326
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Abstract
In this report the functional anorectal disorders, the etiology of which is currently unknown or related to the abnormal functioning of normally innervated and structurally intact muscles, are discussed. These disorders include functional fecal incontinence, functional anorectal pain, including levator ani syndrome and proctalgia fugax, and pelvic floor dyssynergia. The epidemiology of each disorder is defined and discussed, their pathophysiology is summarized and diagnostic approaches and treatment are suggested. Some suggestions for the direction of future research on these disorders are also given.
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327
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Régimbeau JM, Panis Y, Marteau P, Benoist S, Valleur P. Surgical treatment of anoperineal Crohn's disease: can abdominoperineal resection be predicted? J Am Coll Surg 1999; 189:171-6. [PMID: 10437839 DOI: 10.1016/s1072-7515(99)00092-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Anoperineal Crohn's disease (APCD) runs an unpredictable course. Although this course is relatively benign in most patients, some will eventually require abdominoperineal resection (APR). The aim of this study was to identify prognostic factors of longterm APR in patients with APCD. STUDY DESIGN From 1980 to 1996, 119 patients were operated on for APCD (mean +/- SD age 30 +/- 13 years; range 11 to 96 years). Patients were divided into two groups: those undergoing APR and patients without APR at the end of followup. The following prognostic criteria were studied: (1) age at onset of Crohn's disease (CD) and at the first manifestation of APCD, gender, APCD as the first manifestation of CD, and interval between the onset of CD and the first manifestation of APCD; (2) for the first manifestation of APCD, the type and number of lesions and the results of surgical treatment; and (3) associated intestinal localizations of CD and the type and number of manifestations of APCD during followup. RESULTS Mean followup from the first manifestation of APCD was 93 months (range 1 to 398 months). At the end of followup, 30 patients had undergone APR (25%). Logistic regression analysis showed that four criteria seemed to be associated with an increased risk of APR: age at first APCD (p < 0.02), fistula as the first manifestation of APCD (p < 0.04), more than three APCD lesions during followup (p < 0.01), and rectal involvement by CD (p < 0.000001). When, as in eight patients, these criteria were all present, APR was performed during followup in 100% of patients. In the absence of all four criteria (eight patients), APR was never performed. CONCLUSIONS This study allowed us to identify patients with APCD at high risk of APR. For these patients, early prevention of CD recurrence should be attempted by aggressive medical therapy.
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328
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Abstract
Endoluminal magnetic resonance imaging (MRI) has become an important technique in the diagnostic work-up of patients with anorectal diseases. The high spatial resolution of endoluminal MRI gives a detailed demonstration of the anal and rectal anatomy and pathology. This technique has been demonstrated to be superior to endoluminal sonography and body coil MRI. Endoanal MRI and phased-array coil MRI seem to have comparable results in perianal fistulas, but comparative data are lacking. Phased-array coil MRI is the imaging technique of choice for imaging rectal tumors, while endoluminal MRI is the alternative technique for imaging rectal tumors and the preferred technique for imaging anal tumors. Endoluminal MRI is superior to phased-array coil MRI in fecal incontinence, as phased-array coil MRI does not give the detailed spatial resolution required for evaluation of anal sphincter lesions.
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329
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deSouza NM, Williams AD, Gilderdale DJ. High-resolution magnetic resonance imaging of the anal sphincter using a dedicated endoanal receiver coil. Eur Radiol 1999; 9:436-43. [PMID: 10087112 DOI: 10.1007/s003300050688] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The use of a surface coil in MR imaging improves signal-to-noise ratio of adjacent tissues of interest. We therefore devised an endoanal receiver coil for imaging the anal sphincter. The probe is solid and re-usable: it comprises a saddle geometry receiver with integral tuning, matching and decoupling. It is placed in the anal canal and immobilised externally. Both in vitro and in vivo normal anatomy is identified. The mucosa is high signal intensity, the submucosa low signal intensity, the internal sphincter uniformly high signal intensity and the external sphincter low signal intensity on T1- and T2-weighted images. In females, the transverse perineal muscle bridges the inferior part of the external sphincter anteriorly. In perianal sepsis, collections and the site of the endoanal opening are identified. In early-onset fecal incontinence following obstetric trauma/surgery, focal sphincter defects are demonstrated; in late-onset fecal incontinence external sphincter atrophy is seen. In fecally incontinent patients with scleroderma, forward deviation of the anterior sphincter musculature with descent of rectal air and feces into the anal canal is noted. The extent of sphincter invasion is assessed in low rectal tumours. In children with congenital anorectal anomalies, abnormalities of the muscle components are defined using smaller-diameter coils. Such information is invaluable in the assessment and surgical planning of patients with a variety of anorectal pathologies.
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330
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Felt-Bersma RJ, Poen AC, Cuesta MA, Meuwissen SG. Referral for anorectal function evaluation: therapeutic implications and reassurance. Eur J Gastroenterol Hepatol 1999; 11:289-94. [PMID: 10333202 DOI: 10.1097/00042737-199903000-00013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
AIM To determine the impact of anorectal function evaluation (AFE) on patients and referring specialists. PATIENTS AND METHODS In one year, 135 patients were referred for AFE, which consisted of proctoscopy, anal manometry, rectal compliance, anal sensitivity measurement and anal endosonography. Questionnaires were sent to the patients and referring specialists. RESULTS In 70% of the 135 patients there was total agreement about the referring and final diagnosis. The response rate of the patients was 78% (n = 100) and that of the specialists was 91% (n = 117). The experience with regard to pain and embarrassment during AFE was good. Of the women, 13% preferred a female investigator. Fifty-nine patients answered that they had received one or more treatments after referral: surgery (n = 32), medication (n = 16), diet (n = 5), physiotherapy (n = 1) or a combination of the above (n = 5). Of the 41 patients who did not receive another treatment, 29 were reassured and 12 did not experience any benefit from the visit, thus bringing the total benefit of the referral to 88%. The anorectal complaints before AFE and at follow-up improved significantly in the treated group (P < 0.0001). The advice given was followed by the referring specialist in 98 cases (84%). The quality of the advice given was considered good in 98 (84%). The opportunity of referral for AFE was considered useful in 108 cases (93%). In 71 patients, information from both the specialist and the patient was obtained. Three patients had therapies that were not advised and 19 patients did not follow the advice (mainly dietary). In the 135 patients, AFE changed the management in 34 patients (25%). In the other 101 patients, endosonography was of value in determining the size of sphincter defects or the fistula tracks. CONCLUSION AFE was well tolerated and changed the management in 25% of patients. Additional advice and reassurance were given in many patients; only 12% of patients claimed to have no benefit from the referral. Anal endosonography seems the most valuable test.
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331
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Guin JD, Fields P, Thomas KL. Baboon syndrome from i.v. aminophylline in a patient allergic to ethylenediamine. Contact Dermatitis 1999; 40:170-1. [PMID: 10073456 DOI: 10.1111/j.1600-0536.1999.tb06026.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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332
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Barnett JL, Hasler WL, Camilleri M. American Gastroenterological Association medical position statement on anorectal testing techniques. American Gastroenterological Association. Gastroenterology 1999; 116:732-60. [PMID: 10029631 DOI: 10.1016/s0016-5085(99)70194-0] [Citation(s) in RCA: 156] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
This document presents the official recommendations of the American Gastroenterological Association (AGA) on Anorectal Testing Techniques. It was approved by the Clinical Practice and Practice Economics Committee on May 17, 1998, and by the AGA Governing Board on July 24, 1998.
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333
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Stoker J, Rociu E, Zwamborn AW, Schouten WR, Laméris JS. Endoluminal MR imaging of the rectum and anus: technique, applications, and pitfalls. Radiographics 1999; 19:383-98. [PMID: 10194786 DOI: 10.1148/radiographics.19.2.g99mr01383] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Anorectal diseases (e.g., fecal incontinence, perianal and anovaginal fistulas, anorectal tumors) require imaging for proper case management. Endoluminal magnetic resonance (MR) imaging has become an important part of diagnostic work-up in such cases. Optimal endoluminal MR imaging requires careful attention to patient preparation, imaging protocols, and potential pitfalls in interpretation. Comfortable positioning and the use of an antiperistaltic drug are vital for adequate patient preparation. Selected sequences and imaging planes are used in imaging protocols tailored for specific diseases. In fecal incontinence, three-dimensional sequences allow detailed demonstration of the anal anatomy and related defects. In perianal and anovaginal fistulas, longitudinal imaging planes help determine the superior extent of the abnormality. In anorectal tumors, T1-weighted turbo spin-echo MR imaging can help detect extension into the perirectal fat and T2-weighted turbo spin-echo MR imaging is used to optimize contrast between tumor and the rectal wall. Off-axis and radial imaging planes are used in all anorectal diseases to minimize partial volume effects. Potential pitfalls include various parts of the normal anal anatomy mimicking sphincter defects, veins and hemorrhoids mimicking fistulas and abscesses, and overhanging tumor mimicking more extensive tumor. Adequate patient preparation combined with proper technique and a knowledge of potential pitfalls will allow optimal endoluminal MR imaging of the rectum and anus.
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334
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Fathi DJ. Common anorectal symptomatology. Prim Care 1999; 26:1-13. [PMID: 9922291 DOI: 10.1016/s0095-4543(05)70098-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The primary care physician must make rapid diagnostic and therapeutic decisions pertaining to all body systems on a daily basis. Anorectal symptomatology generally is straightforward. Once the physician becomes familiar with the various disease processes that underlie hematochezia, anorectal pain and irritation, and changes in stooling habits, he or she can become more comfortable with managing anorectal disease in the office.
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335
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Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. Following external review, the paper was approved by the committee on May 17, 1998.
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336
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Abstract
A systematic approach to the patient with anorectal complaints allows for an accurate and efficient diagnosis of the underlying problem. The process can be divided into the interview, the examination, treatment, and conveyance of information. Throughout this process, the patient must be reassured and made as comfortable as possible. A successful interaction with the patient leads to a diagnosis and a treatment plan that is acceptable to both the physician and the patient.
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337
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Vincent C. Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax, and pruritus ani. Prim Care 1999; 26:53-68. [PMID: 9922294 DOI: 10.1016/s0095-4543(05)70101-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anal fissures, proctalgia fugax, levator ani syndrome, and pruritus ani are common causes of anorectal pain and irritation. The clinician who obtains a thorough history and performs a complete examination can accurately diagnose these disorders. Ancillary tests seldom are helpful and rarely are necessary. Most patients suffering from these conditions readily respond to conservative therapy provided in the primary care practitioner's office.
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338
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Kamm MA. Diagnostic, pharmacological, surgical and behavioural developments in benign anorectal disease. THE EUROPEAN JOURNAL OF SURGERY. SUPPLEMENT. : = ACTA CHIRURGICA. SUPPLEMENT 1999:119-23. [PMID: 10029377 DOI: 10.1080/11024159850191562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The investigation of benign anorectal disease has been transformed by new techniques of imaging such as anal endosonography and magnetic resonance imaging. This has led to more specific surgical treatments when structural damage is identified. It has also led to the identification of newly recognised pathologies, such as primary internal sphincter degeneration which causes passive faecal incontinence. A variety of new treatment modalities is also emerging. Pharmacological therapies are assuming great importance in relation to anal disease, with topical glyceryl trinitrate now the first treatment of choice for chronic anal fissure. For patients with intractable constipation behavioural techniques to modify pelvic floor and intestinal function are now the mainstay of therapy. New approaches to the surgical therapy of incontinence include the use of an artificial bowel sphincter, and the electrical stimulation of sacral nerves to modify pelvic floor function.
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339
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Abstract
Endoluminal MRI of the rectum and anus was introduced in the first half of this decade to overcome the limitations of endoluminal sonography and body coil MRI. Endoluminal MRI is the imaging method of choice for fecal incontinence and anal tumors, whereas it is a competitive imaging method to phased array coil MRI in patients with perianal fistulas or rectal tumor. The purpose of this article is to describe the technique and major indications of endoluminal MR imaging of the anus and rectum.
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340
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Fursland E. Back to front. NURSING TIMES 1999; 95:26-8. [PMID: 10067567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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341
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De Parades V, Sultan S, Bauer P, Parisot C, Atienza EP. [Ano-rectal side effects of suppositories]. SERVIR (LISBON, PORTUGAL) 1999; 47:39-43. [PMID: 12035172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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342
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Candela F, Serrano P, Arriero JM, Teruel A, Reyes D, Calpena R. Perianal disease of tuberculous origin: report of a case and review of the literature. Dis Colon Rectum 1999; 42:110-2. [PMID: 10211529 DOI: 10.1007/bf02235192] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE A case of anal tuberculosis in an otherwise asymptomatic patient with bleeding anal ulcers is presented. The clinical features of this entity and the problems in differential diagnosis between anal infectious vs. inflammatory diseases are discussed. METHODS The management and outcome of the case of an adult patient who presented with perianal ulcers is described. RESULTS On a three-drug antituberculous regimen, symptoms abated, radiographic infiltrates improved, and perianal ulcers healed. CONCLUSION Anal tuberculosis is an extremely rare disease. A tuberculous origin must be considered when the cause of perianal ulcers is unclear to avoid undesirable delays in the diagnosis and treatment of this disease.
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343
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Abstract
We describe a child with an unusual presentation of perianal streptococcal dermatitis which included fever, acral scarletiniform desquamation, and extension of erythema to involve the genitalia and proximal thighs, as well as the commonly seen well-defined erythema of the perianal area. We suggest that isolated group A beta-hemolytic streptococci (GAS) in our patient produced a pyrogenic exotoxin similar to that which appears in scarlet fever.
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344
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de Arriba Méndez JJ, Ríos Laorden J, Solís García del Pozo J. [Fecal incontinence caused by a streptococcal perianal disease]. ANALES ESPANOLES DE PEDIATRIA 1998; 49:653-4. [PMID: 9972640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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345
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Neto MS, Carvalho CH, Fadul R, Ambrogini C, Ferreira LM. [Langerhans cell histiocytosis in anogenital region]. Rev Assoc Med Bras (1992) 1998; 44:344-6. [PMID: 9852657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
The Langerhans cell histiocytosis (LCH) of the genital tract is rare, with only 48 cases related in the literature. There were reported only 2 cases in the anogenital region. We reported the third case of LCH in the anogenital region; patient was female, 31 years-old, caucasian and the diagnosis was confirmed by electron microscopic magnification. The treatment was local surgical excision and systemic chemotherapy.
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346
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[Condylomata acuminata of the anorectal region. Quality Assurance Committee of the German Society of Dermatology and the Professional Organization of German Dermatologists e. V]. DER HAUTARZT 1998; 48 Suppl 1:S104-6. [PMID: 9866063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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347
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[Anal eczema. Quality Assurance Committee of the German Society of Dermatology and the Professional Organization of German Dermatologists e. V]. DER HAUTARZT 1998; 48 Suppl 1:S101-3. [PMID: 9866062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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348
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Hilfiker PR, Debatin JF, Schwizer W, Schoenenberger AW, Fried M, Marincek B. MR defecography: depiction of anorectal anatomy and pathology. J Comput Assist Tomogr 1998; 22:749-55. [PMID: 9754111 DOI: 10.1097/00004728-199809000-00016] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
With the advent of open-configuration MR systems, enabling image acquisition in a vertical patient position, MR defecography has become possible. MR defecography permits analyses of the anorectal angle, opening of the anal canal, functioning of the puborectal muscle, and descent of the pelvic floor during defecation. The rectal walls are well delineated on the GRE images, permitting visualization of intussusceptions and rectoceles. The concomitant depiction of structures surrounding the anorectal canal is helpful in the assessment of a spastic pelvic floor and the descending perineum syndrome and in permitting visualization of enteroceles. Dynamic MR defecography is an attractive alternative in the evaluation of defecation disorders.
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349
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Kulshrestha S, Kulshrestha M, Prakash G, Gangopadhyay AN, Sarkar B. Management of congenital and acquired H-type anorectal fistulae in girls by anterior sagittal anorectovaginoplasty. J Pediatr Surg 1998; 33:1224-8. [PMID: 9721991 DOI: 10.1016/s0022-3468(98)90155-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
METHODS Thirteen girls with congenital or acquired H-type anorectal fistulae underwent surgery between 1991 and 1996. In all cases, besides a normally placed anal canal, there was a fistulous communication between the anorectum and the genital tract. On the basis of the level of fistulous communication, these cases were divided into three groups: high, intermediate, and low (perineal canal). All patients underwent anterior sagittal anorectovaginoplasty. Surgical technique included division of all intervening tissue in midline between the perineal skin and the fistula. The whole fistulous tract was excised, and the remaining surrounding tissue was repaired in different layers. Of 13 patients, 12 were operated on without a protective colostomy. RESULTS There was no recurrence in any case, and all patients had good cosmetic results with a normal sphincter control. Although various techniques have been suggested for the surgical correction of H-type anorectal fistulae, most of them are applicable only to the low-lying fistula (perineal canal). CONCLUSIONS To date, there is no satisfactory method available for correction of high fistula. The methods suggested for high fistula (abdominoperineal pull-through and endorectal pull-through) appear to be too extensive for this condition. Our technique of anterior sagittal anorectovaginoplasty can be used not only for low fistula but can also be used for intermediate and high types of fistulae. This technique is simple, safe, takes less time, and achieves good anatomic and functional reconstruction of the perineum.
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350
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Hofstetter WL, Ly P, Anthone G, Ortega AE, Vukasin P, Beart RW. Prevalence and distribution of anorectal misdiagnoses. West J Med 1998; 168:549. [PMID: 9656010 PMCID: PMC1305086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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