Perineal Involvement Research Articles

Acantholytic Dyskeratoses of the Vulva: Clinicopathologic Characterization of 16 Cases and Review of the Literature.

The vulva and perineum are rarely involved by acantholytic dyskeratoses, including Hailey-Hailey disease, Darier disease, papular acantholytic dyskeratosis of the genitocrural area, acantholytic dyskeratotic acanthoma, and warty dyskeratoma. These entities show broad histomorphologic overlap, generally requiring clinical correlation for definitive classification. This institutional series aims to better characterize vulvar acantholytic dyskeratoses and provide a practical literature review and diagnostic aid for gynecologic pathologists. Our institutional archives contained 16 vulvar acantholytic dyskeratoses diagnosed between 1990 and 2023. Affected patients were 36 to 79 (mean, 58) years old and presented with one or more asymptomatic (n = 9) or pruritic (n = 6) lesions involving the vulva (predominantly the labia majora), with additional perineal involvement in 2. Four patients have known Hailey-Hailey disease. Eleven cases comprised singular, raised, erythematous, or skin-colored papules, measuring 0.2 to 0.6 (mean, 0.3) cm. Two patients had oligofocal (both with known Hailey-Hailey disease) vulvar lesions, and 2 had multifocal vulvar lesions (one with known Hailey-Hailey disease). Histologically, all showed acantholysis and dyskeratoses (abundant in 8, focal in 8, with corps ronds generally more conspicuous than corps grains). Additional features included suprabasal clefting (n = 14), dermal papillomatosis (n = 12), and acanthosis (n = 8). Adnexal involvement was rare (n = 1). No histologic features reliably distinguished sporadic versus syndromic acantholytic dyskeratoses. Sporadic lesions were cured by local excision. Patients with Hailey-Hailey disease were variably responsive to corticosteroids. Neither our series nor the literature indicate a significant correlation between sporadic or syndromic acantholytic dyskeratosis and squamous cell carcinoma. Important differential diagnoses include pemphigus vulgaris and pemphigus vegetans, for which direct immunofluorescence may be performed, when indicated.

Defining the Optimal Antibiotic Duration in Necrotizing Skin and Soft Tissue Infections: Clinical Experience from a Quaternary Referral Center.

Background: Early initiation of broad-spectrum antibiotic agents is a cornerstone of the care of necrotizing skin and soft tissue infections (NSTI). However, the optimal duration of antibiotic agents is unclear. We sought to characterize antibiotic prescribing patterns for patients with NSTI, as well as associated complications. Patients and Methods: Using an NSTI registry, we characterized antibiotic use at a quaternary referral center. Kaplan-Meier analyses were used to describe overall antibiotic duration and relative to operative source control, stratified by presence of other infections that independently influenced antibiotic duration. Factors associated with successful antibiotic discontinuation were identified using logistic regression. Results: Between 2015 and 2018, 441 patients received antibiotic agents for NSTI with 18% experiencing a complicating secondary infection. Among those without a complicating infection, the median duration of antibiotic administration was 9.8 days (95% confidence interval [CI], 9.2-10.5) overall, and 7.0 days after the final debridement. Perineal NSTI received fewer days of antibiotic agents (8.3 vs. 10.6) compared with NSTI without perineal involvement. White blood cell (WBC) count and fever were not associated with failure of antibiotic discontinuation, however, a chronic wound as the underlying infection etiology was associated with greater odds of antibiotic discontinuation failure (odds ratio [OR], 4.33; 95% CI, 1.24-15.1). Conclusions: A seven-day course of antibiotic agents after final operative debridement may be sufficient for NSTI without any secondary complicating infections, because clinical characteristics do not appear to be associated with differences in successful antibiotic discontinuation.

Clinical Profile of Necrotising Soft Tissue Infection Patients in a North Indian Hospital

Background: Necrotizing soft tissue infections (NSTIs) or necrotizing fasciitis are infections of the subcutaneous tissue and fascia with variable involvement of the overlying skin and underlying muscle. They can be initiated by trivial injuries and can be idiopathic. Material & Methods: It is an retrospective observational study conducted in our surgical unit of a tertiary care centre, from January 2017 to December 2022, were observed for age, gender, occupation, socioeconomic status, body mass index (BMI) clinical features, radiological findings (size, site, status, involvement of tissue compartments and bone). A total of 118 patient records were analyzed. Results: 60% patients were over 50 years of age and 64.2% were males. 69.85 cases had body mass index more than 30 kg/m2. 50.9% patients had history of alcohol abuse and 32.1% cases gave history of intravenous drug abuse. 73.6% cases had foul smelling discharge on presentation while fever and sepsis was seen in 64.2% and 52.8% cases, respectively. Lower limb and perineal involvement was seen in more than two third of the cases. 69.4% cases were anaemic while 44.1% had hypoalbuminemia. More than 85% cases had leucocytosis. 40.7% cases required ionotropes and 22.03% cases needed ventilatory support on admission. Diabetes mellitus was the most common associated co morbidity, seen in 53.4% cases. Conclusion: The necrotizing soft tissue infections are a significant health problem and carry high mortality and morbidity rates. The condition carries high association with modifiable risk factors like anaemia, hypoalbuminemia, diabetes mellitus and obesity.

Fournier’s gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas’s NHS Foundation Trust

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

P569 Can thiopurines prevent crohn’s disease endoscopic postoperative recurrence in at risk patients?

Abstract Background Postoperative relapse (POR) of Crohn’s disease (CD) is frequent in the absence of prophylactic treatment. Screening for known risk factors allows to stratify patients and consider appropriate therapy. In Tunisia, the cost-effectiveness of thiopurines makes it prescribed even when moderate or high risk of POR. The aim was to describe the efficacy of thiopurines in preventing endoscopic POR in patients at risk. Methods We conducted a retrospective study enrolling CD patients who underwent curative ileo-caecal resection and received thiopurines to prevent POR. They all had at least one risk factor for POR knowing: smoking, fistulizing phenotype, extensive ileal resection (≥ 50 cm), previous bowel resection. The risk was moderate in the presence of one risk factor and high if at least two factors. Patients with a follow-up less than 6 months were excluded. All patients had undergone ileocoloscopy to screen for endoscopic POR wich was stratified according to the Rutgeerts score. Endoscopic POR was defined by a score ≥ i2 and was severe if score ≥i3. Results Thirty nine patients were included with a sex ratio M/F =1.8 and a mean age of 31 years. CD was ileal and ileocolic in 92.3% and 7.7% respectively, with perineal involvement in 7.2%. The mean extent of ileal resection was 39.7±4 cm. The ileal and colonic histological margins were pathologic in 17.9% and 7.7% respectively. Risk factors for POR were distributed as follow: Active smoking (28.2%), previous bowel resection (17.9%), fistulizing phenotype (84.6%) extensive resection (35.9%). The risk was high in 51.3% and moderate in 48.7% of cases. The delay of introduction of thiopurines was on average 31.8±53 days from the restoration of digestive continuity at a mean dose of 2.3 mg/kg and ileocoloscopy was performed at a mean delay of 19.3 months. Rutgeerts' score was as follows: i0, i1, i2, i3 and i4 in 34.7%, 8.2%, 16.3%, 6.1% and 10.2% respectively. Endoscopic POR was noted in 43.6% and was severe in 21.6% of cases. The cumulative POR rate was 16% at 6 months, 52% at 12 months and 67.5% at 24 months. In univariate analysis, factors associated with endoscopic POR on thiopurines were male gender (p=0.012), laparotomy (p=0.02), the extent of ileal resection and extensive ileal resection (p=0.003). In multivariate analysis, the factors retained were male gender with an OR=11 (p= 0.024) and the extent of ileal resection with an OR=1.05 (p=0.02). Time to introduction of thiopurines, fistulising phenotype and smoking did not significantly influence the risk of POR. Conclusion Thiopurines would be able to prevent endoscopic POR in more than half of the patients at risk. However, anti-TNF therapy should be indicated immediately in males and in cases of extended ileal resection.

Impact of Crohn's disease on obstetrical management

ObjectivePatients with Crohn's disease (CD) may have perineal lesions or a history of anorectal surgery that raise concerns about complications during delivery resulting in a discussion of cesarean section. Our objective was to study the impact of CD on the mode of delivery. MethodWe conducted a retrospective study between 2005 and 2019 of the pregnancy outcomes of patients with CD. The primary endpoint was the performance of a cesarean section for a reason related to CD. ResultsAmong 76 consecutive pregnancies, 19 patients underwent CD-related cesarean section (25%). The main element associated with scheduling a cesarean section was the existence of perineal involvement in 94.7% of cases, compared to 12.3% in the rest of the CD population (p<0.05). The perineal lesions most often involved were fistulas (47.4% versus 1.7%; p = 0.042). There was a history of perineal surgery in 78.9% of cases in the cesarean group vs 10,5% (p < 0.05) and a history of obstetric anal sphincter injury (OASI) in 10.5% of cases vs. 0 (p = 0.047). In women who gave birth vaginally, there were 17.9% episiotomy and one case of OASI (2.6%). ConclusionThe factors that influenced the choice of delivery route were perineal damage, history of perineal surgery and history of OASI.

Mucinous adenocarcinoma in perianal fistula in Crohn's disease: Case report and literature review.

SummaryIntroduction and importanceCrohn's disease (CD) is a chronic bowel disease that, due to exacerbated inflammation, can lead to complications such as the development of perianal fistulas. The development of mucinous adenocarcinoma in perianal fistulas in patients with CD is rare and, consequently, few reports exist in the literature.Case presentationWe report the case of a 71-year-old man diagnosed 22 years ago with CD with perineal involvement, who came with complaints of intense perianal pain, a gluteal mass, and local bleeding. Tomography of his abdomen showed an expansive, heterogeneous, and solid perianal mass on the right, with interspersed necrotic/liquefied areas and possible mucinous content. The patient was referred to the surgery department for an incisional biopsy, which confirmed mucinous adenocarcinoma. The patient underwent extra levator abdominoperineal rectal resection (APR) with partial prostatectomy.Clinical discussionPerineal mucinous adenocarcinoma arising in a fistula associated with CD is very rare. Since the symptoms overlap, early diagnosis of malignancy is difficult. Histological analysis is the gold standard for its diagnosis. Surgical resection through APR is well-established and, despite being a complex procedure with potential complications, tends to have good results. However, the locoregional and inguinal lymph node involvement was related to a worse progression in this case.ConclusionThe diagnostic hypothesis of mucinous adenocarcinoma should be suspected in CD patients who present long-term perineal involvement with fistulas. Biopsies and imaging exams should be performed to aid the diagnosis of the condition and thus contribute to the surgical plan.

P295 Proctitis during Crohn’s disease, would it be a factor in the sustainability of anoperineal fistulas?

Abstract Background Rectal involvement during Crohn’s disease (CD) was identified as a risk factor associated with poor therapeutic response of anoperineal fistulas (APF). The aim of our study was to evaluate the impact of rectal mucosal healing on the healing of APF during CD treated with anti-Tumour Necrosis Factor Alpha (anti-TNFα). Methods We conducted a monocentric retrospective study, including records of all patients followed for CD with APF treated with anti-TNFα over a 10-year period [2010 - 2020]. We collected clinical, biological, endoscopic and radiological data as well as the evolution of the patients on anti-TNFα. The therapeutic response was assessed clinically and radiologically by perineal MRI. Healing of the rectal mucosa was investigated by endoscopy with biopsies, and compared with that of the APF. Results A total of 38 patients were included, with a mean age equal to 42 years [26 - 73] and a M/F sex ratio equal to 0,4. Two patients (5,2%) had exclusively perineal involvement. APF was associated with luminal involvement in 94,7% of cases. Twenty-three patients (60,5%) had associated proctitis. APF were complex in 92,1% of cases, associated with a perineal abscess in 44,7% of cases and anorectal stricture in 7,9% of cases. All patients had received anti-TNFα after disappearance of perineal collections if initially present (Infliximab (92,1%), Adalimumab (7,9%)) combined with thiopurines in 97,4% of cases. After a mean follow-up of 40 months, the response of the APF to treatment was associated with healing of the rectal mucosa in 10 patients (43,5%), healing of the APF alone with persistence of proctitis was observed in 6 patients (26,1%), healing of the rectum with persistence of APF was described in only one patient (4,3%). The absence of rectal and anoperineal healing together was observed in 6 patients (26,1%). In a univariate study and using the chi-square test, there was no statistically significant relationship between rectal mucosal healing and APF healing after treatment with biotherapy with p = 0,069 [95% confidence interval]. Conclusion Our results suggest that healing of the rectal mucosa does not influence the natural history of anoperineal fistulas in Crohn’s disease. Larger scale studies are needed to confirm these results.

A predictive model for prolonged hospital length of stay in surgical burn patients

BackgroundImprovement in the care of burn patients has led to decreased mortality. Length of stay (LOS) has been used as a marker for quality of care in this population. However, the historical association of LOS as correlating only with % burn surface area (BSA) injury has been questioned with retrospective data suggesting other factors may also be associated with LOS. A model to predict prolonged LOS does not exist but could provide important information for clinicians and patients. MethodsData from January 2014 to December 2016 was used to develop a predictive model utilizing multivariable logistic regression. Prolonged hospital LOS was the outcome used with multiple covariates utilized to identify various associations. Odds ratios (OR) and their associated 95% confidence interval (CI) were reported for each covariate in the final regression model. Model performance in both the training and validation sets was evaluated using area under the receiver operating characteristic (ROC) curve (AUC) for discrimination and the Hosmer–Lemeshow (HL) test for goodness-of-fit. ResultsA total of 441 patients was included in the final analysis, 296 (67.1%) of which were in the training set. Within the training set, the median hospital LOS was 14 days with a range of 4 to 205 days. Patient age (in decades), hypertension, total BSA, involvement of perineum, and abnormal white blood cell count were independent risk factors for prolonged hospital length of stay. When using this separate dataset, the model had an AUC of 0.81 (95% CI 0.74–0.88) and had good calibration based on the HL-test (p=0.10). ConclusionsProlonged hospitalization following burns is predicted by patient age (in decades), TBSA, hypertension, perineal involvement, and abnormal white blood cell count.

Evaluation of Patient-Reported Outcomes in Burn Survivors Undergoing Reconstructive Surgery in the Rehabilitative Period.

Health-related quality of life is decreased in burn survivors, with scars implicated as a cause. The authors aim to characterize the use of reconstructive surgery following hospitalization and determine whether patient-reported outcomes change over time. The authors hypothesized improvement in health-related quality of life following reconstructive surgery. Adult burn survivors undergoing reconstructive surgery within 24 months after injury were extracted from a prospective, longitudinal database from 5 U.S. burn centers (Burn Model System). Surgery was classified by problem as follows: scar, contracture, and open wound. The authors evaluated predictors of surgery using logistic regression. Short Form-12/Veterans RAND 12 health survey outcomes at 6, 12, and 24 months were compared at follow-up intervals and matched with nonoperated participants using propensity score matching. Three hundred seventy-two of 1359 participants (27.4 percent) underwent one or more reconstructive operation within 24 months of injury. Factors that increased the likelihood of surgery included number of operations during index hospitalization (p < 0.001), hand (p = 0.001) and perineal involvement (p = 0.042), and range-of-motion limitation at discharge (p < 0.001). Compared to the physical component scores of peers who were not operated on, physical component scores increased for participants undergoing scar operations; however, these gains were only significant for those undergoing surgery more than 6 months after injury (p < 0.05). Matched physical component scores showed nonsignificant differences following contracture operations. Mental component scores were unchanged or lower following scar and contracture surgery. Participants requiring more operations during index admission were more likely to undergo reconstructive surgery. There were improvements in Short Form-12/Veterans RAND 12 scores for those undergoing scar operations more than 6 months after injury, although contracture operations were not associated with significant differences in Short Form-12/Veterans RAND 12 scores.

Predictors of mortality, limb loss, and discharge disposition at admission among patients with necrotizing skin and soft tissue infections.

Necrotizing soft tissue infections (NSTI) represent a heterogeneous group of rapidly progressive skin and soft tissue infections associated with significant morbidity and mortality. Efforts to identify factors associated with death have produced mixed results, and little or no data is available for other adverse outcomes. We sought to determine whether admission variables were associated with mortality, limb loss, and discharge disposition in patients with NSTI. We analyzed prospectively collected data of adult patients with surgically confirmed NSTI from an NSTI registry maintained at a quaternary referral center. Factors independently associated with mortality, amputation, and skilled nursing facility discharge were identified using logistic regression. Between 2015 and 2018, 446 patients were identified. The median age was 55 years (interquartile range, 43-62). The majority of patients were male (65%), white (77%), and transferred from another facility (90%). The perineum was most commonly involved (37%), followed by the lower extremity (34%). The median number of operative debridements was 3 (interquartile range, 2-4). Overall mortality was 15%, and 21% of extremity NSTI patients required amputation. Age greater than 60 years; creatinine greater than 2 mg/dL; white blood cell count greater than 30 x 10^ /μl, platelets less than 150 × 10/μL, and clostridial involvement were independently associated with greater odds of death; perineal involvement was associated with lower odds of death. Age greater than 60 years; sex, male; nonwhite race; diabetes; chronic wound as etiology; leg involvement; transfer status; and sodium, less than 130 mEq/L were independently associated with amputation. Age greater than 60 years; sex, female; nonwhite race; perineal involvement; and amputation were associated with skilled care facility discharge. Necrotizing soft tissue infections are a heterogeneous group of infections involving significantly different patient populations with different outcomes; efforts to differentiate and predict adverse outcomes in NSTI should include laboratory data, comorbidities, infection site, and/or etiology to improve predictions and better account for this heterogeneity. Prognostic, Level III.

51 Patient Reported Outcomes Following Rehabilitative Surgery in Burn Survivors

Burn survivors have surgical needs after their incident hospitalization. Little is understood regarding what predicts these operations and their effect on patient reported outcomes (PROs). We aim to characterize the use of burn-related operations post-hospitalization and determine whether PROs change during this time. We hypothesized improvement in PROs following surgery adjusting for patient and burn factors. Adult burn survivors with complete data through 2 years post-hospitalization were extracted from the Burn Model Systems, a prospective observational database from 4 US burn centers. Surgical and non-surgical patients were compared. Predictor variables included patient and injury characteristics and inpatient procedures; these were modeled with logistic regression. Health states were measured with Veterans RAND 12 item health survey (VR-12). Burn-related operations were organized into 3 categories: wound, scar, and contracture. The average treatment effect of surgery was modeled with propensity score matching. 372 of 1,359 patients (27.4%) underwent ≥ 1 burn-related operation within 2 years of discharge. Factors that increased the likelihood of operations included number of operations at incident hospitalization (p<0.001), hand and perineal involvement (p=0.001 & 0.042), and range of motion limitation (p<0.001). VR-12 physical health scores rose for all cohorts except those needing wound operations. VR-12 mental health scores rose for those not receiving surgery, but stagnated or declined for surgical cohorts. After adjustment, scar related operations showed no significant changes in physical or mental component scores. Contracture operations were not significantly associated with changes to physical component scores, but showed a decline in mental component scores at 12-month visits (p<0.001). The number of operations at incident hospitalization was the strongest predictor of needing later surgery. Patients with ongoing surgical needs for wounds appear to have poorer quality of life than matched peers. Contracture and scar surgeries were not associated with gains in global well-being compared to matched non-surgical peers. Additional qualitative studies are needed to understand why these data suggest a discrepancy to what is observed in the clinical setting with regard to reconstructive surgery. Better informed shared decision making with patients when deciding on rehabilitative burn surgery.

Outcomes in patients with Fournier’s gangrene originating from the anorectal region with a particular focus on those without perineal involvement

Background and aimFournier’s gangrene (FG) is a fulminant infection in the external genital region and perineum. The present study explored the clinical features of FG originating from the anorectal region, from primary conditions such as anal fistulas and abscesses.MethodsA retrospective analysis was performed in order to identify the factors associated with clinical outcomes in FG patients derived from two hospitals—the Sixth Affiliated Hospital of Sun Yat-sen University and People’s Hospital Affiliated to Fujian University of Traditional Chinese—over the period from May 2013 to April 2017.ResultsSixty FG patients were included in this study. The common causative microorganisms cultured were Escherichia coli species. Genital and perirectal regional involvement was evident in 52 and 59 cases, respectively, although the perineum was unaffected in 7 cases (12%), as confirmed by imaging examination and surgical exploration. Management with early radical debridement and broad-spectrum antibiotic therapy is effective with an acceptably sepsis mortality (1.7%). Ten patients underwent protective colostomy. No patient underwent an orchidectomy and required urinary diversion.ConclusionsFG originating from the anorectal region can be rapidly progressive and life-threatening. Infection can spread superiorly to the genital region without the involvement in perineal tissue. An aggressive surgical debridement of non-viable tissue is essential for satisfactory outcomes and a protective colostomy is not mandatory.

Preoperative CT Findings and Interobserver Reliability of Fournier Gangrene.

The objective of our study was to delineate CT findings and anatomic areas of involvement of surgically proven Fournier gangrene (FG) and determine interobserver reliability. This study was a single-center retrospective study of patients with FG who underwent CT before surgical débridement of FG during a 9-year period. Thirty-eight patients with FG, 17 male and 21 female patients, underwent preoperative CT. Two radiologists reviewed the CT studies and recorded findings and anatomic areas of involvement. CT findings were categorized according to a previously described CT scoring system for necrotizing fasciitis and included the presence or absence of fascial air, muscle or fascial edema, fluid tracking, lymphadenopathy, and subcutaneous edema. Cohen kappa was calculated for interobserver reliability. Mean body mass index (BMI [weight in kilograms divided by height in meters squared]) was 42, and 22 of 38 (58%) patients had diabetes. Mean BMI and proportion of patients with diabetes were significantly higher in female patients (mean BMI = 46; 16/21 with diabetes) than male patients (mean BMI = 36; 6/17 with diabetes). CT studies of most patients showed fascial air (36/38 [95%], both readers 1 and 2). Interobserver reliability was substantial to almost perfect for all CT findings except lymphadenopathy, for which it was fair (κ = 0.37). Genital, perineal, and ischiorectal involvement were seen in 87% (33/38), 87% (33/38), and 32% (12/38) of patients for reader 1 and 84% (32/38), 84% (32/38), and 26% (10/38) of patients for reader 2 (κ = 0.29, penis; κ = 0.65, scrotum; κ = 0.91, vulva and labia; κ = 0.68, perineal involvement; κ = 0.80, ischiorectal involvement). Most CT findings of FG and anatomic areas of involvement showed good interobserver reliability. A high proportion of female patients with FG were observed in this study compared with prior series.

Anorectal injuries in children: a 20-year experience in two centers.

Anorectal injuries in children are not frequently reported and their management is challenging. This report reviews the experience in managing this type of injuries in two medical centers over 20 years. An institutional database search for patients who were treated for anorectal injuries between 1994 and 2015 was undertaken. Twenty cases were located and medical records reviewed. This study was conducted with institutional review board approval (#572-14). There were 6 girls and 14 boys with ages ranging between 1 and 15 years (mean 7 years). Eleven patients sustained penetrating trauma, while nine sustained blunt trauma. The mechanism of injury was variable and associated injuries were more common in blunt trauma. Most common presenting symptoms were rectal bleeding (n = 12) and anal pain (n = 11), followed by abdominal pain in six patients. Eighteen anorectal injuries were extraperitoneal and two intraperitoneal. Among patients with extraperitoneal injuries, 12/18 were managed by primary repair with (6) or without (6) fecal diversion and 2/18 by wound irrigation and drainage with fecal diversion and delayed repair. Four patients had superficial anal and perineal injuries that were irrigated and left to heal by secondary intention. Two patients with intraperitoneal rectal injuries underwent primary repair with fecal diversion. Follow-up period ranged from 2 weeks to 8 years (mean 2 years). There were three cases of wound infection, one case of suture line leak requiring reoperation and one case of vesicorectal fistula in a patient with combined trauma of the rectum and urinary bladder. There was no mortality. Fecal continence was preserved in all patients available for follow-up evaluation. Primary repair of the perineal wound and anal sphincters can be performed safely in most cases given hemodynamic stability. Fecal diversion should be saved for cases with severe perineal involvement or cases with substantial associated injuries and concern of gross contamination.

Contemporary diagnosis and management of Fournier's gangrene.

Fournier's gangrene, an obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the overlying skin, is a rare but severe infective necrotizing fasciitis of the external genitalia. Mainly associated with men and those over the age of 50, Fournier's gangrene has been shown to have a predilection for patients with diabetes as well as people who are long-term alcohol misusers. The nidus for the synergistic polymicrobial infection is usually located in the genitourinary tract, lower gastointestinal tract or skin. Early diagnosis remains imperative as rapid progression of the gangrene can lead to multiorgan failure and death. The diagnosis is often made clinically, although radiography can be helpful when the diagnosis or the extent of the disease is difficult to discern. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be used to stratify patients into low, moderate or high risk and the Fournier's Gangrene Severity Index (FGSI) can also be used to determine the severity and prognosis of Fournier's gangrene. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics. After initial radical debridement, open wounds are generally managed with sterile dressings and negative-pressure wound therapy. In cases of severe perineal involvement, colostomy has been used for fecal diversion or alternatively, the Flexi-Seal Fecal Management System can be utilized to prevent fecal contamination of the wound. After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for satisfactory functional and cosmetic results.

Clitoral involvement of squamous cell carcinoma of the vulva: Localization with the worst prognosis

ObjectiveThe overall 5-year survival of patients with vulvar squamous cell carcinoma (SCC) is 70%. The clinical impression is that localization of SCC on the clitoris may lead to worse prognosis. The aim of this study is to assess the disease specific survival (DSS) in patients with clitoral SCC compared to patients with SCC without clitoral involvement. MethodsAll consecutive patients with primary vulvar SCC treated with surgery at the Department of Gynaecologic Oncology at the Radboud university medical centre (Radboudumc) between March 1988 and January 2012, were analysed. The clinical and histopathological characteristics and DSS rates of patients with (N = 72) and without clitoral SCC (N = 275) were compared. Furthermore, patients with clitoral involvement were compared to patients with perineal SCCs (N = 52) and other central SCCs without clitoral and/or perineal involvement (N = 117). ResultsPatients with clitoral SCC more often had larger and deeper invaded tumours, lymphovascular space involvement (LVSI), positive surgical margins and a higher percentage of positive lymph nodes. Kaplan–Meier survival analyses showed worse DSS in patients with a clitoral SCC compared to patients without clitoral involvement. Multivariable analysis showed that not clitoral involvement, but invasion depth, differentiation grade and lymph node status are independent prognostic factors. ConclusionsPatients with clitoral SCC have worse survival compared to patients without clitoral involvement. This is probably caused by unfavourable histopathological characteristics of the tumour rather than the localization itself. Prospective studies are needed to further assess the influence of localization of the vulvar SCC on prognosis.

Inflammatory bowel disease in an underdeveloped region of Northeastern Brazil.

To evaluate the demographic characteristics and clinical phenotypes of inflammatory bowel disease (IBD) in a geographic area in Northeastern Brazil. This retrospective study was conducted at the Hospital of the Federal University of Piauí in Northeastern Brazil. Demographic characteristics and clinical phenotypes of IBD were analyzed in relation to the time of diagnostic confirmation, which was defined as the date of disease onset. Data were collected between January 2011 and December 2012 and included all census patients 18 years of age or older during that period for whom there was diagnostic confirmation of Crohn's disease (CD), ulcerative colitis (UC), or unclassified colitis according to the Montreal criteria. We also analyzed the period of time between the onset of clinical manifestations and the diagnosis of IBD (delay in the diagnosis). Statistical analyses included means and standard deviations for numeric variables and the Pearson χ2 adherence test for nominal variables. The annual index occurrence and overall prevalence of IBD at our institution were also calculated, with P values<0.05 indicating statistical significance. This study was approved by the Institutional Ethics and Research Committee. A total of 252 patients with IBD were included, including 152 (60.3%) UC patients and 100 (39.7%) CD patients. The clinical and demographic characteristics of all patients with IBD showed a female to male ratio of 1.3:1.0 and a mean age of 35.2 (SD=14.5) years. In addition, the majority of patients were miscegenated (171, 67.9%), had received higher education (157, 62.4%), lived in urban areas (217, 86.1%), and were under the age of 40 years (97, 62.5%). For patients with CD, according to the Montreal classification, the predominant features present from the onset of disease were an age between 17 and 40 years (A2); colonic disease location (L2); and nonstricturing, nonfistulizing disease behavior (B1). However, approximately one-quarter of all CD patients demonstrated perineal involvement. We also observed considerable delay in the diagnosis of IBD throughout the entire study period (mean=35.5 mo). In addition, the annual index occurrence rose from 0.08 to 1.53 cases/10(5) inhabitants/year during the study period, and the prevalence rate was 12.8 cases/10(5) inhabitants in 2012. Over the last two decades, there was a noted increase in the frequency of IBD in the study area. In this study, there was a predominance of patients with UC, young people under 40 years of age, individuals with racial miscegenation, and low annual incomes.

Bull Gore injury- Its impact and surgical management

Bull gore injuries are among the commonest accidents in rural india, where people make their living rearing the livestock. The injuries thus sustained include the direct penetrating injuries caused by horns of the animal and blunt injuries sustained like chest & spine injuries, long bone fractures. A thorough head to toe examination is therefore essential in evaluating such patients. The commonest site of injury in bullgore cases is the abdomen and perineal region. The reason for perineal involvement is its anatomical configuration. Injuries involving the perineal region pose a great challenge in management due to poorly understood anatomy and difficulty in accessing the injury site. Perineal injuries are associated with delayed complications like anovaginal fistula, urethrorectal fistula, loss of sphincter function due to injury to the anal canal. This paper describes the spectrum of five bull gore injury cases involving lower abdomen and perineum that presented to our emergency department and how they were managed efficiently in our hospital.

Biological immunomodulators improve the healing rate in surgically treated perianal Crohn’s fistulas

The role of biological therapy in perianal fistulas associated with Crohn's disease (CD) is uncertain as available data are confused and conflicting. In order to provide some clarity to the issue we have examined a large cohort of patients with perianal fistulas and CD and stratified them according to use of biological agents. Patients with perianal Crohn's fistulas treated between June 1999 and June 2009 were stratified according to use of biological agents and outcome was examined. Healing was defined as absence of fistula or drainage. Prior to surgery perianal sepsis was eradicated with drains or setons. Endpoints were defined as either complete healing, improvement (minimal symptoms and drainage) or unhealed, as noted at subsequent outpatient follow-up. Variables assessed were age, body mass index, smoking, perineal involvement with Crohn's granuloma and type of procedure. Fisher's exact test and χ(2) test were used for analysis. Two hundred and eighteen patients had anal fistulas and CD. Mean follow-up was 3.2±3 years with mean age 38.8±12.2years and body mass index of 25.3±6. One hundred and seventeen patients (53.7%) underwent surgery alone (Group A) and 101 patients (46.3%) underwent surgery and biological immunomodulator treatments (Group B). Demographic data and CD history were similar between groups. Surgeries included seton drainge (n=90), fistulotomy (n=22), rectal advancement flap (n=39), fistulotomy plus seton (n=47) and others (n=20). Overall improvement in Group A was in 42 patients (35.9%) vs 72 patients (71.3%) in Group B (P=0.001). There was no significant difference in other studied variables between both groups. There is a definite role for biological therapy as an adjuvant to surgery in patients with perianal fistulas and CD.