Anal Canal

Background One-stage pull-through operation has become increasingly popular for treatment of Hirschsprung's disease. The one-stage transanal pull-through was introduced in the late 1990s and has rapidly replaced traditional procedures in infants and young children in many surgical centers. Objective The aim of this study is to determine feasibility and safety of transanal primary repair in adolescent and adults. Methods Fifteen patients who underwent transanal endorectal pull-through were prospectively studied. All patients presented by chronic refractory constipation with the age ranged from 11 to 22 years. The patients were followed up for a mean of 18 months. Anal continence and postoperative complication were evaluated. Results Incomplete continence in the form of soiling occurred in four patients (26.6%) and improved gradually with conservative management. No patients suffered from complete incontinence. Anastomotic strictures occurred in two patients and were successfully treated with regular dilatations. One patient had continued outlet obstruction and revision was considered for him. One patient complicated with low perianal fistula which needed fistulectomy. There was no impotence in adults. These findings indicate that one-stage transanal endorectal pull-through operation in adolescent and adults is feasible and safe.

Background: The aim of this study was to compare functional results and quality of life (QoL) of two salvage techniques: coloanal anastomosis (CAA) or perineal reconstruction after abdominoperineal resection for very low rectal cancer. Methods: Between 1991 and 2001, 50 patients were operated for a very low rectal adenocarcinoma and analyzed after a follow-up greater than one year and because there was no relapse or no treatment, they were included in the analysis. Thirty-eight patients had a CAA, including: straight anastomosis (n ¼ 23), J pouch (n ¼ 10), coloplasty (n ¼ 2) and intersphincteric resection (n ¼ 3). Twelve patients underwent a PC. Results: Vaizey's incontinence score was equivalent for the two groups: CAA 12 (0e22) versus PC 11 (8e13). The only differences were more frequent fractioned stools for the CAA group and increased pad soiling for the PC group. Overall QoL scores (QLQ C-30) were equivalent for CAA and PC. Conclusions: For very low rectal tumors, the choice of surgical technique must be based on oncologic rather than future functional or QoL criteria, because both approaches seem to provide similar results.

Smce 1934, 30 patients with ulcerative colitis or polyposis co11 have undergone mucous proctectomy and ilioanal reservorr surgery at the University of Britrsh Columbia affiliated hospitals. Preoperative evaluation included review of the clmlcal and pathologic data. In 28 patients, manometrlc and electromyographm studies of the anal sphincter were performed and the results are reported herm, as are the results of postoperative studies in 12 patients Twenty-eight patients with a mean age of 33 7 years (range 20 to 53 years) were studled There were 10 women and 18 men All but one patlent with polyposls co11 had ulcerative cohtls Each patlent underwent rectal mucosectomy and creatron of an lleoanal reservoir The tnphcate, S configuration was used m 26 patients, and the remammg 2 patients had a duphcate J pouch Conventional dlgrtal exammatron by the same observer (FRS) m all patients allowed a chmcal estimate of the restmg and maximal contracting pressures of the sphmcter to be created Manometrm studies were carried out using a pneumohydrauhc capillary mfuslon system (Arndorfer Medical Supplies, Greendale, WI) and a multdumen catheter with an outer dmmeter of 4 8 mm The three 0 8 mm side openmgs were posltloned radially around the catheter 5 cm from the catheter tip The perfused catheters were connected m parallel wrth Slemens water-filled pressure transducers The electrmal output was fed to the amphfrers of a multnhannel mkJet recorder (Mmgograph 829 Contmuous perfusion of each lumen of the catheter with degassed water was performed at a rate of 0 6 ml/mm Pressure profiles of the length and tone of the sphmcter at rest were obtained by msertlon of the tip of the catheter mto the rectum and slow pullthrough Centimeter markings on the catheter allowed measurement of the sphmcter length With the catheter side openings posltloned at

Early-stage (T1-T2 N0 M0) true perianal tumors are very uncommon, and the scientific literature is scant. Based on common features with anal canal carcinomas (aCCs), perianal skin cancers and aCCs are included in the same tumor classification and treated similarly. In fact, contouring radiation therapy guidelines do not differentiate between the two subsites. However, anal canal tumors and perianal skin cancers have different lymphatic drainage patterns. Modulation of radiotherapy treatment volumes can be considered for the latter. We performed a literature review to analyze the sites at higher risk of microscopic spread in patients with early-stage perianal cancer to tailor the selection of radiation therapy elective volumes.

Objectıve: To compare the morphometric data relating to the muscular structures of the anal canal, in patients with chronic anal fissure and in control group, examined at a 3.0 Tesla MR system. Subjects and methods: Forty-seven consecutive patients with chronic anal fissure and randomly selected 40 patients who had no claims for perianal disease during their life time were included in the study. T2-weighted sagittal, high-resolution (HR) T2-weighted, and contrast-enhanced fat-suppressed T1-weighted oblique axial and oblique coronal images were retrospectively analyzed by two observers in consensus. Thickness of sphincteric muscles, anal canal length, anorectal angle, thickness of anococcygeal ligament, depth of Minor triangle, width between subcutaneous sphincters, vascularity of posterior commissure, visibility of posterosuperior projection of external sphincter, and angle between the distal anal canal and posterosuperior projection of external sphincter (H angle) in patients and in controls were compared and analyzed using t test, Mann-Whitney U test, and Spearman correlation. Results: The patients with chronic anal fissure had longer anal canal (51.50 mm ± 0.91 vs. 44.11 mm ± 0.71; p = 0.000), thicker internal anal sphincter muscle at mid-anal level (4.18 ± 0.15 vs. 3.39 ± 0.07; p = 0.007), and wider space between subcutaneous external sphincters (11.39 ± 0.50 vs. 6.89 ± 0.22; p = 0.000). In patients, there was a positive correlation between H angle and external sphincter thickness at proximal (r = 0.347; p = 0.021), middle (r = 0427; p = 0.000), and distal (r = 0.518; p = 0.000)) levels of the anal canal. Conclusıon: 3.0 Tesla MR imaging provides detailed information about the morphometric changes in the anal sphincter muscles in patients with chronic anal fissure.

Objectıve: To compare the morphometric data relating to the muscular structures of the anal canal, in patients with chronic anal fissure and in control group, examined at a 3.0 Tesla MR system. Subjects and methods: Forty-seven consecutive patients with chronic anal fissure and randomly selected 40 patients who had no claims for perianal disease during their life time were included in the study. T2-weighted sagittal, high-resolution (HR) T2-weighted, and contrast-enhanced fat-suppressed T1-weighted oblique axial and oblique coronal images were retrospectively analyzed by two observers in consensus. Thickness of sphincteric muscles, anal canal length, anorectal angle, thickness of anococcygeal ligament, depth of Minor triangle, width between subcutaneous sphincters, vascularity of posterior commissure, visibility of posterosuperior projection of external sphincter, and angle between the distal anal canal and posterosuperior projection of external sphincter (H angle) in patients and in controls were compared and analyzed using t test, Mann-Whitney U test, and Spearman correlation. Results: The patients with chronic anal fissure had longer anal canal (51.50 mm ± 0.91 vs. 44.11 mm ± 0.71; p = 0.000), thicker internal anal sphincter muscle at mid-anal level (4.18 ± 0.15 vs. 3.39 ± 0.07; p = 0.007), and wider space between subcutaneous external sphincters (11.39 ± 0.50 vs. 6.89 ± 0.22; p = 0.000). In patients, there was a positive correlation between H angle and external sphincter thickness at proximal (r = 0.347; p = 0.021), middle (r = 0427; p = 0.000), and distal (r = 0.518; p = 0.000)) levels of the anal canal. Conclusıon: 3.0 Tesla MR imaging provides detailed information about the morphometric changes in the anal sphincter muscles in patients with chronic anal fissure.

To examine the patterns and predictors of third-degree and fourth-degree laceration in women undergoing vaginal delivery. We identified a population-based cohort of women in the United States who underwent a vaginal delivery between 1998 and 2010 using the Nationwide Inpatient Sample. Multivariable log-linear regression models were developed to account for patient, obstetric, and hospital factors related to lacerations. Between-hospital variability of laceration rates was calculated using generalized log-linear mixed models. Among 7,096,056 women who underwent vaginal delivery in 3,070 hospitals, 3.3% (n=232,762) had a third-degree laceration and 1.1% (n=76,347) had a fourth-degree laceration. In an adjusted model for fourth-degree lacerations, important risk factors included shoulder dystocia and forceps and vacuum deliveries with and without episiotomy. Other demographic, obstetric, medical, and hospital variables, although statistically significant, were not major determinants of...

Renal cell cancer (RCC) has the ability to metastasize to various organs, including the anal canal which is reported to be the rarest location. An 88-year-old male patient who had previously been treated for right RCC subsequently developed distant metastases to the prostate, lungs, and small bowel. Four years following nephrectomy, the patient presented with a bleeding anal mass which was excised and has been proven to be an anal canal metastasis of RCC. Eight months post excision, regrowth occurred. The patient underwent stereotactic ablative body radiotherapy resulting in satisfactory regression during the 2-month follow-up period, without episodes of bleeding. The treatment options for metastatic post-nephrectomy disease should be considered with a multidisciplinary approach in order to achieve satisfactory symptom relief.

Stany W. Lobo, Mangala Kumari, Thejodhar Pulakunta, Sudarshan S, Rajasekaran Koteeswaran, Tiffany Kurian Department of professional and medical education, Meharry Medical College, Nashville, Tennessee, USA Department of Anatomy, Division of Human Biology, International Medical University, Kuala Lumpur, Malaysia Department of medical Neuroscience, Dalhousie University, Halifax, Canada Department of Anatomy, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, India Department of Pathology/ Microbiology, Eastern Virginia Medical School, Norfolk, Virginia, USA Touro College of Osteopathic medicine, Middletown, New York, USA

Background: The objective of this study was to determine the pattern of congenital cardiac disease among children attending UNTH, Enugu, Nigeria. The nature of these abnormalities and the outcome were also considered. The exact etiology is unknown but genetic and environmental factors tend to be implicated. The difference in the pattern obtained worldwide and few studies in Nigeria could be due to genetic, environmental, socioeconomic, or ethnic origin. Methods: A retrospective analysis of discharged cases in which a review of the cases of all children attending children outpatient clinics including cardiology clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu over a five year period (January 2007-June 2012) was undertaken. All the children presenting with cardiac anomalies were included in the study and the cases were investigated using ECG, X-ray and echocardiography studies. Results: A total of 31,795 children attended the children outpatient clinics of the hospital over the study period. Of these, seventy one (71) had cardiac diseases. The overall prevalence of cardiac disease is 0.22%. The commonest symptoms were breathlessness, failure to thrive and cyanosis. Almost all types of congenital detects were represented, the commonest being isolated ventricular septal detect (VSD), followed by tetralogy of Fallot. One of these cardiac anomalies presented with Downs's syndrome and another with VACTERAL association. Conclusions: The results of this study show that 0.22% per cent of children who attended UNTH in Enugu State had congenital cardiac abnormalities and the commonest forms seen were those with VSD.

We aimed to describe anal ultrasound for monitoring anorectal malformations. Methods: A descriptive and retrospective study of patients diagnosed and/or intervened with anorectal malformations rated by anal ultrasonography, between 2016-2017, was performed. We employed a transducer of 10 megahertz to identify the anatomy of the anal channel. Results: Eight patients, 5 men and 3 women were included, with a mean of 8.37 years old (range, 3-11). Three patients had a diagnosis of an anterior anus (not operated). Surgery was performed in 5 patients: 2 had a rectourethral fistula, 1 had a rectovesical fistula, and 1 had a rectovestibular and a perineal fistula. The most significant ultrasound findings were partial absence of the anterior part of the external sphincter, internal sphincter hypertrophy in the middle channel, and absence of internal sphincter in the median and high channel plus the absence of external sphincter in the anterior region. These results belonged to a patient with clinical incontinence and to 2 patients that were previously diagnosed with an anterior anus. Conclusions: Anal ultrasonography is a non-invasive method, economic, and feasible to be performed without anesthesia. It offers useful anatomical information to establish the best therapeutic option. Its main limitation is the unfeasibility of carrying it out on patients under 3 years old.

Objectives: To compare the labour curves of primigravid women with fourth degree perineal laceration with those of control subjects, and to identify characteristics of the labour curve that are associated with anal sphincter disruption. In this retrospective case-control study we constructed labour curves describing the mean cervical dilation and head descent for 72 primigravidas with fourth degree laceration and compared these with the labour curves of 72 consecutive primigravidas having a vaginal delivery without sphincter laceration. The control cervical dilatation curve resembled the Friedman labour curve, consisting of an acceleration phase, a phase of maximal slope, and a deceleration phase. In contrast, the dilatation curve of the laceration group was longer and had an increasing rate of dilatation without a deceleration phase. While the rate of head descent progressively decreased in the control group, it accelerated in the laceration group. Labour curves for the sphincter laceration and control groups were different. Increasing rates of cervical dilatation and head descent were associated with fourth degree perineal laceration. Objectifs : Comparer les partogrammes de primigravides présentant une lacération périnéale du quatrième degré à ceux de témoins, ainsi qu'identifier les caractéristiques du partogramme qui sont associées à la rupture du sphincter anal. Méthodes : Dans le cadre de cette étude cas-témoins rétrospective, nous avons élaboré des partogrammes décrivant la dilatation cervicale et la descente de la tête moyennes, pour ce qui est de 72 primigravides présentant une lacération du quatrième degré, et nous les avons comparés à ceux de 72 primigravides consécutives connaissant un accouchement vaginal sans lacération du sphincter. Résultats : La courbe de dilatation cervicale des témoins ressemblait au partogramme Friedman : il comptait une phase d'accélération, une phase de pente maximale et une phase de décélération. En revanche, la courbe de dilatation du groupe « lacération » était plus longue et comptait un taux croissant de dilatation sans phase de décélération. Bien que le taux de descente de la tête ait connu une baisse progressive au sein du groupe témoin, il a connu une accélération au sein du groupe « lacération ». Les partogrammes des groupes « lacération du sphincter » et « témoin » étaient différents. Les taux croissants de dilatation cervicale et de descente de la tête ont été associés à la lacération périnéale du quatrième degré.

he utility of sonography in the evaluation of the anatomy of the female internal organs is well established, but little has been reported on the characterization of vaginal masses. Vaginal masses can present in different manners and may produce surprising findings during surgery. Gartner duct cysts, 1 solid masses, 2,3 urethral diverticula, 4-7 and Bartholin glands 8,9 have been reported by varied 2-dimensional (2D) sonographic techniques. There are case reports of varied masses evaluated by magnetic resonance imaging (MRI) or computed tomography. Positivepressure urography using a Trattner catheter and voiding cystography have been used for evaluation of masses and cysts around the urethra. An Ovid search from 1950 to September 2012 using the terms "ultrasound," "Gartner duct cysts," "urethral diverticulum," "Bartholin gland," "vaginal mass," "3D," "3-dimensional," and "sonography" revealed no studies that used 3-dimensional (3D) endovaginal sonography as we describe, identifying a gap in the understanding of the use of this technique. We have previously described this technique for identification of levator ani muscles and authenticated its interobserver and interdisciplinary reproducibility. The aim of this pictorial essay is to demonstrate the utility of 3D endovaginal and endoanal sonography for visualization of a variety of vaginal masses. All phases of this study were approved by the

Aim Structural anal sphincter damage may be secondary to obstetric anal sphincter injury, perineal trauma or anorectal surgery. We reviewed the spectrum of anal sphincter injuries and their outcomes in a tertiary care colorectal unit. Methods Data of patients who underwent anal sphincter repair between 2004 and 2008 were analyzed retrospectively. Outcomes were compared with respect to etiology, type of repair, previous attempts at repair and manometry findings. Outcomes were defined as good or poor based on patient satisfaction as the primary criteria. Results Thirty-four patients underwent anal sphincter repair. Twenty-two injuries were obstetric, eight traumatic, and four iatrogenic. All patients underwent overlap sphincteroplasty with six additional anterior levatorplasty and seven graciloplasty. Twenty-three (67.6%) patients had a good outcome while nine (26.4%) had a poor outcome. All patients who had augmentation anterior levatorplasty had a good outcome. Fifty percent of patients with a previous sphincter repair and 42.9% requiring augmentation graciloplasty had a poor outcome. Median resting and squeeze anal pressures increased from 57.5 to 70 cmH 2 O and 90.25 to 111 cmH 2 O in those with a good outcome. Conclusions Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

To modify our technique of perianal anesthesia and use it in patients with painful conditions of the rectum and/or anus. A total of 31 consecutive patients with anal-rectal problems underwent prostate needle biopsy. Of these, 17 were referred to our hospital after vain attempts to insert a transrectal ultrasound probe. Patients received a perianal-pericapsular injection of 1% lidocaine. Pain perception was separately assessed for probe insertion and biopsies using a visual pain analog score. Only in 1 patient were we unable to insert the transrectal ultrasound probe. The mean patient age was 65.28 Ϯ 5.35 years. We performed a mean of 12.25 biopsies per case. At probe insertion, the mean pain score was 2.2 Ϯ 0.83. During the biopsy punctures, the mean pain level was 2.53 Ϯ 1.054. We did not find any increase in the complication rate related to the anesthesia method. Modified perianal anesthesia can be used for transrectal ultrasound-guided biopsy of the prostate in patients with anal-rectal problems, because it provides significant pain relief. UROLOGY 69: 139 -141, 2007.

To modify our technique of perianal anesthesia and use it in patients with painful conditions of the rectum and/or anus. A total of 31 consecutive patients with anal-rectal problems underwent prostate needle biopsy. Of these, 17 were referred to our hospital after vain attempts to insert a transrectal ultrasound probe. Patients received a perianal-pericapsular injection of 1% lidocaine. Pain perception was separately assessed for probe insertion and biopsies using a visual pain analog score. Only in 1 patient were we unable to insert the transrectal ultrasound probe. The mean patient age was 65.28 Ϯ 5.35 years. We performed a mean of 12.25 biopsies per case. At probe insertion, the mean pain score was 2.2 Ϯ 0.83. During the biopsy punctures, the mean pain level was 2.53 Ϯ 1.054. We did not find any increase in the complication rate related to the anesthesia method. Modified perianal anesthesia can be used for transrectal ultrasound-guided biopsy of the prostate in patients with anal-rectal problems, because it provides significant pain relief. UROLOGY 69: 139 -141, 2007.

To make the gynaecologists familiar with the procedure of continuous repair of rectal mucosa and repair the anal sphincter by other than figure of 8 suture and to compare the effectiveness of these procedures with the traditional procedures this study was planned. This was a observational comparative study. This study was carried out in one public medical college hospital and two private hospitals in Dhaka city and out side. Total 18 (Eighteen) patients were included in this study . Age, parity, residence were different but all had fourth degree perineal tear. Tears were repaired by traditional approach in half of the patients who were grouped under A and with the new approach in another half, grouped under B. Follow up was carried out at an interval of 6 weeks, 12 weeks, 24 weeks in both groups and the findings were compared. Among 18 patients a large number of women were mother of one child and were of 21 -25 years age group. At post operative period - wound infection was nil. Per...

Fistula in-ano is an abnormal chronic infected
tunnel ( tract ) between the rectum or the anal canal and perianal skin
usually ,with granulation tissue which connecting a primary orifice
( internal ) to a secondary one ( external) .This morbid antity represents a dilemma for both ,patients and surgeon-proctologists because of postoperative issues occurrence such as fecal incontinence
.The surgical management of this infectious condition has emerged
nowadays ,by emphasing new surgical techniques that preserve anal
sphincter's integrity and functional Over the last decade, numerous
techniques sparing anal sphinters have gained popularity such as endoscopic approach ( VAAFT ), Laser, fibrin glue, transanal advancement flap repair [1, 6]. In the same perspective, we are presenting in
this paper, our preliminary outcomes of a combination of endoscopic approach (VAAFT) with Radifrequency

Magnetic resonance images of the anal canal show small, circular, low-intensity areas arranged in a row and a high-intensity area surrounding them internally and externally in the longitudinal muscle layer that cannot be explained by current anatomical findings. The purpose of this study was to elucidate the detailed structure of the longitudinal smooth muscle of the anal canal and to interpret the magnetic resonance image of the longitudinal muscle. Specimens for macroscopic anatomy and histology were obtained from six and seven cadavers, respectively. The histological nature of the longitudinal muscle was examined by staining serial transverse and coronal sections of the lateral wall of the anal canal with Masson's trichrome stain and using immunohistochemistry for smooth and skeletal muscle fibers. Dense and sparse areas of smooth muscle fibers coexisted in the longitudinal muscle layer. The dense areas formed columnar muscle bundles approximately 1.0-1.5 mm in diameter, and they continued from the longitudinal muscle bundles of the rectum. The columnar muscle bundles of the longitudinal anal muscle were internally and externally surrounded by sparsely arranged smooth muscle fibers that ran longitudinally. The coexistence of dense and sparse areas of smooth muscle fibers suggests that the structure of the smooth muscle is optimized for its function. This histological nature is probably reflected in the magnetic resonance image of the longitudinal muscle as the coexistence of low-and high-intensity areas. Clin. Anat. 33:619-626, 2020.

The male pelvic floor is a complex structure formed by several muscles. The levator ani muscle and the perineal muscles are important components of the pelvic floor. The perineal muscles comprise the external anal sphincter, bulbospongiosus, superficial transverse perineal muscles, and ischiocavernosus. Although the connections of the muscles of the pelvic floor have been reported recently, the anatomical details of each muscle remain unclear. In this study, we examined the male pelvic floor to clarify the connection between the muscles related to function. Fifteen male pelvises were used for microscopic dissection, and three male pelvises were used for histological examination. On the lateral aspect, the perineal muscles were connected to each other. Bundles of the levator ani muscle extended to connect to the perineal muscles. In addition, the extended muscle bundle from the levator ani muscle and the perineal muscles surround the external urethral sphincter. On the medial aspect,...

The region anterior to the anal canal in women is composed of intertwined smooth and skeletal muscles. The present study aimed to clarify skeletal muscle morphology in the anterior region of the anal canal. The pelvic floor muscles of 28 pelvic halves from 16 female cadavers (mean age 79.75 years) were dissected from the inferior aspect to examine the perineal muscles, followed by midline transection and dissection from the inner surface to examine the pelvic outlet muscles. The bulbospongiosus muscle was found to be attached to the lateral surface of the external anal sphincter. The superficial transverse perineal muscle crossed superiorly to the bulbospongiosus and coursed medially toward its contralateral muscle bundle deep to the anterior portion of the external anal sphincter. The superficial transverse perineal muscle formed the middle sling. From the medial aspect, the anterior part of the levator ani was divided into anterior and posterior bundles to form the anterior and posterior slings, respectively. This study proposes that three muscular slings could be important in supporting the pelvic floor in women. In addition, this study shows that the anterior skeletal muscular wall of the anal canal is composed of the anterior muscle bundle of the levator ani, superficial transverse perineal, and proper external anal sphincter muscles.

Little is known about the epidemiology of anal human papillomavirus (HPV) infection in women. We studied 251 human immunodeficiency virus (HIV)-positive and 68 HIV-negative women for the presence of anal HPV by use of polymerase chain reaction (PCR) and hybrid capture. Medical and behavioral risk factors were evaluated; 76% of HIV-positive and 42% of HIV-negative women were found to have anal HPV DNA via analysis by PCR (relative risk [RR], 1.8; 95% confidence interval [CI], 1.3-2.5). Among 200 women for whom there were concurrent anal and cervical HPV data, anal HPV was more common than cervical HPV in both HIV-positive (79% vs. 53%) and HIV-negative women (43% vs. 24%). By multivariate analysis of HIV-positive women, CD4 + cell counts р200 cells/mm 3 , compared with counts 1500 cells/mm 3 (RR, 1.4; 95% CI, 1.1-1.5), and cervical HPV infection (RR, 1.3; 95% CI, 1.1-1.4) were associated with anal HPV infection. Women 145 years old had reduced risk, compared with women !36 years old (RR, 0.80; 95% CI, 0.50-0.99), as did African American women (RR, 0.86; 95% CI, 0.72-1.0), compared with white women. Anal HPV infection is underrecognized in HIV-positive and high-risk HIV-negative women. Substantial evidence has accumulated that links infection with human papillomavirus (HPV) to the development of cervical cancer. HPV 16, and 45 are most strongly associated with invasive squamous cell cancer of the cervix, and HPV 16 is found to be the most common of these in most studies . Several studies also have shown a strong association between anal cancer and HPV of the same types as those associated with cervical cancer . Likewise, there is a strong relationship between HPV infection and anal squamous intraepithelial lesions (ASILs), the putative anal cancer precursor, again with the same spectrum of HPV types as those found in the cervix .

The purpose of this study was to characterize the spinal distribution of afferent and efferent pathways that innervate the levator ani (LA) muscle in the female squirrel monkey. Study design: Cholera toxin B (CTB) was injected unilaterally into the LA muscle of 5 monkeys to identify primary sensory neurons in the dorsal root ganglia (DRG) and motor neurons in the spinal cord that contribute fibers to the LA nerve. Fluoro-Gold (FG) was injected into the external anal sphincter of 2 of these animals to label pudendal motor neurons (1 of these animals underwent unilateral LA neurectomy before CTB injection). Spinal cord and DRG were processed for immunofluorescence 3 to 7 days after injections. Results: Retrograde transport of CTB from the LA muscle labeled primary afferent neurons in the ipsilateral DRG, their central projections, and motor neurons in the medial portion of the ipsilateral ventral horn of the spinal cord (L7-S2 segments). Injection of FG into the external anal sphincter labeled cells in Onuf's nucleus, primarily in L7. Importantly, CTB-labeled LA motor neurons were virtually absent in Onuf's nucleus, where all pudendal motor neurons are located. CTB-labeled processes were observed within Onuf's nucleus, adjacent to FG-labeled pudendal motor neurons, and appeared to derive from dendrites of LA motor neurons that project into Onuf's nucleus.

PURPOSE: Mthough anal endosonography provides clear images of anal sphincters, the probe in the anal canal may distort epithelial structures and sphincter muscles may be compressed, producing inaccurate muscle thickness measurements. The aim of this study is to describe a new approach using vaginal endosonography to image the anal canal undistorted. METHODS: Twenty females (10 healthy volunteers and 10 with fecal incontinence) had both anal and vaginal endosonography performed. RESULTS: The undisturbed anorecmm, submucosa, anal cushions, and anal sphincter muscles were clearly visualized by vaginal endosonography, and anatomy was described. Mthough anal and vaginal endosonographic measurements of internal sphincter muscle thickness correlated (r = 0.83; P = 0.01), anal endosonography consistently underestimated the thickness (2.3 + 0.5 vs. 3.2 + 1.2 mm; mean _+ standard deviation). Anterior internal and external anal sphincter defects were identified accurately with both techniques. CONCLUSIONS: Vaginal endosonography is a new technique that enables accurate imaging of anal sphincters and epithelial structures at rest. In addition to making the diagnosis of anal sphincter defects, it has potential applications in the imaging of anovaginal sepsis and malignancy and possibly in understanding the pathogenesis of anal fissure and hemorrhoids.

Perianal abscess is a benign but common clinical condition that may cause substantial discomfort to suffering patients and carries a significant burden on healthcare services. The
prevalence and risk factors of perianal abscess in Ethiopia were
not, however, known prior to the time of this investigation. The
purpose of the current study is to determine the frequency of perianal abscesses and their risk factors among patients who visit our
university hospital’s surgical emergency department

Objective Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques. Method We retrospectively analysed a prospectively entered database composed of 146 patients (112 M; 34 F), undergoing operations for CF of cryptoglandular origin. The patients were divided in two groups: Group A: (EAF); n = 71 patients; Group B: (ISR); n = 75 patients. Results Forty-two fistulas (28.7%) were recurrent, 98 trans-sphincteric (TS) and 37 suprasphincteric (SS). Twenty-six (17.7%) patients had some degree of preoperative continence disturbances, 11 in Group A vs 15 in Group B (P = 0.47). After a mean follow up of 13 months (12-60), fistula persisted or recurred in 13 (18.3%) patients in Group A vs eight (10.6%) in Group B (P = 0.19) irrespective of the fistula type (TS or SS). Thirty-one (43.6%) patients in Group A vs 16 (21.3%) in Group B presented postoperative continence disturbances (P < 0.001). No changes were observed with the Faecal Incontinence Quality of Life Scale (FIQLS). Group A patients had a significant reduction of maximal rest pressure after surgery. After ISR, no significant changes in pressures were observed. Immediate sphincter repair can be a therapeutic option in selected cases of CF, mainly when associated with incontinence or increased risk factors.

BackgroundThe acronym VATER/VACTERL association describes the combination of at least three of the following cardinal features: vertebral defects, anorectal malformations, cardiac defects, tracheoesophageal fistula with or without esophageal atresia, renal malformations, and limb defects. Although fibroblast growth factor‐8 (FGF8) mutations have mainly found in patients with Kallmann syndrome, mice with a hypomorphic Fgf8 allele or complete gene invalidation display, aside from gonadotropin‐releasing hormone deficiency, parts or even the entire spectrum of human VATER/VACTERL association.MethodsWe performed FGF8 gene analysis in 49 patients with VATER/VACTERL association and 27 patients presenting with a VATER/VACTERL‐like phenotype (two cardinal features).ResultsWe identified two heterozygous FGF8 mutations in patients displaying either VATER/VACTERL association (p.Gly29_Arg34dup) or a VATER/VACTERL‐like phenotype (p.Pro26Leu) without limb anomalies. Whereas the duplication mutatio...

The acronym VATER/VACTERL association is used to describe the non-random co-occurrence of vertebral defects (V), anorectal malformations (A), cardiac defects (C), tracheo-esophageal fistula with or without esophageal atresia (TE), renal malformations (R), and limb defects (L). We report a familial case of VATER/VACT-ERL association in which both the index case and her maternal uncle displayed four major component features of the disorder. A systematic literature search identified 12 previously described familial cases. However, on comparison, both members fulfilled the diagnostic criteria for VATER/VACTERL association only in one instance, and ours is the second such report. Although, a SNP arraybased analysis identified no causal genomic alteration, the findings in the present family suggest that genetic factors are implicated in the development of the disorder.

Resumen Objetivo: Presentamos nuestra experiencia en el tratamiento quirúrgico de esta patología con la técnica de la rectosigmoidectomía perineal. Material y método: Se trata de una serie retrospectiva, consecutiva de 17 pacientes. Resultados: Predomina el género femenino y el promedio de edad es de 62 años. La morbilidad alcanza el 23%, aunque casi toda de menor gravedad, con solo un paciente reoperado. La recidiva es del 6%, con mejoría de los síntomas en un 88%. Conclusión: Concluimos que es una técnica segura, con una morbilidad controlada y con buenos resultados a mediano plazo con un adecuado control de la recidiva y mejoría de la continencia en un alto porcentaje de los pacientes.

Object-Nerve transfers are an effective means of restoring control to paralyzed somatic muscle groups and, recently, even denervated detrusor muscle. The authors performed a cadaveric pilot project to examine the feasibility of restoring control to the urethral and anal sphincters using a femoral motor nerve branch to reinnervate the pudendal nerve through a perineal approach. Methods-Eleven cadavers were dissected bilaterally to expose the pudendal and femoral nerve branches. Pertinent landmarks and distances that could be used to locate these nerves were assessed and measured, as were nerve cross-sectional areas. Results-A long motor branch of the femoral nerve was followed into the distal vastus medialis muscle for a distance of 17.4 ± 0.8 cm, split off from the main femoral nerve trunk, and transferred medially and superiorly to the pudendal nerve in the Alcock canal, a distance of 13.7 ± 0.71 cm. This was performed via a perineal approach. The cross-sectional area of the pudendal nerve was 5.64 ± 0.49 mm 2 , and the femoral nerve motor branch at the suggested transection site was 4.40 ± 0.41 mm 2 . Conclusions-The use of a femoral nerve motor branch to the vastus medialis muscle for heterotopic nerve transfer to the pudendal nerve is surgically feasible, based on anatomical location and cross-sectional areas.

Congenital malformations can be manifested as combinations of phenotypes that co-occur more often than expected by chance. In many such cases, it has proved difficult to identify a genetic cause. We sought the genetic cause of cardiac, vertebral, and renal defects, among others, in unrelated patients. We used genomic sequencing to identify potentially pathogenic gene variants in families in which a person had multiple congenital malformations. We tested the function of the variant by using assays of in vitro enzyme activity and by quantifying metabolites in patient plasma. We engineered mouse models with similar variants using the CRISPR (clustered regularly interspaced short palindromic repeats)-Cas9 system. Variants were identified in two genes that encode enzymes of the kynurenine pathway, 3-hydroxyanthranilic acid 3,4-dioxygenase (HAAO) and kynureninase (KYNU). Three patients carried homozygous variants predicting loss-of-function changes in the HAAO or KYNU proteins (HAAO p.D16...

To assess the etiology, treatment, and utility of anal ultrasound in men with fecal incontinence and to review the outcomes of conservative (nonoperative) treatment. The etiology of fecal incontinence in women is almost exclusively from obstetric or iatrogenic surgical injuries resulting in damage to the anal sphincters and/or pudendal nerves. Corresponding data on men with fecal incontinence are sparse.

A subset of patients with ulcerative colitis (UC) have a benign course and an overall favorable prognosis. Early identification of these low-risk patients may allow for a less aggressive therapeutic approach and possible reduction of therapy-associated risks. The aim of this project was to identify the genetic predictors of benign UC phenotype. UC patients were selected from the National Institute of Diabetes and Digestive and Kidney Diseases Inflammatory Bowel Disease Genetics Consortium. Benign phenotype was defined as no need for immunomodulatory or biological therapy, hospitalizations, or colectomy. The association between benign UC phenotype and known loci linked to the risk of inflammatory bowel disease (IBD) was evaluated. The results for 156 index single-nucleotide polymorphisms (SNPs) from the known IBD loci were extracted for the main analysis. The association of the benign phenotype to a genetic burden score was also evaluated. None of the index SNPs from the IBD loci rea...

Although it is known that individuals living with HIV have a higher HPV prevalence, the impact of individual HPV types on HIV acquisition is less clear. In this prospective cohort study we investigated the relationship between HPV types and incident HIV infection among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru. Six hundred HIV-negative Peruvian MSM and TW participated in a 2-year study with biannual visits. At baseline, participants completed a computerized, self-administered questionnaire on sexual behavior and HPV knowledge and underwent a physical exam including anogenital swabs for HPV DNA (37 genotypes via linear array testing) and HIV testing; follow-up visits included the questionnaire and HIV testing. Participant mean age was 25 years (range = 18-40), with 48.9% self-identifying as gay and 86.5% reporting having sex exclusively with men. At baseline, 530 participants had HPV DNA present (61.1% with high-risk HPV, 84.9% with low-risk HPV). Among...

Amaç: Rektal yabancı cisimler acil serviste nadir görülen bir durumlardır. Bu olguların yönetiminde doğru öykünün alınması ve doğru tedavi algoritmasının uygulanması önemlidir. Bu çalışmanın amacı rektal yabancı cisim ile acil servise (AS) başvuran hastaları değerlendirmektir.

Background: Gonorrhoea notifications are rapidly rising in men who have sex with men (MSM). We developed a model to assess mouthwash as a novel intervention for gonorrhoea control. We developed a model of Neisseria gonorrhoeae (NG) transmission to explain anatomic site-specific prevalence of gonorrhoea among MSM. The model was calibrated to available epidemiological and behavioral data. We estimated the contribution of various sexual acts to gonorrhoea incidence and evaluate the potential impacts of screening scale-up and utilization of mouthwash on the gonorrhoea epidemic. We calibrated the model to prevalence of oropharyngeal, anal, and urethral gonorrhoea of 8.6% (7.7-9.5%), 8.3% (7.4-9.1%), and 0.20% (0.04-0.35%), respectively, among MSM. Oropharynx to oropharynx transmission through kissing is estimated to account for nearly three quarters of all incident cases (71.6% [64.4-80.5%]) of gonorrhoea in MSM. Substantially increasing annual oropharynx screening for gonorrhoea from the current 40% to 100% may only halve the prevalence of gonorrhoea in MSM. In contrast, the use of mouthwash with moderate efficacy (additional 1% clearance per daily use) would further reduce the corresponding prevalence rates to 3.1% (2.2-4.4%), 3.8% (2.3-4.9%), and 0.10% (0.06-0.11%), and a high-efficacy mouthwash (additional 1.5% clearance per daily use) may further halve the gonorrhoea prevalence. Without oropharynx to oropharynx transmission, we could not replicate current prevalence data. Conclusions: Despite a dearth of empirical data, our model suggests that kissing could potentially play an important role in NG transmission among MSM. Control through sexually transmitted infection screening alone is unlikely to have a substantial impact on the gonorrhoea epidemic in MSM.

Bevezetés: Az anális carcinoma incidenciája az utóbbi évtizedekben folyamatosan emelkedett, különösen a humán immundefi cientia vírussal fertőzött homoszexuális populációban. Az anális laphámrák potenciális prekurzora az anális intraepithelialis neoplasia, amelynek elődleges szűrőtesztje a citológiai vizsgálat. Célkitűzés: A szerzők a Semmelweis Egyetem, Bőr-, Nemikórtani és Bőronkológiai Klinika Országos STD Centrumában humán immundefi cientia vírus pozitív betegeknél végzett anális citológiai vizsgálatok eredményének értékelését tűzték ki célul.

Current issues in the management of clinically negative inguinal lymph nodes in squamous cell carcinoma of the anal canal. Quality of the available evidence. The first line of management of squamous cell carcinoma (SCC) of the anal canal is chemo-radiation. The radiation field includes, in addition to the anal region and the perirectal nodes, the iliac and both inguinal triangles to target the inguinal nodes. More recently a selective approach has been investigated in patients with non-palpable inguinal nodes utilizing sentinel node biopsy and PET scan. Methods Medline was searched using the keywords, squamous cell carcinoma, anal canal, inguinal lymph nodes, sentinel node and radiotherapy. Relevant articles were reviewed with regard to the management of inguinal nodes in SCC of the anal canal. Currently the management of clinically normal inguinal nodes in SCC of the anal canal is prophylactic radiation of both inguinal areas. Clinically involved nodes are included in the radiation field plus a boost of radiation to the groin that harbor involved nodes. The radiation is refined recently by intensity modulation radiotherapy (IMR) to involve the diseased area and minimize radiation exposure of normal adjacent tissues. Alternatively, more recently, a selective approach with utilization of sentinel node biopsy and radiation to microscopically involved nodal areas has been described. The treatment of clinically normal inguinal nodes is currently by prophylactic radiation of both inguinal regions. It is possible that in the future radiation of clinically normal inguinal may become more selective with an increasing reliance on sentinel node biopsy. Further studies are needed in this field to assess the efficacy of this approach.

Background: Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence. Objectives: The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence. Patients and methods: Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated. Results: Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively ( P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse. Conclusions: Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.

This study assessed the utility and limitations of anal cytology as a screening method for women infected with human papilloma virus (HPV) in the lower genital tract. Furthermore, this study aimed to establish risk factors for pathological anal cytology/biopsy findings, the prevalence of anatomopathological lesions associated with positive anal brushings, and the frequency of concomitant lesions of the lower genital tract. A cross-sectional, retrospective, descriptive study in 207 women with HPV-associated lesions of the lower genital tract and 25 women with immunosuppression was carried out. Anal cytology, high resolution anoscopy, and biopsy of suspicious lesions were performed. In total, 232 anal brushings were performed: 184 (79.3%) were negative, 24 (10.34%) showed atypical squamous cells of undeterminated significance, 18 (7.7%) showed low-grade squamous intraepithelial lesions, and 6 (2.6%) showed high-grade squamous intraepithelial lesion. Cytohistological correlation was obtained for 70 cases. The sensitivity of anal cytology in detecting intraepithelial lesions was 70%, whereas the specificity was 93%. The sensitivity of the method for detecting high-grade lesions (84%) was higher, than that for detecting low-grade lesions (66%). The most frequently associated pathology was vulvar lesion. It is important to perform anal brushings in women who have had lower genital tract biopsies for HPV-associated lesions due to the high prevalence of anal lesions in such patients. Anal cytology is useful for detecting high-grade lesions but the sensitivity for detecting low-grade lesions is low. It is of the utmost importance to perform high-resolution anoscopy and biopsy in women with suspicious lesions in order to confirm the pathology. Diagn.

This study aimed to assess the prevalence of and associated risk factors for anal high-risk human papillomavirus (hr-HPV) infection among men who have sex with men (MSM) and transgender women (TGW) in Indonesia, Thailand, and Malaysia. This was baseline data from a prospective cohort study with clinic sites in Jakarta and Bali (Indonesia), Bangkok (Thailand), and Kuala Lumpur (Malaysia). MSM and TGW aged 18 years and older from Indonesia, Thailand, and Malaysia were enrolled. Demographic and behavioral characteristics were assessed, and anal samples were collected for HPV genotyping. Multivariate logistic regression models were used to assess risk factors for anal hr-HPV overall and among HIV-positive participants. A total of 392 participants were enrolled, and 48 were TGW. As many as 245 were HIV-positive, and 78.0% of the participants were on combination antiretroviral therapy (cART). Median CD4 count was 439 cells/mm 3 and 68.2% had undetectable HIV-RNA. HIVpositive participants had significantly more hr-HPV compared to HIV-negative participants (76.6% vs 53.5%, P < .001). HPV-16 was the most common high-risk type (20%), whereas HPV-33, -39, and -58 were significantly more common among HIV-positive participants. HIV-positive participant significantly associated with anal hr-HPV infection compared with HIV-negative (OR: 2.87, 95% CI: 1.76-4.70, P .001), whereas among HIV-positive participants transgender identity had lower prevalence of hr-HPV infection (OR: 0.42, 95% CI: 0.19-0.91, P = .03). High-risk HPV infection was very common among MSM and TGW in South-East Asia. Overall, HIV-infection, regardless of cART use and immune status, significantly increased the risk, while among HIV-positive participants transgender identity seemed to decrease the risk of anal hr-HPV.

Anal continence is a complex process that depends on the interplay of several integrating factors. The most important of these factors are the integrity and the function of the anal sphincters. Not all defects in the anal sphincters present with symptoms of fecal incontinence. This is mostly attributed to the collaboration of the other factors that compensates for the sphincter defect, yet to a certain extent. Proper understanding of how the anal continence is being orchestrated is imperative for decision making as it can serve to alter the management plan accordingly.

Anal incontinence causes psychological, social and adaptive troubles prejudicial to the quality of life both in children and adults. Therefore, the detailed knowledge of its causes and the improvement of diagnostic and therapeutic methods increase the possibilities of a more adequate social life to patients with congenital anomalies or sphincteric lesions or degenerations. In this work, a manometric study was developed through an experimental model so as to analyze alterations in behavior of muscle groups responsible for the anorectal sphincteric mechanism, previous to and after proximal and distal lesions. Twenty-two pigs aged between 25 and 30 days, weighing 5-7 kg, were randomly divided into two groups. They were submitted to lesions of different levels in the anorectal muscle. The animals were studied by anorectal manometry (rectoanal inhibitory reflex and vector volume) before and after the lesions. The Student t test and the Wilcoxon test were applied for the statistical analyses, considered p B 0.05. The proximal lesion preserved sphincter relaxation, retarding its closure [speed of relaxation recovery 4.35 ± 2.10 vs. 2.70 ± 1.32 mm/s (p = 0.001)], but it reduced the maximum pressure [62.45 ± 20.02 vs. 40.36 ± 12.59 mmHg (p = 0.004)] and vector volume [2,749 ± 921 vs. 1,591 ± 1,379 mmHg 2 cm (p = 0.005)]. There was an increment in the high-pressure zone [5.09 ± 1.04 vs. 6.36 ± 1.50 mm (p = 0.005)], but the asymmetry percentage and the sphincter length were maintained. The distal lesion did not alter the rectoanal inhibitory reflex, the high-pressure zone length, the asymmetry percentage, or the vector volume. Nevertheless, the sphincter length increased [11.82 ± 2.82 vs. 14.09 ± 2.39 mm (p = 0.022)] and the maximum pressure decreased [60.55 ± 22.05 vs. 40.91 ± 13.41 mmHg (p = 0.004)]. The alterations observed due to proximal lesion of the anorectal sphincter suggest a direct and more important interference of the levator ani muscle in the function of the sphincteric musculature than that caused by the distal lesion.