Anal Sphincter Involvement Research Articles

Treatment of recurrent anal fistula using an autologous cartilage plug: a pilot study.

The aim of the present study was to assess a novel autologous cartilage plug technique used to treat anal fistula in ten patients. All ten patients had undergone at least two prior operations for recurrent fistulas. The plugs were prepared using the patients' own cartilage, which was obtained from either the nose or the ear, diced into pieces, and wrapped with oxidized regenerated cellulose. During the same session, fistula tracts were curetted using cytology brushes, and then, the cartilage plug was inserted into the tract. Routine postoperative examinations were performed at 2, 4, 8, 12, and 24 weeks after surgery. Magnetic resonance imaging was performed before surgery and at 3 and 6 months postoperatively. Relief of symptoms, radiological healing, recurrence, and continence were evaluated. The ten patients included six males and four females, with a median age of 39 years (range 25-70 years) and a median of three previous fistula operations (range 2-7 operations). Nine patients had cryptoglandular abscess, and one patient had Crohn's disease. The majority of the patients had transsphincteric fistulas with substantial anal sphincter involvement. The cartilage donor site was the nose for one patient and the ear for nine patients. The median follow-up time was 24 months (range 10-32 months). Of the ten patients, nine had fistula treatment without any short-term complications. The fistula failed to heal in one patient. Among the nine patients whose operations were initially successful, two late recurrences were observed. The cartilage plug seems to be a promising alternative for anal fistula treatment.

A Case of Endometriosis in Episiotomy Scar with Anal Sphincter Involvement and Extension into Ischiorectal Fossa

ABSTRACT Episiotomy scar endometriosis is characterized by presence of endometrial tissue (glands and stroma) and is a rare condition. It may also extend and involve the anal sphincter. The ideal treatment is wide excision to prevent recurrence but it may cause fecal incontinence, if the anal sphincter is involved. We describe here a case with much deeper extension into ischiorectal fossa. She was treated with wide local excision and primary sphincteroplasty. She has remained free of recurrence up to 12 months follow-up. How to cite this article Jain S, Ghoshal S, Kumar M, Jain M. A Case of Endometriosis in Episiotomy Scar with Anal Sphincter Involvement and Extension into Ischiorectal Fossa. J South Asian Feder Obst Gyne 2014;6(2):123-125.

Radiotherapy for Perianal Extramammary Paget's Disease: A case report

Extramammary Paget\'s disease (EMPD) is a rare, usually non-invasive intraepithelial skin adenocarcinoma which predominantly involves vulvar, perianal, scrotal and penile skin. Management of EMPD is rather complicated due to multifocal involvement, lack of clear tumor boundaries and clinically occult extensions. High recurrence rates following surgery together with the goal of achieving a better cosmetic and functional outcome have prompted the utilization of non-surgical treatment modalities in the management of EMPD. Radiotherapy may either be used as adjunct to surgery after recurrence or may be employed in the treatment of patients with high risk of local failure after surgery. 76-year-old male patient was admitted to Gulhane Military Medical Academy with the complaints of persistent anal itching. He was diagnosed with perianal Paget’s disease after consecutive skin biopsies. The patient was deemed unsuitable for surgery due to external anal sphincter involvement which was detected by endoanal ultrasonography and he was treated with curative radiotherapy in our department. We reviewed the pertinent literature, and discussed treatment options and outcomes. In conclusion, we recommend radiotherapy as a treatment option for patients with perianal Paget’s disease with curative intent.

The clinical features and management of perineal endometriosis with anal sphincter involvement: a clinical analysis of 31 cases

The aim of this study was to investigate the appropriate measures for diagnosing and treating perineal endometriosis (PEM) with anal sphincter involvement. Between January 1992 and April 2011, the clinical features, diagnosis and management of 31 patients who were diagnosed with PEM with anal sphincter involvement at the Peking Union Medical College Hospital were retrospectively analyzed using their clinical records. A range of 6-78 months of outpatient follow-up after surgery were conducted for these 31 patients but was extended by telephone interviews with 29 patients conducted in December 2011. All 31 patients had a history of vaginal delivery. The level of serum CA(125) was elevated in only 2 (6.5%) cases. All cases received surgical treatment, which included narrow excision (NE, close to the edge of the endometrioma) with primary sphincteroplasty (PSp) for 30 cases and incomplete excision (IE) for 1 case. Of the 30 cases in the NE group, 20 (66.7%) received hormone therapy preoperatively. Up until December 2011, there was one recurrence (3.6%) of PEM in the NE group. PEM relapse occurred in the IE patient 6 years after the initial IE surgery. Perineal abscesses were found in one patient post-operatively. No complaint of dyspareunia and no fecal incontinence episodes were observed during follow-up. Based on our own experience, NE and PSp may be indicated for the treatment of PEM with anal sphincter involvement.

A Case of Endometriosis in Episiotomy Scar with Anal Sphincter Involvement

Endometriosis is defined as the presence of endometrial tissue apart from its usual location (endometrium). It is the second most prevalent benign gynecologic disease after the presence of fibroids in women of childbearing age (incidence of 10% - 25%). Endometriosis predominantly locates on peritoneal surfaces, but it also affects the vagina, vulva, recto-vaginal septum and perineum, usually secondary to surgical or obstetric trauma. We present a case of a patient with perineal endometriosis (single nodule) in the scar of episiotomy and involvement of external anal sphincter with local and catamenial pain but with continence maintained. The endometric nodule was removed, and wide dissection and sphincteroplasty were performed. Afterwards, treatment with GnRh analogues was prescribed for a four-month period. Surgical outcome was successful and the patient was asymptomatic during subsequent menstruations.

CA 125 serum values in surgically treated endometriosis patients and its relationships with anatomic sites of endometriosis and pregnancy rate

Endometriosis is a benign gynecologic disease defined as the presence of functional endometrial glands and stroma outside the uterine cavity, causing dysmenorrhea, dyspareunia, menstrual irregularities, and infertility. Serum CA-125 measurement is now a consolidated method for diagnosing this condition, and its interpretation has posed a number of problems, particularly regarding utility in diagnosing minimal-mild endometriosis, whereas its value as a diagnostic aid in moderate-severe stages is well recognized. In our cohort, serum CA-125 values were significantly elevated in patients with ovarian and mixed endometriosis lesions (median levels 48 U/mL), compared with those who had exclusively extraovarian foci (median levels 27 U/mL), and so the correlation between this marker and the surgical and pathologic finding of ovarian and deep endometriosis was found to be statistically significant; however, the location did not affect the fertility rate.

Clinical application of intersphincteric resection in the anal-preserving operation for ultra-low rectal carcinoma

To investigate the clinical application of intersphincter resection (ISR) combined with total mesorectal excision (TME) and colon-anal anastomosis in the treatment for ultra-low rectal carcinoma. To review and analyze retrospectively the data of 34 patients with ultra-low rectal carcinoma (without external anal sphincter involvement) who received treatment of ISR, TME and colon-anal anastomosis. Partial resection of internal sphincter was performed in the patients with a distal edge of the tumor greater than or equal to 2 cm from the dentate line. Subtotal removal of the rectum was performed between 1 cm and 2 cm. Total resection was performed in less than 1 cm or involvement of dentate line. Reconstruction of digestive tract was done by manual colon-anal anastomosis. The average distance from distal excised margin to the tumor was 2.3 (1.8 - 3.2) cm among 34 patients. The pathological types were as follows: 28 cases of adenocarcinoma (11 were well differentiated, 17 moderately differentiated), 1 case of papillary carcinoma and 5 cases of villous adenoma with malignant change. The postoperative pathological stages were: Dukes stage A in 28 cases, stage B in 1 and stage C in 5 cases. The pTNM staging was 28 cases in phase I, 1 in phase IIa, 4 in phase IIIa and 1 in phase IIIb. The T stages of the patients were as following: 16 Tl, 17 T2 and 1 T3. Postoperative anastomotic stenosis occurred in 3 cases, anastomotic dehiscence in 2 cases and rectovaginal fistula in 2 cases. The ability of controlling feces of patients decreased significantly in the early postoperative period, and restored gradually at 6 to 12 months after operation. Anastomotic recurrence occurred in 1 case at 5 months after operation and liver metastasis in 1 case at 40 months. With strictly grasping indications, radical resection can be attained and anal sphincter preserved by ISR combined with TME and colon-anal anastomosis. It is an effective sphincter-preserving operation.

Presentation and management of perineal endometriosis

Objective To analyze the clinical presentation of perineal endometriosis and evaluate its treatment. Methods Clinical data were analyzed from the records of 36 patients with perineal endometriosis who were operated on between 1983 and 2007 at Peking Union Medical College Hospital, and followed up for 0.5 to 14 years. Results The incidence of perineal endometriosis was 0.31% among the women with endometriosis treated surgically at the hospital. The latent period was between 4 months and 13 years. All patients had cyclical and painful lesions. Of the 36 patients, 5 (13.9%) also suffered from pelvic endometriosis. All patients without anal sphincter involvement were cured after complete surgical excision. In 7 patients who had anal sphincter involvement, disease recurred because of incomplete excision. Conclusion Perineal endometriosis can be diagnosed on the basis of clinical features and surgical excision is the treatment of choice. The recurrence rate of perineal endometriosis is related to sphincter involvement making preoperative evaluation of anal sphincter important.

Clinical analysis of 30 patients with perineal endometriosis

To investigate the diagnosis and treatment of perineal endometriosis. The clinical date of 30 patients with perineal endometriosis, aged 32.3 (23 approximately 44), who were admitted 1983 - 2006, operated on, and followed up for 0.5 approximately 13 years, were analyzed. The incidence of perineal endometriosis was 0.32% among the total endometriosis cases. Five of these 30 patients (16.7%) suffered from perineal endometriosis combined with pelvic endometriosis. The latent period was 4 months to 13 years. There was no significant difference in onset of age. All patients had cyclical and painful lesions. The level of CA125 was normal. All patients were cured after complete surgical excision. Diagnosis of perineal endometriosis can be made based on the patients' history and clinical manifestations. Surgical excision is the first choice of treatment. The recurrent rate of the cases without anal sphincter involvement is lower than that with anal sphincter invasion since the complete incision can be made. It is important to evaluate pre-operatively if the anal sphincter is involved.

Endoanal ultrasonography in the diagnosis and operative management of perianal endometriosis: report of two cases

We report two cases of perianal endometriosis in which we were greatly assisted by endoanal ultrasonography. Patient 1 was a 43-year-old woman with perianal pain. Endosonography showed a hypoechoic mass in the anterior perianal region without involvement of the anal sphincter. Local excision was performed under spinal anesthesia without damage to the anal sphincter. Patient 2 was a 30-year-old woman with perianal pain coinciding with her menstrual period. Endosonography showed a heterogeneous mass containing cystic anechoic areas in the right anterior perianal region and involving the external anal sphincter. Wide excision, including the episiotomy scar and part of the external anal sphincter, and primary sphincteroplasty were performed under spinal anesthesia. According to our experience, preoperative endosonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Operative management should be determined on the basis of preoperative and intraoperative ultrasonographic assessment.

Perineal endometriosis in episiotomy scar with anal sphincter involvement: report of two cases and review of the literature

Perineal endometriosis with anal sphincter involvement is a rare occurrence with only nine cases reported so far. Two such cases are presented, and the literature is reviewed. In presented cases, diagnosis was suspected at clinical exam. Anal manometry was performed in both cases and endoanal ultrasound in one case. Wide surgical excision of endometriotic mass together with part of external anal sphincter was carried out in both cases. The procedure was followed by anal sphincter reconstruction in an "overlapping" fashion in the first and "apposition" technique in the second case. Histopathologic tests confirmed endometriosis. The recovery was uneventful in both cases with excellent functional results. Two years after the operation, patients are asymptomatic and fully continent. According to the literature and our own experience, wide excision of endometrioma with primary sphincteroplasty seems to be the best chance of cure with satisfactory functional results and should be recommended.

2084: Advantages of 3D sonography in determination of tumor invasion depth in patients with rectal tumors

Objectives: Determination of tumor invasion depth and anal sphincter involvement in patients with rectal tumor is important for therapy choice. Standard transrectal sonography (TS) is obligatory part of TNM-staging in these patients. It allows to visualize five layers of rectal wall, pararectal structures and tumor invasion depth. Investigation goal was to reveal the possibilities of sonography with 3D reconstruction in estimation of invasion depth of rectal and anal cancer.

Endoanal sonography in the assessment of perianal endometriosis with external anal sphincter involvement

Endoanal sonography can be used in the assessment of benign and malignant anal conditions and to evaluate the anatomy of the anal sphincters. We used endoanal sonography with a 10-MHz rotating endocavitary probe to evaluate a 45-year-old woman with a perianal mass, fecal incontinence, and menses-associated perianal pain. She had had 2 vaginal deliveries requiring episiotomies. Biopsy of the mass showed endometrial tissue. The ultrasound examination showed a perianal mass and an external anal sphincter injury. A wide excision and sphincteroplasty were performed, with improvement of fecal continence and pain. Histopathologic examination of the mass confirmed perianal endometrioma in an episiotomy scar.

Critical Commentary to Hidradenitis Suppurativa Polyposa

Hidradenitis suppurativa is a chronic inflammatory dermatological condition that affects apocrine gland–bearing skin. It is characterized by the development of recurrent abscesses and sinus tract formation. Common sites of involvement include the axillae, groin, perineum, buttocks, and inframammary folds. Until recently the assessment of disease activity in hidradenitis suppurativa was mostly clinical. However, in recent years our institution has increasingly used magnetic resonance imaging (MRI) to delineate sinus tract formation and anal sphincter involvement in patients with anogenital disease. This chapter discusses the epidemiology of hidradenitis suppurativa and the role of MRI in directing the medical and surgical management of patients with the anogenital form of disease.

Endometriosis in episiotomy scar with anal sphincter involvement

A case of endometriosis in an episiotomy scar with involvement of the external anal sphincter is presented. The clinical, operative, and pathologic findings are reported. The question of etiology and treatment is discussed, and the literature is reviewed. Wide excision of the ectopic endometrial tissue with primary reconstruction of the external sphincter was curative, and the functional result was excellent. It is suggested that this treatment policy should be recommended for these cases.

Squamous cell carcinoma of the anal canal: Treatment by external beam irradiation

External beam radiation therapy alone or in combination with curietherapy is the recommended treatment for anal canal carcinoma in some countries. In others, surgery is the sole accepted treatment. The results for 64 patients treated by external radiotherapy alone show excellent survival for stage T1T2 tumors but results are poor for large tumors (stage T4). The overall 5 year crude survival rate is 46%. The 5-year results are better for stage T1T2 (72%) than for stage T3T4 (35%). The presence of inguinal node involvement at first examination is a very poor prognostic sign. Local recurrences and metastases are infrequent for stage T1T2, but are more common for stage T3 and T4. Complications follow radiotherapy more frequently in those with stage T3 and T4 tumors. The analysis of local recurrences, complications and survival shows that radiation therapy may be sufficient treatment for stage T1 and T2 and for some stage T3 tumors. The importance of anal sphincter involvement and the poor quality of life for patients who are cured but develop complications, shows the need for combined treatment with surgery and perhaps with chemotherapy. For small tumors the results obtained by external radiotherapy alone are comparable with those obtained by external radiotherapy and curietherapy in terms of survival and complications.