Perianal Area Research Articles

Acute Urinary Retention Following Primary VaricellaZoster Virus Infection

Background Acute urinary retention following primary varicella-zoster virus infection (chickenpox) is very rare. Case Presentation We present a case of 34 years old male patient presented with acute urinary retention following primary varicella-zoster virus infection (chickenpox), there was no lesion detected neither by MRI brain nor whole spinal cord imaging. There was a typical blistering rash over the face, trunk, back and upper limbs but sparing the perennial and perianal area. Conclusion Once herpes zoster is found in lumbar lumbosacral region be alert there is possibility of voiding dysfunction like acute retention of urine. The effective treatment plan includes antiviral therapy and urethral catheterization. Most of urological symptoms due to herpes zoster subsides in the very short duration with active guideline treatment. Keywords: Varicella-zoster virus infection; Blister-like rash; Acute urinary retention.

The role of biologic treatment in special scenarios in hidradenitis suppurativa: Facial and nape phenotype, dissecting cellulitis of the scalp, and lymphedema

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder affecting the hair follicle which typically affects the axilla, inguinal, submammary, and perianal areas. Atypical HS, such as facial HS, dissecting cellulitis of the scalp (DCS), nape HS, and HS lymphedema has also been described. There is scarce evidence about the treatment of atypical HS. To describe the efficacy of biologic drugs and adjuvant therapeutic interventions used in patients with atypical HS who had an inadequate response to systemic antibiotics. Prospective case series study of patients with atypical HS (facial HS, DCS, nape HS, and HS lymphedema) treated with biologic drugs in a HS Clinic setting. Disease activity indexes, sociodemographic, clinical, and safety variables were collected. Two patients met criteria for Facial HS, three met criteria for DCS/nape HS and three patients met criteria for HS lymphedema. Patients with facial HS achieved rapid improvement without requiring other therapies. Patients with DCS, nape HS, and HS lymphedema showed variable response, with decrease of activity indexes, and requiring adjuvant treatments. Biologic drugs are useful in the management of special HS locations. In the case of facial HS, biologic therapy seems to be quite effective as monotherapy. In the cases of DCS, HS lymphedema and nape HS, treatment combination or intensification may be needed.

Nigam’s pinch test to locate a chronic deep seated small perianal abscess

Background: Nigam’s pinch test (NPT) is for localization of chronic perianal abscess and incision over it.Methods: A description of Nigam’s pinch test and demographics are presented.Results: 20 cases of chronic deep seated perianal abscess were treated with the help of Nigam’s pinch test at Max Hospital, Gurgaon from August 2013 to August 2020. All incisions were directly made over the abscess and in no case a second incision was required. No recurrence and fistula formation occurred.Conclusions: Chronic deep seated perianal abscess usually has no signs except deep pain in perianal area or pain while passing stool. In such cases, there is no visible or palpable swelling, oedema or redness. Sometimes, it becomes difficult to put incision on the right site and more than one incisions are applied. Nigam’s pinch test helps in localization of small deep perianal abscess and correct site of application of incision avoiding multiple incisions. Nigam’s pinch test avoids post operative complications, specially recurrence and fistula-in-ano formation.

THE CLINICAL FEATURES AND PROGNOSTIC VALUE OF INFLAMMATORY POLYPS IN THE J POUCH OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED BY PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS

Abstract Background Patients with inflammatory bowel disease (IBD) sometimes require proctocolectomy with ileal pouch-anal anastomosis (IPAA) due to medically refractory colitis or neoplasia. However, pouchitis can develop in up to 80% of patients after the surgery. Given that previous studies demonstrated an association between chronic pouchitis and inflammatory polyps, we hypothesize that inflammatory polyps can be a predictor for pouch outcomes. This study assesses the frequency, risk factors, and prognosis of the J pouch with inflammatory polyps. Methods This is a retrospective single-center study of IBD patients treated by total proctocolectomy with IPAA and who subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different anatomic areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. Endoscopic findings included erythema/edema, erosions/friability, ulcerations, stenosis, granularity, loss of vascular pattern, and inflammatory polyps. To compare the J pouch with and without inflammatory polyps, we evaluated all available pouchoscopies and included any patient who had inflammatory polyps noted at least once. Demographic and clinical data were also assessed. Fisher’s test was used for a univariate analysis to assess factors contributing to inflammatory polyps in the J pouch. Logistic regression analysis was performed by including univariate variables with a P-value < 0.05. To assess the relevance between inflammatory polyps and pouch excision, log-rank test and Kaplan-Meier curve were used. Results We reviewed 1,195 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 61 patients (14.3%) with at least 1 inflammatory polyp in the J pouch. The most common anatomical location developing inflammatory polyps was the distal pouch (23, 38%), followed by the proximal pouch (21, 34%), afferent limb (13, 21%), rectal cuff (9, 15%), and inlet (7, 11%). Multivariable analysis showed that inflammatory polyps were significantly associated with male sex (OR = 2.8; 95% CI = 1.4–5.3; P = 0.002), postoperative anti-TNF drugs (OR = 2.9; 95% CI = 1.6–5.4; P < 0.001), and pouchitis (OR = 6.1; 95% CI = 1.4–25.9; P = 0.015) (Table). Kaplan-Meier curve showed that inflammatory polyps significantly increased the risk of pouch excision (P = 0.03) (Figure 1). Conclusion Our analysis found that more than 10% of IBD patients with a J pouch developed inflammatory polyps. Male patients had an increased risk of inflammatory polyps in the J pouch. Furthermore, our study suggested that inflammatory polyps can develop in patients with pouchitis requiring anti-TNF drugs and are an independent predictor of pouch excision. Table Figure 1

Risk factors for transmission of carbapenem-resistant Enterobacterales to healthcare personnel gloves and gowns in the USA

Hospitals are sources for acquisition of carbapenem-resistant Entero-bacterales (CRE), and it is believed that the contamination of healthcare personnel (HCP) hands and clothing play a major role in patient-to-patient transmission of antibiotic-resistant bacteria. The aim of this study was to determine which HCP types, HCP-patient interactions, and patient characteristics are associated with greater transmission of CRE to HCP gloves and gowns in the hospital. This was a prospective observational cohort study that enrolled patients with recent surveillance or clinical cultures positive for CRE at five hospitals in four states in the USA. HCP gloves and gown were cultured after patient care. Samples were also obtained from patients' stool, perianal area, and skin of the chest and arm to assess bacterial burden. Among 313 CRE-colonized patients and 3070 glove and gown cultures obtained after patient care, HCP gloves and gowns were found to be contaminated with CRE 7.9% and 4.3% of the time, respectively. Contamination of either gloves or gowns occurred in 10.0% of interactions. Contamination was highest (15.3%) among respiratory therapists (odds ratio: 3.79; 95% confidence interval: 1.61-8.94) and when any HCP touched the patient (1.52; 1.10-2.12). Associations were also found between CRE transmission to HCP gloves or gown and: being in the intensive care unit, having a positive clinical culture, and increasing bacterial burden on the patient. CRE transmission to HCP gloves and gown occurred frequently. These findings may inform evidence-based policies about what situations and for which patients contact precautions are most important.

Short- and mid-term effects on performance, health and qualitative behavioural assessment of Romane lambs in different milk feeding conditions

The common practice of artificially rearing lambs from prolific meat breeds of sheep constitutes a welfare issue due to increased mortality rates and negative health issues. In this multidisciplinary study, we investigated the possible short- and mid-term advantages of artificially feeding fresh ewe's milk instead of commercial milk replacer on lambs' growth, health and welfare. Romane lambs were either separated from their mothers on D3 and fed with Lacaune ewes' milk (LAC, n = 13) or milk replacer (REP, n = 15), or they were reared by their mothers (MOT, n = 15). On D45, they were weaned, gathered in single-sex groups until the end of the study on D150. Lamb performance and biomarkers of overall health were assessed by measuring: growth, dirtiness of the perianal area, enteric pathogens in the faeces, total antioxidant status and redox status assessed by plasma reduced glutathione/oxidised glutathione ratio, and immune response after vaccination against chlamydiosis. As an exploratory approach, blood cell transcriptomic profiles were also investigated. Last, qualitative behaviour assessment (QBA) was performed as an integrated welfare criterion. Lacaune ewes' milk and REP never differed in their average daily gain but grew less than MOT lambs in the early suckling period and just after weaning. No effect was detected afterwards. On D30, LAC and REP lambs had lower total antioxidant and higher redox status than MOT lambs but did not differ among themselves. Lacaune ewes' milk and MOT had a cleaner perianal area than REP lambs on D21, while faecal pathogen infection did not vary between the treatment groups. After vaccination, LAC also had a stronger immune response on D90 compared to REP lambs. Transcriptome analysis performed on D150 showed differential gene expression, mainly in relation to inflammatory, immune and cell cycle response, between male lambs of the LAC group and those of the MOT and REP groups. Based on QBA, LAC lambs never differed from MOT lambs in their general activity and varied from REP only on D21; REP lambs were always more agitated than MOT lambs. In conclusion, artificial milk feeding impaired early growth rate, health and emotional state mainly during the milk feeding period and at weaning. Feeding artificially reared lambs with fresh ewe's milk partly mitigated some of the negative effects induced by milk replacer but without achieving the full benefit of being reared by the mother.

Perianal Care Proven to Reduce the Incidence of Diaper Dermatitis

Maintaining a clean perianal area is an attempt to prevent and treat diaper dermatitis. The purpose of cleaningthe perianal area is to prevent irritation. The practice of cleaning the perianal area is done by consideringthe physiology of the skin such as, normal flora, bacteria, and skin pH. Cleaning the perianal area can usewater and a soft cloth without rubbing the skin hard. The purpose of applying evidence based in nursingpractice is to identify the effect of perianal care by using water against diaper dermatitis with skin integrityissues. Search evidence of nursing practice used the PICO analysis. Thirty-four toddlers were divided intotwo groups: the intervention group (n = 17) and the control group (n = 17). The analysis used was Wilcoxon,and Mann-Whitney test. There was no significant difference in diaper dermatitis score in the interventiongroup and control group (?> 0.05). Cleaning the perianal area using water and tissues can be used to preventand treat diaper dermatitis.

Ecthyma gangrenosum as a serious complication of Pseudomonas aeruginosa infection in departments of paediatric oncology.

In most cases ecthyma gangrenosum is a consequence of Pseudomonas aeruginosa bloodstream infection in immunodeficient patients. This bacterium is characterized by multi-drug resistance and has a number of mechanisms that allow it to survive even in extreme conditions. The disease is characterized by an aggressive course involving the skin and mucous membranes, leading to ulceration with signs of necrosis within 12 to 24 h. Treatment includes targeted antibiotic therapy and surgical cleansing of the wound. If the perianal area is occupied, a colostomy may be performed. Prevention of bacterial infections involves taking special precautions when handling a patient with immunodeficiency.

Tratamiento quirúrgico de la Gangrena de Fournier: Desbridamiento y cobertura. Serie de 7 casos

Introduction: Fournier’s disease is a type of necrotizing fasciitis, which is quickly progressive and involves mainly the testicular, perineal and perianal areas. Its etiology is polymicrobial, being associated to multiple risk factors.Due to its complexity, its treatment comprises antibiotic therapy, as well as two surgical steps, including the first one various surgical interventions, which consist in aggressive debridement of the nonviable tissue, and a second step, in which the coverage of the resulting defect is undertaken, for which multiple surgical techniques are available, although it has not been clarified which one should be indicated. Objectives: To find out which surgical techniques are used for coverage in Fournier’s disease and the length of the hospital stay that each one associates, as well as the characteristics of the patients with this disease. Material and methods. We selected all the patients whose diagnosis was Gangrene Fournier when discharged form hospital, who also underwent surgical coverage of the resulting defect in the Department of Plastic and Reconstructive Surgery in Hospital Reina Sofía of Córdoba, Spain. From these patients, we recollected data about the coverage surgical technique undertaken, length of the hospital stay, demographic characteristics of the patients, associated risk factors, possible precipitating factors, as well as anatomical affected areas. Subsequently, absolute and relative frequencies were calculated. Results. Most patients were middle-advanced aged males. The perineal area was the most common affected one. The most usual risk factors were hypertension and smoking. The split-thickness skin graft was the coverage technique most frequently used. Conclusions. Fournier’s disease is potentially severe illness which requires a multidisciplinary approach, involving multiple surgical operations, as well as a long hospital stay. The coverage surgery presents high heterogeneity, being primary closure, secondary closure, split-thickness skin graft and fascio/musculocutaneous flap considered among the surgical techniques available.

Випадок інфекцій, що передаються статевим шляхом, у поєднанні з ВІЛ-інфекцією

Introduction. The affinity of sources of infection, the prevalence of sexual transmission, as well as belonging to the contingent of people at risk of STIs and HIV, suggests the possibility of simultaneous infection with pathogens of these diseases. The objective of the work is to study the features of the clinical course, the psycho-emotional state, diagnosis and treatment of STIs associated with HIV infection. Materials and methods. The clinical case of STIs on the background of HIV-infection in women aged 41 years is presented, the diagnosis and treatment methods are described. Results. A separate case of STIs associated with HIV in women aged 41 years is described, as well as the features of the anamnesis, clinical course, objective, laboratory and instrumental research, the results of treatment of the patient. These data demonstrate that the presence of ulcers in the genital area and perianal area, which persist for a long time without signs of healing on the background of local therapy, may be the first manifestation of STIs on the background of HIV-infection. The full range of STI/HIV studies, taking into account immunological status, was crucial for diagnosis and etiopathogenetic therapy, which led to improvement of the patient`s condition, namely complete epithelialization of ulcers and regression of urogenital symptoms. Conclusions. The presence of a malignant of ulcerative process in the anogenital area in STIs, in particular, herpetic and trichomonas etiology is one of the markers of HIV/AIDS.

Gaint Condylomata Acuminate of Buschke-Lowenstein in Woman with HPV Infection: Clinical Presentation and Treatment

Buschke-Lowenstein Tumor (BLT) is a very rare sexually- transmitted disease associated with human papillomavirus type 6 and 11, but rare cases of oncogenic HPV types including HPV 16 and HPV 18 were also reported. BLT is located in the genital, anorectal and perianal regions. It is regarded as a type of verrucous carcinoma occurring on anogenital mucosal surfaces where it is locally invasive but displays a benign cytology. Buschke-Lowenstein tumor can be associated with a high rate of recurrence and a risk of malignant transformation to invasive SCC, especially in patients with oncogenic types of HPV. We report the case of a 59-year-old female patient who addressed our clinic for a large, exophytic, cauliflower-like tumor involving the vulva, perineum and perianal regions with 20 years duration. The first lesions had been appeared on vulva and after 3 years period they grown slowly and covered perineum and perianal area. They had cauliflower like surface, with different sizes. In some points erosions and yellowish secretion with odor are observed. Histologic examination of a biopsy specimen of large tumor presented nets of well- differentiated squamous cell carcinoma, as well as a marked mononuclear cell infiltrate and conspicuous koilocytosis. HPV DNA for 6 and 11 types was detected with PCR. The patient was sent to the gynecology surgery department for excision and remains under the supervision of the dermatology and oncology department for rapid treatment of relapses and early detection of malignant transformation.

A case report on the management of fistula-in-ano by modified conventional ksharasutra therapy: A sphincter-saving technique

Introduction: Fistula in ano is one of the challenging diseases due to the lack of ideal treatment modalities and its high rate of recurrence. Fistulas with multiple openings are very difficult to manage considering the preservation of sphincter muscles. Modern science has developed many techniques in this area but mostly all were failures and resulted in complications like anal incontinence. Ksharasutra therapy is accepted worldwide as the ideal treatment modality of fistula in ano by its simultaneous cutting and healing property. Main Clinical Findings and Diagnosis: In this case, a 37 year old male patient presented with complaints of swelling over the right perianal area and intermittent pus discharge from that swelling for 1 year. On local examination, there were two external openings at 10 and 11'O clock position 4 cm away from the anal verge and a sentinel tag at 6'O clock position. Per rectal examination revealed induration and tenderness at 11'O clock above the dentate line. Intervention: It was managed by a new sphincter saving technique, modified conventional Ksharasutra therapy to fasten the recovery period and minimize the postsurgical pain. Conclusion: Fistula was completely healed by 5 weeks. No complications reported from the patient and no recurrence was happened after 6 months of follow up.

Axillary Reconstruction for Hidradenitis Suppurativa with an Inner- Arm Transposition Flap

Hidradenitis suppurativa is a chronic and disfiguring skin disease characterized by multiple abscesses and sinuses. It can affect any area with apocrine sweat glands and has the potential to involve multiple sites concurrently. Commonly affected sites include the axilla, groin, perineum, and perianal areas. In this report, we describe an innovative technique for reconstructing axilla HS using an inner-arm transposition flap.

Recurrent Perianal Abscess Secondary to Cutaneous B-cell Lymphoma

Fistula-in-ano lies at the chronic end of the spectrum of perianal suppuration which is responsible for waxing and waning coarse of the disease. Recurrent infection of the fistulous tract is responsible for off and on abscess formation. Recurrent abscess formation without a fistula is a very rare entity. Here, we present a case of recurrent perianal abscess without a perianal fistula. A 45-year-old male with renal transplant on immunosuppression presented with recurrent perianal abscess which was drained multiple times and prescribed antibiotics as per culture sensitivity. Magnetic resonance imaging was Performed which did not reveal any fistula formation. The patient was subjected to a biopsy of the lesion which came out to be a B-cell lymphoma. The patient was successfully treated by a multidisciplinary team at our tertiary care center. With this case report, we conclude that recurrent abscess formation in perianal area in an immunosupressed patient may be due to an underlying cutaneous lymphoma. This disease needs multidisciplinary approach for successful management.

Persian Traditional Medicine in Treatment of Ulcerative Colitis: a Case Report

Background and objectives: Ulcerative colitis (UC) is a chronic inflammatory bowel disease. Herbal medicines such as Persicaria bistorta, Pistacia lentiscus, Punica granatum, and Myrtus communis manifesting a variety of pharmacological properties and effects, have been widely implicated in the treatment of UC. We report a case of UC in a 42-year-old male patient. Methods: The patient presented frequent passage of bloody stool, severe cramping, and abdominal pain. This was accompanied by fatigue, excessive mucus, and pus in the stool. He had a 12 years prehistoric diagnosis of ulcerative colitis and received conventional therapy, which yielded no improvement in the symptoms. His regimen was then switched to the Persian traditional treatment employing the “Sahj” formula (including Persicaria bistorta, Pistacia lentiscus, Boswellia frereana, Punica granatum, and Myrtus communis) for 4 months. Results: After 18 days of traditional therapy with “Sahj” tablet, there was a significant improvement in his UC symptoms as evidenced in the increased frequency of his bowel movements (twice daily), absence of bloating, cramping, or abdominal pain and a normal bloodless stool. A colonoscopy report and digital rectal examination 4 months post-treatment, revealed a normal perianal area, cecum, and terminal ileum. Conclusion: The results suggest that the Persian traditional “Sahj” medicine possesses pharmacological properties that render it effective in the treatment of UC and mucosal diseases. However, further clinical trials are needed to evaluate and confirm the efficacy and safety of “Sahj” therapy.

Herpes simplex as a complex interdisciplinary problem. Clinical case

To show the effectiveness of the use of the drug Panavir in patients with a combined clinical manifestation of viral herpetic lesions of the oral mucosa and genital area. Patient S., 42 years old, complained of discomfort, pain and rashes in the mouth and on the genitals. To assess the patient's condition, clinical (dental examination using luminescent stomatoscopy and dermatovenerological examination) and laboratory methods were used: clinical blood and urine tests, microscopy of smears from the urethra, cervical canal, vagina, rectum and PCR-examination of the discharge from the elements of the lesion of the oral mucosa, urethra, cervical canal and the contents of vesicular rashes on the skin of the perianal area. The prescribed antiviral treatment with the inclusion of 0.004% Panavir scheme in the form of injections and drugs for topical use on the oral mucosa, genitals and on the skin, made it possible to quickly achieve a resolution of the inflammatory infectious process. On the third day after the start of therapy, the patient noted a decrease in the area of inflammation. Subjective sensations in the form of discomfort during urination, burning and soreness in the foci were leveled. After 7 days, the foci in the mouth and on the skin of the perianal area completely regressed. The use of Panavir in the complex treatment of severe forms of recurrent herpes virus lesions of the oral mucosa and genital area has shown its high efficiency, good tolerability, no side effects and an increase in the remission period.

156. How Does Exposure to C. Diffogenic Antibiotics Impact Multidrug-resistant Organism Colonization and Environment Contamination in Nursing Homes?

BackgroundAntimicrobial stewardship program (ASP) outcomes are often measured in the acute care setting, less is known about the effect of acute care antibiotic exposures on multidrug-resistant organism (MDROs) colonization of nursing home (NH) patients. We assessed exposure to antibiotics commonly associated with Clostridioides difficile (C. diffogenic agents) on post-acute care patient colonization and room environment contamination (Figure 1).Figure 1. Conceptual Diagram of Hospital Antibiotic Exposure’s Influence on Patient Colonization and Room Environment Contamination with Multidrug-Resistant Organisms MethodsMDRO surveillance of post-acute care patients in 6 NHs between 2013–16. We screened patient hands, nares, oropharynx, groin, perianal area, and high-touch room environment surfaces for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant Gram-negative bacilli (rGNB). C. diffogenic agents were defined as fluoroquinolones, 3rd/4th generation cephalosporins, penicillin combinations, lincosamides, and carbapenems. Multivariable logistic regression was used to assess whether hospital antibiotic exposure is an independent risk factor for MDRO colonization and room environment contamination on study enrollment.ResultsWe enrolled 618 patients: average age was 74.4 years; 57.4% female; 62.3% white; 9.9% had indwelling devices (Table 1). Three hundred-fifty patients (56.6%) were MDRO colonized on enrollment: 98 (15.9%), MRSA; 208 (33.7%); VRE; 196 (31.7%), rGNB. Sixty-eight percent of patient rooms were MDRO contaminated: 166 (26.9%), MRSA; 293, (47.4%). VRE; 182 (29.5%), rGNB.A majority (59.4%) of patients were exposed to an antibiotic before admission. Of which, 239 (65.1%) were exposed to a C. diffogenic antibiotic. In multivariable analysis, C. diffogenic antibiotic exposure was an independent risk factor for MDRO colonization (OR, 1.94; 95% CI, 1.35–2.79), MDRO room environment contamination (OR, 1.94; 95% CI, 1.43–2.63), VRE colonization (OR, 4.23; 95% CI, 2.59–6.90), and VRE room environment contamination (OR, 2.58; 95% CI, 2.00–3.33).Table 1. Clinical Characteristics and MDRO Burden on Study Enrollment, Stratified by Hospital Antibiotic Exposure Status Multivariable Analysis of Hospital Antibiotic Exposure Status as Risk Factor for Proximal and Distal MDRO Outcomes ConclusionHospital exposure to antibiotics is associated with an increased risk of VRE colonization and room environment contamination on NH study enrollment. These observations highlight the potential influence of hospital-based ASPs on MDRO prevalence and transmission in NHs.Disclosures All Authors: No reported disclosures

P026 Assessment of Contributing Factors for Fistula Development in Patients with Inflammatory Bowel Disease Treated by Proctocolectomy with Ileal Pouch-Anal Anastomosis.

BACKGROUND: In patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or the development of neoplasia, and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for those with colitis. However, despite a preoperative diagnosis of ulcerative colitis (UC), a phenotype of the J pouch which has features similar to Crohn’s disease (CD) may develop after the surgery. This study aims to assess the frequency and risk factors of fistula development in IBD patients with a J pouch. METHODS: This is a retrospective single-center study of IBD patients treated by total proctocolectomy with IPAA and who subsequently underwent pouchoscopies at the University of Chicago between January 2007 and December 2019. We reviewed the endoscopic findings in different anatomic areas of the pouch (the afferent limb, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area). Endoscopic phenotypes were classified into 5 main categories: (1) afferent limb, (2) inlet involvement, (3) diffuse inflammation of the pouch body, (4) cuffitis, and (5) J pouch with fistulas. This analysis included pouches with any type of fistulas that developed ≥6 months after ileostomy takedown. We assessed clinical data and pathological findings of the resected colon including deep, focal inflammation, and granulomas generally thought to be unique features of CD. Deep inflammation included ulcerations, fissures, and lymphoid aggregates observed below the level of the mucosa. Fisher’s test was used for univariate analysis to assess factors contributing to fistula development. Logistic regression analysis was performed as a multivariable analysis including variables with a P-value < 0.10 in the univariate analysis. RESULTS: We reviewed 1,359 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 18.8% of patients (78/414) with a J pouch and fistulas ≥ 6 months from ileostomy takedown. Ninety-one percent of patients were preoperatively diagnosed with UC. The most frequent type of fistula was perianal fistula (60.3%), followed by enterovaginal or rectovaginal fistula (24.4%), and fistula from the pouch (7.7%). Among 325 IBD patients with available pathological reports of resected colon, 86 patients (26.5%) showed deep inflammation and 88.4% (76/86) of patients were diagnosed with UC rather than CD by our pathologists. On univariate analysis, we did not find any significant clinical factors for fistula development in patients with a J pouch. As for pathological data, our univariate and multivariable analyses showed that deep inflammation of the resected colon was significantly associated with fistula development (OR = 3.52; 95%CI = 1.84-6.72; P < 0.001), but focal inflammation and granulomas were not. Notably, this association was not observed in patients with other endoscopic phenotypes of the J pouch. CONCLUSION: In this tertiary cohort of patients with a preoperative diagnosis of UC, we found that deep inflammation of the resected colon is a specific predictor for fistula formation in the J pouch. These findings suggest that in such patients a careful monitoring and early treatment strategy may be beneficial.

Transposition Flaps for Reconstruction of Perianal Skin Defects After Tumor Resection

ABSTRACT Objective To investigate the application of transposition flaps in the reconstruction of perianal skin defects after tumor resection. Methods From September 2018 to December 2019, 16 cases of perianal skin defects were repaired with unilateral or bilateral transposition flaps. The wound size before closure ranged from 4 cm × 8 cm to 7 cm × 10 cm. Fourteen patients achieved primary healing. Wound dehiscence occurred in one patient at the flap tip, whereas a slight infection occurred in another patient, which healed after a dressing change. During the follow-up period of 3–6 months, all patients were satisfied with the perianal area both aesthetically and functionally. Conclusion Transposition flaps are a promising option for the repair of perianal skin defects after tumor removal. Owing to the simplicity of the flap design, the wide popularity of this flap type among surgeons is anticipated.

Alteration of gene expression related to vulvar smooth muscle, extracellular matrix and innervation in vulvar lichen sclerosus: A pilot study.

Lichen sclerosus (LS) is a chronic inflammatory disease with a potential for atrophy, destructive scarring, functional impairment, and increased risk of malignant evolution. 1 , 2 Notably, a significant number of LS patients are asymptomatic. It is most frequently seen in the anogenital area. 3 Women with vulvar LS often present with severe pruritus and soreness of the vulvar and perianal areas. 4 In advanced stages, there is destruction of the vulvar anatomy. 2 If untreated, it is associated with a 2% to 6% lifetime risk of malignant squamous neoplasia of the vulva. 5 , 6 , 7 Otherwise, potent topical corticosteroid is the gold standard for obtaining remission and reducing malignancy in vulvar LS. 7 , 8 Despite the possibility for treatment, the true etiology of LS remains unknown. 7 In long‐standing and classic LS, the lymphocytic infiltrate is located under a band of homogenized collagen below the dermo‐epidermal junction. 9 One study showed a significantly increase of pro‐inflammatory cytokines in LS patients. 10 We hypothesize that the elevated inflammation of LS leads to alteration of smooth muscle, subcutaneous adipose tissue, extracellular matrix (ECM), and innervation of the vulva and aim to evaluate the changes of tissues by testing the expression of marker genes. To avoid the disturbance of various treatments, only untreated patients were included for this study.