Anal Reconstruction Research Articles

Factors contributing to emotional distress when caring for children with imperforate anus: a multisite cross-sectional study in China.

Imperforate anus (IA) has a life-long impact on patients and their families. The caregivers of children with IA (CoCIA) might experience distress, which could be detrimental to them physically and mentally. However, there are limitations in the related studies. This study aimed to investigate the prevalence of IA and the associated factors contributing to the distress experienced by CoCIA. A cross-sectional study was conducted in three tertiary children's hospitals from November 2018 to February 2019. Distress was assessed using the Chinese version of the Kessler Psychological Distress Scale, and possible determinants were assessed by the Caregiver Reaction Assessment, the Parent Stigma Scale, the Parent Perception of Uncertainty Scale, and the Social Support Scale. Demographic and clinical information was also collected. Multiple regression analysis was performed to explore the association between variables. Out of 229 CoCIA, 52.9% reported experiencing a high level of distress or above. The data analysis revealed that health problems associated with caregiving, stigma, uncertainty, social support, and children who underwent anal reconstruction surgery 1 year before or earlier could significantly predicate caregivers' distress, and these factors could explain 50.1% of the variance. The majority of the caregivers of children with IA experience high levels of distress, particularly when their children undergo anal reconstruction surgery 1 year before or earlier. Additionally, health problems related to caregiving, stigma, uncertainty, and low social support could significantly predicate caregivers' distress. It is important for clinical staff to be aware of the prevalent situation of caregivers' distress and to make targeted interventions focused on addressing modifiable factors that should be carried out in family-based care.

Successful separation of male pygopagus with anal canal and urethral reconstruction: a case report

BackgroundPygopagus is a type of conjoined twin binding at the buttocks. Some cases of pygopagus involve the fusion of the gastrointestinal tract, urinary tract, and spinal cord. Few cases of male pygopagus have been reported; however, the prognosis after separation is unclear. Herein, we report a case of male pygopagus in which successful separation was performed with the reconstruction of the anal canal.Case presentationTwins with male pygopagus were born at 35 weeks by cesarean section. They shared a common anus, penis, and scrotum with four testes. The infants had normal defecation and urination after birth. The separation surgery was scheduled when they were 5 months. Two distinct anesthesia teams and four surgical teams (neurosurgery, pediatric urology, plastic surgery, and pediatric surgery) were involved in the multidisciplinary approach. After separating the spinal cord, we found that the anal canal and sphincter muscle complex were fused near the anal aperture, and we separated them. The fused penis and testis were separated and reconstructed using the same incisional line as the other separation, and the reconstructions of the anal canals with the sphincter muscle complex were completed. Both patients had an uneventful postoperative course. At 2 years of age, they could walk and defecate independently. In addition, they voided spontaneously without urinary incontinence at the time of 3 years and 11 months.ConclusionsSeparation of the spinal cord with anal canal and urethral reconstruction is important for male pygopagus patients as it allows them to preserve their independent function.

Standards of anal fissure management in Europe and the United States

Anal fissure is the second most common proctological disorder after haemorrhoids. The majority of researchers agree that conservative treatment should be the first stage of anal fissure management. The procedures used for the treatment of anal fissure are the biggest subject of disagreement. The aim of this article is to review and compare thedifferences in the methods of anal fissure management in certain European countries and in the United States. Anal fissure treatment varies between different countries. In many algorithms, fissurectomy combined with anal skin advancement flap reconstruction is listed as the first treatment option. Posterior sphincterotomy, which is frequently performed in Poland, is not included in any of the algorithms quoted in this paper; lateral sphincterotomy is preferred instead. No algorithm recommends manual anal dilation, which is consistent with our observations that this procedure is associated with uncontrolled tearing of sphincter muscle fibres and a high risk of incontinence. This article reviews and compares the differences in the methods of anal fissure treatment in certain European countries and in the United States.

Transanal and transabdominal combined endoscopic resection of rectal stenosis and anal reconstruction based on transanal endoscopic technique.

To propose a method for the resection of the rectal anastomotic stenosis and anal reconstruction based on the transanal endoscopic technique through a transanal and transabdominal combined endoscopic resection, and to verify its clinical effectiveness. Thirty-eight patients with anastomotic stenosis wereadmitted to the Sixth Affiliated Hospital, Sun Yat-sen University, China, fromJanuary 2016 to September 2019. Patients were divided into an experimental group (17patients) and a control group (21 patients)subjected to theremoval ofthe intestinal stenosis followed by anal reconstruction, they underwent transanal and transabdominal endoscopic surgery and traditional transabdominal surgery, respectively. Data on intraoperative blood loss, operation time, postoperative recovery, and prognosis were collected. (1) The median intraoperative blood loss was approximately 100 ml, without conversion to laparotomy during the surgery and intraoperative complications. The safety of the surgical operation was improved. (2) The operation time was shortened compared to previous reports, and the median operative time was 193 min. The average time of transanal endoscopic dissociation to the retroperitoneal fold was 76 min. (3) Laparoscopic assistance was carried out on 14 of the17 patients, and the incision was reduced. (4) The short-term curative effect was quite satisfactory, without permanent stoma. The average time to recover food intake after the surgery was 1.5 days. The average ambulation time was 3 days. Within 30 days after the surgery, one case suffered anastomotic leakage and then underwent refunctioning stoma through a second surgery. One patient suffered from intestinal obstruction, and the condition was improved through a conservative treatment. One case experienced delayed abdominal wound healing. The transanal and transabdominal endoscopic resection of the rectal anastomotic stenosis and anal reconstruction reduced the difficulty of the surgery, improved its safety, shortened the operation time, decreased the operative complications, and enabled patients to recover well after surgery.

Atresia Ani (Imperforated Anus) in Calves: Clinical, Surgical and Pathological Aspects

Background: Anal atresia is a congenital malformation, which often affects calves, and is related to the imperforation of the membrane that separates the endoderm of the posterior intestine from the ectodermal anal membrane. It is commonly associated with other congenital malformations and skeletal anomalies. The clinical signs generally appear in the first days of the animal's life, due to a retention of feces. The diagnosis is clinical and is based on observation, anamnesis and a physical examination of the animal. The only viable treatment is surgical. This paper aims to report 6 cases of anal atresia in bovine calves, 4 males and 2 females that were successfully treated surgically. Cases: This work reports 6 cases of anal atresia in 4 male calves and 2 female calves. Three presented total atresia (type II), one partial (type I) and in both female calves, anal atresia and rectovaginal fistula (type IV) were observed. The animals were all of undefined race. Five of the cases were from northern Tocantins, 4 males and 1 female (anal atresia with rectovaginal fistula), and 1 female (anal atresia with rectovaginal fistula) was from Valença, RJ. All animals were born active, by eutocic/natural birth, and assumed a quadrupedal position followed by the first feeding as normal. They were aged between 2 days and 6 months, and had a clinical history of abdominal distention and difficulty or inability defecating, and the females both also had a rectovaginal fistula, all cases compatible with anal atresia. Based on the patient's history and clinical examination, surgical treatment for anal reconstruction was decided upon. Postoperative treatment consisted of enrofloxacin [2.5 mg/kg - intramuscularly (IM), once daily (SID), for 5 days] and fluxinin meglumine [1.1 mg/kg - IM, SID, for 3 days] ; as well as a healing ointment which was applied to the area of the surgical wound, every 12 h, for 7 days. There were no trans-surgical complications. The animals showed progressive recovery after anal reconstruction and the stitches were removed in all cases on the 10th postoperative day, with no postoperative complications and no recurrence of any clinical signs from that moment on.Discussion: The study of congenital and hereditary changes enables the identification of their origins, can help prevent new cases and, some of them, are open to economically viable treatment and/or correction that can improve the well-being of the animal and prevent economic losses due to death or animal sacrifice, as reported in the present study. Anal atresia is the most common congenital defect of the lower gastrointestinal tract in calves, being an isolated abnormality, or associated with other malformations, especially of the distal spinal column such as the absence of a tail (perosumus acaudato), as one of the animals in this study. The clinical signs and physical examination are sufficient to establish the diagnosis, as demonstrated in this report, which is usually made in newborn animals, due to the lack or difficulty in defecation associated with no anal orifice and/or swelling in the perineal region. The treatment of choice for anal atresia is surgical, in order to construct an anal neo-orifice and thus avoid endotoxemic shock as well as providing relief and well-being for the animals. As observed in this study, when anal atresia is diagnosed early, and surgical treatment is properly instituted, the prognosis is favorable. The surgery is considered of low complexity, quick and it can be carried out in the field. Thus, from a commercial point of view, considering the costs of the procedures and the value of the calf at the end of weaning, such treatments are beneficial to the owners. In addition, the surgical treatment is essential for animal health and welfare in cases of anal atresia.Keywords: cattle, congenital defects, hereditary pathology, perosomus acaudato, surgery.

Fistulotomy followed by anal sphincter reconstruction – indications, benefits and pitfalls of the method

Fistula-in-ano is a disease which has challenged surgeons for centuries because of high postoperative complication rates including recurrences, and symptoms of postoperative gas and stool incontinence. The paper addresses the surgical method of fistula excision followed by sphincter reconstruction. The procedure is not new, but it has gained popularity in recent years. The primary indications for its use include complex high anal fistulas, posterior transsphincteric fistulas in patients with good baseline continence, and fistulas of “borderline” height, involving approximately 50% of the external sphincter mass. In cases of high and/or complex fistulas, the first stage of management is typically loose seton drainage to reduce the risk of infection. Prior to surgical intervention, it is important to assess the patient’s preoperative continence status. The paper presents the surgical technique of the intervention, outlines possible complications, and reviews the literature reporting the experiences of other authors who use the method. Fistulotomy followed by sphincter reconstruction is a bold surgical approach. It requires extensive experience in performing colorectal surgical procedures, and it is suitable for a selected group of patients. On account of possible complications including impaired postoperative gas and stool continence, the patient should receive appropriate information before surgery, and sign the surgical consent form. Fistulotomy followed by sphincter reconstruction is a good therapeutic option in patients with recurrent high anal fistulas unsuccessfully treated by other methods.

Comparison of clear cell carcinoma and benign endometriosis in episiotomy scar - two cases report and literature review

BackgroundMalignant endometriosis in an episiotomy scar is rare; only seven cases have been reported previously. Here, we compare two cases of benign endometriosis and clear cell carcinoma.Case presentationThe first case was a 54-year-old woman who presented with a large perineal lesion in her episiotomy scar with high 18F-fluorodeoxyglucose uptake. This location had a history of endometriosis many years ago. She underwent radical excision of the mass and bilateral inguinal lymph node dissection. Histological and immunohistochemical analysis confirmed the presence of clear cell carcinoma arising from endometriosis. Assisted radiotherapy was performed after surgery due to a positive lymph node. No recurrence was detected over a 1-year follow-up period. The second case deals with a 3 × 2 cm mass in the episiotomy scar of a 33-year-old woman. Part of the anal sphincter was resected because of the close proximity of the lesion. Because the disease lay very close to the anus, she received anal sphincter reconstruction combined with mass excision. Pathology result showed typical endometrial glands and interstitial tissues.ConclusionsDeleterious change only happens in patients experiencing perineal endometriosis. Complete excision is crucial for this form of disease; sometimes impairment of the anal sphincter is also necessary. Patients with malignancy required a combination of treatments in order to improve their prognosis.

Anal Reconstruction of Type II Atresia Ani in a 3-day Old Malin Lamb

Anal Reconstruction of Type II Atresia Ani in a 3-day Old Malin Lamb

Low anterior resection syndrome (LARS)

Patients develop a variety of bowel dysfunction following low or very low anterior resection for rectal cancer. These symptoms are known collectively as low anterior resection syndrome (LARS), and the extent to which it affects the quality of life of these patients can be assessed by the LARS score. Knowledge about anorectal functional anatomy is a prerequisite to understanding the aetio-pathology and clinical manifestation of LARS. Structural and functional impairment of the internal and external anal sphincter and the anal transition zone, loss of reservoir function of the rectum, increased colonic motility, proximal diversion, enteric nervous system remodelling and neuropathy of autonomic nerves in the pelvis are known to cause LARS. Assessment of patients with LARS with MRI scan, endoanal ultrasound and anorectal manometry will help to identify the cause for LARS. Treatment of LARS will have to be tailored to the individual patient. The treatment protocol can start with conservative measures like pelvic floor rehabilitation, colonic irrigation and biofeedback therapy. Medication with Imodium and serotonin receptor antagonists may help some patients with LARS. Sacral nerve stimulation is a minimally invasive technique that has been used to treat patients with LARS for more than one year. Stoma creation will be considered in those with major LARS persisting for more than two years. Meticulous dissection with preservation of nerves and anal sphincters and anastomotic reconstruction techniques such as an end to side anal anastomosis or a colonic–J pouch anal anastomosis can minimize the occurrence of LARS.

Triple VY Advancement Flap For Vulva And Anal Reconstruction In Extensive Perineal Squamous Cell Carcinoma In-Situ

Background : Algorithm for vulvar reconstructions in defects after oncologic resection of vulvar tumors has been established. It goals are to restores form and function for the purpose of coitus, micturition, and defecation. The purpose of this article is to present our experience in vulvar and anal reconstruction.
 Method : A 43-year-old female with extensive vulvar, perineal and anal squamous cell carcinoma in-situ and groin lymph nodes metastasis requiring defect coverage after tumor resection. The defects involving exposed soft tissue around vulvar, perineal and anal areas.
 Result : Vulvar and anal reconstruction was done in stages utilizing triple VY advancement flap. The reconstruction was successful with preservation of sexual and anal functions; and minimal scarring.
 Conclution: Extensive vulvar and anal defects can be reconstructed by recruiting local tissue. VY advancement flap is one of the best options in these reconstructions.

Anal reconstruction after a rare complication of routine haemorrhoid treatment

Anal stenosis is a well‐documented complication that can occur from anorectal surgery. This condition can be disabling and causes significant patient discomfort. Various surgical techniques for the treatment of anal stenosis have been described in the literature, however, its successful management still remains as a technical challenge. Here, we present a case of a patient who suffered from anal stenosis after a complication of sclerotherapy treatment of haemorrhoid, which was successfully managed by anal reconstruction with V‐Y advancement flaps.

Mo1751 Is There a Difference in Short-Term Outcomes When Colonic J-Pouch Anal Anastomosis Reconstruction is Performed following Laparoscopic vs. Open Low Anterior Resection?

Mo1751 Is There a Difference in Short-Term Outcomes When Colonic J-Pouch Anal Anastomosis Reconstruction is Performed following Laparoscopic vs. Open Low Anterior Resection?

Giant condyloma acuminatum of the anorectum: successful radical surgery with anal reconstruction.

Buschke-Löwenstein tumor, or giant condyloma acuminatum, is a relatively uncommon lesion of the anus with aggressive local invasive behavior which may present as a large warty tumor of the genital region with expansive and destructive growth. Many sporadic reports have been published suggesting various therapeutic strategies. We report a case of Buschke-Löwenstein tumor treated with conservative surgery followed by reconstructive procedures without a loop colostomy

Clinical application of artificial anal reconstruction after laparoscopic abdominoperineal resection in low rectal cancer patients

To assess the outcome and quality of life artificial anal reconstruction after laparoscopic abdominoperineal resection(APR) in low rectal cancer patients. Clinical data of 60 cases with low rectal cancer undergoing APR in our department from January 2010 to January 2013 were retrospectively analyzed. Sixty patients were divided into 2 groups according to anal reconstruction procedure, inclding 32 patients of abdominal colostomy as colostomy group and 28 patients of in-situ artificial anal reconstruction as anal reconstruction group. After a median follow-up of 1 year, the quality of life was assessed by Fetal Incontinence Quality of Life Scale(FIQL scale) and Cleveland Clinic Florida Fecal Incontinence Scores(CCS-FIS scale). In addition, the outcome and complications were compared between the two groups. Compared with the colostomy group, the anal reconstruction group presented longer operation time [(204.8 ± 18.8) min vs. (173.3 ± 23.5) min, P<0.01], later passage time [(45.1 ± 9.3) h vs. (27.7 ± 9.4) h, P<0.01], and higher incidence of mucosal edema(42.9% vs. 18.8%, P<0.05). There were no significant differences in average hospital stay and other complication morbidities(all P>0.05). After follow-up, the embarrassment scale in anal reconstruction group was better compared to colostomy group(3.1 vs. 2.2, P<0.01). However, there were no significant differences in the lifestyle, coping and depression scales between the two groups (all P>0.05). Twenty(71.4%) patients in anal reconstruction group had satisfactory continence 1 year after operation. In-situ artificial anal reconstruction after laparoscopic abdominoperineal resection can preserve fecal function in low rectal cancer patients and improve the quality of life after APR operation.

Vaginal tightening surgery by strengthening the pelvic floor support

Objective To explore the related pelvic floor anatomy to the pathological vaginal relaxation and key points of the vaginal tightening surgery. Methods The vaginal tightening surgery was performed in 24 cases of vaginal relaxation. The key points of this operation included levator ani muscle suturation and perineal body reconstruction, and anal sphincter reconstruction as in case of the muscle injury grade Ⅲ. Results The degree of levator ani muscle separation was positively correlated with that of vaginal relaxation in all the 24 cases. 18 cases were followed up from 6 months to 2 years, and had no complications of rectovaginal fistula and infections. The average level of perineal body was increased from 2.3 cm to 3.5 cm. Vaginal length of 6 cm from vaginal orifice was proper with good tightness. The patients felt strong anal contraction, enhanced ability of vaginal tightening and improved quality of sex life. There were no more infections of genitourinary tract. Conclusions Through levator ani muscle suturation and perineal body reconstruction, it can get the vaginal tightening effect. Key words: Vaginal relaxation; Naginal tightening surgery; Levator ani suturation; Perineal body reconstruction

Anatomic basis of anorectal reconstruction by dynamic graciloplasty with pudendal nerve anastomosis.

Dynamic graciloplasty has been proposed for anal reconstruction, but this method has 2 major drawbacks. First, an electrical device is required for control of the gracilis. The anastomosis with the pudendal nerve will provide more physiological control. Second, the limitation in the mobility of the muscle flap results in wrapping the anal canal with the muscle's distal portion, which is tendonlike and inelastic. Enhancing the mobility of the muscle flap will enable wrapping with the proximal, muscle-like, and extensible portion, possibly providing better sphincteric function. However, the basis for such an operative method is lacking. The aim of this study is to provide the basis for the refined method of anal sphincter reconstruction by dynamic graciloplasty with pudendal nerve anastomosis and to verify the feasibility of lengthening the nerve to the gracilis muscle flap by dissecting into the muscle belly, detaching the gracilis muscle from its origin, and enhancing the mobility of the muscle flap. This is a retrospective, descriptive study. The results from the anatomical study on 9 cadavers are reported. Tension-free anastomosis of the pudendal nerve and nerve to the gracilis was successfully performed in all the 9 cases: in 2 cases, by lengthening the nerve. The detachment of the muscle origin improved the mobility of the muscle flap, and the more proximal portion could be used for wrapping the anal canal, as confirmed in 4 cases. The limited number of cases was a shortcoming of this study. By lengthening the nerve to the muscle, the gracilis can be used for anal sphincter reconstruction with pudendal nerve anastomosis, negating the need for an electrical device. By detaching the origin of the gracilis muscle, its proximal portion can be used to wrap the anal canal, possibly enabling a longer functional canal with stronger constricting force and better vascularity. These modifications to past methods may improve fecal continence after the operation.

Surgical approaches to fecal incontinence in the adult

Surgical treatment of anal incontinence is indicated only for patients who have failed medical treatment. Sphincterorraphy is suitable in case of external sphincter rupture. In the last decade, sacral nerve stimulation has proven to be a scientifically validated solution when no sphincter lesion has been identified and more recently has also been proposed as an alternative in cases of limited sphincter defect. Anal reconstruction using artificial sphincters is still under evaluation in the literature, while indications for dynamic graciloplasty are decreasing due to its complexity and high morbidity. Less risky techniques involving intra-sphincteric injections are being developed, with encouraging preliminary results that need to be confirmed especially in the medium- and long-term. Antegrade colonic enemas instilled via cecostomy (Malone) can be an alternative to permanent stoma in patients who are well instructed in the techniques of colonic lavage. Stomal diversion is a solution of last resort.

Pressing the nerve alters muscle fiber types of the peroneus longus in rats: preliminary evidence for external anal sphincteroplasty.

BackgroundStudies have demonstrated that anal reconstruction with a gracilis graft pressing the dominant nerve could be used to treat fecal incontinence. However, the detailed mechanism by this remains unknown. Herein, we evaluated the alteration in muscle fiber types and contractility of the peroneus longus muscle in rats after pressing its dominant nerves.Material/MethodsThe rat soleus and peroneus longus were exposed during surgery. The superficial peroneal nerve was pressed so that the peroneus longus temporarily lost its innervation. The epimysium between the soleus and the peroneus longus was removed. The end point of the soleus was cut off and the epimysium of the contact surfaces of the soleus and the peroneus longus were sutured. Five months later, peroneus longus contractility was recorded by the myograph system, and types of muscle fibers were observed using the myosin ATPase staining method.ResultsThe skeletal muscle fiber type underwent adaptive changes due to double innervations with both fast and slow muscle nerves. Compared with other groups, the percentage of type I fibers in the peroneus longus increased significantly in the group of rats with the pressure on the nerve and removal of the sarcolemma. The maximal contraction and relaxation time at the single twitch and complete tetanus of the peroneus longus were also increased.ConclusionsOur results show that pressing dominant nerves alter the skeletal muscle fiber types of the peroneus longus, which lead to increased maximal contraction and relaxation time, and significantly improve the ability in resistance to fatigue in rats. This study provides a basis for future clinical studies for external anal sphincter reconstruction using gracilis grafts that are doubly innervated by pressing on its dominant nerve.

Board 136 - Program Innovations Abstract Obstetric Anal Sphincter Injury Construction, Destruction and Reconstruction for Procedural Skills Training (Submission #292)

Board 136 - Program Innovations Abstract Obstetric Anal Sphincter Injury Construction, Destruction and Reconstruction for Procedural Skills Training (Submission #292)

Surgical Repair of Atresia Ani ( Imperforate Anus ) in Newborn Kids and Lambs

Atresia ani is a congenital defect describes absence of a normal anal opening. It is fatal unless surgical correction is carried out to provide anal opening. In female, the rectum may break through vagina forming a rectovaginal fistula permitting defecation via the vulva. Surgical treatment of atresia ani is indicated to save the animal life and to improve body weight gain. Ten kids and eight lambs suffering from atresia ani referred to the veterinary health center at the Jordan University of Science and Technology in the period of 2004-2009 suffering from atresia ani. Clinical examination and ultrasonography confirmed atresia ani without any other intestinal congenital deformities. Affected animals were subjected to surgical anal reconstruction following animal casting, site preparation and analgesia. A circular perineal skin tissue was excised to explore the pelvic cavity associated with blunt dissection of the perineal region exposing the blind cull- de- sac of the rectum. The blind rectum segment was opened and the meconium was evacuated. Full thickness rectum and was secured using simple interrupted stiches. Anal reconstruction proved successfully for all treated kids and lambs. The new stoma provides a permanent patent orifice for normal passage of feces until the age of slaughter. This surgery was legitimate, considering the high incidence of atresia ani, simple, economic, and lifesaving surgical technique. Anal reconstruction in affected animal is an obligatory surgery rather than alternative euthanasia. Anal reconstruction increases body weight gain and decreases the economic loss in the small ruminant herd industry due to atresia ani.