Prevalencia y características genotípicas de la infección anal por papilomavirus en una cohorte de hombres que tienen sexo con hombres VIH-positivos / Prevalence and genotypic characteristics of anal papillomavirus infection in a cohort of HIV-positive men who have sex with men

RESUMEN Objetivo: Determinar la prevalencia y las características genotípicas de la infección anal por papilomavirus en hombres que tienen sexo con hombres (HSH) VIH-positivos. Materiales y métodos: Es un estudio observacional prospectivo de corte transversal en HSH VIH-positivos del Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, realizado entre setiembre del 2017 y diciembre del 2018. El estudio del papilomavirus se realizó con una técnica de reacción en cadena de polimerasa evaluando 21 genotipos estratificados según el riesgo oncogénico: seis de bajo riesgo y quince de alto riesgo. Resultados: Se evaluaron 214 HSH VIH-positivos. La prevalencia general de la infección anal por papilomavirus fue de 70% (150/214). 86% (129/150) tuvieron genotipos de alto riesgo oncogénico, de ellos 79% (102/129) tuvieron dos o más genotipos de papilomavirus. Los genotipos de alto riesgo oncogénico más frecuentes fueron: VPH-16, 31% (46/150); VPH-52, 22% (33/150); VPH-33, 21% (31/150); VPH-58, 21% (31/150) y VPH-31, 20% (30/150). El VPH-18 alcanzó el 7% (10/150). Los genotipos de bajo riesgo oncogénico más frecuentes fueron: VPH-6, 30% (45/150) y VPH-11, 29% (44/150). Conclusiones: La prevalencia de la infección anal por papilomavirus en HSH VIH-positivos es muy alta en el hospital investigado. La gran mayoría de estas infecciones se producen con genotipos de alto riesgo oncogénico. El papilomavirus 16 fue el genotipo de alto riesgo más frecuente.

ABSTRACT Objective: To determine the prevalence and genotypic characteristics of anal papillomaviruses in HIV-positive men who have sex with men (MSM). Materials and methods: This is a prospective cross-sectional observational study of HIV-positive MSM at Almenara General Hospital between September 2017 and December 2018. HPV detection and typing was performed using a polymerase chain reaction technique that evaluated 21 genotypes stratified according to oncogenic risk into six low-risk and fifteen high-risk. Results: we evaluated 214 HIV-positive MSM. The overall prevalence of anal infection by papillomavirus infection was 70% (150/214). 86% (129/150) were caused by high-risk genotypes, 79% (102/129) of them were affected by a two or more-papillomavirus genotype. The most frequent high-risk genotypes were HPV-16, 31% (46/150); HPV-52, 22% (33/150); HPV-33, 21% (31/150); HPV-58, 21% (31/150) and HPV-31, 20% (30/150). In addition, HPV-18 reached 7% (10/150). The most frequent low-risk genotypes were HPV-6, 30% (45/150) and HPV 11, 29% (44/150). Conclusions: Prevalence of anal papillomavirus infection in HIV-positive MSM is very high in the hospital investigated. Most of these infections occurs with high-risk oncogenic genotypes. Papillomavirus 16 was the most frequent high-risk genotype.

Caso infrecuente de melanoma del canal anal

Introducción: El melanoma anorrectal es un tumor infrecuente que se caracteriza por ser agresivo y de mal pronóstico; constituye el 1 % entre los tumores malignos colorrectales. Es más frecuente en pacientes femeninas de más de 50 años y alcanza un pico máximo en la octava década de la vida. Objetivo: Presentar las características clínicas de una paciente con melanoma del canal anorrectal. Caso clínico: Se estudió a una paciente femenina de 61 años que acudió a consulta de gastroenterología, por presentar constipación de varios meses de evolución, asociada a tenesmo rectal, anorexia, astenia y pérdida de peso de forma rápida y progresiva. Se le diagnosticó un melanoma anorrectal, en estado avanzado de la enfermedad, por lo que tuvo mala evolución. Conclusiones: Con una anamnesis y exploración física minuciosa, asociado al uso de los medios diagnósticos disponibles y un elevado índice de sospecha, se consigue con la paciente, que el estudio y diagnóstico se hicieran con prontitud y con ello imponer tratamiento.

Introduction: Anorectal melanoma is an infrequent tumor characterized by aggressive and poor prognosis; it constitutes 1% among colorectal malignancies. It is more frequent in female patients over 50 years of age and reaches a maximum peak in the eighth decade of life. Objective: To present the clinical characteristics of a patient with melanoma of the anorectal canal. Clinical case: A 61-year-old female patient was studied, who came to the gastroenterology department for constipation of several months of evolution, associated with rectal tenesmus, anorexia, asthenia and rapid and progressive weight loss. He was diagnosed with anorectal melanoma, in advanced stage of the disease, for which he had poor evolution. Conclusions: With a thorough anamnesis and physical examination, associated with the use of the available diagnostic means and a high index of suspicion, it is achieved with the patient, that the study and diagnosis were made promptly and thus impose treatment.

Carcinoma neuroendocrino de canal anal: presentación de un caso y revisión bibliográfica

Introducción: Los carcinomas neuroendocrinos (NEC) de canal anal son neoplasias extremadamente raras, representando del 1 a 1,6% de la totalidad de los tumores neuroendocrinos (NET). Suelen ser poco diferenciados, muy agresivos y con alta tendencia a metastatizar. Caso clínico: Mujer de 52 años diagnosticada de fisura anal. Durante la esfinterotomía lateral interna (ELI) se evidencia un pólipo milimétrico aparentemente hiperplásico. Biopsia: NEC de alto grado. En el estudio de extensión se observa engrosamiento de la mucosa del canal anal que invade el esfínter interno, sin enfermedad a distancia. Se realiza amputación abdominoperineal laparoscópica donde se objetiva infiltración del tabique rectovaginal, por lo que se realiza resección y vaginoplastia. AP: NEC con estadio PT4B N2A, por lo que se indica quimioterapia adyuvante. Discusión: La presentación clínica de los NEC de canal anal es inespecífica, diferenciándose de otros tumores colorrectales en que hasta el 67% de los pacientes presentan metástasis al diagnóstico, siendo la supervivencia media de 11 meses. Si diagnosticamos un NEC localizado de forma incidental, es fundamental la celeridad en su tratamiento, dada su agresividad.

Introduction: Neuroendocrine carcinomas (NEC) of the anal canal are extremely rare neoplasms, representing 1 to 1.6% of all neuroendocrine tumors (NET). They are usually poorly differentiated, very aggressive and with a high tendency to metastasize. Clinical case: A 52-year-old woman diagnosed with anal fissure. During the LIS, an apparently hyperplastic millimetric polyp is evidenced. Biopsy: high-grade NEC. The imaging study shows thickening of the mucosa of the anal canal that invades the internal sphincter, without metastases. We performed a laparoscopic abdominoperineal amputation, and noticed an infiltration of the rectovaginal septum, so resection and vaginoplasty was performed. Pathology: NEC with stage PT4B N2A, for which adjuvant chemotherapy is indicated. Discussion: The clinical presentation of NEC of the anal canal is nonspecific, differing from other colorectal tumors in that up to 67% of patients have metastases at diagnosis, with a median survival of 11 months. When an incidentally localized NEC is diagnosed, prompt treatment is essential, given its aggressiveness.

Sexually transmitted infections lesions found during colonoscopies

Introduction: Anal examination and videoanoscopy (VA) are rarely performed during colonoscopies. In recent years, there has been a considerable increase in lesions of sexually transmitted anal and rectal infections, but these conditions are not noticed or reported during routine colonoscopy. Objective: To raise awareness regarding the fortuitous findings of lesions and sexually transmitted infections (STIs) in colonoscopy exams and to demonstrate that anal examination and VA provide important information and should be routinely performed. Methods: We conducted a descriptive retrospective study in 16,132 patients screened by colonoscopy and VA between 2006 and 2018. Among numerous other findings, the presence of anal condylomata and sexually transmitted retitis or perianal dermatitis was observed. The rates of each finding were calculated, and the patients were subdivided by sex and into age groups by blocks of ten years. Results: Among the 16,132 colonoscopies performed, 26 cases of condyloma (0.16%) and 50 cases of proctitis or perianal dermatitis suspicious for STI (0.33%) were found. Conclusion: Performing anal examination and VA systematically in all routine colonoscopies enabled the identification of numerous anal conditions, including several fortuitous cases of STIs. The study proposes that anal examination and VA should be performed in all routine colonoscopies and, in suspected cases, complementary tests for STIs. (AU)

Manejo Clínico ­ Quirúrgico de pacientes con Fisura Anal en la Unidad de Coloproctología del HECAM / Clinical-Surgical Management of patients with Anal Fissure in the Unit HECAM Coloproctology

La fisura anal es una de las enfermedades más antiguamente descritas, la misma que, ha tenido hasta el momento múltiples tratamientos tanto médicos como quirúrgicos, existiendo controversias en su algoritmo terapéutico. Constituye una de las patologías cuyo diagnóstico y tratamiento corresponde a la Especialidad de Coloproctología, afecta a ambos sexos y a cualquier edad y puede ser aguda o crónica. Proponemos el presente Protocolo para un adecuado manejo de la patología, de manera que sirva de guía en la toma correcta de decisiones basadas en la evidencia y el consenso de quienes integramos la Unidad Técnica de Coloproctología del Hospital de Especialidades Carlos Andrade Marín.

Anal fissure is one of the oldest described diseases, which has so far had multiple medical and surgical treatments, with controversies in its therapeutic algorithm. It is one of the pathologies whose diagnosis and treatment corresponds to the Coloproctology Specialty, it affects both sexes and any age and can be acute or chronic. We propose the present Protocol for an adequate management of the pathology, so that it serves as a guide in the correct decision making based on evidence and consensus of those who integrate the Technical Unit of Coloproctology of the Hospital de Especialidades Carlos Andrade Marín.

Histoplasmosis in the anal canal: case report and literature review

We herein present the case of a patient with anal condylomatosis concomitant with histoplasmosis, whose diagnosis was only possible through the collection of material and the subsequent evidence of a primary pulmonary focus. Histoplasmosis is a fungal disease whose contamination occurs through the respiratory route, and it can spread to the digestive tract, but the anus is rarely affected. It is important to have a high degree of suspicion to make the diagnosis, especially in immunosuppressed patients.

Anal cancer in systemic lupus erythematosus patients is a neglected condition / Câncer anal em pacientes com lúpus eritematoso sistêmico é uma condição negligenciada

Patients with systemic lupus erythematosus have a higher incidence of neoplasms associated with human papillomavirus infections, such as those that affect the vulva, the vagina, and the cervix; however, little is known about the frequency of anal cancer among these patients. Although there are recommendations for screening for this cancer in immunosuppressed individuals, it is possible that this procedure is not strictly followed. We describe the case of a 47-year-old woman with systemic lupus erythematosus who was treated with immunosuppressants and developed advanced anal squamous cell carcinoma after adequate treatment and healing of a high-grade cervical squamous intraepithelial lesion. Five years after the completion of the anal cancer treatment, the patient presented with cystic hepatic lesions that were histopathologically confirmed to be metastatic squamous cell carcinoma. This report aimed to highlight the need for anal cancer screening in patients with lupus, particularly if there was a history of cervical cytopathological alterations. (AU)

Resumo Pacientes com lúpus eritematoso sistêmico apresentam maior incidência de neoplasias associadas a infecções por HPV, como aquelas que acometem a vulva, a vagina e o colo do útero, mas pouco se sabe sobre a frequência de câncer anal entre essas pacientes. Embora existam recomendações para o rastreamento desse câncer em indivíduos imunossuprimidos, é possível que esse procedimento não esteja sendo rigorosamente seguido. Descrevemos uma mulher de 47 anos com lúpus eritematoso sistêmico, tratada com imunossupressores, que desenvolveu um carcinoma escamocelular anal avançado após tratamento adequado e cicatrização de lesão intraepitelial escamosa cervical de alto grau. Cinco anos após o término do tratamento do câncer anal, a paciente apresentou lesões císticas hepáticas cujo resultado citopatológico confirmou ser carcinoma escamocelular metastático. O presente relato teve como objetivo chamar atenção para a necessidade do rastreamento do câncer anal em pacientes com lúpus, principalmente se houver história prévia de alterações citopatológicas cervicais. (AU)

Clinicopathological characteristics and prognosis of anorectal malignant melanoma / 中华普通外科杂志

Objective:To investigate the impact of the clinicopathological characteristics of anorectal malignant melanoma (ARMM) on the prognosis.Methods:The clinicopathological data of 40 ARMM patients undergoing surgery at the Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences from Apr 2012 to Apr 2022 were collected, and the impact of different clinicopathological factors and treatment modalities on the overall survival of ARMM patients was investigated using Kaplan-Meier survival analysis and multifactorial Cox proportional risk model analysis.Results:Among 40 ARMM patients , 16 were male and 24 were female. The median age of onset was 61 yr. The median follow-up period for all patients was 47 (25-69) months, with a median survival of 19 (15-23) months and 1-year and 3-year survival rates of 74.3% and 21.7%, respectively. There was no statistically significant difference in survival time between the two groups of patients receiving wide local excision and abdominoperineal resection( χ2=1.281, P=0.258). Univariate analysis showed that overall survival in patients with ARMM was related to tumour diameter, depth of infiltration, specimen margin and lymph node metastasis ( χ2=1.281, P=0.039; χ2=3.760, P=0.042; χ2=6.581, P=0.010; χ2=21.683, P<0.001), and multivariate analysis suggested that lymph node metastasis was an independent risk factor for overall survival in patients with ARMM. Conclusion:Tumour diameter, depth of infiltration, specimen margin and lymph node metastasis were important prognostic influences in ARMM, and lymph node metastasis was an independent risk factor for overall survival in ARMM patients.

O índice da taxa de fadiga é maior em crianças com constipação e incontinência fecal por retenção / The fatigue rate index is higher in children with functional constipation and retentive fecal incontinence

ABSTRACT Background: The Fatigue Rate Index (FRI) is a parameter in anorectal manometry (ARM) to assess sustained voluntary contraction, considering the squeeze pressure and fatigability of the external anal sphincter. It is used in adults to detect fecal incontinence even in patients who present normal squeeze pressures. The FRI in adult patients with functional constipation is similar to controls. Objective: The aim of this study was to evaluate the feasibility and values of FRI in children in relation to the values previously established in adults and comparing children with functional constipation and retentive fecal incontinence to children without retentive fecal incontinence. Methods: This retrospective study evaluated 105 ARM performed from Jan 2014 to Apr 2015. 42 patients were selected (were able to perform a voluntary contraction and had no co-morbidities other than functional constipation). 14 (33.3%) of those collaborated in sustaining contraction for 40 seconds (s), allowing the evaluation of the FRI. Patients with retentive fecal incontinence secondary to functional constipation (n=7, aged 6 to 13 years, six boys) were our interest group. Patients with functional constipation without fecal incontinence (n=7, aged 6 to 13 years, four boys) were considered a reference group. The ARM were performed with a radial eight-channel perfusion catheter (DynamedTM, São Paulo, Brazil) and the FRI was calculated (Proctomaster 6.4) in the first 20 s and overall 40 s of sustained voluntary contraction. Results: 14 of the selected 42 collaborated in sustaining contraction for 40 s, allowing the evaluation of the FRI. In the first 20 s of contraction, the fecal incontinence group showed a significantly higher mean FRI (2.48±1.39 min) compared to the reference group (1.13±0.72 min, P=0.042), which was not observed in the 40 s interval due to less uniform contraction. The anal resting pressure was higher in the fecal incontinence group (76.83 mmHg) than in the reference group (54.13 mmHg), but the statistical study did not reach significance (P=0.051). Conclusion: The FRI is feasible in children. The mean FRI obtained in this study is lower than the reported in constipated adults. The mean FRI among children with functional constipation and retentive fecal incontinence is higher than among constipated children without retentive fecal incontinence.

RESUMO Contexto O índice de Taxa de Fadiga (ITF) é um parâmetro na manometria anorretal (MAR) que é utilizado para avaliar a contração voluntária sustentada, considerando a pressão máxima de contração e a fatigabilidade do esfíncter anal externo. Este parâmetro é utilizado em adultos para diagnóstico da incontinência fecal mesmo entre paciente que apresentem pressões máximas de contração normais. O ITF em pacientes adultos com constipação é similar a controles. Objetivo: Avaliar a factibilidade e os valores do ITF em crianças com constipação e incontinência fecal por retenção em relação aos valores previamente estabelecidos para adultos, e comparar os dados das crianças com constipação intestinal funcional com e sem incontinência fecal por retenção. Métodos Este estudo retrospectivo avaliou 105 MAR realizadas de janeiro de 2014 a abril de 2015. 42 pacientes foram selecionados (foram capazes de realizar uma contração voluntária e não apresentavam outras comorbidades além da constipação). 14 destes pacientes cooperaram em manter a contração voluntária por 40 segundos, permitindo a avaliação do ITF. Pacientes com incontinência fecal por retenção secundária a constipação (n=7, 6 a 13 anos, seis meninos) constituíram nosso grupo de interesse. Pacientes com constipação funcional sem incontinência fecal por retenção. (n=7, 6 a 13 anos, quatro meninos) constituíram o grupo de referência. As MAR foram realizadas com cateter de perfusão de oito canais radiais (DynamedTM, São Paulo, Brazil) e o ITF foi calculado (Proctomaster 6.4) nos primeiros 20 segundos e também nos 40 segundos totais da contração voluntária sustentada. Resultados: Dos 42 pacientes selecionados, 14 (33%) colaboraram mantendo o platô de contração uniforme durante 40 segundos, permitindo a avaliação do ITF nos primeiros 20 segundos de contração, o grupo com incontinência fecal apresentou uma média de ITF significativamente mais alta (2,48±1,39 min) em comparação ao grupo de referência (1,13±0,72 min, P=0,042), o que não foi observado no intervalo de 40 segundos devido a contração menos uniforme. A pressão anal de repouso foi mais elevada no grupo com incontinência fecal (76,83 mmHg) do que no grupo de referência (54,13 mmHg), porém o estudo estatístico não atingiu significância (P=0,051). Conclusão: O ITF é factível em crianças. A média do ITF obtida neste estudo é mais baixa do que o reportado em adultos constipados (2,8 min). A média do ITF entre crianças constipadas com incontinência fecal por retenção fui superior ao do que observado em crianças constipadas sem incontinência fecal retentiva.

Metástasis cutánea metacrónica de carcinoma escamoso de canal anal / Methachronical cutaneous metastasis of squamous carcinoma of the anal canal / Metástase cutânea metacronica de carcinoma escamoso do canal anal

El tratamiento correcto de carcinoma escamoso avanzado requiere de un manejo multidisciplinar entre cirujanos, anatomopatólogos, radioterapeutas y radiólogos. Los protocolos están claros cuando nos hallamos ante una enfermedad localizada, sin embargo, cuando la enfermedad es metastática no existe evidencia científica de los pasos a seguir. Presentamos una paciente con un carcinoma escamoso del ano con una única metástasis cutánea metacrónica que fue tratada con cirugía y radioterapia posterior con buena respuesta.

The right therapy of anal cancer needs a multidisciplinary management of surgeons, pathologists, radiotherapists and radiologist. The treatment of squamous cell carcinoma of the anal canal is well-known when the patient presents a locally disease, nevertheless, there is a lack of information with the advanced anal cancer. We report a case of a 74-year-old woman with a solitary methachronical cutaneous metastasis of anal cancer which responded perfectly to surgery and radiotherapy.

A correta terapêutica do câncer anal necessita de uma gestão multidisciplinar de cirurgiões, patologistas, radio terapeutas e radiologistas.O tratamento do carcinoma espinocelular do canal anal é bem conhecido quando o paciente apresenta uma doença local, porém, há uma falta de informação sobre o câncer anal avançado. Relatamos o caso de uma mulher de 74 anos com metástase cutânea metacrônica solitária de câncer anal que respondeu perfeitamente à cirurgia e à radioterapia.

Research progress of 5-aminolevulinic acid-mediated photodynamic therapy for the treatment of anal canal condyloma acuminatum / 中国基层医药

Condyloma acuminatum is a sexually transmitted disease caused by human papillomavirus infection. In recent years, the incidence of anal canal condyloma acuminatum is gradually increasing, which seriously affects the physical and mental health of patients. At present, various treatment options are available for condyloma acuminatum. There is no method to completely eradicate condyloma acuminatum. 5-Aminolevulinic acid-mediated photodynamic therapy is a novel approach that uses photosensitizers and light to treat condyloma acuminatum and has been widely used in the clinic. This paper reviews the underlying action mechanism of 5-aminolevulinic acid-mediated photodynamic therapy and the clinical research progress of 5-aminolevulinic acid-mediated photodynamic therapy for the treatment of anal canal condyloma acuminatum.

Occurrence and risk factors of anal margin edema after Milligan-Morgan hemorrhoidectomy in patients with mixed hemorrhoids / 中国基层医药

Objective:To investigate the risk factors of anal margin edema after Milligan-Morgan hemorrhoidectomy (MMH) in patients with mixed hemorrhoids.Methods:The clinical data of 600 patients with mixed hemorrhoids undergoing MMH in the First People's Hospital of Wenling from January 2017 to January 2020 were retrospectively analyzed. The patients were divided into study (with anal margin edema, n = 272) and control (without anal margin edema, n = 328) groups according to whether anal margin edema occurred after surgery. Gender, age, surgical incision suture, internal anal sphincter relaxation, infection, intraoperative operation, postoperative defecation, and postoperative fumigation with traditional Chinese medicine were compared. The risk factors of anal margin edema after MMH were analyzed by univariate analysis and logistic regression analysis. Results:There were no significant differences in suture of surgical incision [20.22%(55/272) vs. 18.29% (60/328)], infection [15.44% (42/272) vs. 17.68% (39/328)], internal anal sphincter relaxation [15.81% (43/272) vs. 17.68% (58/328)], and postoperative fumigation with traditional Chinese medicine [72.79% (198/272) vs. 71.65% (235/328)] between the two groups ( χ2 = 0.35, 1.60, 0.37, 0.09, all P > 0.05). Multivariate logistic regression analysis showed that female gender, age ≤ 60 years, unreasonable postoperative operation, and abnormal defecation were all independent risk factors for anal margin edema after MMH ( OR = 2.28, 2.52, 5.95, 3.07, all P < 0.05). Conclusion:Gender, age, surgical operation, and postoperative defecation are the risk factors for anal margin edema after MMH. Clinically, it is necessary to carry out reasonable perioperative intervention to avoid the occurrence of postoperative anal margin edema.

Carcinoma Epidermoide de Canal Anal. A propósito de un caso

El cáncer de canal anal y ano, es considerado como poco frecuente, sin embargo, ha aumentado ligeramente su incidencia representando del 1 al 2% de todas las neoplasias del intestino grueso. Dentro de los factores que se asocian a la génesis de estos tumores se encuentra la afección por el virus del papiloma humano. Se presenta el caso de una paciente femenina de 32 años que acude al servicio de Radioterapia del Hospital Clínico Quirúrgico Hermanos Ameijeiras, con antecedentes de Síndrome de Down y diagnóstico de un carcinoma epidermoide del ano y región perianal, variante exofítico y con antecedentes de infección por el virus del papiloma humano. Es evaluada en equipo multidisciplinario y no tiene criterio de cirugía por el tamaño tumoral, por lo que se decidió según estadiamiento la quimioradioterapia concurrente. La paciente presentó una respuesta completa al tratamiento con radioterapia, sin presentar complicaciones, con lo que se demuestra la efectividad de la radioterapia en los tumores del ano y canal anal.

Cancer of the anal canal and anus is considered rare, however, its incidence has slightly increased representing 1 to 2% of all neoplasms of the large intestine. Among the factors that are associated with the genesis of these tumors is the condition by the human papillomavirus. We present the case of a 32-year-old female patient who attends the Radiotherapy service of the Hermanos Ameijeiras Clinical Surgical Hospital, with a history of Down Syndrome and a diagnosis of a squamous cell carcinoma of the anus and perianal region, exophytic variant and with a history of infection by the human papillomavirus. It is evaluated in a multidisciplinary team and has no surgical criteria due to tumor size, so it was decided according to staging concurrent chemoradiotherapy. The patient presented a complete response to treatment with radiotherapy, without presenting complications, which demonstrates the effectiveness of radiotherapy in tumors of the anus and anal canal.

O câncer do canal anal e do ânus é considerado raro, porém, sua incidência aumentou ligeiramente representando 1 a 2% de todas as neoplasias do intestino grosso. Entre os fatores associados à gênese desses tumores está a condição pelo papilomavírus humano. Apresentamos o caso de uma paciente do sexo feminino de 32 anos que atende ao serviço de Radioterapia do Hospital Cirúrgico Clínico Hermanos Ameijeiras, com histórico de Síndrome de Down e diagnóstico de carcinoma celular escamoso do ânus e região perianal, variante exofítica e com histórico de infecção pelo papilomavírus humano. É avaliado em equipe multidisciplinar e não possui critérios cirúrgicos devido ao tamanho do tumor, por isso foi decidido de acordo com a chemoradioterapia simultânea. O paciente apresentou resposta completa ao tratamento com radioterapia, sem apresentar complicações, o que demonstra a eficácia da radioterapia em tumores do ânus e do canal anal.

Isquemia aguda del canal anal / Acute Ischemia of the Anal Canal

Introducción: La isquemia anal aguda con gangrena es una entidad infrecuente, con escasa literatura publicada al respecto, cuyas cifras de mortalidad descritas se sitúan en un 20 por ciento - 40 por ciento de los casos. Debe considerarse en ancianos con enfermedad aterosclerótica que presenten síntomas gastrointestinales inferiores y shock hipotensivo. Puede ser causada por oclusión vascular aguda, enfermedad vascular grave o un estado de bajo flujo, aunque en algunos casos se presenta sin enfermedad vascular preexistente. Objetivo: Presentar la literatura existente acerca del manejo diagnóstico y terapéutico de la isquemia de canal anal en base a un caso clínico diagnosticado y tratado de urgencia en el hospital "Marina Baixa". Caso clínico: Se presenta un caso de isquemia espontánea de canal anal en paciente de 76 años de edad con morbilidad cardiovascular asociada. Debuta como cuadro séptico sin evidencia de causa desencadenante. Conclusiones: Las pruebas endoscópicas y radiológicas deben realizarse con urgencia y la valoración quirúrgica está siempre justificada en estos pacientes debido a la alta tasa de mortalidad descrita en el manejo conservador del cuadro. En casos graves, la reanimación preoperatoria y cirugía urgente para resecar el segmento gangrenoso es necesaria. Sin embargo, el tratamiento de la proctitis isquémica aguda es controvertido y depende, en parte, del estado basal del paciente y los hallazgos clínicos, siendo importante examinar otras posibles etiologías de proctitis isquémica y así determinar qué pacientes necesitan intervención quirúrgica temprana en comparación con una actitud más conservadora(AU)

Introduction: Acute ischemic gangrene of the anus is an infrequent entity, with little published literature, whose reported mortality figures are 20-40 percent of cases. It should be considered in elderlies with atherosclerotic disease who present lower gastrointestinal symptoms and hypotensive shock. It can be caused by acute vascular occlusion, severe vascular disease, or a low-flow state, although in some cases it presents without pre-existing vascular disease. Objective: To present the existing literature on diagnostic and therapeutic management of ischemia of the anal canal upon the base of a clinical case diagnosed and treated as an urgency at Marina Baixa hospital. Clinical case: The case is presented of a 76-year-old patient with spontaneous ischemia of the anal canal and associated cardiovascular morbidity. It debuts as a septic condition without evidence of a triggering cause. Conclusions: Endoscopic and radiological tests should be performed urgently. Surgical assessment is always justified in these patients, due to the high mortality rate described in the conservative management of the condition. In severe cases, preoperative resuscitation and urgent surgery to resect the gangrenous segment is necessary. However, managment of acute ischemic proctitis is controversial and depends, in part, on the patient's baseline status and clinical findings, while it is important to examine other possible etiologies of ischemic proctitis and thus determine which patients need early surgical intervention compared to a more conservative attitude(AU)

Rectal damage control: when to do and not to do / Control de daños de recto: que hacer y que no hacer

Abstract Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.

Resumen El trauma de recto es poco frecuente, pero generalmente se asocia a lesiones de órganos adyacentes en la región pélvica y abdominal. Estudios recientes han cambiado los paradigmas del manejo tradicional derivados del trauma militar, mostrando mejores resultados en la morbilidad y mortalidad. Sin embargo, las técnicas de control de daños en el trauma rectal aún son controvertidas. El objetivo de este articulo es proponer el algoritmo de manejo del paciente con trauma rectal e inestabilidad hemodinámica, según los principios de la cirugía de control de daños. Se propone que las lesiones del recto en su porción intraperitoneal sean manejadas de la misma manera que las lesiones del colon. Mientras que el manejo de las lesiones extraperitoneales del recto dependerá del compromiso de la circunferencia rectal. Si es mayor del 25% se recomienda realizar una colostomía. Si es menor, se propone optar por el manejo conservador o el reparo primario. Saber que hacer o que no hacer en el trauma de recto marca la diferencia.

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study

ABSTRACT BACKGROUND: The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial. OBJECTIVE: To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury. DESIGN AND SETTING: Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail. METHODS: The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes. RESULTS: The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001). CONCLUSION: Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

A new mixed surgical treatment for grades iii and iv hemorrhoids: modified selective hemorrhoidectomy combined with complete anal epithelial retention / Um novo tratamento cirúrgico para hemorroidas mistas graus iii e iv: hemorroidectomia seletiva modificada combinada com retenção epitelial anal completa

ABSTRACT Background: Varicose veins appear above and below the dentate line in mixed hemorrhoids, which seriously affects anal function and quality of life. Aim: To propose an improvement in tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery. Methods: A prospective randomized controlled study was designed enrolling 200 patients with grade III and IV hemorrhoids. They were divided into control and observation groups. The control received Milligan-Morgan surgery, and the observation the modified tissue-selecting therapy stapler combined with complete anal canal preservation surgery. All patients were followed for six months to evaluate the treatment differences. Results: In final, control group included 82 and observation 87. The average operation time of the control group was significantly lower than that of the observation, while the bleeding volume was significantly lower in control group. The control group VAS score was 3 (1, 4), and observation 4 (2, 5). There was no significant difference in the incidence of urinary retention, bleeding and wound margin edema after surgery at one month postoperatively. Digital incidence of anal stenosis in the observation group was significantly lower than in control; the same occurred with residual anal margins. The postoperative anal canal diameter was significantly larger than the control group. Wexner anal incontinence score showed that no anal incontinence occurred in both groups, and the control group scored was significantly higher than observation. In final six months follow-up, the observation group did not experience any relapse and four cases were found among controls. The treatment satisfaction of the observation group was better. Conclusions: In grades III and IV hemorrhoids, modified tissue-selecting therapy combined with complete anal canal preservation had better prognosis and treatment satisfaction than Milligan-Morgan procedure, and it is a new surgical method for patients with advanced mixed hemorrhoids.

RESUMO Racional: Veias varicosas aparecem acima e abaixo da linha dentada nas hemorroidas mistas, afetando seriamente a função anal e a qualidade de vida. Objetivo: Propor melhoria na terapia de seleção de tecido de reparo do coxim anal combinado com retenção completa epitelial do canal anal em comparação com a operação de Milligan-Morgan. Métodos: Estudo prospectivo randomizado controlado foi desenhado envolvendo 200 pacientes com hemorroidas graus III e IV. Eles foram divididos em grupos de controle e observação. O controle recebeu operação de Milligan-Morgan, e o de observação procedimento de seleção de tecido modificado combinado com operação completa de preservação do canal anal. Todos os pacientes foram acompanhados por seis meses para avaliar as diferenças de tratamento. Resultados: No final, o grupo controle incluiu 82 e o de observação 87. O tempo médio de operação do grupo controle foi significativamente menor do que o de observação, enquanto o volume de sangramento foi significativamente menor no grupo controle. O escore VAS do grupo controle foi 3 (1, 4) e no de observação 4 (2, 5). Não houve diferença significativa na incidência de retenção urinária, sangramento e edema da margem da ferida no pós-operatório de um mês. A incidência de estenose anal digital no grupo observação foi significativamente menor do que no controle; o mesmo ocorreu com as margens anais residuais. O diâmetro do canal anal pós-operatório foi significativamente maior nele do que o grupo controle. A pontuação de incontinência anal de Wexner mostrou que nenhuma incontinência ocorreu em ambos os grupos, e a pontuação do grupo de controle foi significativamente maior do que no de observação. Nos últimos seis meses de acompanhamento, o grupo observação não teve nenhuma recaída e quatro casos foram encontrados entre os controles. A satisfação com o tratamento do grupo observação foi maior. Conclusões: Nas hemorroidas graus III e IV, o tratamento de seleção de tecido modificado combinado com a preservação completa do canal anal teve melhor prognóstico e satisfação do que com o procedimento de Milligan-Morgan, e é um novo método cirúrgico para pacientes com hemorroidas mistas avançadas.

Anorectal manometry standard of a brazilian population at productive age without pelvic floor disorders: a prospective volunteered study / Valores manométricos anorretais para a população brasileira eutrófica em idade produtiva e sem distúrbios do assoalho pélvico: estudo prospectivo com voluntários

ABSTRACT Background: Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities. Aim: To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female. Methods: Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders. Results: Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003). Conclusions: Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal

RESUMO Racional: Devido à falta de padrões normais de manometria anorretal no Brasil, os dados utilizados estão sujeitos a padrões de normalidade descritos em diferentes nacionalidades . Objetivo: Determinar os valores e a faixa da manometria anorretal de pessoas em idade produtiva, sem distúrbios do assoalho pélvico, comparando os parâmetros obtidos entre homens e mulheres. Métodos: Análise prospectiva de dados clínicos, como gênero, idade, raça, índice de massa corporal (IMC) e manometria anorretal, de voluntários de uma referência universitária brasileira em distúrbios do assoalho pélvico. Resultados: Quarenta pessoas foram incluídas, com idade média de 45,5 anos nos homens e 37,2 nas mulheres (p=0,43). De acordo com homens e mulheres, respectivamente em mmHg, as pressões de repouso foram semelhantes (78,28 vs. 63,51, p=0,40); pressões de contração (153,89 vs. 79,78, p=0,007) e pressão total de compressão (231,27 vs. 145,63, p=0,002). Os homens apresentaram valores significativamente maiores de contração esfincteriana, assim como o comprimento médio do canal anal funcional (2,85 cm nos homens vs. 2,45 cm nas mulheres, p=0,003). Conclusões: Os níveis normais de pressão esfincteriana no Brasil diferem dos utilizados até o momento como padrão normal da literatura. O gênero masculino apresenta maior tônus ​​do esfíncter anal externo em relação ao feminino, além de maior extensão do canal anal funcional

SMILE-like lesion in the anal canal

Stratified mucin-producing intraepithelial lesion (SMILE) is an intraepithelial lesion with overlapping features of the high-grade squamous intraepithelial lesion (HSIL) and adenocarcinoma in situ (AIS). Currently, it is well described in the cervix. We present a case showing similar SMILE-like lesions in the polypectomy specimen from the anal canal along with invasive adenocarcinoma components. This lesion showed an immuno-profile characteristic of a SMILE lesion described in the cervix, such as p63 negativity, high ki67 index, and nuclear positivity for p16. It might be arising from the Human papillomavirus prone transitional region of the anal canal as described in the cervix. However, we could not assure this association and etiological link due to insufficient material in the formalin-fixed paraffin-embedded block. Notwithstanding, we strongly suggest that the HPV is the main driver for this SMILE-like lesion similar to what is described in the cervix. To our knowledge, this is the first case report of a SMILE lesion in the anal canal. Further studies will be required to elucidate the underlying pathogenetic mechanism of SMILE-like lesions described in the anal canal.

Clinical study on the treatment of anal fistula by transsphincter fistulectomy / 中国基层医药

Objective:To investigate the clinical effect of transsphincter fistulectomy in the treatment of anal fistula.Methods:Seventy-three patients with anal fistula who received treatment in Zhoushan Hospital from March 2016 to March 2020 were included in this study. They were randomly assigned to undergo either conventional incision combined with thread-drawing drainage (control group, n = 35) or transsphincter fistulectomy (observation group, n = 38). Operative time, wound healing time, length of hospital stay, Visual Analogue Scale (VAS) score 24 and 48 hours after surgery, complications, the improvement in anal sphincter function before and 3 months after surgery were compared between the two groups. Results:Operative time, wound healing time and length of hospital stay in the observation group were (49.83 ± 7.67) minutes, (20.78 ± 3.54) days and (5.31 ± 1.27) days, which were significantly shorter than those in the control group [(62.31 ± 5.45) minutes, (25.87 ± 3.10) days, (7.78 ± 1.32) days, t = 8.063, 6.512, 8.133, all P < 0.05). The VAS score 24 and 48 hours after surgery in the observation group were (2.43 ± 0.64) points and (1.21 ± 0.36) points, respectively, which were significantly lower than those in the control group [(3.87 ± 1.23) points, (2.83 ± 0.97) points, t = 6.347 and 9.607, both P < 0.05]. The incidence of complication in the observation group was significantly lower than that in the control group [5.26% (2/38) vs. 28.57% (10/35), χ2 = 7.206, P < 0.05]. Conclusion:Transsphincter fistulectomy in the treatment of anal fistula has good therapeutic effects, can reduce pain and has little impact on the function of anal sphincter. It is innovative and scientific.