Local excision and mucosal advancement for anorectal ulceration in patients infected with human immunodeficiency virus

Current concepts in anal fissures

INTRODUCTION

Anal fissure is a common and distressing problem the true incidence of which is probably higher than recorded. There is a progressive understanding of the etiopathogenesis of this entity and the changing trend in its management approach. This is a systematic review of available published literature looking at current management options in anal fissures.

METHODS

A MEDLINE-based search of the relevant literature from 1970 to 2004 was performed on the current concepts in etiopathogenesis and management of anal fissure.

RESULTS

The current opinion is a drift toward conservative measures as the first- and second-line approaches rather than surgery for treatment of anal fissure. Simple and readily available measures with less complication, good patient compliance, and satisfaction requiring no hospitalization should first be considered.

CONCLUSIONS

Most anal fissures heal with medical therapy, but their limitations include side effects, poor compliance, and recurrence of the fissure. A cautious surgical approach is required to treat those who do not respond to medical therapy.

The management of persistent and recurrent chronic anal fissures

There are numerous definitive reviews concerning aetiology and management of acute and chronic anal fissures. The problem of persistence and recurrence after surgical and nonsurgical therapy has not been specifically addressed and there is little evidence-based guidance for the management of this difficult group of patients. A review of the literature with particular reference to persistence and recurrence of chronic anal fissures is presented and an algorithm of management incorporating evidence-based data is suggested.

Fissurectomy with posterior midline sphincterotomy and anoplasty (FPSA) in the management of chronic anal fissures

Although lateral internal sphincterotomy is widely accepted as the treatment of choice for anal fissures, we report our experience of successfully treating 195 consecutive patients with posterior chronic anal fissures by performing fissurectomy with midline sphincterotomy and anoplasty (FPSA). The surgical technique is described and its indications and results are briefly discussed.

Anorectal surgery in patients infected with human immunodeficiency virus: factors associated with delayed wound healing

OBJECTIVE

A review of all anorectal operations in patients infected with human immunodeficiency virus (HIV) was performed to assess the incidence, variety, and clinical course of anorectal disease in these patients and to identify factors influencing wound healing.

SUMMARY BACKGROUND DATA

Anorectal disease is the most common indication for surgical intervention in patients infected with HIV. The cause and management of HIV-related anorectal conditions, which differ significantly from non-HIV-related diseases, are not clear. There also is considerable variation in the reported results of surgical procedures, including wound healing. St. Vincent's Hospital, Sydney, is situated in an area with the highest concentration of individuals infected with HIV in Australia.

METHODS

The medical records of all identified patients infected with HIV who had an anorectal operation at St. Vincent's General Hospital between January 1, 1988, and January 31, 1995, were reviewed retrospectively. Logistic regression, Mann-Whitney U test, and Fisher's exact tests were used for analysis.

RESULTS

One thousand five hundred two patients with acquired immune deficiency syndrome (AIDS), equivalent to 26.8% of all known patients with AIDS in Australia at this time, were admitted to this hospital during the 7-year period. One hundred one patients infected with HIV underwent 161 anorectal operations. All patients were male homosexuals (98 patients, 97%) or bisexuals (3 patients, 3%), with intravenous drug use an additional risk factor in 5 patients (5%). Thirty-seven percent of patients had more than one operation. Seventy-two percent of patients were Centers for Disease Control (CDC) group 4 (AIDS) at operation, 27% were group 2, 1% was group 3, and none were group 1. Accurate information about wound healing was available for 74% of first operations, and univariate and multivariate logistic analyses of these showed that when the CD4+ T-lymphocyte count was <50 cells/ microL, healing was significantly retarded (p = 0.016). The Centers for Disease Control group, patient age, and serum albumin were not significant predictors of wound healing. The interval between HIV diagnosis and operation was not associated with impaired wound healing, but recognition of AIDS more than 1 year before operation was associated with significantly better wound healing compared with those in whom AIDS developed within the year before operation (p = 0.025). In the patients for whom accurate wound healing information was available, only 40% had healed their wounds by 3 months after operation. Wound healing was worst for patients with chronic fissures, only 16% of whom had healed their wounds at 3 months. The wound healing rate was worse for repeat operations than for first operations. Ten percent of patients had anorectal malignancies, none of which were diagnosed clinically before or during operation.

CONCLUSIONS

Wound healing is a significant problem after anorectal operations in patients infected with HIV, especially when the CD4 count is <50/microL. Although there seems to be little or no benefit from more invasive operations in some cases, thorough examination with adequate biopsies is required in all cases. The best management of anorectal disease in patients infected with HIV still is unclear.

Complicated anorectal sepsis

These complex anorectal conditions are difficult to diagnose because clinical features overlap. In general, an aggressive approach is reserved for hidradenitis suppurativa and necrotizing infections. Patients with Crohn's disease, hematologic disorders, or AIDS are often treated more conservatively, but the correct timing and degree of aggressiveness of surgical intervention may considerably improve the overall outcome. The increasing incidence of AIDS and the frequency with which infected patients present to surgical clinics make it imperative that all surgeons have a working knowledge of the conditions associated with this syndrome. Expertise is required not only to diagnose and treat these conditions but also to protect oneself and others from being inadvertently infected with the HIV. A high index of suspicion and constant vigilance permit the successful resolution of many of these challenging problems.

Severe complications of perianal sepsis in patients with human immunodeficiency virus

Fifty human immunodeficiency virus (HIV)-infected patients with perianal sepsis were studied. Seven (14 per cent) had serious septic complications, four patients with severe necrotizing gangrene, and three with abscesses in the mediastinum, liver and brain respectively. CD4+ lymphocyte counts were significantly lower in patients with severe septic complications as compared with those with uncomplicated perianal sepsis (P < 0.05). In patients with HIV presenting with rare (metastatic) abscesses, perianal sepsis must always be kept in mind as a possible focus. Although HIV-infected patients have a limited life expectancy perianal fistulas and abscesses should be aggressively treated, because of the high risk of severe complications.