Frequency and Risk Factors of Severe Postoperative Bleeding After Proctological Surgery: A Retrospective Case-Control Study

Purpose

The aim of this study was to assess frequency and risk factors of severe bleeding after proctological surgery requiring hemostatic surgery observed after publication of the French guidelines for anticoagulant and platelet-inhibitor treatment.

Methods

All patients who underwent proctological surgery between January 2012 and March 2017 in a referral center were included. Delay, severity of bleeding, and need for blood transfusion were recorded. Patients with severe postoperative bleeding were matched to controls at a 2:1 ratio adjusted on the operator, and the type of surgery.

Results

Among the 8,890 operated patients, 65 (0.7%) needed a postoperative hemostatic procedure in an operating room. The risk of a hemostatic surgery was significantly increased after hemorrhoidal surgery compared with other procedures (1.9% vs. 0.5%, P<10-4) and was most frequent after Milligan-Morgan hemorrhoidectomy (2.5%). Mean bleeding time was 6.2 days and no bleeding occurred after day 15. Blood transfusion rate was 0.1%. Treatment with anticoagulants and platelet inhibitors were managed according to recommendations and did not increase the severity of bleeding. The risk of severe bleeding was significantly lower in active smokers vs. non-smokers in univariate (16.9% vs. 36.2%, P=0.007) and multivariate (odds ratio, 0.31; 95% confidence interval, 0.14-0.65) analysis whereas sex, age, and body mass were not significantly associated with bleeding.

Conclusion

Severe postoperative bleeding occurs in 0.7% of patients, but varies with type of procedure and is not affected by anticoagulant or antiplatelet treatment. These treatments given in accordance with the new guidelines do not increase the severity of postoperative bleeding.

Endorectal Advancement Flap With Muscular Plication in Anovaginal and Anterior Perineal Fistulas

Purpose

Endorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas.

Methods

This retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms.

Results

Thirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%).

Conclusion

This study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.

Increased Long-term Risk of Anal Fistula After Proctologic Surgery: A Case-Control Study

PURPOSE

Anal fistula is a common condition in proctology, usually requiring surgical treatment. Few risk factors have been clearly identified based on solid evidence. Our research objective was to determine whether history of anal surgery was a risk factor for subsequent anal fistula.

METHODS

We conducted a case-control study from January 1, 2012 through December 31, 2013 in our tertiary center, comprising 280 cases that underwent surgery for anal fistula and 123 control patients seeking a consultation for upper gastrointestinal symptoms. Patients with inflammatory bowel disease were excluded. For both cases and controls, the following variables were recorded: sex, any prior anal surgery, diabetes mellitus, infection with human immunodeficiency virus, and smoking status. For each variable, confidence interval and odds ratio (OR) were calculated.

RESULTS

In univariate analysis, male sex (73.2% vs. 31.7%, P < 0.0001), active smoking (38.1% vs. 22%, P = 0.0015), and prior anal surgery (16.0% vs. 4.1%, P = 0.0008) were associated with higher risk of anal fistula. In multivariate analysis, only male sex (OR, 5.5; 95% confidence interval [CI], 5.42 to 9.10; P < 0.0001) and previous anal surgery (OR, 4.48; 95% CI, 1.79 to 13.7; P = 0.0008) remained independently associated with anal fistula occurrence.

CONCLUSION

The epidemiology of anal fistula is poorly assessed despite the high frequency at which it is diagnosed. Our findings suggest that history of any kind of anal surgery is a risk factor for further onset of anal fistula. Surgeons and patients must be informed of this issue.

[Anorectal manifestations in systemic diseases]

Numerous systemic diseases (vasculitis, connective tissue disease or sarcoidosis) can display an involvement of the perianal skin, the rectum and/or the anus. Such knowledge is important in order to treat these complications specifically when possible. Lesions of the anorectum arising from systemic diseases can sometimes cause perforations in the peritoneal cavity (if concerning the higher portion of the rectum) and/or fistulization to the anal margin. Differential diagnosis, mostly infectious or inflammatory (Crohn's disease) must be ruled out in every case. Other systemic diseases can display specific manifestations as this is the case in scleroderma which can lead to anal incontinence. Despite the relative rarity of these manifestations, their ignorance would forbid global management of these complex diseases. It should thus be detected in each consultation and a regular follow-up must be provided with a proctologist and/or a gastroenterologist when needed.

Diagnosis and Management of a Cryptoglandular Actinomycotic Fistula-in-Ano: An Update on 7 New Cases and a Review of the Literature

Purpose

Primary anal actinomycosis of cryptoglandular origin, a rare cause of anal suppurative disease, requires specific management to be cured. The aims of this retrospective study were to describe clinical, morphological, and microbiological features of this entity and to evaluate management practices for new cases observed since 2001.

Methods

This was a retrospective case series conducted at the Diaconesses-Croix Saint-Simon Hospital in Paris.

Results

From January 2001 to July 2016, 7 patients, 6 males and 1 female (median, 49 years), presenting with an actinomycotic abscess with a cryptoglandular anal fistula were included for study. The main symptom was an acute painful ischioanal abscess. One patient exhibited macroscopic small yellow granules (“sulfur granules”), another “watery pus” and a third subcutaneous gluteal septic metastasis. All patients were overweight (body mass index ≥ 25 kg/m²). Histological study of surgically excised tissue established the diagnosis. All the patients were managed with a combination of classical surgical treatment and prolonged antibiotic therapy. No recurrence was observed during follow-up, the median follow-up being 3 years.

Conclusion

Actinomycosis should be suspected particularly when sulfur granules are present in the pus, patients have undergone multiple surgeries or suppuration has an unusual aspect. Careful histological examination and appropriate cultures of pus are needed to achieve complete eradication of this rare, but easily curable, disease.

Particular aspects of proctology for anoperineal lesions in Crohn's disease

All practitioners caring for patients with Crohn's disease (CD) must know all the various aspects of anoperineal lesions in this singular entity. Suppuration in CD does not follow the classic routes and spaces of diffusion and is often associated with endolumenal lesions that can evolve on their own. Abscesses and fistulas require specific medico-surgical management where seton drainage, staged operative and sphincter-sparing procedures have a dominant place. The variability of associated lesions and the particularly individualized efficacy of drugs call for case-by-case management, thus, making standardization and comparisons difficult. Recent therapeutic progress has led to modifications of the minimally invasive management policies practiced in the last decades.

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases

AIM

The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula.

METHOD

We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum.

RESULTS

During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17-84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn's disease (20). Of the 62 non-Crohn's patients previous treatment was common and included surgery (42), antibiotics alone (41) and non-steroidal anti-inflammatory drugs (21).

CONCLUSION

Horseshoe extension in anal fistula is uncommon. With Crohn's disease excepted, the majority had had previous treatment.

Value of cytologic Papanicolaou smears and polymerase chain reaction screening for human papillomavirus DNA in detecting anal intraepithelial neoplasia: comparison with histology of a surgical sample

BACKGROUND

The performance of cytologic screening and its correlation with histology and polymerase chain reaction (PCR) detection of human papillomavirus (HPV) DNA have not been evaluated in populations with a low prevalence of anal intraepithelial neoplasia (AIN). The objective of the current study was to analyze the significance of abnormal smears relative to the histology and PCR detection of HPV DNA.

METHODS

A cytologic smear and a viral sample were taken in 300 consecutive patients undergoing surgery (Milligan-Morgan hemorrhoidectomy and/or fissurectomy) who gave their informed consent.

RESULTS

The cytologic smear was normal in 216 of 290 patients (74.5%). Four high-grade and 19 low-grade intraepithelial neoplastic lesions were identified. In 5 patients, high-grade lesions could not be excluded, 30 lesions were of undetermined significance, and there were 16 cellular modifications with a non-neoplastic appearance. The PCR test for HPV was positive in 18.7% of patients, and a high-risk genotype was identified in 63.6% of positive samples. Histologic examination of the surgical samples was normal in 92.3% of patients. The 23 AIN samples were distributed as follows: 13 grade 1 AIN (AIN1), 6 AIN2, and 4 AIN3. The sensitivity of cytologic smears and PCR for detecting AIN was 56% and 60.8%, respectively, and specificity was 77% and 84.5%, respectively. Combining the 2 tests increased sensitivity to 78% but decreased specificity to 68%.

CONCLUSIONS

Compared with a large surgical sample, anal cytologic Papanicolaou smears and HPV PCR exhibited sensitivity and specificity that varied, depending on the risk of HPV infection and AIN. Positive HPV DNA screening increased with AIN grade, and high-risk HPV testing was particularly helpful.

Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair

AIM

Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique.

METHOD

Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn's disease with proctitis, malignant or radiation-related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure-of-eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days.

RESULTS

Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28-78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn's disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow-up of 14 (2-67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre- and postoperatively were 1.3 (0-15) and 0.6 (0-6), respectively.

CONCLUSION

The success rate was promising with no deterioration of anal continence.

Stapled haemorrhoidopexy: 6 years' experience of a referral centre

AIM

To prospectively evaluate the long-term results and assess patient satisfaction after stapled haemorrhoidopexy (HS).

METHOD

A total of 150 patients (121 male patients) with symptomatic grade II (n = 50) or III (n = 100) haemorrhoids underwent stapled HS. Patients were followed up during consultations at regular intervals, allowing prospective data collection. A final telephone follow up was also undertaken.

RESULTS

Follow up data were obtained for 130 of 150 patients (86.6%). After a median follow up of 39 months (range, 12-72), 90% of the patients were fully satisfied and 92% were free of haemorrhoidal symptoms. There were no intraoperative complications. Postoperative bleeding that required operation was observed in five patients (3.3%). Most late postoperative complications were benign and easily resolved: unexplained pain for over a month (n = 1), external haemorrhoidal thrombosis (n = 2), anal fissure (n = 6) one with hypertrophic papilla, anal fistula (n = 1), rectal stenosis (n = 1), anal incontinence for (n = 1). Eight patients needed rubber band ligation to treat persistent or recurrent symptomatic prolapse. Four patients (2.6%) were reoperated on during the follow up period but none for haemorrhoidal pathology.

CONCLUSION

Stapled HS procedure is effective and has low morbidity, high patient satisfaction and provided good long-term control of haemorrhoidal symptoms in the treatment of second and third-degree haemorrhoids.

Seton drainage and fibrin glue injection for complex anal fistulas

OBJECTIVE

The study aimed to evaluate the efficacy of fibrin glue in the treatment of complex anal fistula.

METHOD

Thirty consecutive patients with a complex anal fistula underwent glue instillation after an 8 week period of seton drainage. Cure was defined as complete closure of any secondary opening, absence of fistula seepage, and no abscess formation.

RESULTS

The mean age of the patients (15 males) was 40.5 (range, 22.8-69.1) years. The mean duration of follow-up was 11.7 (range, 0.2-33.5) months. Complete closure of the fistula was achieved in 17 patients at 1 month but in two patients a delayed abscess occurred. At the end of follow-up, 15 (50%) patients were considered to have been cured. The success rate was no different in cases of Crohn's disease or when postoperative antibiotic therapy was given. There was, however, a significant difference in success following regional vs general anaesthesia (68.4 vs 18.2% success, P = 0.02).

CONCLUSION

Fibrin glue cured 50% of our first 30 patients, and regional anaesthesia was predictive of success.

[Cryptoglandular anal fistulas]

Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis. Characteristically they have an endoanal primary opening, a fistula track and an abscess and/or an external purulent opening. Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia. Treating the fistula track occurs afterwards and aims to dry up the purulent discharge and avoid recurrence of the abscess by means of surgical fistulotomy. These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence. This explains the increasing interest in sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue.

Prevalence of anal cytologic abnormalities in a French referral population: a prospective study with special emphasis on HIV, HPV, and smoking

PURPOSE

Studying anal cytology to detect intraepithelial neoplasia has been demonstrated to be useful in highly selected populations. This study was designed to determine the frequency of abnormal smears in a wide sample of patients consulting for anorectal symptoms.

METHODS

An anal smear was proposed during each consultation during a three-month period.

RESULTS

A total of 205 patients (112 females) were included. After the consultation, visible condylomas were detected in 12 (6 percent) of the cases. Two hundred three (99 percent) smears were able to be analyzed. No case of high-grade squamous intraepithelial lesion was found. Four cases of low-grade squamous intraepithelial lesion were found, all in HIV patients with a history of condylomatous lesions. Forty smears were interpreted as atypical squamous cells of undetermined significance and 159 were normal. The prevalence in this population of low-grade squamous intraepithelial lesion was 19 percent (4/21) in HIV seropositive males, and 15 percent (4/26) in the case of a past history of condyloma. The factors associated with an abnormal smear (low-grade squamous intraepithelial lesion or atypical squamous cells of undetermined significance) were a history of anal condylomatous lesions (odd ratio, 4.9; range, 2.1-11.5), HIV seropositivity (odd ratio, 4; range, 1.6-9.9), and smoking (odd ratio, 2.1; range, 1.1-11.5).

CONCLUSIONS

This work confirms that the frequency of low-grade squamous intraepithelial lesion is raised in HIV-seropositive males and also where there is a history of condyloma, which corroborates the necessity for regular monitoring and screening of these patients at risk. This study also suggests that the use of tobacco is associated with anal cytologic abnormalities.

Proctalgia fugax: demographic and clinical characteristics. What every doctor should know from a prospective study of 54 patients

PURPOSE

This prospective study was designed to describe a typical attack of proctalgia fugax.

METHODS

Patients were recruited from May 2003 to June 2004. Whatever the reason for consultation, they were systematically asked: "Do you ever suffer intermittent and recurring anorectal pain lasting for at least three seconds?" If the answer was yes, they were interviewed with a questionnaire and had a proctologic examination. The criterion for proctalgia fugax was a positive answer with a negative examination.

RESULTS

The study included 1,809 patients. Fifty-four of these patients (3 percent) had proctalgia fugax and 83 percent of them had never sought medical advice for this problem. The mean age was 51 (range, 18-87) years. Thirty-seven patients were females (69 percent). The onset of pain was sudden and without a trigger factor in 85 percent of cases. Attacks occurred in the daytime (33 percent) as well as at night (35 percent). The pain was described as cramping, spasm-like, or stabbing in 76 percent of cases. It did not radiate in 93 percent of cases. There were no concomitant symptoms in 81 percent of cases. Attacks stopped spontaneously in 67 percent of cases. The average duration was 15 minutes (range, 5 seconds to 90 minutes). The average annual number of attacks was 13 (range, 1-180).

CONCLUSIONS

Proctalgia fugax affects twice as many females as males at approximately aged 50 years. Commonly the roughly once-monthly attack occurs as a sudden pain with no trigger factor, diurnally as often as nocturnally. The nonradiating cramp, spasm, or stabbing pain, without concomitant symptoms, is most severe on average after 15 minutes and declines spontaneously.

Bilan préthérapeutique initial du carcinome épidermoïde invasif de l’anus

Anal epidermoid carcinoma is a rare malignant tumor, comprising less than 5% of all carcinomas of the colon, rectum, and anus. The primary therapy now includes radiotherapy, often in combination with chemotherapy. Radical surgery is now rarely indicated. Therapeutic indications are based on locoregional staging, the presence of visceral metastases and an evaluation of the medical history. Anorectal endosonography is helpful in evaluating locoregional extension. In addition, magnetic resonance imaging, positron emission tomography scanning and inguinal sentinel lymph node procedure should play a role in a more selective approach in patients with anal carcinoma.

An uncommon perianal nodule: Hidradenoma papilliferum

Hidradenoma papilliferum is a rare, benign, cystic, papillary apocrine gland tumor that occurs almost exclusively in women in the skin of the anogenital region. We present the case of a 66 year old woman who presented with a progressively enlarging perianal nodule. We provide a review of the literature emphasizing the clinico-pathological characteristics and differential diagnosis. Local excision is necessary for identification and cure. No recurrence was observed after one year follow-up.

Fistula in ano surgery has no impact on pudendal nerve terminal motor latency

BACKGROUND

Anal fistula surgery is recognized as a major risk factor for anal incontinence. This incontinence is mainly due to surgical sphincter lesions, although a neurogenic mechanism through damage to the pudendal nerve is not excluded. The objective of our study was to evaluate the influence of anal surgery on the anal terminal motor latency of the pudendal nerve (PNTML).

MATERIALS AND METHODS

The PNTML values were measured pre- and postoperatively, respectively, in 33 patients (28 men, 5 women) treated for anal suppuration and 34 patients (21 men, 13 women) undergoing pedicular hemorrhoidectomy using the Milligan and Morgan technique.

RESULTS

The average age was 49.6 years in the hemorrhoid group and 45 years in the fistula group (p=0.19). There was no difference in the sex ratio between the two groups (p=0.06). In the anal fistula group, the preoperative mean PNTML was 2.42 (+/-0.46) ms on the infected side and 2.40 (+/-0.42) ms on the healthy side, with a significant difference from the control group's preoperative ipsilateral latencies: 2.73 (+/-0.60) ms (p=0.02, p=0.01). The variations in the postoperative PNTML of the fistula group, both on the healthy side (DeltaPNTML=0.06+/-0.42 ms) and on the diseased side (DeltaPNTML=0.03+/-0.40 ms), are comparable with those of the hemorrhoid group (DeltaPNTML=0.01+/-0.48 ms; p=0.63, p=0.84).

CONCLUSION

The nervous conduction of the pudendal nerves does not seem to be altered by the presence of an infectious process in the ischiorectal fossa nor by the surgical procedure. However, a more refined electrophysiological study would seem to be necessary to assess the repercussions on the perineal innervation.

Endorectal ultrasonography in predicting rectal wall infiltration in patients with deep pelvic endometriosis: a modern tool for an ancient disease

PURPOSE

This study evaluated the validity of endorectal ultrasonography in predicting rectal infiltration in patients with deep pelvic endometriosis.

METHODS

Patients were recruited consecutively in the Department of Surgical Gynecology of Diaconesses Hospital from April 1996 to July 2003. Inclusion criteria were the suspicion of deep pelvic endometriosis on the basis of outpatient history and/or clinical symptoms with a mass palpable on bimanual examination that might infiltrate the rectal wall. There were no exclusion criteria. Endorectal ultrasonography was performed by the same investigator with a 7.5-MHz to 10-MHz rigid probe, producing a 360 degrees view of the rectal wall and adjacent areas. We used surgical and histopathologic findings as the "gold standard" to evaluate the validity of endorectal ultrasonography.

RESULTS

This study was based on 37 patients (mean age, 35.8 (range, 26-46) years) who underwent surgery. The time between endorectal ultrasonography and surgery ranged from 4 to 529 (mean, 88.7) days. Eight patients had endometriosis nodules penetrating the rectal wall. Endorectal ultrasonography showed sensitivity, specificity, a positive predictive value, and a negative predictive value of 87.5, 97, 87.5, and 97 percent, respectively, in the diagnosis of infiltration of the rectal wall by endometriosis.

CONCLUSIONS

Endorectal ultrasonography is a reliable technique for visualizing rectal infiltration in patients with deep pelvic endometriosis. It should be more widely used by gynecologists because knowing about rectal infiltration before surgery is fundamental to defining the best possible surgical approach.

Toxine botulique et fissure anale chronique

Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

Perianal actinomycosis: diagnostic and management considerations

INTRODUCTION

Primary anal actinomycosis of cryptoglandular origin, mainly due to Actinomyces israelii, a specific and rare cause of anal suppurative disease, needs to be recognized because it can be cured using specific treatments.

METHOD

Data were reviewed from 6 patients with actinomycotic anal abscesses of obvious cryptoglandular origin observed in a single proctology unit between 1983 and 2000. Therapeutic management included conventional surgical treatment of anal sepsis followed by a specific oral antibiotic therapy maintained until the surgical wound had completely healed.

RESULTS

All but one of the patients were men (median age, 53 years). All abscesses, except one, were indolent. No patient presented macroscopic "sulphur granules" in the pus, but one presented "watery pus". The diagnosis was established by histological study of the surgically excised tissue or by anaerobic culture of the pus. In the one HIV-positive patient, an uncommon organism was isolated: Actinomyces meyeri. Two cases of recurrence were observed without evidence of Actinomyces infection.

CONCLUSION

Actinomycosis should be suspected particularly in indolent anal suppuration. The absence of macroscopic "sulphur granules" does not mean this diagnosis can be ruled out. Careful histological examination of the excised tissue and appropriate anaerobic cultures of pus should be carried out to achieve complete eradication of this rare, but easily curable disease.

Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis--an effective but not risk-free procedure: a prospective study of 33 patients

PURPOSE

This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis.

METHODS

All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas.

RESULTS

The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5-15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent).

CONCLUSION

Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.

Anal sphincter injury after forceps delivery: myth or reality? A prospective ultrasound study of 93 females

PURPOSE

This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury.

METHODS

We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery.

RESULTS

Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P=0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2-16.7)).

CONCLUSIONS

Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.

Anoperineal tuberculosis: diagnostic and management considerations in seven cases

PURPOSE

Anoperineal tuberculosis is a rare extrapulmonary form of the disease that we must learn to recognize because it requires specific treatment.

METHODS

Data from seven patients with anoperineal tuberculosis observed in a Parisian proctology unit between 1982 and 1999 were reviewed.

RESULTS

All the patients were male (median age, 55 years); five were born in underdeveloped countries, and two were still living there. The average length of time between first manifestation of the disease and diagnosis was three years (range, 3 months to 9 years); all patients had undergone surgery previously. There were six recurring anal fistulas (complex in 5 cases) and one recurring abscess. In every case, the diagnosis had been suspected or confirmed by systematic histologic study of the surgically excised tissue. An association with pulmonary tuberculosis was found in each case. Treatment included two parts: conventional surgical treatment of anal sepsis and specific medical antituberculosis treatment. Evolution was favorable in all cases, with no recurrence of disease. Human immunodeficiency virus infection did not increase the incidence of anoperineal tuberculosis.

CONCLUSION

Tuberculosis should be suspected in all recurrent fistulas. Histologic examination of the excised tissue and a lung x-ray should be performed to avoid delay in diagnosing an easily curable disease.

Respective value of pudendal nerve terminal motor latency and anal sphincter electromyography in neurogenic fecal incontinence

Fecal incontinence may be related to a neurogenic injury. Electrodiagnostic tests including pudendal nerve terminal motor latency (PNTML) and external anal sphincter electromyography (AEMG) have been proposed to reveal anal nerve damage. The aim of this study was to assess the respective value of PNTML and AEMG in the diagnosis of fecal incontinence. This study included 80 women (range 23-85 years) with fecal incontinence secondary to obstetrical and/or surgical trauma. They were evaluated by performing PNTML and AEMG. The electrophysiological results were compared and interpreted in the light of anorectal manometry (ARM) results. Electrodiagnostic test abnormalities were found in 64 of 80 patients (80%), including 28 patients with abnormal results for both tests and 36 patients with only one abnormal test. Overall, a neurogenic AEMG pattern was found in 64% of patients and a prolonged PNTML in 51%. No correlation was found between PNTML value and either AEMG grade or ARM parameters, while AEMG grade strongly correlated with squeeze pressure measured by ARM. This study showed that AEMG and PNTML did not give redundant information and allowed to explicit the mechanisms of neurogenic fecal incontinence. We found that AEMG was more sensitive and more closely related to the anal functional status (ARM parameters) than PNTML. These electrodiagnostic tests, particularly AEMG as performed in everyday practice, are useful in the assessment of neurogenic fecal incontinence.

Prosthetic rectopexy to the pelvic floor and sigmoidectomy for rectal prolapse

BACKGROUND

Full thickness rectal prolapse in young adults with normal pelvic floor is a disease in which the rectum is exceedingly long and mobile. Surgical treatment should correct both anatomical defects by combined rectopexy and colonic resection, which is expected to be less constipating than rectopexy alone. The aim of this study was to describe an original procedure of rectopexy to the pelvic floor with prosthetic material combined with sigmoid resection, and to evaluate prospectively anatomical and functional results.

METHODS

Thirty-five patients (30 women) of median age 44 years (range 18 to 74) were operated on for full thickness rectal prolapse with normal pelvic floor. The rectum was mobilized posteriorly without division of the lateral ligaments and attached to the pelvic floor previously repaired with a nonabsorbable mesh. The sigmoid colon was resected with hand-sewn anastomosis. Clinical results were assessed by a questionnaire.

RESULTS

There were no deaths or any septic or anastomotic complications. Small bowel obstruction was corrected laparoscopically in 1 patient. Mean hospital stay was 8 days (range 6 to 14). Mean follow-up was 34 months (range 10 to 93). No recurrence was seen. Preoperatively, 33 patients (94%) complained of constipation mainly with emptying problems (21 patients) and 25 patients (71.5%) were incontinent. Postoperatively, no constipated or incontinent patient's condition worsened. Rectal emptying was restored in 17 patients (81%). Eighteen incontinent patients (72%) regained full continence. On the other hand, 2 patients with normal bowel function worsened and 1 patient with an altered rectal compliance after Delorme's operation became incontinent.

CONCLUSIONS

In young adults with rectal prolapse and normal pelvic floor undergoing prosthetic rectopexy and sigmoid resection (a) morbidity was low, (b) anatomical control was obtained in all cases, (c) emptying problems were corrected, and (d) deleterious effects are likely to occur if they had no constipation before operation or if rectal compliance was previously altered.