Anorectal Pathology Research Articles

A study on plication of piles

Background: Haemorrhoids are specialized, highly vascularized ‘cushions’ forming discrete masses of thick sub-mucosa containing blood vessels, smooth muscles and elastic and connective tissues limited to the anal canal and perianal area. The cause of haemorrhoids remains unknown. Numerous factors contribute to haemorrhoidal diseases such as constipation, prolonged squatting, pregnancy, aging, hereditary, portal hypertension, abdominal tumor and defecation habits. Methods: This prospective study was carried out in the department of surgery, GMCH, Udaipur, Rajasthan, India from June 2014 to December 2015 after taking the permission from institutional ethics committee. Patients from both sexes of various age groups having haemorrhoids and associated anorectal pathology such as fissure were included. Patients with prolapsed piles, thrombosed piles and piles secondary to anorectal tumor were excluded from the study. Preoperative Bisacodyl 2 tablets at night before operation and Sodium picosulphate enema was given early morning on the day of surgery to ensure a clear visualization of anal canal. Operative technique: With the patient in lithotomy position after appropriate anesthesia anal stretching was done and thereafter tissue forceps was applied to the skin tags corresponding to the three major piles. A Babcock forceps was then applied to the pile mass above the level of pectinate line. Then the held pile mass was transfixed and ligated with silk 1-0 atraumatic needle suture at the proximal end of the internal haemorrhoids in order to occlude the superior haemorrhoidal vessel as they enter the internal haemorrhoids. If there were any small secondary pile the same procedure would be done. A small piece of gauge soaked with 2% xylocaine jelly would be left in anus as dressing. Results: Total 50 patients of piles were examined and most of the patients were between 31-50 years of age (60%) with males preponderance. All the patients in this study had bleeding per rectum as the main symptom. Among all patients 60% received some form of conservative treatment and partially relieved. Out of 50 patients, 38% had 1st degree piles, 58% had 2nd degree piles and rest had 3 rd degree piles. In this study of plication of piles 94% of cases had no pain, 6% of cases who had pain were also suffering from fissure. The results of plication of piles are satisfactory and only 2% of the patients had pain for which long term analgesics were given. Conclusions: The treatment of haemorrhoids has been widely discussed and various methods are being employed by majority of surgeons throughout the world. In the plication of piles one should appreciate the fulfilment of above mentioned requirements.

Syphilis? An Unusual Cause of Surgical Emergency in a Human Immunodeficiency Virus-Infected Man.

We report on a human immunodeficiency virus-infected man undergoing urgent anorectal surgery, with multi-centimeter fungating masses discovered inside the anus. Initial pathology was inconclusive. After the patient developed a disseminated rash postoperatively determined to be secondary syphilis, the anorectal pathology was reviewed and Treponema pallidum DNA was amplified by polymerase chain reaction from the mass.

DIAGNÓSTICO Y MANEJO PRECOZ DE LA GANGRENA DE FOURNIER

early diagnosis and management of Fourniers gangrene aim: The aim of this study is to report the results of a series of patients diagnosed with Fournier's gangrene underwent surgical debridement plus broad-spectrum antibiotics in the emergency department of the Hospital Barros Luco-Trudeau (HBLT) between 2009 and 2013, in terms of mortality associated with the disease. Material and Methods: Between 2009 and 2013, a case series of patients with diagnosis of Fournier's gangrene treated in the Emergency Department of the Hospital Barros Luco-Trudeau. The outcome variable was mortality attributed to the disease (MAD). Other variables were: age, sex, comorbidities, focus of origin, waiting time for antibiotic treatment and surgery to start, number of surgical debridement and agents isolated from cultures. Descriptive statistics were used, with calculation of measures of central tendency and dispersion. results: During the study period, 56 patients were identified with diagnosis of Fournier's gangrene (60.7% were male) with a mean age of 52 years (23-75 years old). The MAD was 48.2%. The most common comorbidity was diabetes (66.6%). The more prevalent focus of origin was anorectal pathology (42.9%). The average waiting time from diagnosis to initiation of antibiotic therapy and surgery was 40 minutes (15-80) and 580 minutes (20-4320), respectively. The required surgical debridement average was 4. Isolated on the intraoperative tissue cultures agent was E. coli (51.8%). conclusion: Mortality attributable to Fournier's gangrene is similar to that observed in the literature.

Gastrointestinal surgery and the acquired immune deficiency syndrome.

Acquired immune-deficiency syndrome (AIDS) is becoming an increasing problem to the surgeon. The impact of HIV/AIDS on surgical practice include the undoubted risk to which the surgeon will expose him or herself, the atypical conditions that may be encountered and the outcome and long term benefit of the surgical treatment in view of disease progression. The two factors most associated with surgical outcome and poor wound healing were AIDS and poor performance status (ASA score). This article questions whether gastrointestinal surgical procedures can be safe and effective therapeutic measures in HIV/AIDS patients and if surgical outcome is worthy of the surgeon's ethical responsibility to treat. As HIV/AIDS patients are not a homogeneous group, with careful patient selection, emergency laparotomy for peritonitis confers worthwhile palliation. However, aggressive surgical intervention must be undertaken with caution and adequate peri-operative care is required. Symptomatic improvement of anorectal pathology may make delayed wound healing an acceptable complication. Alternatives to surgery can be contemplated for diagnosis, prophylaxis or palliation.

Comparing Ksharasutra (Ayurvedic Seton) and open fistulotomy in the management of fistula-in-ano.

Background:Most commonly practiced surgical “lay open” technique to treat fistula-in-ano (a common anorectal pathology) has high rate of recurrence and anal incontinence. Alternatively, a nonsurgical cost efficient treatment with Ksharasutra (cotton Seton coated with Ayurvedic medicines) has minimal complications. In our study, we have tried to compare these two techniques.Materials and Methods:A prospective randomized control study was designed involving patients referred to the Department of General Surgery in RG Kar Medical College, Kolkata, India, from January 2010 to September 2011.Results:Among 50 patients, 26 were in Ksharasutra and 24 were in fistulotomy group. 86% patients were male and 54% of the patients were in the fourth decade. About 74% fistulas are inter-sphincteric and 26% were of trans-sphincteric variety. Severe postoperative pain was more (7.7% vs. 25%) in fistulotomy group, while wound discharge was more associated with Ksharasutra group (15.3% vs. 8.3%). Wound scarring, bleeding, and infection rate were similar in both groups. Ksharasutra group took more time to heal (mean: 53 vs. 35.7 days, P = 0.002) despite reduced disruption to their routine work (2.7 vs. 15.5 days work off, P <0.001). Interestingly, pain experienced was less in Ksharasutra group, there was no open wound in contrast to fistulotomy and it was significantly cost effective (Rupees 166 vs. 464).Conclusion:Treatment of fistula-in-ano with Ksharasutra is a simple with low complications and minimal cost.

P442: The value of SSR recordings in the assessment of autonomic nervous dysfunction in patients with sacral-pudendal impairment

P442: The value of SSR recordings in the assessment of autonomic nervous dysfunction in patients with sacral-pudendal impairment

Endoscopic ultrasonography: Challenges and opportunities in the developing world.

Endoscopic ultrasonography (EUS) has become a vital diagnostic modality for the evaluation of mediastinal lymphadenopathy, pancreatic cysts and masses, anorectal pathology, subepithelial gastrointestinal lesions, and for the staging of many gastrointestinal and pulmonary malignancies. Establishing a EUS program in a developing country presents many challenges. Doing so in Pakistan has led to the identification of the following challenges: initial investment, ongoing costs (particularly fine needle aspiration needle costs), awareness and cytopathology. Endoscopic ultrasonography has revolutionized aspects of the practice of gastroenterology and oncology in the West. This technique is becoming increasingly available in the developing world, where it poses unique challenges to its practice. These challenges include those relating to service initiation and maintenance costs, physician awareness, and on-site cytopathology access. If these issues are anticipated and addressed in ways appropriate to local circumstances, obstacles to the institution of EUS programs can be overcome.

Efficacy of Electrogalvanic Stimulation in Treatment of Levator Ani Syndrome Revisited

Introduction: Electrogalvanic stimulation (EGS) has been established as a safe and effective treatment for the management of levator ani syndrome (LAS). There is a paucity of recent literature regarding this treatment modality. The purpose of this study is to review recent experience with EGS in the treatment of levator ani syndrome at a single center. Methods: A retrospective review of 22 patients treated with EGS for LAS from 07/04 to 08/08 was done. The EGS protocol begins with 30 minute sessions. Voltage is adjusted based on patient tolerance (range 100-330 volts) and is delivered at a frequency of 100 pulses per sec (pps). Length of treatment is gradually increased with increasing patient tolerance, from 30 to 60 min. Each session starts with minimal voltage and is slowly increased to maximum tolerance, held for 15-20 minutes, then intensity is gradually reduced from the peak of 100-330 volts to a minimum of 10-100 volts. Most patients were treated three times weekly for two weeks (average, six treatments per patients). The mean number of sessions was 7.5 (range 2-15). The average of duration of each session was 29 minutes for the initial visit and 46 minutes for the concluding visit. The intensity was 70% at initial visit, and 88% by the last treatment (330 volts=100%). Results: Twenty two patients were treated (72% males). The mean age was 56 years. The mean duration of symptoms was 60 months (range 3-240). 41 percent of patients had additional anorectal pathology. Over 60% of patients were taking muscle relaxants and/or analgesics. In this cohort, 59% of patients had previous treatment, including biofeedback (32%), botox injection (14%) and epidural injection (14%). Patient assessment of results at the last treatment session: complete relief or significant improvement in 8 patients (36%); moderate improvement in 2 (9%); slight improvement in 7 (32%); and no improvement or worsening of pain in 5 patients (23%). The mean follow up was 11 months (range 0.4-38). There were no complications associated with the EGS. Both multiple linear regression and logistic regression showed the same results. The outcome of patients with levator ani syndrome treated with EGS is related to the number of treatment sessions and history of previous treatments (of any sort). Conclusions: EGS is an effective treatment option in a selected group of patients with LAS. It offers significant to moderate improvement in 45% of patients with essentially no risk. Due to its safety profile and moderate efficacy, it should continue to be considered as a treatment operation for levator ani syndrome.

Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries

Objective: The aim was to study the prophylactic effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries. Background: Acute urinary retention (AUR) after anorectal surgeries is essentially a type of postoperative urinary retention (POUR). It is the most common complication of the procedure. Use of tamsulosin, a super selective alpha 1a adrenergic blocker has been found to reduce the risk of POUR. Patients and Methods: Patients who underwent anorectal surgeries for benign anorectal conditions were included in this study. Patients were randomly assigned into two groups. In one, group (cases), patients were given 0.4 mg of oral tamsulosin only 6 h preoperative and 6-8 h postoperatively. Inability/difficulty to pass urine, which necessitated catheterization after following patient for 24 h was labeled as POUR. Results: A total of 626 patients who underwent surgery for benign anorectal condition were included in the study and grouped into two groups with 313 patients in each group, control and case group. In the control group, 56 patients (17.9%) had inability to pass urine and required catheterization and in the case group, only eight patients (2.5%) needed catheterization following POUR. The difference in the requirement of catheterization following POUR was statistically significant (P = 0.04). Hemorrhoidectomy was the most common anorectal surgery associated with POUR. Conclusion: The use of tamsulosin in preoperative and postoperative period has been found effective to reduce the incidence of POUR following surgeries for benign anorectal pathologies.

Anal and Rectal Endosonography in Clinical Practice: What is the Opinion of Clinicians Regarding Current Indication?

Anal (EcoA) and rectal endosonography (EcoEAR) is a useful test in the evaluation of patients with anorectal pathology. However, there is no clear consensus on its indications. The aim of this study was to determine the opinion of clinicians regarding the current indications and usefulness of this diagnostic test in daily clinical practice. A cross-sectional observational study was conducted using a survey sent to the services of General surgery in a specific area of Spain. The clinical usefulness of the test was evaluated using an analog scale from 0 (lowest value) to 10 (maximum utility) for each pathology. Of the 47 hospitals, 23 responded to the questionnaire (48.9%). The average number of ultrasounds performed in these centers was 217 per year (standard deviation: 140.1, range 73–450) during the last 3 years. The most common indications for this test were: rectal tumor (85%), anal fistula (80%), and fecal incontinence (70%). This test was suggested more, depending on availability in the hospital itself. In conclusion, anal and rectal endosonography remains a very useful diagnostic clinical test in the opinion of clinicians in general and digestive surgery, especially in the evaluation of patients with anal fistula, fecal incontinence, or rectal tumors.

Imagerie Des Prolapsus Perineaux

Colpocystodefecography (CCD) and dynamic MRI with defecography (MRId) allow an alternation between filling and emptying the hollow organs and the maximum abdominal strain offered by the defecation. When applied in imaging these two principles reveal the masked or underestimated prolapses at the time of the physical examination. A rigorous application of the technique guarantees almost equivalent results from the two examinations. The CCD provides voiding views and improved analysis of the anorectal pathology (intussusception, anismus) but involves radiation and a more invasive examination. MRId has the advantage of providing continuous visibility of the peritoneal compartment, and a multiplanar representation, enabling an examination of the morphology of the pelvic organs and of the supporting structures, with the disadvantage of still necessitating a supine examination, resulting sometimes in an incomplete or impossible evacuation. The normal and abnormal results (cystoptosis, vaginal vault prolapse, enterocele, anorectal intussuception, rectocele, descending perineum, urinary and fecal incontinence) and the respective advantages and limits of the various imaging methods are detailed. Dynamic perineal and introital ultrasound remains more limited in the appreciation of posterior colpoceles and especially in anorectal disorders, than CCD or MRId. Endoanal ultrasound is the first line morphological evaluation of the anal sphincter. Transvaginal and introital ultrasound can detect some complications of suburethral tapes and meshes. Morphological and dynamic imaging are essential complementary tools to the physical examination, especially when a precise anatomic assessment is required to understand the functional complaint or when a reintervention is needed.

Efficacy and safety of a salsobromoiodic gel solution in proctological surgery

Surgical procedures for ano-rectal pathologies are always conditioned by an high percentage of side-effects. Indeed, the prevention of probable complications such as the non tissue-recovery or infection is a fundamental topic to guarantee an adequate follow-up. The aim of this comparative study is to assess the short-term outcomes of the use of a solution salsobromoiodic gel solution in postoperative period of patients undergoing proctological surgery. The authors selected retrospectively a population of 80 patients, undergoing surgery for Milligan-Morgan hemorrhoidectomy. Based on the recommended medications postoperatively, patients were divided into two groups: the Group A applied the salsobromoiodic solution gel on the perianal surgical wound in the postoperative period, the Group B did not use any medical facility with the exception of a soap at neutral pH. The clinical features assessed at 5, 10, 15 and 30 days after surgery were: pain, burning and itching lenght, the healing time, the presence or absence of early or late superinfection, the time of re-epithelization, the need for surgical curettage. The subjective evaluation of quality of life was assessed using a Visual Analogue Scale (VAS). There was a statistically significant reduction in length of postoperative pain in patients of Group A compared to Group B (5.6 vs 10.4 days respectively; p<0.005). There was a more rapid wound healing and re-epithelialization in group A, 15 and 21,3 days, respectively, as compared to Group B, 22.9 and 31.7 days (p<0.005). There were no differences between the two groups in terms of burning, itching and early and late bacterial infection. Two patients in Group B required a surgical debridement of the wound. Patients who used postoperatively salsobromoiodic solution declared a better quality of life. The use of salsobromoiodic gel solution in the postoperative proctological surgery, resulted safe and was effective in reducing postoperative pain, in contributing wounds healing and improving the quality of life, as subjectively assessed by each patient.

The Evaluation and Treatment of Hemorrhoids: A Guide for the Gastroenterologist

A references to symptomatic hemorrhoidal disease date back thousands of years and can be found in the ible as well as early Egyptian, Babylonian, and Greek scripts.1–3 The first known mention of this condition is from an Egyptian papyrus in 1700 BC, which advises . . . “Thou shouldest give an ointment of acacia leaves, ground and titurated together . . . and place in the anus, that he recovers immediately.”4 Indeed, there are few diseases more recounted in human history than hemorrhoids. The word hemorrhoid is derived from the Greek, with haima meaning blood and rhoos meaning flowing. Another common word for hemorrhoids used in the vernacular is “pile,” which comes from the Latin pila, meaning a ball. As aptly noted by Senagore, “although few people have died of hemorrhoidal disease, many patients who have undergone certain hemorrhoid therapies wish they had,” and this entity is one of the few diseases with its own patron saint (St Fiachre, the patron saint of gardeners and hemorrhoid sufferers).1 Symptomatic hemorrhoids are common, and those with hemorrhoids along with other anorectal diseases frequently present to the gastroenterologist with lower gastrointestinal (GI) bleeding and perianal complaints for evaluation and treatment. These patients and their referring physicians have an expectation that the gastroenterologist who examines this area should be able to provide comprehensive care of any nonsurgical anorectal ailments that are present. However, in large part because of the fact that formal training in anorectal pathology is not included in the combined Gastroenterology Core Curriculum, the care of these problems is often deferred to surgical specialties.5,6 There now seems to be an increasing recognition of this gap in the training of gastroenterology fellows, because an increasing number of GI programs are beginning to include nonsurgical anorectal care into their curricula. Some have called for the formal inclusion of anorectal entities into GI fellowship training.5 It is the intent of this article to serve as a general introduction of the nonsurgical care of hemorrhoids to gastroenterologists, helping them provide a more complete continuum of care to their patients.

Hemorragia digestiva baja grave en joven de 25 años

Lower gastrointestinal bleeding refers to blood loss originating from a site distal to the ligament of Treitz. The etiology varies depending on the age of patients. Excluding benign anorectal pathology in children and young people, Meckel's diverticulum, juvenile polyps and inflammatory bowel disease are the main causes. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, being present in about 2% of the general population. Most Meckel's diverticulum are asymptomatic and are diagnosed incidentally. About the risk of complications is 4-6%, being bleeding one of them.

Severe lower gastrointestinal bleeding in a 25-year-old patient

Lower gastrointestinal bleeding refers to blood loss originating from a site distal to the ligament of Treitz. The aetiology varies depending on the age of patients. Excluding benign anorectal pathology in children and young people, Meckel's diverticulum, juvenile polyps and inflammatory bowel disease are the main causes. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, being present in about 2% of the general population. Most Meckel's diverticulum are asymptomatic and are diagnosed incidentally. The risk of complications is 4-6%, with bleeding as one of them.

The importance of training in anorectal pathology among medical specialities

The importance of training in anorectal pathology among medical specialities

Prospective analysis of clinician accuracy in the diagnosis of benign anorectal pathology: the value of clinical information

the prevalence of anorectal disorders in general population is high. The aim of this study was to analyze the influence of clinical symptoms on diagnostic accuracy for benign anorectal pathology among different specialists and evaluate the relationship between diagnostic accuracy and years of professional experience. seven typical cases were selected. In a first interview, participants were shown images and asked to make a diagnosis. Afterwards, images with additional information (clinical symptoms) were used. Two groups (group 1 = general surgeons and group 2 = medical specialists who attended emergency department) completed both phases of the study to analyze the influence of clinical symptoms on the final diagnosis. forty four specialists were interviewed. The percentage of participants making a correct diagnosis in groups 1 and 2, respectively, was as follows: case 1 (perianal abscess): 100 vs. 80.6%, (p = 0.157); case 2 (fissure): 92.3 vs. 51.6% (p = 0.015); case 3 (thrombosed hemorrhoid): 92.3 vs. 74.2% (p = 0.321); case 4 (anal condyloma): 100 vs. 87.1% (p = 0.302); case 5 (rectal prolapse): 100 vs. 83.9% (p = 0.301); case 6 (prolapsed hemorrhoid): 92.3 vs. 29% (p = 0.001), and case 7 (fistula): 100 vs. 67.7% (p = 0.021). There were significant differences in the number of correctly diagnosed cases between groups (p < 0.001). Information about clinical symptoms significantly increased overall and specific accuracy. There was no correlation between experience and accuracy. clinical symptoms are important for diagnostic accuracy in anorectal pathology. Training in anorectal pathology in medical specialists is warranted.

Prevalencia de patología ano-rectal en pacientes portadores de VIH/SIDA

The ano-rectal pathology (ARP) is the most common surgical condition in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). Our aim was to determine the current prevalence and clinical characteristics of the ARP in patients with HIV/AIDS in clinical control in the infectious diseases unit of the Hernán Henríquez Aravena Hospital in Temuco. Cross section. Location and period: Infectious Diseases Unit of the hospital during the month of June 2010. Patients with HIV/AIDS under control in the unit, medical records were analyzed and complete physical examination was performed. In the period of study 384 patients were in control in the unit. Fifty had ARP which is a prevalence of 13%. Anal condyloma disease and hemorrhoidal disease were the most common diseases. Most patients (76%) were on antiretroviral therapy with good clinical response. The prevalence of ARP in HIV/AIDS patient has increased in recent years. This study shows a change in the pattern of presentation, being anal condyloma the most common ARP.

That’s Why It’s a 5-Year Program: Resident Acquisition of Anorectal Disease Management Competence

Although surgical residents are expected to be proficient in the diagnosis and management of anorectal pathology upon graduation, there is little data related to the timing and degree of proficiency acquired during training. Prospective study of new patients presenting to a colorectal surgical clinic for evaluation of anorectal complaints over a 3-y period. Trainees performed an initial evaluation and recorded their exam findings, diagnosis, and treatment plan. A separate evaluation by a staff colorectal surgeon was performed, with results compared by an independent reviewer. A total of 236 patient evaluations were included. The accuracy of referral diagnosis was significantly better when originated from a surgeon than from all other referral sources (91.7% versus 59.1%, P = 0.031). The most common conditions were internal hemorrhoids (25%), anal fissures (22%), and external hemorrhoids (19.5%). Internal hemorrhoids were most commonly misdiagnosed as external hemorrhoids (58%). Anal fissures were missed 38% of the time, and were most often given the diagnosis of internal hemorrhoids (45%). Residents also demonstrated difficulty in identifying thrombosis in external hemorrhoids, with a 45% error rate. Medical students and residents had an overall correct primary diagnosis of 69.5%; however, there was a significant improvement in the accuracy of diagnosis from medical students and interns to upper level residents (62.9% versus 81.2%, P = 0.003). Medical treatment plans agreed between resident and staff in 74%, the surgical management agreed in 62%, and overall the residents had the correct diagnosis and corresponding treatment plan in 44%. Additional adjunctive procedures were proposed in 66 patients with residents stating the correct adjunct in 79%. The most frequently missed adjuncts were endorectal ultrasound (34%) and colonoscopy (28%). Surgical trainees demonstrated significant deficiencies in the ability to evaluate and manage anorectal pathology; however, marked improvement occurred with time in training. Common areas of misdiagnosis and therapeutic errors were identified which could aid in curriculum development.

Usefulness of manometry to select patients with anal fissure for controlled anal dilatation

To evaluate the use of anorectal manometry to select patients for controlled anal dilatation. A prospective study was performed using anorectal manometry on all patients with chronic anal fissure who did not have a good response to conservative treatment. Those with increased anal resting pressure were treated with controlled anal dilatation using a two valved anuscope. A second anorectal manometry was indicated after controlled anal dilatation. 19 patients without anorectal pathology (Healthy Control Group) and 57 patients with chronic anal fissure were included in this study. Controlled anal dilatation was performed on 27 patients, maximum resting pressure 122 ± 19 mmHg. In the controlled anal dilatation group the healing rate was 92.5%, mean maximum resting pressure post-controlled anal dilatation was 91 ± 30 mmHg. We found one case of transitory anal incontinence (3.7%). None of the patients had anal incontinence at 18 months of the follow-up. In the remaining 30 patients non selected for controlled anal dilatation (chronic anal fissure control group), a proportion of 53.3% recurrences were registered after conservative treatment. Anal healing of chronic anal fissure and a significant decrease in maximum resting pressure recorded by manometry confirms the success of this procedure. The manometric evaluation of the maximum resting pressure is useful in the selection of chronic anal fissure patients for controlled anal dilatation. The efficacy of dilatation to treat chronic anal fissure in patients with raised anal sphincter pressure was high and complications were rare.