Anorectal Cases Research Articles

HIV-1 infection, but not syphilis or HBV infection, is a strong risk factor for anorectal condyloma in Asian population: A prospective colonoscopy screening study

To investigate the association between anorectal precancerous lesions, including condyloma, and sexually transmitted infections (STI) in Asian population. This prospective study enrolled 2677 patients who underwent high-resolution colonoscopy for anorectal cancer screening. Anorectal lesions were diagnosed based on endoscopic findings and confirmed by biopsy. The association of HIV-1 infection, syphilis, and HBV infection with anorectal lesion was estimated by multivariate logistic regression. In HIV-1-infected patients (n=244), anal canal HPV-DNA was screened and genotyped. Although no malignancy was identified, anorectal condyloma was diagnosed in 32 (1.2%) male patients. 41% of anorectal condyloma cases had no specific lower GI symptoms. Multivariate analysis identified HIV-1 infection, but not syphilis or HBV infection, as an independent significant factor for condyloma (OR: 176.5, 95%CI 22.52-1383, p<0.001). In HIV-1 infected patients, positive type 16/18 HPV-DNA (OR: 4.766, 95%CI 1.838-12.36, p=0.001), lower CD4 cell count (per 100/μl decrement, OR: 1.056, 95%CI 1.056-1.587, p=0.013), and current smoking (OR: 3.828, 95%CI 1.486-9.857, p=0.005) were independently associated with anorectal condyloma. HIV-1 infection, but not syphilis or HBV infection, was identified as a strong risk for anorectal condyloma. Anal HPV 16/18 was highly prevalent in patients with HIV-1 infection, especially in those with condyloma.

MO‐G‐304‐03: Development of Knowledge Models for IMRT Treatment Planning Utilizing a Rapid Learning Approach

Purpose:We present an implementation of the knowledge‐based planning method utilizing a rapid learning approach which enables the accurate evolution of models as new data are collected during daily clinical practice.Methods:The efficacy of knowledge‐based planning depends on the accuracy of the knowledge models. Existing methods for knowledge modeling are all based on batch training approach using a static set of training cases. In this study, we investigate a rapid learning approach to train the models using plans from daily clinical practice. A base knowledge model is first established from an existing database. Then each subsequent case continuously evaluates and updates the knowledge model. At each step, evaluation criteria including the studentized residual and the leverage are calculated. They are used to identify outliers from the current model and their causes. Different learning actions are triggered by these criteria. The efficiency and accuracy of the learning approach is quantified by the learning curve. As an initial validation, 100 cases in the pelvic region, including low‐to‐intermediate risk (n=40), high risk (n=20) prostate, and anorectal (n=40) cases are used. The model‐predicted generalized equivalent uniform dose (gEUD) for bladder and rectum are compared with clinical values by a bootstrap validation method.Results:The Median Absolute Differences between the predicted OAR gEUD and the clinical values in all three types of cases gradually decrease as increasing number of training cases are added in training. The knowledge models learned by this method reach comparable level of prediction accuracy at 2.1% of prescription dose as in batch training mode but with less training cases.Conclusion:The rapid learning approach facilitates incremental learning of knowledge models from clinical cases of multiple cancer types with improved efficiency. This approach will realize effective implementation of knowledge‐based planning in clinics where new cases and cancer types continue to accumulate.Partially supported by NIH/NCI under grant #R21CA161389 and a master research grant by Varian Medical Systems.

Clinical effect and nursing care of ultrasonic atomization with traditional Chinese medicine on wound healing after anorectal operation patients

Objective To discuss the clinical effect and appropriate nursing for wound healing after anorectal operation with ultrasonic atomization in traditional Chinese medicine. Methods A clinical research method for random distribution was conducted. Totals of 120 anorectal surgery cases matched with the inclusion criteria were randomly divided into the observation group (TCM group) of 60 cases, and the control group (potassium permanganate group) of 60 cases. The average disappear time of post-operative symptoms were respectively observed and the number of days of wound healing were respectively recorded between the two groups. Results In the observation group, the average disappear time of post-operative symptoms of pain, edema, cataclysm, hematochezia and the healing time were (8.20±1.56), (4.33±0.46), (7.56±1.38), (3.67±1.49) and (14.17±1.58)days, which were significantly shorter than those of the control group (t=4.313, 3.765, 4.983, 3.038, 7.560, respectively; P<0.05). The post-operative healing rate of the 7th and 14th day were (53.66±1.88)% and (89.46±2.13)%, which were significantly higher than those of the control group (t=6.89, 15.08, respectively; P<0.01). In the observation group, 38 cases were significantly effective, 20 cases were effective, and 2 cases had no therapeutic effect, which were significantly better than those of the control group (Z=21.76, P<0.01). Conclusions Fumigation with ultrasonic atomization of traditional Chinese medicine can improve post-operative symptoms and promote wound healing after anorectal operation. Key words: Traditional Chinese medicine (TCM); Ultrasonic therapy; Postoperative complications; Anorectal disease; Atomization fumigation

Management of anorectal malformation without ligation of fistula: An approach preventing posterior urethral diverticula

ObjectiveThe posterior urethral diverticulum is a common urologic complication requiring reoperations in anorectal malformation cases (ARM). We present a series of 24 cases of male ARM managed without ligation of fistula. Material and methodsA prospective study was conducted between July 2010 and June 2012 including male neonates with ARM, where rectobladder neck and rectoprostatic fistula were approached by the abdominal route. The fistulous tract was dissected to the distal-most possible length and was excised flush with the urethra without its ligation. A per-urethral catheter was placed in situ. A record was made of any features of urinary leak and a micturating cystourethrogram was performed at the 1-year of follow-up. ResultsTwenty-four cases of ARM, 16 with rectobladder neck fistula and eight cases with rectoprostatic fistula were included. Of these, 12 had single-stage primary abdominoperineal pull-through and 10 were managed by primary posterior sagittal anorectoplasty. Two cases with colostomy during the neonatal period were managed by laparoscopic assisted anorectoplasty at 6 months. None of the cases had a urinary leak during the postoperative period. All had a normal micturating cystourethrogram at 1 year. ConclusionsThe approach of dividing fistula without ligation may prevent posterior urethral diverticula, but larger long-term follow-up studies are needed.

Management of Ano-Rectal disorders by Kṣārasūtra: A clinical report.

Background:Ano-rectal complaints are usually benign in origin. Most of the patients suffering with these disorders do not seek medical advice at an early stage due to embarrassment. It results in advancement of the disease and significant disturbance in the quality of life. Among the available treatment modalities of ano-rectal disorders (ARDs), Kṣārasūtra (medicated thread) appears to be the best in terms of relief and nonrecurrence.Aims and Objectives:The aim of this study is to provide evidence-based data about the practical application of Kṣārasūtra (medicated thread) in the management of ARDs.Materials and Methods:An ano-rectal operation theatre was established in September 2012, in association with the Government Ayurvedic Speciality Clinic at District Hospital, Rajahmundry, Andhra Pradesh, to facilitate the AYUSH services in Allopathic Hospitals. Present report includes the details of ARDs treated by Kṣārasūtra (Medicated thread) method during 2012–2013. A total of 127 ano-rectal cases were operated, which included 44 cases of hemorrhoids, 40 cases of fistula-in-ano, 39 cases of fissure-in-ano and three cases of peri-anal abscess. All the cases were analyzed as per the observations, subjective and objective parameters, and follow-up was carried out for a period of 6 months.Results:In the 127 ARDs treated, 45 patients suffering from hemorrhoids, 36 patients got complete relief, marked relief observed in 4 patients, moderate relief observed in 5 patients. In fistula-in-ano, out of 40 patients 29 patients got complete relief, marked relief was seen in 7 patients out of them 4 patients were referred to anti-tubercular treatment center, 4 patients left against medical advice. In fissure-in-ano-out of 39 patients, 32 patients got complete relief, 5 patients got marked relief, moderate relief observed in 2 patients. These results authenticate the effectiveness of Kṣārasūtra, no adverse effects or recurrence observed in any case.Conclusions:ARDs are efficiently treated by Kṣārasūtra technique with prompt symptomatic resolution and prevention of recurrence and complications.

Detection of Anorectal and Cervicovaginal Chlamydia Trachomatis Infections following Azithromycin Treatment: Prospective Cohort Study with Multiple Time-Sequential Measures of rRNA, DNA, Quantitative Load and Symptoms

BackgroundDetermination of Chlamydia trachomatis (Ct) treatment success is hampered by current assessment methods, which involve a single post-treatment measurement only. Therefore, we evaluated Ct detection by applying multiple laboratory measures on time-sequential post-treatment samples.MethodsA prospective cohort study was established with azithromycin-treated (1000 mg) Ct patients (44 cervicovaginal and 15 anorectal cases). Each patient provided 18 self-taken samples pre-treatment and for 8 weeks post-treatment (response: 96%; 1,016 samples). Samples were tested for 16S rRNA (TMA), bacterial load (quantitative PCR; Chlamydia plasmid DNA) and type (serovar and multilocus sequence typing). Covariates (including behavior, pre-treatment load, anatomic site, symptoms, age, and menstruation) were tested for their potential association with positivity and load at 3–8 weeks using regression analyses controlling for repeated measures.FindingsBy day 9, Ct positivity decreased to 20% and the median load to 0.3 inclusion-forming units (IFU) per ml (pre-treatment: 170 IFU/ml). Of the 35 cases who reported no sex, sex with a treated partner or safe sex with a new partner, 40% had detection, i.e. one or more positive samples from 3–8 weeks (same Ct type over time), indicating possible antimicrobial treatment failure. Cases showed intermittent positive detection and the number of positive samples was higher in anorectal cases than in cervicovaginal cases. The highest observed bacterial load between 3–8 weeks post-treatment was 313 IFU/ml, yet the majority (65%) of positive samples showed a load of ≤2 IFU/ml. Pre-treatment load was found to be associated with later load in anorectal cases.ConclusionsA single test at 3–8 weeks post-treatment frequently misses Ct. Detection reveals intermittent low loads, with an unknown risk of later complications or transmission. These findings warrant critical re-evaluation of the clinical management of single dose azithromycin-treated Ct patients and fuel the debate on defining treatment failure. Clinicaltrials.gov Identifier: NCT01448876.

S16.4 Lymphogranuloma Venereum in Men Who Have Sex with Men. An Ongoing Epidemic Since 10 Years, But Still Not Tackled

LGV is endemic in large parts of the tropics. Since 2003 anorectal LGV is also endemic among Men who have Sex with Men (MSM) throughout the industrialised world. Currently we see an increase in de incidence of LGV cases among MSM in Amsterdam. Occasional cases of heterosexual LGV are usually imported from endemic countries.LGV is caused by Chlamydia trachomatis (Ct) biovar L. Compared to non-L biovar infections, LGV has a completely different clinical picture characterised by an invasive, lymph destructive and fibrosing inflammatory reaction. The majority of MSM with LGV are HIV co-infected (up to to 85%), and a considerable portion is hepatitis C co-infected.LGV requires extensive treatment in contrast to non-L Ct infections, thus correct biovar identification is clinically relevant. Routinely LGV is excluded in Ct positive anal, ulcer, and bubo samples. Urethral LGV is not screened routinely. The vast majority of reported LGV cases comprise anorectal infections. Infections residing at other locations than the rectum could form an undiagnosed and undertreated reservoir contributing to ongoing LGV transmission. We recently found concurrent urethral LGV infections in 2.1% of MSM with anorectal LGV. Moreover, 6.8% of the partners of anorectal LGV cases had a urethral LGV infection. This shows that urethral LGV is common, probably key in transmission, and missed in current routine LGV screening algorithms.In European MSM the majority of LGV infections is caused by biovar L2b (Amsterdam variant). Based on clonal relatedness of prevalent LGV strains, there is evidence that the LGV epidemic among MSM prevailed already in the United States in the 1980s and was introduced into Europe by the end of the last century via the highly internationalised network of sexual contacts among MSM. A new LGV variant was unveiled and designated L2c.

SU-E-T-707: Evaluation of the Quality of Organs-At-Risk Dose Sparing in Anorectal and Prostate IMRT Plans

Purpose: To evaluate the quality of organs-at-risk (OARs) dose sparing in IMRT plans for anorectal and prostate cancer cases utilizing organ-based knowledge models to predict OAR DVHs.MethodsThe quality of OAR dose sparing in IMRT plans are evaluated by organ specific knowledge models. The knowledge models are built upon prior expert plans and accounts for patient specific anatomy. The knowledge models predict the optimal OAR sparing for bladder, small bowel and femoral heads in anorectal cases and bladder, rectum and femoral heads in prostate cases. We tested 20 anorectal plans and 20 prostate plans using the knowledge models for quality assurance. The reference dosimetric parameters for each test plan generated by knowledge models are compared with the corresponding actual plan values. The inter-quartile range of their differences is used as an indication of the quality variation of the dose sparing quality for a specific OAR for each site. Results: The inter-quartile-ranges of the deviations between reference dosimetric parameters and actual plan values in anorectal plans are (in percent of prescription dose): bladder D50%: 14.6%, D5%: 7.6%, small bowel D50%: 2.4%, D5%: 5.9%, femoral heads D50%: 11.6%, D5%: 9.6%. The inter-quartile ranges in prostate plans are: bladder D50%: 2.5%, D5%: 6.3%, rectum D50%: 9.6%, D5%: 3.9%, femoral heads: D50%: 10.9%, D5%: 13.9%. The significant smaller inter-quartile-range for small bowel indicates highly consistent dose sparing quality for this organ. The larger inter-quartile-range for bladder D50% in anorectal plans compared with that in prostate plans indicates the larger quality variation of bladder dose sparing in anorectal plans and should warrant improvement. Conclusion: Based on the patient specific OAR dose sparing references generated by knowledge models, we found the dose sparing quality for small bowel is highly consistent while there is larger variation in the quality of bladder dose sparing in anorectal plans. Partly supported by NIH/NCI and a Varian master research grant.

Anorectal and inguinal lymphogranuloma venereum among men who have sex with men in Amsterdam, the Netherlands: trends over time, symptomatology and concurrent infections

ObjectivesTo examine lymphogranuloma venereum (LGV) trends over time among men who have sex with men (MSM) visiting the Amsterdam sexually transmitted infection (STI) clinic; to investigate anal LGV symptomatology; and...

Nonclosure of rectourethral fistula during posterior sagittal anorectoplasty: Our experience

Aim:To study the effect of nonclosure of rectourethral (RU) fistula and to do a comparative analysis of the complications with and without nonclosure of RU fistula during posterior sagittal anorectoplasty (PSARP) in anorectal malformation cases (ARM).Materials and Methods:A total of 68 cases of ARM were included in the study group, of which 34 cases were those in whom RU fistula was not closed (group A) during PSARP. Another 34 successive cases were included in study group B in whom the RU fistula was closed as is conventionally done by using interrupted sutures.Results:Comparatively, group A had none or minimum urological complications as compared to Group B.Conclusion:RU fistula closure is not mandatory during PSARP and nonclosure avoids urological complications. It especially avoids urethral complications, which are 100% preventable.

Anorectal atresia and Variants at Predicted Regulatory Sites in Candidate Genes

Anorectal atresia is a serious birth defect of largely unknown etiology but candidate genes have been identified in animal studies and human syndromes. Because alterations in the activity of these genes might lead to anorectal atresia, we selected 71 common variants predicted to be in transcription factor binding sites, CpG windows, splice sites, and miRNA target sites of 25 candidate genes, and tested for their association with anorectal atresia. The study population comprised 150 anorectal atresia cases and 623 control infants without major malformations. Variants predicted to affect transcription factor binding, splicing, and DNA methylation in WNT3A, PCSK5, TCF4, MKKS, GLI2, HOXD12, and BMP4 were associated with anorectal atresia based on a nominal P value < 0.05. The GLI2 and BMP4 variants are reported to be moderately associated with gene expression changes (Spearman's rank correlation coefficients between -0.260 and 0.226). We did not find evidence for interaction between maternal pre-pregnancy obesity and variants in MKKS, a gene previously associated with obesity, on the risk of anorectal atresia. Our results for MKKS support previously suggested associations with anorectal malformations. Our findings suggest that more research is needed to determine whether altered GLI2 and BMP4 expression is important in anorectal atresia in humans.

O3-S4.04 Time to cure chlamydia: prospective study on detection of anorectal and cervicovaginal chlamydia after directly observed treatment with azithromycin

BackgroundWhen a person, diagnosed with Chlamydia trachomatis (Ct), is being treated for Ct, STI Centres generally advise a short period of sexual abstinence; in most cases no test of cure...

Clinical study of Manjishthadi Ghrita in vrana ropana

Healing of vrana (wound) is either primary or secondary by nature. Secondary healing requires more attention than primary healing. Basically, two things, shodhana (making free from undesirable healing factors) and ropana (closure of wound), are desirable for proper healing. Many drugs have been described in classics for healing, but none of them is capable of healing the wound individually. Hence, to fulfill the aim, manjishthadi ghrita was prepared with the help of 7 drugs having vrana ropana effects and was evaluated clinically for its healing properties in this study. It was used topically in postoperative wounds, mostly of ano-rectal cases, twice a day, for 21 days. The follow-up period was 1 month to observe the healing as well as vaikritapaham (reduced deformity) properties and any untoward effects of the drug. A randomized control clinical trial was done. Out of 45 patients, 24 patients in group A were treated with “Manjishthadi Ghrita” (treated group), while 21 patients in group B (standard group) treated with povidine iodine ointment. Better result was observed in the treated group in comparison to the standard group. No adverse effect was observed in any patient. Manjishthadi ghrita can be prescribed as a local healing agent for common wound.

How much colorectal surgery do general surgeons do?

Surgical subspecialization has croded the traditional domain of the general surgeon. The purpose of this study was to assess the volume and distribution of colon and rectal cases performed by general surgeons. The American Board of Surgery database was queried to identify and categorize the number of colorectal cases performed yearly by "generalists" (general surgeons) recertified between 1995-1997. There were 2,434 general surgeons (those with a basic certificate only) recertified. The mean number of large bowel cases was 33 (range 0-243). Thirty-one cases represented the 70th percentile and 60 cases represented the 90th percentile. The mean number of anorectal cases was 12.3 (range 0-185). The 70th percentile was 15 cases, and the 90th percentile was 26 cases. Seventy-five percent of general surgeons perform > or = 17 large intestine cases each year, whereas, only 25% perform > 16 total anorectal cases. General surgeons perform a substantial number of colon resections and relatively few anorectal cases. It is unclear whether this is an issue of anorectal training in general surgery programs or referral patterns.

Impact of a colon and rectal surgeon on a general surgery residency training program.

Most general surgery residents obtain scant exposure to anorectal disease during training. The aim of this study was to determine whether adding a colon and rectal surgeon to the faculty of a general surgery training program improves the amount or quality of the anorectal surgical experience. The surgical experience of all graduating residents from our university teaching program was reviewed during a ten-year period. Complete case data were obtained from the Residency Review Committee for surgery. The total small-intestine, colon and anorectal caseload was analyzed during the five-year period preceding the arrival of the colon and rectal surgeon and compared with the subsequent five-year period after the surgeon's arrival. There was a substantial increase in small-intestine (470 vs. 306) and anorectal cases (462 vs. 338). There was a particularly dramatic increase in anorectal cases performed during the chief resident year (159 vs. 36), which held true for all categories of anorectal cases. The addition of a full-time colon and rectal surgeon to a university general surgery residency program was associated with an increase in small-intestine and especially anorectal cases. However, most striking was the greater than fourfold increase in the number of anorectal cases performed during the chief resident year. This seems to reflect an increase in complexity of anorectal cases and an increased interest in anorectal surgery among general surgery residents.

The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991. The Australian Gonococcal Surveillance Programme.

To review and analyse the changing incidence of gonorrhoea and the increasing antibiotic resistance in gonococci in Australia from 1981 to 1991. Use of data from the sample of gonorrhoea in Australia examined by the Australian Gonococcal Surveillance Programme (AGSP), a continuing long-term multi-centric study of gonococcal disease and gonococcal susceptibility to antibiotics, over the period 1 July, 1981 to 30 June, 1991. Over 32,000 cases and strains from defined sources were examined in the 10 year study period. The number of cases of gonorrhoea in the sample decline from a peak of 6599 in 1982-1983 to 1121 in the final year under review, a reduction of 83%. Periods when greater than average reductions in incidence occurred in different groups were noted. Ano-rectal gonorrhoea in men decreased sharply in 1985 during an overall decline of 92.5% recorded between 1 July, 1981 to 30 June, 1987. However, the incidence of ano-rectal cases in males rose in subsequent years while gonorrhoea, overall, continued to decrease and at a greater rate after 1985. Antibiotic resistance in gonococci in Australia was manifested both as a progressive increase in the levels of intrinsic resistance to the penicillins and through the appearance and spread of penicillinase-producing N gonorrhoeae (PPNG). At the end of the review period in June, 1991, 8.8% of gonococcal isolates in Australia showed high levels of intrinsic resistance to the penicillins and 13% of strains were PPNG. These separate mechanisms of resistance appeared at different times in different parts of Australia, and their importance also varied throughout the country. Most infections with PPNG were acquired by men overseas whereas most women with PPNG were infected locally. Endemic spread of PPNG was a significant problem in Sydney and Melbourne, but decreased in importance in the later years of the study. In the past decade a large reduction in the incidence of gonorrhoea and, by implication, other STDs has occurred in the past decade in Australia. In some groups of patients the decline in incidence is continuing while in others a slight increase has been noted. Resistance to antibiotics of gonococci in Australia was mainly restricted to the penicillins, but through both chromosomal and plasmid-mediated mechanisms. This resistance was seen particularly in Sydney and Melbourne where endemic cycles of transmission of PPNG were established, and in infected travellers from S-E Asia in other centres. Valid and comparable, and regionally relevant data are a continuing requirement for assessing and modifying antibiotic treatment regimens for gonococcal disease.

Comfort in cases of anorectal surgery

The comfort of the patient suffering from an anorectal disease can be safeguarded through a sequence of carefully chosen measures: 1. 1. Examination should be made without causing distress. Painful lesions are localized from the anorectal line downward, and can be diagnosed by vision and gentle palpation. 2. 2. Premedication protects the patient from the pain of enemas and the fear of surgery. 3. 3. By substituting caudal, transsacral or local anesthesia for spinal anesthesia, headaches can be prevented. Oil anesthesia, chiefly zylcaine, in 7 to 10 cc. dosage under-laid beneath the cut surface produces partial prolonged anesthesia. Complete prolonged anesthesia is not desired as it may lead to transient incontinence. 4. 4. Postoperative comfort is best assured by individualized standard routine orders, signed together with the history and physical examination records. Text of routine orders is presented. Analysis of 200 anorectal surgical cases, as to complications and results, points the way to caution and improved procedure.