference between the two groups could be demonstrated. Surgical treatment of low fistula-in-ano may be undertaken in patients with Crohn's disease, provided the bowel disease is under adequate control.

1. Clinical Studies of Resting Pressure and Rhythmical Activity of the Anal Canal in Patients with Anal Diseases

Anorectal manometric study with balloon method was performed in healthy adults and patients with anal diseases, and their resting pressure and rhythmical activity were studied.The results obtained are the following.1) In healthy adults, the resting pressures were lowered with their years, and its tendency was remarkable in 5 to 6 decade of ages.Their rhythmical activities were 14.1 cycles/min. and 11.3 cycles/min. in distal and proximal canals respectively, and "ultra slow wave " was observed in 6.5 % of the control subjects.2) The resting pressure in patients with first or second-degree haemorrhoids or with fissures was significantly higher than that of control subjects, but it was lower in patients with third-degree haemorrhoids." Ultra slow wave " was seen in 50 % of haemorrhoids and 80 % of fissure patients respectively. 3) High anal pressure and "ultra slow wave" were not observed after the operation when the postoperative courses were uneventful.4) Thus, it is concluded that manometric study in patients with anal disease is useful for consideration of their causes and surgical treatments and also applicable for the assessment of their postoperative course.

The incidence and prevalence of inflammatory bowel disease in North Tees Health District.

The experience with inflammatory bowel disease in a stable, defined population in northeast England is described. In this population, the incidence of inflammatory bowel disease was higher than expected. In particular, a high incidence of colorectal and anal Crohn's disease was found. The literature is reviewed in order to identify some of the factors responsible for this unusual prevalence of inflammatory bowel disease in the study population. No explanation for our unexpected findings can be advanced.

Pruritus ani: is anal sphincter dysfunction important in aetiology?

Forty-three patients whose principal symptom was pruritus ani were studied. Twenty-eight had anal disease, while in 15 no such disease could be shown. Maximum resting pressures and transient and sustained pressures of the anal canal in response to rectal distension were measured by manometry. Although the maximum resting pressure in the patients with no disease was about the same as that in the group with disease, the pressures recorded in response to rectal distension were significantly lower. These results show that the anal sphincter relaxes in response to rectal distension more readily in patients with no anal disease. Hence soiling may occur, which may be a factor in the genesis of pruritus ani.

Colposcopy in Anorectal Disease

The colposcope was introduced into colon and rectal surgery for the evaluation of anal and perianal disease. The standard technics of gynecologic colposcopy were used. The indications included evaluations of pruritus ani, condyloma, mass lesions, unexplained bleeding or pain, and follow-up of patients previously treated for carcinoma of the anus or lower rectum.

Bladder Fistula

<h3>Common1</h3> Congenital anal atresia Crohn's disease Diverticulitis Malignant neoplasm of colon, bladder, or reproductive system Postoperative or postpartum complications Radiation therapy Trauma <h3>Uncommon</h3> Appendicitis Embedded stone eroding through bladder wall Foreign body Lymphogranuloma venereum Pelvic inflammatory disease, endometritis Schistosomiasis Tuberculous enterocolitis Ulcerative colitis <h3>Diagnosis</h3> Intestinovesical fistula secondary to Crohn's disease. <h3>Comment</h3> Figure 1, roentgenogram of the pelvis obtained with the patient in the supine position during an intravenous pyelogram, demonstrates a collection of gas in the urinary bladder and an irregular filling defect in the superior wall of the bladder. Figure 2 is a selected view from a combined barium examination of the small bowel and colon demonstrating an ulcerated stenotic loop of ileum with a fistulous communication to the urinary bladder and a colovesical fistula. Figure 3 is a roentgenogram of

The study of anorectal disease by colposcopy.

The incidence of significant, but otherwise nonapparent, perianal and anal disease in mildly symptomatic patients in this series was 6 per cent. Colposcopy helped define these lesions. Because perianal and anal neoplasms develop slowly and become manifest late, diagnosis is difficult. Colposcopy allows easier and earlier detection in patients with vague early complaints.

Ulcerative Colitis or Crohn’s Colitis: Is Differentiation Necessary?

Three types of colitis are now recognized. In the late 1950's and early 1960's, 51 per cent of our patients having colectomy had classic chronic ulcerative colitis. Of our patients operated on at that time, 39 per cent had Crohn's colitis and 10 per cent had colitis of indeterminate type. These three types of colitis should be differentiated because of the high risk of cancer of the colon in patients with long-standing chronic ulcerative colitis. We have not seen an increased risk of carcinoma associated with Crohn's colitis. We performed resection with anastomosis in approximately one third of patients with Crohn's colitis, but recurrent disease developed in two thirds. In contrast, recurrent Crohn's disease developed in only 5.7 per cent of patients having colectomy with ileostomy. Toxic megacolon associated with Crohn's colitis has been seen only in the early clinical stage of the disease. From the standpoint of management and prognosis, attempts to differentiate between the two major types of colitis are appropriate. We have outlined some of the basic clinical and pathologic differences between these two types of colitis.

Colectomy with ileoproctostomy for ulcerative colitis: report of five cases.

Twenty-five patients with ulcerative colitis were treated by abdominal colectomy with ileorectal anastomosis. Five additional case reports available since and initial publication in 1964 are presented. Proctocolectomy with permanent ileostomy remains the operation of choice for most patients requiring resectional surgery for ulcerative colitis. For selected patients abdominal colectomy with ileorectal anastomosis is a satisfactory alternative. Such patients should possess an otherwise healthy anorectum with only mild to moderate proctitis. Anal ulcer (chronic fissure-in-ano), fistula-in-ano, and symptomatic hemorrhoidal disease are considered contraindications to this operative procedure.

Internal Anal Sphincter Derangement with Anal Fissures

Rectosphincteric manometric studies in patients with anal fissures demonstrated an abnormal internal anal sphincter reflex in response to rectal distention. This abnormal reflex response, characterized by an overshoot contraction immediately after a normal relaxation, was present in all 7 patients with fissures, but not in 17 subjects without anal disease. In 3 patients studied after treatment, the response returned to normal. These studies suggest that reflexly stimulated internal sphincter spasm plays a role in the pathogenesis of anal fissures, and that surgical approaches should be directed to the internal, rather than the external anal sphincter.

A Senile Case of Complicated Fistula-in-ano with Lethal Course

Authors experienced an old patient with complicated fistula-in-ano and diabetes mellitus followed an unhappy course.Generally, at first, the conservative therapy is used to accept in the anal disease. In regard to the anal fistula, it is not correct, especially in old patients.Surgical operation should be performed to the old patient with anal fistula in early stage.