Anal Margin Research Articles

A Mature Cyst Teratoma with Malignant Transformation in Squamous Cell Carcinoma Presenting Like a Sigmoid Fistula: A Case Report of a Rare Differential Diagnosis of a Giant Colonic Diverticulum

Mature cystic teratoma is the most common form of ovarian germ cell tumor. Mature cystic teratoma is a benign tumor, mainly diagnosed in young women, with non-specific symptoms. However, the risk of malignant transformation exists (1-2%). Squamous cell carcinoma is the most frequently encountered histological form. Giant colonic diverticulum is a rare complication of diverticular disease, characterized by a diverticulum larger than 4 cm which can sometimes be confused with other digestive pathologies (appendicitis, small bowel perforation ...). We report a case of an ovarian squamous cell carcinoma arising from a mature cystic teratoma, presenting like a sigmoid fistula, with an initial doubt with the diagnosis of a giant colonic diverticulum. A 68-year-old woman was admitted for chronic hypogastric abdominal pain with a doubt concerning the diagnosis between a mature cystic teratoma and a giant colonic diverticulum. A computed tomography scan was performed revealing a perisigmoid cyst with hydro-aeric level in favor of a giant colonic diverticulum. The pelvic MRI rather suggested a left ovarian cyst, fistulated in the sigmoid colon. Finally, the colonoscopy confirmed this hypothesis with the visualization of a sigmoid fistula located 15cm from the anal margin in connection with a cavity containing hairs. Biopsies revealed a squamous cell carcinoma. After a negative extension assessment, a posterior pelvectomy was performed with pelvic and lumbo-aortic lymph node dissection. The pathological diagnosis was an ovarian pT4N1R0 squamous cell carcinoma. An adjuvant chemotherapy is still in progress.

Giant Acuminated Condyloma in a HIV Positive Migrant Patient: Is There a Benefit on Giving the HPV Vaccine To the Men Who Have Sex With Men Population? Case Report and Literature Review

Anal cancer is a serious health problem in HIV-positive Men who have Sex with Men (MSM), and precursor lesions like anal intraepithelial neoplasia; are well defined. Anal intraepithelial neoplasia (AIN), a human papillomavirus (HPV)- associated anal cancer precursor lesion, is frequent among human immunodeficiency virus (HIV)-positive men who have sex with men and women (MSMW). There is a paucity of data published on the progression of high-grade AIN to invasive cancer as well as on clinical and virological characteristics comparing anal margin and anal canal carcinoma. Men who are infected with HIV and MSM are at particularly high risk for persistent HPV infection and HPV-induced lesions. The treatment of high-grade squamous intraepithelial lesions (HISL) in HIV positive MSM associating the adjuvant vaccine against HPV is likely to be cost-effective, with benefits reported in the age group above 38 years. It is convenient to design large controlled studies that enroll the MSM population infected with HIV, as in our patient; to evaluate the benefits of the HPV vaccine.

A case of inverted serrated polyp that mimics a submucosal tumor

A 68-year-old woman underwent colonoscopy because of abdominal discomfort and changing of bowel movements for half a year. A submucosal protruded lesion, 4 mm × 5 mm, with smooth and intact cover mucosa was found at the rectum 4 cm from the anal margin (A). EUS with a miniprobe revealed a heterogenously hyperechoic lesion with clear margins (B, yellow arrow). The lesion was mainly located between the mucosal and submucosal layers, with a maximum size 3.8 × 4.5 mm in diameter. A thin layer of submucosal structure existed beneath the lesion (B, yellow arrow). The physical examination, laboratory examinations, and abdominal and pelvic CT revealed no remarkable findings. Endoscopic submucosal dissection (ESD) was recommended, and the lesion was removed en bloc. Pathologic examination revealed serrated intestinal mucosa within the muscularis mucosal layer, which was consistent with inverted serrated polyps. The lesion also demonstrated the characteristics of low-grade intraepithelial neoplasia. Genetic testing indicated the existence of a BRAF gene mutation. Histopathologic analysis showed the serrated tubular features (C, black arrows) of this lesion and a small area of defective muscularis mucosae (D, yellow box) on top of the protrusion.

Anal Dysplasia Among Patients With Multiple Human Papillomavirus Anal Lesions: Mosaic or Homogeneity?

Purpose Anal dysplasia is caused by chronic infection with the human papillomavirus and exposes to the risk of anal cancer. The aim of this study was to evaluate the distribution of dysplasia anal grade among patients operated on for multiple anal condylomas with no macroscopic differences.Methods This is a cross-sectional study of patients operated on for multiple anal condylomas including a mapping of dysplasia by performing systematically for each patient one biopsy on visible lesion from each of the 4 quadrants on anal margin and in anal canal. All biopsies were read independently by 2 different pathologists.Results Among 72 patients, 60 were men and 48 were human immunodeficiency virus (HIV)-infected with a median age of 37.5 years. The proportion of high-grade squamous intraepithelial lesion (HSIL) was higher in the anal canal (41.7%) compared to the margin (20.8%) (P = 0.004). HSIL frequency did not differ according to the quadrant (anterior, posterior, right, and left) of the 2 areas. HSIL on anal canal was not associated with HSIL on anal margin and vice versa (P = 0.390). Neither age nor sex was associated to HSIL but HIV positivity increased the risk of HSIL on the anal margin (P = 0.010).Conclusion Anal dysplasia is heterogeneously distributed in the anal canal as well as between anal canal and anal margin. The diagnostic of the grade of dysplasia for a person should require multiple biopsies on the canal and anal margin.

Tamis sin Cierre de la Brecha Quirúrgica

Antecedentes: La cirugía mínimamente invasiva transanal (TAMIS), es una técnica que resulta especialmente útil en lesionesde recto extra peritoneal difíciles para el abordaje por vía anterior.Actualmente sigue siendo controversial el cierre del defecto rectal por debajo de la reflexión peritoneal. La suturaendoluminal es uno de los aspectos más desafiantes del procedimiento y la literatura es discordante con respecto al cierrede la brecha quirúrgica. Nuestro objetivo es realizar un estudio descriptivo de una serie consecutiva de pacientes conlesiones de recto extraperitoneal sometidos a cirugía de TAMIS, dejando el lecho quirúrgico abierto.Objetivo: Descriptivo prospectivo longitudinal.Material y Método: Entre agosto de 2013 y julio de 2019 se incluyeron, en forma consecutiva, todos los pacientes conlesiones de recto extra peritoneal, operados con técnica de TAMIS, que presentaron lesiones benignas ≥ a 3 centímetros dedifícil resolución endoscópica, tumores neuroendocrinos ≤ de 2 cm, adenocarcinomas T1N0 sin signos histológicos de malpronóstico, adenocarcinomas T2N0 con elevado riesgo quirúrgico o que rehusaron la cirugía radical y pacientes con dudasde la remisión completa luego de la neoadyuvancia. Todos los procedimientos fueron realizados por el mismo cirujano y entodos se dejó el lecho quirúrgico abierto.Resultados: En un período de 6 años se trataron 35 pacientes con técnica de TAMIS, con una edad promedio de 61 años±12.El tamaño promedio de las lesiones fue de 3.68±2.1 cm (0.7- 9 cm) y la distancia desde el margen anal al extremo distal de lalesión de 5.7±1.48 cm (3 a 8.5 cm). El tiempo operatorio fue de 39.2±20.5 min y el tiempo de internación de 33±28.2 horas.La anatomía patológica de las lesiones resecadas fue: 15 adenomas, 3 tumores carcinoides y 17 adenocarcinomas. 1 ypT0,4 carcinomas in situ, 4 tumores T1 y 8 tumores T2. En todos los casos se dejó el defecto rectal abierto, con un seguimientomínimo post operatorio de 9 meses. No hubo mortalidad y la morbilidad global fue de 14.2% (5 pacientes). Dos pacientesfueron re internados para el tratamiento del dolor (Clavien-Dindo II) y 3 pacientes (8.5%) presentaron sangrado postoperatorio, de los cuales solo 1 (2.8%) requirió re intervención (Clavien-Dindo III). No hubo complicaciones infecciosas,estenosis de recto postquirúrgicas ni perforaciones hacia la cavidad abdominal.Conclusión: Nuestros resultados permiten describir a la técnica de TAMIS dejando la brecha quirúrgica abierta, como unatécnica con buenos resultados, alta factibilidad y baja tasa de complicaciones.

A cohort study of treatment outcomes after radiotherapy in vulva carcinoma patients

Carcinoma of the vulva is an uncommon tumour. For locally advanced vulval cancer with proximity to the urethra or anal margin, surgery often involves exenteration with colostomy or urinary diversio...

Sacrococcygeal dimensions and curvature are associated with resection quality in rectal cancer excision.

Technical factors affect oncologic outcomes in rectal cancer surgery. The anatomy of the bony pelvis can affect technical aspects of surgery, but is seldom considered preoperatively. We performed a morphometric analysis of the bony pelvis in patients having rectal cancer resection to assess its effect on surgical specimen quality. We performed a retrospective analysis of a prospectively maintained database of patients who had resection for rectal cancer from January 2014 to December 2017. Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) images were accessed and measurements of sacrococcygeal distance, sacrococcygeal recess depth/area, sacrococcygeal angulation, anteroposterior pelvic inlet/outlet, pubic height and interspinous distance were made. Outcome measures included anatomical variation, operating time and mesorectal specimen grade. In patients having extra-levator abdominoperineal excision (eLAPE) with coccygectomy, the completeness of coccygeal resection was assessed by postoperative CT scan. Data were analysed using binomial and multinomial logistic regression and linear regression. One hundred and twenty-two consecutive rectal cancer resections were performed (39 open, 42 laparoscopic, 12 laparoscopic-converted and 29 robotic). The median age was 72years (range: 29-88years). The male:female ratio was 83:39. Eighty-one patients had anterior resection, 8 had low Hartmann's resection and 32 had APE. Of those who had APE, 21 had eLAPE (all with coccygectomy). Females had a larger pelvic inlet (female: 124.9mm, male: 114.9mm), interspinous diameter(female:112.8mm, male:97.6mm), sacrococcygeal depth (female:42.6mm, 39.35mm) and sacrococcygeal area recess than males (female: 3697mm2, male: 3481.5mm2). Males had a greater pubic height (female: 51.8mm, male: 54.05mm) and greater sacrococcygeal distance (female: 116.7mm, male: 123.65mm) than females. In patients having anterior resection, tumour distance from the anal verge (p = 0.004), sacrococcygeal distance (p = 0.006) and sacrococcygeal curvature (p = 0.002) were associated with specimen quality. In patients who had eLAPE, median preoperative coccygeal length was 41mm (IQR: 35.1-45.5). The median length of coccygeal resection was 9mm (IQR: 1-17.45mm). The median length of coccyx remaining postoperatively was 33mm (IQR: 21.35-39mm). Sacrococcygeal curvature and distance as well as tumour distance from the anal margin were associated with specimen quality in anterior resection. Coccygectomy was not performed as completely as surgeons thought. Surgeons should include sacrococcygeal bony anatomy in rectal cancer surgical planning to potentially improve outcomes in both anterior resection and eLAPE approaches.

Four new species and one new subspecies of the Ghoria albocinerea Moore, 1878 species-group from northern Indochina and China (Lepidoptera, Erebidae, Arctiinae, Lithosiini).

The Ghoria albocinerea Moore, 1878 species-group is established for a complex of species having the characteristic silver whitish forewing coloration and pattern presented mostly by a broad longitudinal shade along the anal wing margin. Four new species and one new subspecies of the species-group are described: Ghoria nanlingica dytiko ssp. n. (China: Sichuan), Ghoria dammay sp. n. (North Vietnam), Ghoria longivesica sp. n. (China: Yunnan and North Thailand), Ghoria mubupa sp. n. (China: Yunnan) and Ghoria synnefo sp. n. (North Vietnam). Adults, male and female genitalia of the new taxa and the related Ghoria albocinerea (the central and eastern Himalayas), Ghoria nanlingica Dubatolov, Kishida Wang, 2012 (China: Guangdong) and Ghoria sinotibetica Dubatolov, Kishida Wang, 2012 (China: Sichuan) are illustrated.

Application of titanium clip marking in localization of 37 cases of rectal cancer before radiotherapy

AbstractObjectivesAt present, locating radiotherapy targets for rectal cancer is mostly assisted by computed tomography (CT) and/or magnetic resonance (MR) imaging. This article discusses the role of the upper and lower margins of rectal cancer lesions under colonoscopy in accurately delineating target areas of radiotherapy.MethodsA total of 37 patients with rectal cancer diagnosed by histopathology at the Shandong Provincial Cancer Hospital, affiliated with Shandong University, from 1 July 2017 to 1 August 2018 were selected before treatment. The upper and lower margins of the lesion were marked by titanium clips under the assistance of ultrasound and a magnifying endoscope in each patient, as well as the lower edge of the titanium clip from the anal margin. In the same position and in a thermal plastic membrane body fixation device, patients underwent CT and MR examinations to outline the gross tumor target area (GTV). The radiation therapy planning system calculated the length of the GTV under CT and MR (GTVCT, GTVMR), and the distance from the lower edge of the GTV to the anal margin. The application value of titanium clip labeling by colonoscopy in radiotherapy localization for rectal cancer was evaluated according to differences of GTV lengths by three methods.ResultsGTVs measured by endoscopic titanium clip labeling, CT localization, and MR localization were 5.84 ± 2.035 cm,6.97 ± 1.658 cm, and 5.45 ± 2.088 cm, respectively. The length of GTVtitanium clip was not significantly different from the length of GTVMR (P = 0.162). The marked lesion lengths by the endoscopic titanium clips and MR localization were significantly smaller than that measured by CT (GTV titanium clip < GTVCT, GTVMR < GTVCT, P < 0.001). The distance between the lower margin of the titanium clip and the anal margin (4.19 ± 1.647 cm) was not significantly different from MR (4.41 ± 1.624 cm; P = 0.231). The distance from the inferior margin of the lesion to the anal margin was significantly greater in measurements from the endoscopic titanium clip and MR localization than CT localization (3.53 ± 1.394 cm; P < 0.001). None of the patients had adverse reactions, such as bleeding or perforation.ConclusionsTumors labeled with titanium clips through colonoscopy contribute to the precise delineation of the target area before radiotherapy for rectal cancer. This technique is shown to have value in clinical application.

Low rectal cancer treatment strategies: a cohort study assessing watch and wait.

Treatment strategies for low rectal cancer have been evolving toward achieving less treatment morbidity with the same oncological success-we aimed to assess the results of the new watch and wait (W&W) strategy in our cohort. A tertiary care cohort study was conducted. New patients with rectal adenocarcinoma up to 6 cm from the anal margin, cM0, locally staged higher than cT1N0, evaluated between November 2014 and October 2018, were included. All 93 patients received neoadjuvant radiotherapy ± chemotherapy. Re-evaluation was planned 8-12 weeks after the end of treatment. Patients showing clinical complete response (cCR) were given the choice of either to proceed to surgery or to enter W&W. Of the 93 patients, 82.8% were re-evaluated and 20.8% had cCR. Patients in clinical stages II/III were significantly less likely to achieve cCR than those in stage I (p=0.017). After a mean follow-up of 17.44 months, there were 4 regrowths in the 16 patients under W&W, all submitted to R0 surgery, ypN0; there were no deaths or local recurrences; one patient with regrowth had distant recurrence. Sixty patients underwent direct surgery after a mean follow-up of 16.23 months; 3 patients had local and distant recurrences; 7 others had only distant recurrences; there were 8 deaths. There were no statistically significant differences between patients under W&W and patients who underwent direct surgery regarding local or distant recurrences, or death (p > 0.9; p = 0.44; p = 0.19, respectively). The W&W strategy for low rectal cancer achieved the same oncological outcomes as the traditional strategy while sparing some patients from surgery.

Risk factors of anastomotic leakage after robotic surgery for low and mid rectal cancer

Objective: To investigate the risk factors associated with anastomotic leakage after robotic surgery in mid-low rectal cancer. Methods: A retrospective case-control study method was conducted. Inclusion criteria: (1) 18 to 80 years old; (2) pathologically confirmed rectal cancer; (3) distance <10 cm from tumor to anal margin; (4) robotic anterior rectal resection. Patients with previous history of colorectal cancer surgery, distant metastases or other malignant tumors, undergoing emergency surgery, with severe abdominal adhesions or those receiving combined organ resection were excluded. Based on the above criteria, 636 patients undergoing robotic radical sphincter-preserving surgery for mid-low rectal cancer in Zhongshan Hospital from January 2015 to December 2018 were included in this study, including 398 males (62.6%) and 238 females (37.4%) with a mean age of (61.9±11.3) years. Sixty-eight cases (10.7%) received neoadjuvant chemoradiotherapy. Amony the 636 included patients, 123(19.3%) underwent natural orifice specimen extraction surgery (NOSES) and 15 (2.3%) underwent preventive stoma. According to the cirteria developed by the International Rectal Cancer Research Group in 2010, the anastomotic leakage was classified as grade A (no requirement of intervention), B (requirement of intervention), and C (requirement of operation). Logistic regression was used to analyze the relationship between anastomotic leakage and clinicopathological factors. Factors in univariate analysis with P<0.05 were included in the multivariate analysis. Results: Anastomotic leakage occurred in 38 cases (6.0%). The grading of anastomotic leakage was grade A in 13 cases (2.0%), grade B in 19 cases (3.0%), and grade C in 6 cases (0.9%). The 3-year disease-free survival rate of patients with anastomotic leakage and without anastomotic leakage was 83.5% and 83.6% respectively (P=0.862); the 3-year overall survival rate of the two group was 85.1% and 87.5% respectively (P=0.296). The results of univariate logistic regression analysis showed that male (P=0.011), longer operation time (P=0.042), distance ≤5 cm from tumor to anal margin (P=0.012), more intraoperative blood loss (P=0.048) were associated with anastomotic leakage (all P<0.05). NOSES was not associated with anastomotic leakage (P=0.704). Multivariate analysis confirmed that male (OR=3.03, 95%CI: 1.37 to 7.14, P=0.010), operation time ≥180 minutes (OR=2.04, 95%CI: 1.03 to 3.99, P=0.040), distance ≤5 cm from tumor to anal margin (OR=2.56, 95%CI:1.28 to 5.26, P=0.008) were independent risk factors for anastomotic leakage. Conclusion: Male, short distance from tumor to anal margin, and long operation time are independent risk factors for anastomotic leakage in patients undergoing robotic mid-low rectal cancer radical surgeries. These patients need to be cautiously treated during surgery.

Effects of tumor distance from anal verge on survival outcomes for rectal NENs and lymphatic metastasis risk score for colorectal NENs.

To explore whether the distance of rectal neuroendocrine neoplasms from the anal margin has an impact on the prognosis of patients and evaluate lymphatic metastases risk score for colorectal neuroendocrine neoplasms (NENs). Clinical pathological and follow-up data of 71 patients identified as colorectal neuroendocrine neoplasms by pathology from July 2011 to July 2019 were carefully collected. Among 71 patients with colorectal NENs, most of the tumors were rectal NENs (62 cases). A total of 26 patients were in the presence of lymph node metastasis, and 44 patients had negative lymph nodes. Patients with lesions from the anal margin > 5cm in rectum have a better prognosis (P = 0.022). Tumor stage (P = 0.034) and grade (P = 0.001) were independent risk predictors of lymphatic metastases. We developed a lymphatic metastasis risk score for rectal NENs, and patients with the score ≥ 7.5 were more likely to develop lymph node metastases (area 0.958, 95% CI 0.903-1.000, P = 0.000) with a sensitivity of 72.2% and a specificity of 97.3%. Patients with lesions from the anal margin > 5cm and lymphatic metastasis risk score ≥ 7.5 should be treated actively.

Acute Management of Parikartika (fissure in ano) by Tila Taila Matra basti: Case study.

In today’s modern life style which is more over sedentary life having more diseases than ever .one of them is fissure in ano caused by many reasons such as low fibre diet, non vegetarian diet, low physical activity, junk food, irregular meals, stress which all causes irregular bowel movements and constipation leads to the passage of hard stool causing erosion and deep tear through the skin of anal margin extending in to anal canal which named as parikartika i.e. fissure in ano. In this study a single case was taken to treat the acute stage of fissure in ano with tila taila matra basti for 3 days only. assessment was done on the basis of acute pain ,burning sensation, spasm, itching ,constipation(hard stool).The acute stage was controlled in 1 hour to 2 days .

More than just the number of denticles: morphometric and limb variability in Neotropical cladoceran Alonella dadayi (Crustacea: Cladocera: Chydoridae).

The aim of this study is to describe the limb morphology of Alonella dadayi Birge (Cladocera: Chydorida) and this species' morphometric variability regarding the carapace and postabdomen. We report for the first time a population whose individuals do not have denticles on the posteroventral corner of the carapace. Although we have observed intra- and interpopulation variability of the limbs (especially the proportion of Inner Distal Lobe setae), Alonella dadayi can also be differentiated from closely related species by the morphology of the exopodite of the second limb. The morphometric analyses show high variability in the shape of the carapace, when regarding the ventral margin and posterodorsal corner. In the postabdomen, we observed a significant variation in the preanal, anal and postanal margins. Keeping in mind the wide range of the geographic distribution of Alonella dadayi and its high morphological variability, it is possible that this taxon comprises a species complex. Such a chance needs to be tested in future studies.

When do defecation function and quality of life recover for patients with non-ostomy and ostomy surgery of rectal cancer?

BackgroundRectal cancer (RC) surgery often results in permanent colostomy, seriously limiting the quality of life (QOL) in patients in terms of bowel function. This study aimed to examine defecation function and QOL in RC patients who underwent non-ostomy or ostomy surgery, at different time-points after surgery.MethodsIn total, 82 patients who underwent an ostomy and 141 who did not undergo an ostomy for the treatment of RC at our colorectal surgery department between January 2013 and January 2015 were enrolled. Surgical methods, tumor distance from the anal margin (TD), anastomosis distance from the anal margin (AD) and complications were compered between the non-ostomy and ostomy surgery groups. QOL was compared between the two groups at years 2, 3, and 4 after surgery. The Wexner score and the validated cancer-specific European Organization for Research and Treatment of Cancer (EORTC QLQ-CR30) questionnaire scores were assessed for all patients in January 2017. SPSS 21.0 was utilized for all data analyses.ResultsSurgical methods, TD, and AD significantly differed between the non-ostomy and ostomy surgery groups (all P < .001). However, no differences were found in the number of complications between the groups (P = .483). For the 192 patients undergoing Dixon surgery, role function (RF), global QOL (GQOL), sleep disturbance, and the incidence of constipation showed significant differences between the two groups (P = .012, P = .025, P = .036, and P = .015, respectively). In the 31 cases of permanent ostomy, we observed significant differences in GQOL scores, dyspnea incidence, and financial difficulties across the different years (P = .002, P = .036, and P < .01, respectively). Across all 223 cases, there were significant differences in social function and GQOL scores in the second year after surgery (P = .014 and P < .001, respectively). However, no differences were observed in the other indices across the three time-points.ConclusionsRC patients undergoing ostomy surgery, especially those with low and super-low RC, revealed poorer defecation function and QOL in the present study. However, 2 years after surgery, most of the defecation and QOL indicators showed recovery.

Anal squamous cell carcinoma in KwaZulu-Natal Province, South Africa, with special reference to the influence of HIV infection on clinical presentation and management outcome.

Anal carcinoma is rare. Clinicopathological features influencing outcome have not been determined in HIV-negative and HIV-positive patients in South Africa. To compare presentation and treatment tolerance among HIV-positive and negative patients. This study was a retrospective analysis of prospectively collected data on patients with squamous cell carcinoma of the anus. Patients with known HIV status were extracted from the anal cancer database and analysed. Data analysed included demographics, clinical features, stage, pathology and treatment outcome. There were 268 patients with anal squamous cell carcinoma (n=135 HIV-positive and n=33 negative). The median age was 39years and 53 years for HIV-positive and negative patients, respectively, the male/female ratio was 1:2.7 and 1:1.8 for the two groups, and the ratio of anal margin to canal distribution was 1.3:1 and 1:1. Disease stage was similar, with minor differences. The resection rate was 17% in HIV-positive patients and 9% in those who were HIV-negative. Half the patients in both groups were eligible for definitive therapy, and side-effects of oncotherapy occurred with similar frequency in both groups. The recurrence rate was 7% in both groups and the disease-free interval was similar. Overall survival was longer for HIV-negative patients (p=0.0240). The prevalence of anal squamous cell carcinoma is much higher in individuals with HIV infection than in those who are HIV-negative. HIV-positive patients present at a younger age and with locally advanced disease that responds less well to standard treatment, and their survival is poorer.

Epidemiological and prognostic single center study of anal carcinoma

BackgroundAnorectal carcinoma includes the anal margin, the anal canal, and the lower rectum. The incidences of anal tumors represent 1.4 % of all gastrointestinal tumors. Patients and methodsOur study is retrospective and was conducted at Baghdad Medical City. Patient’s data were collected from the medical records through a predesigned sheet that included the following information: demographic data, medical history, past-history, presenting symptoms, pathological data, and treatment details. ResultsThe median age was 49 years. As regard tumor extension, 85.71 % of patients had anal disease, while anorectal cancer was encountered in 14.28 % of cases only. Male to female ratio was 1:3. Most of cases were SCC 78.57 %. Only 11 patients (39.28 %) were diagnosed as Stage I, whereas 12 patients (42.85 %) had Stage II-III disease. Moderate differentiated tumors are the most common. The tumor mass located between 5–10cm das a distance from anal verge in 12 (42.85 %) of patients. We found 6 (21.42 %) patients with positive virology tests with no specificity detected. APR was the mainstay for treatment of stage I disease. Neoadjuvant treatment followed by TME resection was the treatment found in locally advanced tumors. The mean Overall Survival (OS) for patients received neoadjuvant CRT in the study was 43.5 months, while, the mean OS was 45.73 months in the adjuvant setting. Univariate analysis for OS according to prognostic factors revealed that sites of cancer, grades and histopathology were significant independent prognostic factors for OS in this study. The anal canal tumor was associated with shorter OS (33.25) months in comparison to the anorectal cancer (OS=47.22 months). Based on tumor grade, well and moderate differentiation have better OS (60.21 months) while, poorly grade was associated with shorter OS (43.07 months). On the concern of SCC, it was associated with shorter OS (37 months) in comparison to higher survival in patients with adenocarcinoma (46.13 months). ConclusionAnal canal cancer has poorer prognosis than anorectal. The early-stage has a better OS that needs more effort for early diagnosis and treatment.

Iatrogenic urethro-rectal fistula

Urethro-rectal fistula is a rare pathological entity, most often iatrogenic secondary to prostate surgery, or traumatic secondary to trauma of the pelvis. We report the observation of a 73-year-old patient who consults in urology for urinary discharge through the anus during urination. He is a type I diabetic patient under poorly monitored insulin, he was treated for repeated urethritis, operated 4 months ago for Fournier gangrene with the notion of traumatic urethral catheterization, he presented after the removal of the bladder catheter a dysuria with emission of urine from the anus during urination which motivated a consultation. On clinical examination, the scrotum is supple and well healed after flattening the necrotic areas; absence of cutaneous fistulous pathways; in the digital rectal examination, a small induration is found at 6 cm from the anal margin class II according to the Rivera classification, with a firm prostate of 55 g. Retrograde urethrocystography (A, B, C, D) showed the presence of a urethro-rectal fistula with the presence of multiple moniliform narrowing of the anterior urethra in favor of chronic urethritis with muscular bladder and post-voiding residue. Trans-sphincter posterior surgical procedure according to the York-Mason technique has been proposed to treat this patient.

Surgical treatment of squamous cell cancer with anal margin localization developed on the background of condyloma acuminata: A case report

Surgical treatment of squamous cell cancer with anal margin localization developed on the background of condyloma acuminata: A case report

Short-term clinical efficacy of robotic radical resection for high rectal cancer with transvaginal specimen extraction

Objective: To explore the short-term clinical efficacy of robotic radical resection for high rectal cancer with transvaginal specimen extraction. Methods: A cohort study was carried out. The clinical data of consecutive patients with high rectal cancer who underwent robotic radical resection at the Department of General Surgery of The First Affiliated Hospital of Nanchang University from June 2017 to January 2018 were retrospectively analyzed. Inclusion criteria: (1) preoperative diagnosis of rectal cancer, and distance from tumor to anal margin≥10 cm undercolonoscopy; (2) T1-3 assessed by preoperative imaging examination, and no distant metastasis; (3) female, age≥50 years old, body mass index ≤ 30 kg/m(2); (4) without radiotherapy and chemotherapy before surgery; (5) implementation of robotic radical surgery for high rectal cancer. Fourteen female patients undergoing transvaginal removal of specimen without abdominal incision were included in the no incision group with age of (62.2±9.3) years old and distance from tumor to anal verge of (12.5±0.9) cm. As the match of 1:2, 28 simultaneous patients of high rectal cancer undergoing traditional robotic surgery (surgery interval <8 months) were enrolled to the control group, with age of (60.6±12.8) years old and distance from tumor to anal verge of (11.3±3.8) cm. Short-term efficacy and safty were compared between two groups. Follow-up ended in September 2018. Results: There was no significant difference in baseline data between the two groups (all P>0.05). Compared with the control group, the no incision group had longer operation time [(149.6±15.6) minutes vs. (130.9±12.9) minutes, t=-4.135, P<0.001], shorter time to postoperative flatus [(40.9 ±2.6) hours vs. (51.9±2.9) hours, t=12.049, P<0.001], lower pain score on the operation day and the first day after surgery (using Changhaipainstick) [(3.1±0.4) points vs. (4.6±0.7) points, t=7.458, P<0.001; (2.5±0.3) points vs. (3.3±0.5) points, t=6.142, P<0.001], shorter time to ground activity [(15.6±2.0) hours vs. (24.3±2.5) hours, t=11.102, P=0.030], and shorter postoperative hospital stay [(6.1±0.8) days vs. (7.2±1.3) days, t=2.806, P=0.008], whose differences were statistically significant. There were no significant differences in intraoperative blood loss, proportion of postoperative analgesia patients, and complication within 30 days after surgery (all P>0.05). In the no incision group and the control group,the tumor size was (3.1±0.4) cm and (3.6±0.9) cm, the proximal margin distance was (9.1±1.5) cm and (9.8±1.5) cm, the distal margin distance was (4.3±0.4) cm and (4.5±0.4) cm, the number of harvested lymph node was 15.8±2.4 and 15.2 ± 2.5, and the number of positive lymph node was 0.6±1.3 and 1.1±2.4, respectively, whose differences were not statistically significant (all P>0.05). The mean followed-up period was 10 months (7-14 months) in the no incision group, and 14 months (10-18 months) in the control group. No local recurrence and distant metastasis were found in both groups. Conclusion: Robotic radical resection for high rectal cancer with transvaginal specimen extraction is safe and feasible with advantages of rapid postoperative recovery, less postoperative pain and short hospital stay.