Pneumomediastinum after dilatation of anal stricture following stapled hemorrhoidopexy

Stapling procedure is a new technique for the surgical management of prolapsing haemorrhoids. Some articles have reported severe adverse effects of this operation. We describe a case of an excessive staple-line stenosis followed stapled haemorrhoidopexy. Proctoscopic dilatation resulted in complications of retropneumoperitoneum, pneumomediastinum, subcutaneous emphysema and perianal abscess. Drainage of the abscess was performed, allowing quick recovery. After discharge from the hospital, the patient continued to perform periodic dilatation. Simple proctoscopic dilatation was conducted in an outpatient setting.

Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature

Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.

Total colonic Hirschsprung's disease: a 28-year experience

PURPOSE

The aim of this study was to review outcomes after surgical treatment of total colonic Hirschsprung's disease (TCH).

METHODS

Twenty-five records of patients with TCH treated between 1974 and 2002 were reviewed. Follow-up data were collected using a standardized questionnaire. Objective functional outcome was assessed using a scoring system.

RESULTS

Twenty patients had aganglionosis of the colon and distal ileum, 5 of whom had a more extensive condition. One of these 5 patients underwent an endorectal pull-through (ERPT), 1 underwent intestinal transplantation, and 3 died. Four of the remaining 20 patients underwent a primary ERPT, 16 received a stoma as neonates followed by ERPT in 12, and a Martin-Duhamel procedure or Swenson's operation in 3 (median age, 10.5 months); 1 remains with an ostomy. Postoperative complications included enterocolitis (55%), anal stricture (25%), and perineal excoriation (20%). Mean follow-up were 17.5 years (+/-11.1 years). Eighty-nine percent were free of recurrent enterocolitis. Frequency of bowel movements is 1 to 5 per day in 82% of the patients, 18% have 6 or more bowel movements per day. Occasional soiling is noted in 40% (one third of those requiring nighttime diapers). Overall functional outcome was good in 83%. Those patients with the longest follow-up periods had the best stooling scores (P = .04).

CONCLUSIONS

Surgical treatment of TCH is associated with a number of complications including recurrent enterocolitis and anal strictures. Long-term outcome is quite favorable.

Rectal duplication as an unusual cause of chronic perianal fistula in an adult: report of a case

Duplication of the rectum is a rare embryologic event, but it should be considered as a possibility when perianal fistulas and abscesses remain resistant to conventional standard surgical treatment modalities over the long term. We report the case of a 57-year-old woman who underwent many operations over 30 years for persistent perianal fistulas. After radiological assay by computed tomography, fistulography, and barium enema studies, we performed surgery to remove a cystic mass in the retrorectal region, which was subsequently found to be a rectal duplication. The patient had an uneventful postoperative course and has been asymptomatic for 3 years.

Perianal and vulvar Crohn's disease presenting as suspected abuse

Misdiagnosis of sexual abuse may arise in cases of vulvar and/or perianal diseases such as lichen sclerosus et atrophicus, Behcet's syndrome, bullous diseases, contact dermatitis, or neoplastic lesions. We present the case of a 7-year-old girl who was referred by her general paediatrician to the local hospital for perianal fissures and swelling of the labia majora. A report to the judicial authorities was made, for suspected sexual abuse, and the patient was transferred to the department of paediatric surgery. Here, histopathologic examination of vulvar and rectal biopsies revealed multiple non-caseating and non-confluent epithelioid-gigantocellular granulomas, consistent with a diagnosis of Crohn's disease, with cutaneous involvement of the genitalia. In cases of suspected sexual abuse, examination of children should be performed by a specialist in legal medicine in collaboration with a gynaecologist or paediatric surgeon. If the patient is hospitalised and the question of protection does not arise, physicians should exclude dermatological diseases before reporting to the judicial authorities.

Gastro-intestinal and genito-urinary morbidity after 3D conformal radiotherapy of prostate cancer: observations of a randomized trial

BACKGROUND AND PURPOSE

The late morbidity of a randomized study was analyzed after a follow up of 2 years. The difference in intestinal morbidity was analyzed as a function of the treatment arm and dose volume parameters. The correlation with acute toxicity and (pre-existing) bowel complaints was investigated.

PATIENTS AND METHODS

266 T1-4N0M0 prostate cancer patients were randomized for conventional (open fields) and 3D conformal radiotherapy using beams eye view blocked fields with the same dose (66 Gy) and gross target volume-planning target volume margin (15 mm). Apart from the RTOG toxicity scoring system a patient self-assessment questionnaire was used to obtain detailed information on morbidity.

RESULTS

At 2 years there is only a trend for less rectal toxicity (grade >/=1) in favor of the conformal radiotherapy (grade 1, 47 versus 40% and grade 2, 10 versus 7% for conventional and conformal radiotherapy, respectively (P=0.1). A significant relation was found between late rectal toxicity (grade >/=1) and the volume of the anus and rectum exposed to >/=90% tumor dose (TD). A highly significant relationship is observed between acute rectum and anal toxicity and late rectal toxicity. The patient self-assessment questionnaire analysis revealed that patients are most bothered by compliance related symptoms like urgency, soiling and fecal loss. In a multivariate analysis, all other variables loose significance, when anal volume exposed to >/=90% TD and pre-treatment defaecation frequency are accounted for. Late anal toxicity is low and related only to acute anal toxicity. Late bladder toxicity is related solely to pre-treatment frequency and overall urological symptoms. The incidence of grade 2 toxicity increases with a factor 2.5-4 when (stool or urine) frequency is unfavorable at the start of treatment.

CONCLUSIONS

Conformal radiotherapy at the dose level of 66 Gy does not significantly decrease the incidence of rectal, anal and bladder toxicity compared to conventional radiotherapy. There is a significant relationship between acute and late toxicity and the anal volume exposed to 90% TD. Intestinal (and urological) symptoms at start have a major impact on late toxicity.

Dyschezia in dogs with discrete erosive anal disease and histological lesions suggestive of mucocutaneous lupus erythematosus

Eight dogs suffered chronic defecation problems characterised by severe dyschezia, manifested by signs of fear and vocalisation on defecation. One or more depigmented, discrete erosions, easily bleeding on palpation, were found in the perineal region. Histopathological changes included interface dermatitis, apoptotic keratinocytes, focal hydropic degeneration of basal epidermal cells, focal thickening of the basement membrane zone and dermal lichenoid infiltrations with mononuclear and plasma cells. A diagnosis of cutaneous or discoid lupus erythematosus was made on the basis of these clinical, physical and specific histopathological changes. The dogs were treated systemically with immunomodulating drugs and good results were obtained.

Long-term results of repeat anterior anal sphincter repair

PURPOSE

Anterior anal sphincter repair for obstetric trauma sometimes fails because of breakdown of the repair. The long-term results of repeating the overlapping repair are not known.

METHODS

Twenty-three patients with repeat obstetric-related anterior sphincter repair had previously been assessed at a median of 20 months follow-up, at which time 13 patients (65 percent) felt 50 percent or greater improvement compared with their preoperative symptoms. Patients were reassessed at a median of 5 years (range, 48-86 months) using a questionnaire, an incontinence score, and telephone interview to determine current bowel function, continence, and restriction in activities of daily life and overall satisfaction with the results of surgery.

RESULTS

Twenty-one of 23 patients (median age, 47 (range, 27-66) years) were contacted. One patient was lost to follow-up and one had died of an unrelated cause. Of 21 patients, one was fully continent and 12 more reported symptom improvement of 50 percent or more compared with preoperatively. Four were unchanged, and of the four whose symptoms had deteriorated, two had undergone further surgery for incontinence. Compared with the 20-month assessment, there was no significant change in continence scores (median, 12/20 (range, 1-20) vs. 7/20 (range, 2-19); 20 vs. 60 months), rating of improvement (median, 50 (range, 0-100) percent) at 20 and 60 months), or satisfaction (7/10 (range, 0-10) at 20 and 60 months).

CONCLUSIONS

Repeat anterior sphincter repair results in improved continence for the majority of patients, with no substantial change between the short-term and long-term follow-up.

[Proctalgia Fugax--what's new over the last 100 years?]

Proctalgia Fugax is a benign, self-limiting disease characterized by episodes of intense pain in the anorectal area occurring at infrequent intervals. It is common, but most suffers do not seek medical advice. Although its classical symptomatology was describe more than a century ago, the etiology is unclear. Theories regarding the etiology have centered on alteration in the internal anal sphincter function and morphology. For most patients after gathering a detailed history, reassurance and warm baths will suffice. In persistent cases therapies that induce internal anal sphincter relaxation are the main treatment modalities.

Advances in the treatment of Crohn's disease

The medical therapy of Crohn's disease has improved considerably in recent years. In large part, this is due to the introduction of new efficacious agents, both "biologics" and traditional small molecules. Further study of older drugs has also advanced our ability to devise the optimum approach to individual Crohn's disease patients by better clarifying the benefits, adverse effects, and means to optimize doses of established medications. In this review, we present an evidence-based approach to the medical management of active Crohn's disease, Crohn's disease in remission, and perianal Crohn's disease that emphasizes recent advances that have come from the results of randomized controlled clinical trials.

Review article: The medical treatment of Crohn's perianal fistulas

Perianal fistulas are a frequent manifestation of Crohn's disease. The correct application of the newer diagnostic and therapeutic agents for treating perianal Crohn's disease are beginning to be better defined. In general, a combined medical and surgical approach is preferred. The perianal disease process should first be fully delineated with endoscopy and either MRI or EUS before treatment is begun. Patients are then stratified into one of three groups: simple fistulas and no proctitis; simple fistulas and concomitant proctitis; and complex fistulas. Patients with simple fistulas and no proctitis can be treated medically with a combination of antibiotics and an immunosuppressive agent (azathioprine or mercaptopurine). Patients with simple fistulas and concomitant proctitis should have infliximab added to their treatment plan. Complex fistulas require surgical intervention first prior to medical treatment. A combination of antibiotics, immunosuppressive therapy and infliximab are then initiated to facilitate fistula healing.

The Association Between Late-Onset Fecal Incontinence and Obstetric Anal Sphincter Defects

HYPOTHESIS

Endoanal ultrasonographic results have demonstrated that clinically occult anal sphincter damage during vaginal delivery is common. This may or may not be associated with postpartum fecal incontinence (FI). Bayesian meta-analysis of the literature revealed that at least two thirds of obstetric sphincter disruptions are asymptomatic in the postpartum period. Women with postpartum asymptomatic sphincter damage may be at increased risk for FI with aging compared with those without sphincter injury.

DESIGN

Case series.

SETTING

Tertiary referral center.

PATIENTS

After excluding patients with other possible causes of FI, the histories of 124 consecutive women with late-onset FI after vaginal delivery were analyzed.

MAIN OUTCOME MEASURES

Endoanal ultrasonographic findings, pudendal nerve terminal motor latency assessment, and anal manometric results.

RESULTS

Eighty-eight women (71%) with a median of 3 vaginal deliveries had sphincter defects on endoanal ultrasonographic results. The mean incontinence score, squeeze and resting pressures, median age at last delivery, and median duration of FI were not significantly different between patients with and without sphincter defects. Pudendal neuropathy was more frequent in patients without sphincter defects (10 [30.3%], left side; 12 [36.4%], right side) than in patients with sphincter defects (12 [14.3%] and 16 [19.3%], respectively), with the difference nearly reaching statistical significance (P =.054 and P =.059, respectively). The median age at onset of FI in patients with a sphincter defect was 61.5 years vs 68.0 years in those without a sphincter defect, which was not statistically significant (P =.08).

CONCLUSION

Analysis of the current patient population revealed that 88 women (71%) with late-onset FI after vaginal delivery had an anatomical sphincter defect. Thus, FI related to anal sphincter defects is likely to occur even in an elderly population who had experienced vaginal deliveries earlier in life.

[The organisation and carrying-out of proctological examinations]

Coloproctology, a specialist field requiring specialist knowledge, experience and skill, is dealt with only marginally in current further education courses for doctors. A thorough anamnesis, and here a questionnaire is of great help in procuring rapid and complete information, and examination of the patient in the lithotomy position (being the most comfortable for the patient and the most practical for the doctor) ar vital. A thorough basic diagnosis, independent of the reported symptoms, is always required: 1. Abdominal examination. 2. Inspection and palpation of the anal region with and without abdominal muscular pressure. 3. Digital examination, including the prostate. 4. Rectosigmoidoscopy. 5. Proctoscopy, possibly with anal speculum examination. 6. Test for occult blood in the faeces. Depending on the anamnesis and findings, this basic diagnosis must be supplemented by further tests.

[Outpatient surgery in proctology]

Proctological surgery can be carried out increasingly on an outpatient basis and thus more cost-effectively. The reasons for this are, in addition to modern anaesthetic procedures, short operation times and low complication rates in numerous proctological operations. Fissurectomies, individual haemorrhoidectomies, operations on uncomplicated fistulae and benign anal tumours only rarely need to be carried out nowadays under inpatient conditions. The conditions for successful outpatient surgery are: appropriate diagnosis of the indication, selection of the patients with respect to their suitability for surgery and standardised follow-up care.

Anal function following third degree tears

OBJECTIVE

To assess the anal function of women who have suffered a third degree perineal tear during parturition.

PATIENTS

Fifty-three consecutive women who sustained a third degree tear, between January 1998 and March 2000, at the Princess Anne Maternity Unit, Royal Bolton Hospital were assessed.

METHODS

Women were assessed at 3 months post partum using the Cleveland Clinic Incontinence Score, digital assessment of anal sphincter and endo-anal ultrasound scan.

RESULTS

At 3 months post partum 75% of the participants had no symptoms of anal incontinence, 18% had mild symptoms and 7% had more severe symptoms. Anal endosonography demonstrated normal anal sphincters in 66% of participants, an abnormality in the external sphincter in 29% and a defect in both sphincters in 2%. There was poor correlation between symptoms and scan defects.

CONCLUSION

The incidence of anal incontinence following repair of a third degree tear was not high and it is unlikely that we are missing a hidden pool of symptomatic women. No major change in management policy is required. The routine assessment of anal function in women who had sustained a third degree tear was appreciated by the women and enabled us to identify the small portion of women with significant symptoms.

Can anal manometry predict anal incontinence after fistulectomy in males?

BACKGROUND

Disordered continence is frequently reported after operations for anal fistulae and pre-operative anorectal physiology may be carried out prior to surgery to improve functional outcome. Elderly patients and multiparous females are at higher risk for incontinence, whereas males under 60 have stronger sphincters. The aim of this study was to investigate the predictive role of anal manometry and the causes of postoperative soiling and its effect on the quality of life in males with intact sphincters undergoing excision of either trans or supra sphincteric fistulae.

METHODS

Thirty-eight patients (median age 47 years) were analysed retrospectively. None had previous anal surgery and all were fully continent. Five had Crohn's disease. Anal pressures and rectal sensation were evaluated prior to fistulectomy by means of anal manometry in all cases and after surgery in those who had postoperative incontinence. A cutting seton was used in 17 patients, a rectal advancement flap in 15 and a double rectal-cutaneous flap in six. None had a lay-open. The intersphincteric plane was explored and drained in all cases. A previously described incontinence grading and score was used to assess postoperative soiling. The median follow-up was 22 (range 5-89) months. The patients with postoperative anal incontinence were evaluated with the Gastrointestinal quality of Life Index Questionnaire (0:poor, 4:good) at a median follow-up of 49 months.

RESULTS

Twenty-nine (76%) patients were continent after surgery, whereas 9 (24%) complained of some degree of anal incontinence (minor in 4, severe in 1, the 1-6 incontinence score being 3.7 +/- 1.3 (mean +/- s.d.m.). Their Quality of life score was 3.8 +/- 0.5 (mean +/- sdm). None of them had Crohn's disease, five had frequent diarrhoea, four had a reintervention for either anal fissure or recurrent fistula (two), three had a postseton anal deformity. No difference was found between continent and incontinent patients as far as pre-operative anal pressures were concerned, but the maximum rectal volume threshold was significantly higher in incontinent patients, 165 +/- 67 vs. 123 +/- 49 ml of air (P = 0.04).

CONCLUSIONS

Sphincter division, diarrhoea and anal deformity may cause soiling after fistulectomy in males and it does not severely affect quality of life. Surgery rather than manometry may predict it and rectal sensation may play a role which needs further investigation.

[Case report: tenesmus in a cow with a liver abscess and nephritis]

A two-year-old Swiss Braunvieh cow was referred to our clinic because of tenesmus and weight loss. Clinical examination revealed a moderately abnormal general behaviour and condition, thin body condition and a rectal temperature of 40.1 degrees C. Tenesmus was evident, and rumen and intestinal motility were markedly reduced. All tests for a reticular foreign body were positive. On rectal examination, a round, smooth, firm, non-painful mass with a diameter of approximately 15 cm was palpated far cranially on the right side. Abnormal haematological and biochemical findings included marked anaemia, neutrophilic leucocytosis, markedly elevated concentration of fibrinogen and mildly elevated gamma-glutamyl-transferase activity. The clotting time of the glutaraldehyde test was one minute. Ultrasonographic examination revealed abscesses involving the liver and extending caudally into the right flank region. The liver parenchyma had diffuse changes. Because of a grave prognosis, the cow was euthanized. Postmortem findings substantiated ultrasonographic results; there were abscesses, caused by Fasciola hepatica infestation, originating in the liver and extending into the right flank. As well, there was severe, bilateral, multifocal, suppurative nephritis due to thromboembolism. Based on all the findings, a diagnosis of liver abscess caused by fascioliasis and bilateral suppurative nephritis was made.

[Surgical options in the treatment of perianal Crohn's disease]

INTRODUCTION

About 40% of patients with Crohns disease (CD) have a perianal involvement. Despite the recent introduction of anti-TNF antibody, this therapy has uncertain long-term results and surgery still remains a major treatment option.

AIMS & METHODS

This study relates our experience in surgical management of perianal CD without anti-TNF treatment. From July 92 to February 02, 37 patients with perianal Crohns disease were treated, 43 underwent local operations or faecal diversion for fistulas and/or abscesses. Patients not requiring surgery or in therapy with anti-TNF. were excluded from the study. We analysed the outcome of surgical treatment for perianal CD.

RESULTS

Male to female ratio was 1:0.6, median age was 36,9 years (range 17-62). Perianal disease included 32 fistulas (16 trans-sphincteric, 2 superficial, 2 ano-vaginal, 10 multiple and complex, 2 horseshoe) and 7 abscesses (5 perianal, 2 ischio-rectal). Local surgery included 1 abscess drainage, 5 abscess drainage and fistula incision with seton insertion, 2 fistulotomy, 9 partial fistulectomy and seton insertion. At surgery, 40% of patients were ongoing a medical treatment with 5-ASA and/or antibiotics, 40% with steroids and/or immunosoppressors, 15% only with 5-ASA and 5% no ongoing treatment. The horseshoe fistulas were managed with a fistulotomy and seton insertion. One patient with ano-vaginal fistula required proctectomy and the other one total proctocolectomy. Patients treated by diverting colonostomy (3) had fistula recurrence after its closure in 100%. 20% of patients required total proctocolectomy and ileostomy for extensive intestinal disease. Of the 27 patients undergoing seton insertion or fistulotomy none had faecal incontinence due to the operation and 38% had a 1 year recurrence.

CONCLUSIONS

Perianal CD is a heterogeneous entity, therefore its management is still controversial. Moreover, a high percentage of patients (18% in our series) requires a major surgery due to the extension and seriousness of rectal involvement. In our survey only 12 patients (39%), with trans-sphincteric fistula, could have been theoretically treated with anti-TNF. We wonder if the cost-and-benefit of this medical treatment justifies its application on patients that could undergo a surgical treatment with good long-term results.