The management of anorectal disease in HIV-positive patients

Persistent Ulceration of the Anal Margin in Homosexuals with Hiv Infection

A study of the outcome of surgical treatment of ulceration of the anal margin occurring in male homosexuals with HIV infection was undertaken. Ten patients with acquired immunodeficiency syndrome and three patients with symptomatic HIV infection were referred to the Department of Surgery with painful anal ulceration which had not responded to medical treatment. The medical treatments given prior to surgical referral included high dose oral acyclovir, intravenous foscarnet and broad spectrum antibiotics. Excision biopsy was performed in 12 patients and in 11 cases was followed by healing of the ulcers within 10 weeks. One patient died 2 weeks postoperatively from Pneumocystis carinii pneumonia without healing. The response to excision biopsy was unexpected but suggests that surgical excision may be beneficial for lesions which have failed to respond to aggressive medical treatment.

Treatment of grade 3 anal intraepithelial neoplasia by complete anal mucosal excision without fecal diversion: report of a case

PURPOSE

The aim of this study was to remove completely the risk of malignant transformation without permanent or temporary fecal diversion in a patient with extensive anal intraepithelial neoplasia.

METHODS

All anal canal mucosa and the lowest 1.5 cm of rectal mucosa were excised and the adjacent rectal mucosa and submucosa advanced to the anal verge skin.

RESULTS

The patient achieved normal continence within a month after the operation. Multiple anal canal biopsies at 12 months after the operation revealed normal rectal mucosa.

CONCLUSIONS

Total anal mucosal excision offers a relatively simple means of removing the malignant risk of anal intraepithelial neoplasia without fecal diversion in selected patients.

Current therapy for recurrent and extensive anal warts

PURPOSE

This study was undertaken to review the literature regarding the current therapy for recurrent and extensive anal warts.

METHODS

The available treatments for condyloma acuminatum are reviewed with particular regard to their efficacy for recurrent or extensive anal lesions. Topical agents, surgical methods, and the use of interferon are discussed. Treatment of anal warts in the immunocompromised patient is also addressed.

CONCLUSIONS

Although small lesions may be responsive to repeated applications of topical agents, more extensive lesions require surgical or combination treatment. Intralesional interferon may be a useful adjunct to surgical methods to decrease recurrence.

Surgery for anal lesions in HIV-infected patients

Anorectal manifestations are commonplace in patients with HIV infection. However, standardized or rational treatment of these conditions has not been proposed and many patients are denied adequate treatment based on fear of complications. This review looks critically at the available literature to draw conclusions about treatment, results and complications of surgery for anorectal problems in these patients.

Sexually transmitted diseases and anal manifestations of AIDS

During the past 20 years, there has been an increased use of the anorectum for erotic pleasure. Consequently, this has led to an overwhelming rise in sexually transmitted diseases (STDs) of the anus and rectum. It is important that surgeons involved with the care of colon and rectal disorders be familiar with each of these diseases. The recent AIDS epidemic has been a challenge to the medical community. Equally as challenging is the management of common anorectal disorders in the AIDS patient. AIDS not only influences the manner in which STDs present but is associated with its own spectrum of anorectal disorders. Discussion and management of STDs and anorectal disorders of AIDS patients are presented.

Common complications of wound healing. Prevention and management

The culmination of any operation is a healed wound. Failure of a wound to heal increases time spent in the hospital and the expense, and may start a cascade of progressive complications. Thus, it is important to optimize as many factors as possible before operation and to have the knowledge and resources to deal with wound problems should they occur. This approach involves understanding basic wound healing with its multiple factors, including nutrition, and knowing how to deal with potential adverse factors in wound healing, such as chemotherapy, corticosteroids, and radiation.

Sexually transmitted diseases of the colon, rectum, and anus. The challenge of the nineties

During the past two decades, an explosive growth in both the prevalence and types of sexually transmitted diseases has occurred. Up to 55 percent of homosexual men with anorectal complaints have gonorrhea; 80 percent of the patients with syphilis are homosexuals. Chlamydia is found in 15 percent of asymptomatic homosexual men, and up to one third of homosexuals have active anorectal herpes simplex virus. In addition, a host of parasites, bacterial, viral, and protozoan are all rampant in the homosexual population. Furthermore, the global epidemic of AIDS has produced a plethora of colorectal manifestations. Acute cytomegalovirus ileocolitis is the most common indication for emergency abdominal surgery in the homosexual AIDS population. Along with cryptosporidia and isospora, the patient may present to the colorectal surgeon with bloody diarrhea and weight loss before the diagnosis of human immunodeficiency virus (HIV) disease. Other patients may present with colorectal Kaposi's sarcoma or anorectal lymphoma, and consequently will be found to have seropositivity for HIV. However, in addition to these protean manifestations, one third of patients with AIDS consult the colorectal surgeon with either condylomata acuminata, anorectal sepsis, or proctitis before the diagnosis of HIV disease. Although aggressive anorectal surgery is associated with reasonable surgical results in some asymptomatic HIV positive patients, the same procedures in AIDS (symptomatic HIV positive) patients will often be met with disastrous results. It is incumbent upon the surgeon, therefore, to recognize the manifestations of HIV disease and diagnose these conditions accordingly.