Anorectal Cases Research Articles

Evaluating the clinical application and effect of acupuncture therapy in anal function rehabilitation after low-tension rectal cancer surgery

BACKGROUND According to the indexes of serum and anal function, acupuncture therapy was applied to patients with low rectal cancer in order to avoid the occurrence of anal incontinence and reduce complications. AIM To explore the clinical application and evaluate the effect of acupuncture therapy for anal function rehabilitation after low-tension rectal cancer surgery. METHODS From the anorectal surgery cases, we selected 120 patients who underwent colorectal cancer surgery between January 2020 and December 2022 and randomly divided them into a control group (n = 60), observation group (n = 60), and control group after surgery for lifestyle intervention (including smoking cessation and exercise), dietary factor adjustment, anal movement, and oral loperamide treatment. The serum levels of motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide (VIP), Wexner score for anal incontinence, and incidence of complications were compared between groups. RESULTS After treatment, the VIP and 5-hydroxytryptamine levels in the observation group were lower than those in the control group (P < 0.05). The motilin level was higher than that in the control group (P < 0.05). Postoperative anal incontinence was better in the observation group than in the control group (P < 0.05). The incidence of complications in the observation group was 6.67%, which was significantly lower than that in the control group (21.67%; P < 0.05). CONCLUSION Acupuncture therapy has a positive effect on the rehabilitation of anal function after low-tension rectal cancer surgery; it can effectively help to improve the serum indices of patients, avoid the occurrence of anal incontinence, and reduce the incidence of complications. Popularizing and applying it will be valuable.

Efficacy of Yashtimadhu ghrit matra basti in post-operative management of Ano-rectal Cases – A case Series

Background- Exploitation of analgesics is becoming an advent scenario in the current practice of both medical and surgical cases. Adopting a less complicated and a wholesome beneficial modality for post operative analgesia is the need of the hour. In this case series, focus has been placed on yashti ghrit matra basti as the intervention for pain and wound management of post-operative cases of chronic fissure in ano associated with internal haemorrhoids. Objective- The current study was aimed at post operative analgesia and wound management with yashti ghrit matra basti in ano-rectal cases. Material & Methods-The method adopted here was Lord’s anal dilatation followed by excision of sentinel tags or ligation haemorrhoidectomy according to the case presentation, followed by yashti ghrit mastra basti as primary ayurvedic intervention for post operative analgesia and wound healing. Results -It is found that the planned treatment gave a positive response as post operative analgesia and also played an adjuvant role in wound healing. Conclusion-This case series provides the successful pain and wound management of post-operative ano-rectal cases with a promising ayurvedic intervention.

Karakteristik Malformasi Anorektal di Rs. Bhayangkara dan RSIA Sitti Khadijah 1 Makassar Tahun 2017 – 2022

Anorectal malformation (MAR) is considered as one of the most common congenital intestinal anomalies with an incidence of 1 in 4000 - 5000 births. The purpose of this study was to determine the characteristics of anorectal malformations at Bhayangkara Hospital & RSIA Sitti Khadijah 1 Makassar in 2017 – 2022. This research is a retrospective descriptive study with a cross sectional approach. This type of research was chosen because researchers wanted to find out about the characteristics of anorectal malformation cases at Bhayangkara Hospital & RSIA Sitti Khadijah 1 Makassar in 2018 – 2022. This study involved 13 samples. Based on research that has been done, that the majority of anorectal malformation patients at Bhayangkara Hospital and RSIA Sitti Khadijah 1 Makassar are male (69.2%), have a history of maternal ANC frequency of 4 times (46.2%), and do not have history of the mother taking drugs during pregnancy (61.5%). It was also found that the average birth weight was 2,661 ± 787 grams, the gestational age was 38 ± 1.5 weeks, and the mother's age at delivery was 30 ± 6.7 years. The incidence of anorectal malformations in Makassar is still low. From the data obtained from the two studies, it was not too significant between the two hospitals, Rs. Bhayangkara and RSIA Sitti Khadijah 1 Makassar.

A Randomized Controlled Double Blind clinical trial to evaluate the efficacy of Vedanasthapana Mahakashaya as an anxiolytic and analgesic polyherbal drug in perioperative anorectal cases

Introduction: In surgery, pre-operatively anxiolytic drugs and analgesics are very essential for major or minor surgical procedures to better operative and post-operative outcomes. The Vedanasthapana mahakashaya, described by the Acharya Charaka, is a group of 10 herbs and those herbs are advocated as analgesic, and anxiolytic polyherbal composition by various text books of ayurveda. So, the aim of this study was to evaluate and compare the efficacy of the Vedanasthapana mahakashaya as an analgesic drug during post operative period and as an anxiolytic drug for pre operative anxiety. Metarials & Methods: The study was a prospective, randomized, double blind, controlled trial. 80 patients of anorectal diseases who undergone for surgical intervention were randomly allocated in one of two groups. Group-1 received Vedanasthapana mahakashaya kwath (Decoction), 30ml orally in preoperative and postoperative period while group-2 was treated with Tab. Alprazolam 0.25mg pre-operatively and Tab. Paracetamol 500 mg postoperatively. Anxiety was assessed on the basis of Anxiety score of Hospital Anxiety and Depression Scale (HADS) preoperatively and analgesia was assessed postoperatively by internationally validated Visual Analogue Scale. Inj. Diclofenac sodium 75mg IM was administered as a rescue analgesic. Results: Pain-baseline pain scores were not statistically differed in both groups. Both the groups showed statistically significant reduction in pain at the end of trial period. Both were found to be significantly similar (P 0.4856) but group-1 showed more reduction in pain 84.72% (P<0.0001) than the group-2 which have 80.08% reduction in VAS score (P<0.0001) Anxiety- The values of both the groups were showing statistically significant difference at different observational intervals but the reduction was significantly higher in group-2 (P<0.0158). Conclusion: Administration of the Vedanasthapana mahakashaya decoction is effective for post operative pain relief but less effective for preoperative anxiety.

Birth prevalence of anorectal malformations in England and 5-year survival: a national birth cohort study

ObjectiveTo determine the birth prevalence, maternal risk factors and 5-year survival for isolated and complex anorectal malformations.DesignNational birth cohort using hospital admission data and death records.SettingAll National Health Service England...

Overview of Kshar-sutra in treatment of Ano-rectal diseases- review of cases treated at ACTH in 2011-2012: Retrospective study

Background
 Anorectal disorders including Fissure in Ano, Fistula in Ano and hemorrhoids are among the most common digestive complications. To our knowledge there is no any retrospective study of previous medical record data of Ayurveda Campus and Teaching Hospital (ACTH), Institute of Medicine, Tribhuvan University, Kirtipur, Kathmandu, Nepal available on the prevalence of major anorectal problems. Therefore, this retrospective was carried out to analyze the medical record of Shalya department OPD in fiscal year 2011-12 A.D. to estimate the prevalence of anorectal problems among the patients of anorectal complaints.
 Materials and Methods: This was a retrospective study conducted from January 2020 to December 2020 A.D. All the patients visiting the Department with anorectal complaints were screened. Name, sex, age, address and diagnosis was entered into Microsoft excel 2016 from registers of medical record; and analyzed in SPSS Version 2021 after coding the variables in excel. The findings were presented with percentage and frequency in pie and bar diagram.
 Results: Overall, anorectal cases (n=1067) were enrolled and analyzed in the study. The findings of major anorectal diseases like Fissure in Ano, Fistula in Ano and Hemorrhoids were commonly found in age group of 21-30 year; and followed by 31-40 year and 41-50 year. Fistula in Ano was also significantly found in the old age group of 61-70 year. Furthermore, the prevalence of Fissure in Ano, Fistula in Ano, Internal and External Hemorrhoids were 20%, 32%, 31.2% and 12% among ano-rectal problems in this hospital during this fiscal year respectively.
 Conclusion: Anorectal diseases are one of the common diseases observed in adolescent and adult patients which is more common in male than female. The prevalence of hemorrhoids is higher among Fissure in Ano and Fistula in Ano. Ksharasutra is the most effective procedure for treatment of these anorectal diseases.

SURGICAL TREATMENT OF IATROGENIC COMPLEX RECURRENT EXTRASPHINCTER ANORECTAL FISTULA: A CLINICAL CASE

Background: Anorectal fistula is a benign disease with an average prevalence of 1.69/10,000 population. The disease significantly reduces the life quality and has a tendency to relapse. Repeated surgical treatment can lead to anal sphincter impairment. Paraproctitis is the main anorectal fistulas cause. However, there are also iatrogenic traumatic fistulas that occur after various anorectal surgical interventions.Clinical case: A 44-year old female patient applied to the MSU University clinic in March 2020 with perineal wound with permanent purulent discharge. During examination perianal soft tissue defect was determined, the external fistula opening (40x25x25cm) was visualized at the wound bottom, the internal fistula opening (2x3mm) was visualized at 12h of the clock dial. The perianal area is deformed due to scarring. In 2016 the patient underwent surgical «rectocele elimination, posterior colporaphy, levatoroplasty, plastic surgery of the anterior rectal wall». Obstructive defecation syndrome developed during postoperative period, and repeated surgical treatment was performed – anterior anosfincterolevatoroplasty, Milligan-Morgan hemorrhoidectomy.On the 9th day, there was a «perianal soft tissue rupture» with bleeding and «local anterior rectal wall damage in the suprasphincter zone». Then «the rectal defect suturing» was performed. The perineal wound was left open. The patient was reoperated in 3 months due to a rectovaginal fistula with no effect. A fistulectomy was performed at the Moscow State University Medical Center with the removal of the anal canal defect by mucosal-submucosal flap. The surgical wound heals by secondary tension.Conclusion: The current studies describe a small number of cases of anorectal fistulas secondary to anorectal surgery. At the same time, there is no data on the further surgical management of such patients. It is important to present the iatrogenic anorectal fistulas cases, not only to analyze the fistula cause, but also to describe the surgical treatment method and its efficacy.

A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use.

Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases. To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction. A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time. Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge (median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P = 0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time. An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.

A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery

BackgroundSurgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures. MethodsThe Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents). ResultsA total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P < .001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P < .001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250–400) in 2010 and 225 (150–375) in 2017 (P < .0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92–5.27; P < .0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09–1.20; P < .00001), tobacco use (odds ratio 1.79; confidence interval: 1.37–2.36; P < .0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23–1.82); there was no significant association with procedure performed. ConclusionOver 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

Intestinal cancer in patients with Crohn's disease: A systematic review and meta-analysis.

Although surveillance colonoscopy is recommended by several guidelines for Crohn's disease (CD), the evidence is insufficient to support the validity of this recommendation. Moreover, the efficacy of surveillance colonoscopy for anorectal cancer remains unclear. Therefore, we performed a systematic review of cancer in patients with CD before considering the proper surveillance methods. We conducted a systematic review and meta-analysis examining the incidence of intestinal cancer and a literature review to clarify the characteristic features of cancer in CD. We performed the systematic literature review of studies published up to May 2019. Overall, 7344 patients were included in eight studies. The standardized incidence ratios (95% confidence intervals) of colorectal cancer (CRC) and small bowel cancer (SBC) were 2.08 (1.43-3.02) and 22.01 (9.10-53.25), respectively. The prevalence of CRC and SBC was 57/7344 (0.77%) and 17/7344 (0.23%), respectively, during a median follow-up of 12.55years. Additionally, 54 studies reporting 208 anorectal cancer cases were identified. In patients with anorectal cancer, the prognosis for survival was 2.1±2.3years, and advanced cancer greater than stage T3 occurred in 46/74 patients (62.1%). Many more reports of anorectal cancer were published in Asia than in Western countries. Although we were unable to state a recommendation for surveillance for SBC, we should perform cancer surveillance for CRC in patients with CD. However, the characteristics of cancer may differ according to geography or race. We must establish proper and effective surveillance methods that are independently suitable to detect these differences.

General Surgery Programs Afford Trainees Bound for Vascular Surgery Fellowships Increased Vascular Case Experience

Educators have recently begun to call into question the value of general surgery training prior to completion of a 2-year vascular surgery fellowship. We hypothesized that general surgery residents destined to enter vascular surgery fellowships have an enriched experience in vascular surgery compared to general surgery residents who enter other specialties. We obtained Accreditation Council for Graduate Medical Education case records of general surgery residents completing training in the years 2015-2018. We then stratified graduates into those who went on to enter a vascular surgery fellowship program (GSVS) versus those who went into other fields (GS). Case records were broken down into standard operative categories applied by the RRC for surgery/Accreditation Council for Graduate Medical Education. Each category was compared with a two-sided Student t-test. In addition, we examined experience with general surgery cases we deemed relevant to vascular surgery practice and those not directly relevant to vascular surgery. Between 2015 and 2018 there were 3242 graduates of general surgery programs who did not go on to vascular fellowships and 342 graduates who did enter vascular surgery fellowship programs. As shown in Table I, GSVS residents had significantly greater operative experience in every vascular surgery category than GS residents. Notably, they had twice the exposure to the major categories of aneurysm repair, cerebrovascular repair, and peripheral obstructive. In aggregate, GSVS residents completed 187.2 major vascular reconstructive procedures compared to 108.7 procedures for GS residents. Table II demonstrates the comparative experience in overall general surgery cases. Notably, GSVS residents had less exposure to a variety of cases of less direct relevance to vascular surgery including breast, esophagus, stomach, small intestine, large intestine, anorectal, biliary, spleen, hernia, endocrine, thoracic, complex laparoscopic and endoscopy cases. Conversely, GSVS residents had similar operative exposure to most cases of relevance to vascular surgery including skin and soft tissue, head and neck, abdominal–general, organ transplantation, and trauma. Total cases and major cases did not differ. It is unclear whether increased vascular exposure during general surgery training leads to vascular surgery as a career choice or if residents interested in vascular surgery are now afforded more opportunity to do vascular cases through increased training flexibility in general surgery programs. Regardless, general surgery training appears to offer an enriched vascular and relevant general surgery training experience to those candidates who go on to vascular fellowships. Ongoing analysis is necessary to determine the optimal content of general surgery training necessary for those trainees interested in vascular surgery.Table ICase TypeGeneral surgery residents who did not go on to complete a vascular surgery fellowship (GS)General surgery resident who did go on to complete a vascular surgery fellowship (GSVS)Mean number of casesStandard errorMinimum number of casesMaximum number of casesMean number of casesStandard errorMinimum number of casesMaximum number of casesP valueAneurysm repair5.1500.08605012.6700.569066.0000 Open infrarenal aneurysm repair0.8160.0240171.5200.100010.0000 Endo repair infrarenal aneurysm2.4150.0530236.8250.352039.0000Cerebrovascular9.6930.14207817.6780.8030104.00008.5150.13307515.0350.7160100.0000Periph obstructive18.0810.225012237.5441.3342182.0000 Aortofemoral bypass0.8610.0230121.7870.139028.0000 Femoral-popliteal bypass, vein2.2820.0450253.8300.183019.0000Infrapopliteal bypass, vein1.8780.0410264.1370.236026.0000Abdominal obstructive0.5130.016091.4330.102013.0000Upper extremity1.8010.0350243.0580.159026.0000Thrombolysis/mech thromb0.6480.0260331.5760.136020.0000Vascular trauma2.5240.0430233.6290.173021.0000Endovascular diagnostic6.8120.190011716.6931.0240132.0000 Arteriography4.8800.142010812.7630.7620104.0000Vascular access31.0680.333020145.5291.3742145.000016.0010.19408323.8360.808096.0000Amputations15.4140.188012021.7190.791196.0000 Amputation, below knee5.3990.0730357.6200.296040.0000 Amputation, above knee3.8090.0550285.9770.256033.0000Extra-anatomic bypass1.5700.0320162.8980.150016.0000Endovasc therapeutic0.2460.011070.7870.07508.0000Venous8.3740.14508414.1930.602069.0000Miscellaneous vascular6.0310.0830479.1870.416061.0000Total vascular108.7031.01613506187.1825.57550582.0000 Open table in a new tab Table IICase typeGeneral surgery residents who did not go on to complete a vascular surgery fellowship (GS)General surgery resident who did go on to complete a vascular surgery fellowship (GSVS)P valueMean number of casesStandard errorMinimum number of casesMaximum number of casesMean number of casesStandard errorMinimum number of casesMaximum number of casesSkin and soft tissue59.7790.424524158.3101.37114153.2867Head and neck22.8040.231011621.9590.692187.2570Breast64.1920.507127356.0791.3156153.0000Esophagus11.8580.1520719.6400.361035.0000Stomach39.0180.454229334.8771.1713216.0011Small intestine36.8960.256314334.5500.8927186.0118Large intestine141.2270.68842339132.0232.11039266.0000Anorectal33.3690.287120528.3710.732182.0000Abdomen-general43.6280.354316842.7751.3737296.5478Liver9.9820.1090589.4010.305035.0734Biliary126.2510.73330341118.4742.22642288.0010Pancreas10.3080.1400889.7810.421051.2445Spleen2.6990.0370162.2950.102013.0002Hernia130.7320.64231337118.8831.82546318.0000Endocrine33.4980.375529127.5500.9218107.0000Complex laparoscopica135.8971.36353528125.8683.44675275.0077Hand2.5070.10201772.4330.219026.7579Thoracic39.4350.469529834.7660.87315118.0000Pediatric26.3540.251112726.0120.782394.6735Genitourinary4.0870.0810623.8040.236046.2776Gynecology2.2400.11201491.6780.282085.1164Plastic23.8990.371124222.1350.8822115.0657Nervous system0.0440.005060.0500.02206.7998Orthopaedics1.3590.0720801.0960.181049.2505Organ transplant10.7330.211021910.2780.534058.4994Trauma29.0750.315216230.1671.0224143.2866Endoscopy138.2380.88926511121.0292.00865327.0000Ophthalmology0.0550.005050.0440.01101.3503aIncludes data for year 2017-2018 only. Open table in a new tab

Fundamentals of Anorectal Technical Skills: A Concise Surgical Skills Course.

Anorectal diseases, among the most common surgical conditions, are underrepresented in medical training. The Fundamentals of Anorectal Technical Skills course was developed to provide cost-effective formal training in diagnosis of common anorectal conditions and in commonly performed anorectal procedures using the theories of deliberative practice and perceptual and adaptive learning. First- through third-year general surgery and internal medicine residents and third- and fourth-year medical students participated in a course consisting of didactic instruction and hands on skills stations. The course covered common anorectal conditions, including internal and external hemorrhoids, fissures, condylomata, abscesses, fistula-in-ano, rectal prolapse, pilonidal disease, pruritis ani, and anal and rectal cancer, as well as common procedures such as anoscopy, excision of thrombosed external hemorrhoids, banding of internal hemorrhoids, rigid proctoscopy, incision and drainage of an abscess, administration of local anesthesia, and reduction of rectal prolapse. Before the course, participants completed a questionnaire consisting of demographics; previous anorectal experience, as measured by procedural case volume; confidence diagnosing and treating anorectal conditions; and a clinical knowledge multiple-choice quiz. Immediately following the course, participants took an additional survey reassessing their confidence and testing their clinical knowledge. This study was granted an educational exception by the Institutional Review Board at Walter Reed National Military Medical Center. Forty-three learners participated in this course. Forty-six percent of participants had not participated in any anorectal cases, 26% had participated in 1 to 5 cases, 17% had participated in 6 to 10 cases, 6% had been involved with 11 to15 cases, and 6% had been involved with more than 15 cases. For learners who had no prior experience, 1 to 5 prior cases, or 6 to 10 cases, there were statistically and educationally significant increases in confidence for all diagnoses and procedures. Additionally, there were statistically and educationally significant increases between pre-course and post-course quiz scores for learners who had no prior experience (7.8±2.0 vs. 11.8±2.5, P<0.01, Cohen's d=1.8) and for those who had only participated in 1 to 5 cases (11.0±3.7 vs. 14.2±2.0, P=0.04, Cohen's d=1.1). The changes in quiz scores for learners who previously had been involved with six or more cases were not statistically significant. This course provides a cost-effective training that significantly boosts learners' confidence in diagnosis of common anorectal procedures and confidence in performance of common anorectal procedures, in addition to improving objectively measured anorectal clinical knowledge.

Novel Low-Cost, Low-Fidelity Hemorrhoidectomy Task Trainers

Develop and describe a set of low-cost hemorrhoidectomy task trainer prototypes in the setting of inadequate junior resident surgical skill preparation for anorectal cases. This is a study comparing expert and novice performance and opinions. Three task trainers were developed to simulate dissecting, knot-tying, and suturing in a confined space, like the anus. Participants were asked to dissect the peel off of an orange, tie seven 2-handed knots on a weight, and close a defect in a piece of felt with a running stitch. An 8-oz mason jar was used to simulate the confined space. Participants were asked to fill out a 5-point Likert-based evaluation regarding the skills. The primary outcome was time to complete each task in seconds. Secondary outcome measures were number of errors associated with each task, subjective achievability of tasks, and utility of tasks for improving surgical skills. General surgery residency program at a safety-net academic center. Forty subjects participated in this study. There were 20 experts (7 attending surgeons, 13 PGY-1-PGY-5 surgical residents) and 20 novices (11 third- and 9 fourth-year medical students). Experts knot-tied (59s vs 140s, p < 0.001) and sutured (219s vs 295s, p < 0.001) faster than novices. Experts were able to tie 7 knots in fewer attempts than novices (p < 0.001). There was no significant difference in speed of orange dissection between groups. There were no significant differences in the number or frequency of other errors. All participants felt the tasks were achievable (4.90/5) and would be useful in improving skills (4.93/5). This study demonstrated that a set of low-cost, low-fidelity prototypical hemorrhoidectomy task trainers can discriminate between experts and novices. Simulation models such as these can offer useful practice opportunities for junior general surgery trainees.

A novel group of HPV-related adenocarcinomas of the lower anogenital tract (vagina, vulva, and anorectum) in women and men resembling HPV-related endocervical adenocarcinomas.

Human papillomavirus (HPV) is an oncogenic virus associated with the development of several human cancers. Primary vaginal, vulvar, and anal adenocarcinomas are rare and, to date, have rarely been shown to be associated with HPV infection. We report a series of nine HPV-related adenocarcinomas of the lower anogenital tract distal to the cervix. The tumors involved the vagina (4), anorectum (3), and vulva (2). Two of the three anorectal cases involved men. Patients presented with a vulvar or vaginal mass/nodule, painless rectal bleeding, or during screening colonoscopy. Lesions ranged in size from 3.2 to 8.4 cm. The most salient morphologic characteristic was the presence of papillary or villiform/villoglandular architecture in all cases. Tumors displayed features similar to those of usual type high-risk HPV-related endocervical adenocarcinoma, namely, mucinous or mucin-poor (pseudoendometrioid) features or a hybrid of these, with columnar cells with crowded, cigar-shaped to ovoid irregular nuclei. Mitoses (mostly apical) and apoptotic bodies were easily identified. Adenosis was present in two vaginal cases. One anal tumor featured abundant intracytoplasmic mucin that was multivacuolated in some areas imparting a "clear cell"-like appearance. All tumors were diffusely and strongly positive for p16. Seven of seven tested cases were positive for high-risk HPV by in situ hybridization or polymerase chain reaction. Follow-up information, available in five patients, revealed two local recurrences but no tumor related deaths or distant metastases. We report the first well-documented series of HPV-associated primary adenocarcinomas of the vagina, vulva, and anorectum and broaden the spectrum of HPV-related neoplasia involving the lower anogenital tract in both women and men.

Benign anorectal disease: hemorrhoids, fissures, and fistulas.

Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients’ lives. They are primarily encountered by primary care providers, including internists, gastroenterologists, pediatricians, gynecologists, and emergency care providers. Most complex anorectal disease cases are referred to colorectal surgeons. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical. The aim of this review is to examine the etiology, diagnosis, medical, and surgical treatment for these benign anorectal diseases.

1496. Anorectal Mycoplasma genitalium Is Common Among Nigerian MSM and Associated with HIV

Background Mycoplasma genitalium (MG) is a cause of nongonococcal, nonchlamydial urethritis and may cause subclinical infection of the anorectum, thereby potentiating HIV transmission among men who have sex with men (MSM). We describe the prevalence and incidence of MG among Nigerian MSM.MethodsAdult MSM were recruited in Lagos, Nigeria, and screened for HIV and bacterial sexually transmitted infections (STIs) every 3 months for up to 18 months. HIV infection was diagnosed using a parallel algorithm of rapid tests. PCR testing for Neisseria gonorrhoeae and Chlamydia trachomatis was performed on voided urine and rectal swab specimens. Nucleic acid amplification testing for qualitative detection of MG ribosomal RNA was performed on first and last available specimens. Wald and exact 95% confidence intervals (95% CIs) were calculated for prevalence and incidence, respectively, by anatomic site. Chi-squared test was used to compare proportions across groups of interest.ResultsFrom May 13, 2014–July 25, 2016, 413 MSM were tested for MG with median age 23 (interquartile range 20–26) years and HIV prevalence 67.5% (278/413). Anorectal MG prevalence was 36.8% (150/408, 95% CI 32.1–41.4%) and urogenital prevalence was 12.4% (51/410, 95% CI 9.2–16.0%), including 6.0% (25/413) of participants who were infected at both sites. Among prevalent anorectal MG cases, co-infection with gonorrhea was observed in 25.3% (38/150) and chlamydia in 19.3% (29/150). Among prevalent urogenital MG cases, gonorrhea was observed in 0% and chlamydia was observed in 15.7% (8/51). There was a trend toward more MG among participants with anorectal gonorrhea (46.8% vs. 35.0%, P = 0.07). Thirty-one new anorectal infections were observed over 272 person-years (11.4/100 person-years, 95% CI 7.7–16.2/100 person-years) and 10 incident urogenital infections over 282 person-years (3.5/100 person-years, 95% CI 1.7–6.5/100 person-years). Prevalent or incident MG at any site was more common among HIV-infected participants compared with HIV-uninfected (55.4% vs. 38.8%, P = 0.0016).ConclusionMG was highly prevalent among MSM in this study, including over half of HIV-infected participants. MG should be considered among cases of urethritis that fail to respond to conventional therapies, particularly in populations with a high burden of HIV, STIs, and frequent drug exposures that promote emergence of drug-resistant MG.Disclosures J. Malia, Hologic: Research Contractor, Research support. S. Peel, Hologic: Research Contractor, Research support. C. Gaydos, BioFire: consultant, consulting fee; Cepheid: Speaker’s Bureau, speaker honorarium; Becton Dickinson: Speaker’s Bureau, Speaker honorarium.

Morphologic and Immunohistochemical Characteristics of Anorectal Melanoma.

Anorectal melanoma is a rare aggressive disease. Due to its rarity and considerable histologic and immunohistochemical variabilities, misdiagnosis as lymphoma, carcinoma, sarcoma, and/or gastrointestinal stromal tumor is not uncommon, particularly in amelanotic cases. We reviewed histologic features and immunohistochemical stains of 19 anorectal melanoma cases. Histopathologic features were evaluated including junctional activity, melanin pigment, and morphologic features. Immunohistochemical stains were performed using Sox10, S100 protein, HMB-45, melan-A, CD56, and cytokeratins. Epithelioid histopathologic morphology was observed in 63.2% of the cases followed by 47.4% of the cases with spindle-cell, 26.3% with lymphoma-like, and 26.3% with pleomorphic morphologies. Junctional melanocytic activity was seen in almost half of the cases. Melanin pigment was absent (amelanotic) in nearly 40% of the cases. Immunohistochemically, diffuse positive expression of Sox10, S100 protein, melan-A, and HMB-45 was seen in 100%, 40%, 53.3%, and 38.5% of the cases, respectively. Cytokeratins were negative and CD56 was positive in 2 cases. These findings indicate that anorectal melanomas often show one or combined histolopathologic features without presence of melanin pigment and absence of junctional melanocytic activity. Anorectal melanoma should be kept in mind in the differential diagnosis of malignant neoplasms of anorectal region with epithelioid, spindle-cell, lymphoma-like, and pleomorphic morphologies. Sox10 immunohistochemistry stain can be used as a first-line screening tool to avoid extensive or unnecessary workups and/or potential misdiagnosis.

Muscle complex saving posterior sagittal anorectoplasty

IntroductionPosterior sagittal anorectoplasty (PSARP) published by DeVries and Peña in 1982 had become the preferred surgical technique for the management of anorectal malformations (ARM). The original technique is based upon complete exposure of the anorectal region by means of a median sagittal incision that runs from the sacrum to the anal dimple, cutting through all muscle structures behind the rectum by dividing the levator muscle and the muscle complex. Then, the rectum is located in front of the levator and within the limits of the muscle complex.In this review, we described Muscle Complex Saving-Posterior Sagittal Anorectoplasty (MCS-PSARP), which is a less invasive technique that consists of keeping this funnel-shaped muscle complex completely intact and not divided, and pulling the rectum through this funnel, toward fixing the new anus to the skin. This technique aimed both to respect the lower part of the sphincter mechanism consisting of the muscle complex, and to avoid the disturbance of this important structure by dividing and resuturing it. MethodsWe presented six cases of male patients who were born with anorectal malformation (ARM) and underwent MCS-PSARP. The surgical technique proved to be feasible to achieve the dissection of the rectal pouch and the division of the rectourethral fistula in all patients, by opening only the upper part of the sphincter mechanism, the levator muscle, and keeping the lower part consisting of intact muscle complex. ResultsThe early results in our series are encouraging; however, long-term functional outcomes of these patients are awaited. The surgical tips were also discussed. ConclusionsThis proposed approach in the management of anorectal malformation cases provides an opportunity to maximize preservation of the existing continence mechanisms. It preserves the muscle complex components of the levator muscle intact, allowing a better function of the continence mechanism.

Beta Lactamase Genes of Extended Spectrum Beta Lactamase Producing Escherichia coli from Anorectal Sepsis Cases in Bangladesh

A microbiological study was carried out to determine the prevalence of extended spectrum beta lactamase (ESBL) producing E. coli in anorectal sepsis patients in Bangladesh. One hundred specimens of pus, swab, or exudates from anorectal sepsis cases were studied. All the 61 isolates of E. coli were found to be highly resistant to most of the drugs used. Among these, 14 multidrug resistant E. coli were examined for ESBL production by double disc diffusion method. Six of these were found to be ESBL positive. PCR analysis revealed that 3 of the 6 isolates had coexistence of blaSHV, blaOXA and blaCTXM-1 genes. Two of the isolates had only blaSHV gene, whereas 1 isolate had a combination of blaTEM and blaSHV genes. Three of these were resistant to all the drugs tested, while two were sensitive to getamicin and one to ciprofloxacin. None of the E. coli strains possessed blaCTXM-2, blaCTXM-8, blaCTXM-9, and qnr genes.Bangladesh J Microbiol, Volume 30, Number 1-2,June-Dec 2013, pp 23-29

A Rapid Learning Approach to the Knowledge Modeling of Radiation Therapy Planning

The purpose of this study is to implement a rapid learning method to train the knowledge models to predict the organ-at-risk (OAR) dose sparing in radiation therapy (RT) based on an array of patient anatomical features. We also aim to establish the evaluation criteria and validation method to ensure an accurate and efficient learning process. A rapid learning approach is utilized to train the knowledge models in this study. 100 clinical cancer cases in the pelvic region were retrospectively analyzed. Among them, 40 cases are low-tointermediate risk prostate cases (Type I), 20 are high-risk prostate cases with lymph node irradiation (Type II), 40 are anorectal cancer cases (Type III). Starting from a base model for type I cases, increasing number of cases with more complex planning-target-volume (PTV)-OAR anatomies (type II and type III) were continuously added into the training case pool. The studentized residual and the leverage values are calculated as evaluation criteria at each step. The efficiency and accuracy of the learning method was quantified by the learning curve. The gEUD in the bladder and rectum are compared between the model predictions and actual values for the validation cases. The Median of the Absolute value of their Differences (MAD) are calculated for the validation cases. The MAD of the predicted OAR gEUD in all three types of cases gradually decreases when increasing number of training cases are added in training. The knowledge models learned by this method reach comparable level of prediction accuracies as in batch training mode even less training cases. The rapid learning approach is able to learn knowledge models for multiple cancer types in the pelvic region with comparable accuracy to the batch training method and with improved efficiency. This approach will facilitate the implementation of the knowledge based radiation therapy planning in clinics.