Traumatismo anorrectal contuso. Reporte de un caso y revisión bibliográfica / Blunt anorectal trauma. Case reportand literature review

Introducción: El traumatismo anorrectal es una causa poco frecuente de consulta al servicio de emergencias, con una incidencia del 1 al 3%. A menudo está asociado a lesiones potencialmente mortales, por esta razón, es fundamental conocer los principios de diagnóstico y tratamiento, así como los protocolos de atención inicial de los pacientes politraumatizados. Método: Reportamos el caso de un paciente masculino de 47 años con trauma anorrectal contuso con compromiso del esfínter anal interno y externo, tratado con reparación primaria del complejo esfinteriano con técnica de overlapping, rafia de la mucosa, submucosa y muscular del recto. A los 12 meses presenta buena evolución sin incontinencia anal. Conclusión: El tratamiento del trauma rectal, basado en el dogma de las 4 D (desbridamiento, derivación fecal, drenaje presacro, lavado distal) fue exitoso. La técnica de overlapping para la lesión esfinteriana fue simple y efectiva para la reconstrucción anatómica y funcional. (AU)

Introduction: Anorectal trauma is a rare cause of consultation to the Emergency Department, with an incidence of 1 to 3%. It is often associated with life-threatening injuries, so it is essential to know the principles of diagnosis and treatment, as well as the initial care protocols for the polytrau-matized patient. Methods: We present the case of a 47-year-old man with a blunt anorectal trauma involving the internal and external anal sphincter, treated with primary overlapping repair of the sphincter complex and suturing of the rectal wall. At 12 months the patient presents good outcome, without anal incontinence. Conclusion: The treatment of rectal trauma, based on the 4 D ́s dogma (debridement, fecal diversion, presacral drainage, distal rectal washout lavage) was successful. Repair of the overlapping sphincter injury was simple and effective for anatomical and functional reconstruction. (AU)

Presentaciones de la sífilis anorrectal: la gran simuladora / Anorectal syphilis presentations: the great pretender

Antecedentes: La sífilis es una infección sexualmente transmisible sistémica crónica que afecta a docenas de millones de personas al año. A nivel anorrectal, su manifestación polimórfica obliga al diagnóstico diferencial con enfermedades anorrectales benignas y malignas. Objetivo: Describir las diferentes presentaciones de la sífilis anorrectal a propósito de 5 casos clínicos. Método: Estudio observacional, retrospectivo, descriptivo. Resultados: La mayoría de los pacientes fueron VIH positivos en edad sexual activa. Las manifestaciones registradas, al igual que las reportadas en la bibliografía fueron las fisuras, úlceras perianales y pseudotumores. Conclusiones: La sífilis es considerada "la gran simuladora". En la localización anorrectal se requiere una alta sospecha diagnóstica para diferenciarla de presentaciones similares de otras enfermedades anales benignas, la enfermedad inflamatoria intestinal y el cáncer anorrectal, con el fin de evitar el consiguiente riesgo de sobretratamiento. (AU)

Background: Syphilis is a chronic systemic sexually transmitted infection that affects tens of millions of people annually. At the anorectal level, its polymorphic manifestation requires differential diagnosis with benign and malignant anorectal diseases. Objective: To review the presentation of anorectal syphilis from 5 clinical cases. Methods: Observational, retrospective, descriptive study. Results: Most of the patients were HIV positive in sexually active age. The manifestations recorded and reported in the literature were fissures, perianal ulcers, and pseudotumors. Conclusions: Syphilis is considered "the great pretender". In anorectal syphilis, a high diagnostic suspicion is needed to differentiate it from similar presentations due to other anal conditions, inflammatory bowel disease, and anorectal cancer, to avoid the consequent risk of overtreatment. (AU)

Correlation between development of terminal rectal ganglion and spinal cord/sacral abnormalities in boys with complex anorectal malformations / 陆军军医大学学报

Objective To investigate the relationship between the development of terminal rectal ganglion and spinal cord/sacral abnormalities in boys with complex anorectal malformations(ARMs)in order to improve the understanding of rectal ganglion development abnormalities in ARMs patients.Methods A retrospective trial was conducted on the male patients with complex ARMs admitted to our hospital from 2015 to 2021.The terminal rectal specimens were taken from them during anoplasty.According to the findings on development of terminal rectal ganglion after HE staining,the patients were classified into G1 group(ganglion cells observed)and G2 group(no ganglion cells observed).Imaging techniques were used to evaluate whether there were abnormalities in the spinal cord and sacrum,and their correlation with the terminal rectal ganglion development was analyzed.Results A total of 139 patients were enrolled,and their median age at anoplasty was 5.77(4.57,6.97)months.There were no significant differences between the G1(n=80,57.6％)and G2(n=59,42.4％)groups in ARMs pathological type(P=0.706)and age at surgery(P=0.140).Radiological findings showed there were 48 cases(34.5％)of spinal cord anomalies(SCA),25 cases(18.0％)of sacral abnormalities and 18 cases(12.9％)of coccyx abnormalities.No significant differences were observed in the incidences of SCA and sacral abnormalities between the G1 and G2 groups(P＜0.05).Moreover,the differences of fatty filum terminale and syrinx were statistically significant(P＜0.05).In addition,the ratio of sacrum to coccyx between the G1 and G2 groups were 0.72±0.10 vs 0.67±0.12(P＜0.05)of the anteroposterior position and 0.77±0.09 vs 0.72±0.09(P＜0.05)of the lateral position.Multivariate logistic regression analysis showed that sacral abnormalities,fatty filum terminale and syrinx were independent predictors of rectal terminal ganglion absence in male patients with complex ARMs.Conclusion The development of terminal rectal ganglia in male patients with ARMs is closely associated with the abnormalities of spinal cord and sacrum.Sacral abnormalities,fatty filum terminale and syrinx are independent predictors of rectal terminal ganglion absence in male patients with complex ARMs.

Research Progress of Artificial Intelligence in the Diagnosis and Treatment of Anorectal Diseases / 昆明医科大学学报

In the past 20 years,the development of artificial intelligence has made rapid progress,and it is increasingly applied in the medical field,including medical image-assisted diagnosis and treatment,health management,disease risk prediction and so on.In this paper,the application status of artificial intelligence-assisted detection and diagnosis system based on deep learning in anorectal diseases is summarized,and the new methods related to the diagnosis and treatment of anorectal diseases at home and abroad are summarized.It mainly reviews the research progress of artificial intelligence technology in the diagnosis and treatment of anal fistula,perianal abscess,hemorrhoids and other anorectal diseases.

Correlation between the lateral and anteroposterior sacral ratios in anorectal malformation / 实用放射学杂志

Objective To determine the correlation and agreement of sacral ratio(SR)measured by lateral and anteroposterior radiographs in patients with anorectal malformation(ARM).Methods A retrospective analysis was conducted on the anteroposterior and lateral radiographs images of the sacral vertebrae of patients with ARM.All SR values were measured by three radiologists.Pearson's correlation coefficient were used to assess the correlation between the SR measured by lateral and anteroposterior radiographs.A weighted Kappa statistic was used to measure the agreement between how the anteroposterior and lateral SR categorized observations into risk groups.Results Of the 385 ARM patients,25 patients whose radiographs image quality was insufficient to calculate SR value were excluded.For a given pair of measurements,the mean lateral SR value was 0.08 units greater than the anteroposterior SR value[95%confidence interval(CI)0.06-0.09,P<0.01].Anteroposterior and lateral images had a moderate positive correlation(r=0.79,95%CI 0.73-0.79,P<0.01)and moderate agreement in risk categorization(Kappa=0.62,P<0.01).Anteroposterior and lateral readings conducted by all three radiologists had excellent inter-rater reliability with intraclass correlation coefficient(ICC)for anteroposterior and lateral SR of 0.88 and 0.84,respectively.Conclusion Even though the anteroposterior and lateral SR values have moderate positive correlation,the mean SR value determined by images in the lateral is 0.08 units greater than the anteroposterior.Anteroposterior and lateral SR value conclude different risk categories relatively often.The SR values measured by lateral sacral radiographs are more clinically significant than those measured by anteroposterior radiographs.

CHEN Yongcan's Experience in Treating Postoperative Complications of Anorectal Disease from the Liver and Spleen / 浙江中医药大学学报

[Objective]To summarize the clinical experience of Director CHEN Yongcan in the treatment of postoperative complications of anorectal disease from the liver and spleen.[Methods]Through learning from teachers,collecting clinical medical cases,reviewing relevant literature,analyzing the relationship between liver and spleen and anorectum,the key pathogenesis and main treatment methods of this disease were proposed,and the clinical experience of Director CHEN in treating postoperative complications of anorectal disease from the liver and spleen was expounded,and three medical cases were attached for evidence.[Results]Director CHEN believes that the postoperative complications of anorectal disease are closely related to liver and spleen disorders,and the disease is located in the anorectum,and the liver and spleen are responsible.The relationship between anorectum and liver and spleen reflects in three aspects:physiological communication,functional connection and five elements correlation,and the key pathogenesis is liver and spleen discord and Qi imbalance,and the treatment advocates starting from the liver and spleen,with the three methods of rising,clearing and nourishing,harmonizing the liver and spleen,regulating the Qi movement,and promoting the recovery of anorectal function after surgery.The cited medical cases included the treatment of postoperative constipation of mixed hemorrhoids by raising the spleen and soothing the liver,the treatment of postoperative abdominal distension of anal fistula by clearing the liver and promoting the spleen,and the treatment of postoperative diarrhea of rectal cancer by nourishing the spleen and softening the liver,all of which achieved good therapeutic effects.[Conclusion]Director CHEN has rich experience in the treatment of postoperative complications of anorectal disease from the liver and spleen,which is practical and worthy of promotion.

Penjujukan Eksom Bagi Penyakit Jarang Jumpa, Mullerian Agenesis dan Agenesis Anotectal anomaly: Kajian Kes (Whole Exome Sequencing of a Rare Disease, Mullerian Agenesis and Anorectal Anomaly: A Case Report) / Jurnal Sains Kesihatan Malaysia

@#Mullerian agenesis or Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKH) Type-II is a congenital defect in the Mullerian duct that results in the absence of a uterus in women. The aetiology of this syndrome is unknown and has been considered a sporadic genetic disease. MRKH, together with anorectal anomaly, is an extremely rare condition and has only been reported in a few cases without any information on genetic analysis. This study investigated the mutational profile of a girl diagnosed with MRKH and anorectal anomalies with rectovaginal fistula. The whole exome sequencing (WES) trio-genetic analysis of a 5-year-old Malaysian girl diagnosed with MRKH (having anorectal anomaly with rectovaginal fistula) was performed together with her normal parents, using the Ion AmpliSeq Exome RDY kit (ThermoFisher Scientific, USA). Data were analysed using Torrent Suite v.5.0.4 and annotated using ANNOVAR. Single nucleotide polymorphisms (SNPs) with an allele frequency >0.01 were excluded, and the remaining variants were filtered based on de novo mutations, autosomal recessive, and autosomal recessive genetic traits. Related genes were analysed by biological pathway analysis (g:Profiler) and protein-protein interaction (HIPPIE v.2.3, STRING v.11.5, dan GeneMANIA). A total of 36 mutations were identified, and two of them, the LHX5 (p.P358Q), inherited from the father, and CFTR (p.R1158X), inherited from the mother. There were 28 de-novo mutations from 28 genes. All genes were involved in 27 biological processes that connected with 23 interactions, and are likely to cause MRKH syndrome in this patient.

Elevada prevalencia de malformaciones anorrectales en recién nacidos a gran altitud / High prevalence of anorectal malformations in high-altitude newborns

Introducción. Las malformaciones anorrectales son un grupo de anomalías congénitas de etiología multifactorial, en las que intervienen diversos factores genéticos y ambientales. Los habitantes de regiones de gran altitud están expuestos a hipoxia hipobárica crónica, lo que se ha asociado a una mayor prevalencia de varias anomalías congénitas. Objetivo. El objetivo del estudio es investigar la prevalencia al nacimiento de malformaciones anorrectales en La Paz, Bolivia. Material y métodos. Se realizó un estudio transversal. Los casos fueron recolectados en el Hospital de la Mujer ubicado en La Paz, Bolivia, a una altitud promedio de 3600 metros sobre el nivel del mar. Resultados. De 56206 nacidos vivos registrados durante el periodo de estudio, 30 recién nacidos presentaban malformaciones anorrectales, lo que arrojaba una prevalencia de 5,34 por 10000 nacidos vivos. Esta prevalencia era superior a la prevalencia de 3 por 10000 nacidos vivos registrada anteriormente en la literatura. Conclusiones. Nuestro estudio muestra que la prevalencia de malformaciones anorrectales es mayor en la población de altura de La Paz, Bolivia, en comparación con la prevalencia previamente reportada en la literatura. Se necesitan más investigaciones para identificar los factores genéticos y ambientales subyacentes que contribuyen a esta mayor prevalencia, además de mejorar el diagnóstico y los sistemas de vigilancia.

Introduction. Anorectal matformations are a group of congenital anomalies that have a multifactorial etiology, involving various genetic and environmental factors. Inhabitants living at high-altitude regions are exposed to chronic hypobaric hypoxia, which has been associated with a higher prevalence of congenital anomalies. Objective. It was aimed to investígate the prevalence of anorectal malformations in newborns from La Paz, Bolivia. Material and methods. We conducted a cross-sectional study. Newborns data were collected at the Hospital de la Mujer located in La Paz, Bolivia, at an average altitude of 3600 masl. Results. Out of 56,206 live births were registered during the study period. 30 newborns had anorectal malformations, resulting in a prevalence of 5.34 per 10,000 live births. This prevalence was higher than the previously reported in the literature, 3 per 10,000 live births. Conclusions. Our study depicts the prevalence of anorectal malformations is higher in the population of La Paz-Bolivia living at high-altitude, this when compared to previously reported prevalence in the literature. Further research is needed to identify the underlying genetic and environmental factors that contribute to this increased prevalence, as well as to improve diagnosis and monitoring systems.

Dyssynergic Defecation Concerning Proctalgia Fugax: An Observational Study

Introduction: There is no clarity about manometric findings in patients with proctalgia fugax; evidence shows different results. This study aims to evaluate dyssynergic defecation through anorectal manometry in Colombian patients in two gastroenterology centers in Bogotá, Colombia. Materials and methods: A cross-sectional descriptive observational study in adult patients with proctalgia fugax undergoing anorectal manometry and treated in two gastroenterology centers in Bogotá between 2018 and 2020. Results: 316 patients were included, predominantly women (65%), with a median age of 45.2 (range: 18-78; standard deviation [SD]: 28.3). Four percent of patients had hypertonicity, 50% were normotonic, and 46% were hypotonic. Regarding manometric parameters, 50% had normal pressure, and 46% had anal sphincter hypotonia; 76% had a normal voluntary contraction test. Dyssynergic defecation was documented in 5% of patients, and the most frequent was type I, followed by type III. A rectoanal inhibitory reflex was identified in all patients, 42% with altered sensory threshold and 70% with abnormal balloon expulsion. There was an agreement between the results of the anorectal manometry and the subjective report of the digital rectal exam by the head nurse who performed the procedure. Conclusions: The data obtained in the present study suggest that proctalgia is not related to the elevated and sustained basal contracture of the sphincter but neither to the alteration in voluntary contraction since most patients have typical values.

Introducción: Actualmente, no hay claridad acerca de los hallazgos manométricos en pacientes con proctalgia fugaz, y la evidencia muestra diferentes resultados. Se plantea como objetivo en el presente estudio evaluar la presencia de disinergia defecatoria con manometría anorrectal en pacientes colombianos en dos centros de gastroenterología en Bogotá, Colombia. Metodología: Estudio observacional descriptivo de corte transversal en pacientes adultos sometidos a manometría anorrectal con proctalgia fugaz y atendidos en dos centros de gastroenterología de la ciudad de Bogotá entre el 2018 y el 2020. Resultados: Se incluyó a 316 pacientes, predominantemente mujeres (65%), con mediana de edad 45,2 (rango: 18-78; desviación estándar [DE]: 28,3). El 4% de los pacientes presentaban hipertonicidad, el 50% eran normotónicos y el 46%, hipotónicos. En cuanto a parámetros manométricos, el 50% tenía presión normal y el 46%, hipotonía de esfínter anal. El 76% tuvo una prueba de contracción voluntaria normal. En 5% pacientes se documentó disinergia defecatoria, y la más frecuente fue el tipo I, seguido del tipo III. En todos los pacientes se identificó reflejo recto anal inhibitorio, 42% con alteración en umbral sensitivo y 70% con expulsión de balón anormal, y hubo concordancia entre los resultados de la manometría anorrectal y el reporte subjetivo del tacto rectal de la jefe de enfermería que realizó el procedimiento. Conclusiones: Los datos obtenidos en el presente estudio sugieren que la proctalgia no está relacionada con la contractura basal elevada y sostenida del esfínter, pero tampoco con la alteración en la contracción voluntaria, ya que la mayoría de los pacientes presentan valores normales.

Postoperative analgesic efficacy of nefopam after anorectal surgery: a retrospective observational study

Objective: To examine the effectiveness of nefopam on postoperative pain control after anorectal surgeries. Methods: We retrospectively reviewed the electronic medical records of patients who underwent anorectal surgeries from January 2019 to March 2022 at two medical centers. The data were divided into nefopam and conventional groups. The primary outcome was the number of patients who requested additional opioids in the 24-h postoperative period. The secondary outcomes were numeric rating pain scores (NRPS) within a 24-h postoperative period and analgesic drugs-related side effects. Results: Eighty-seven patients in the conventional group and 60 in the nefopam group were recruited. The nefopam group reported less additional opioid consumption than the conventional group in all dimensions of analysis, including overall, adjusted to anesthetic techniques and types of surgery. However, these did not reach statistical significance (P = 0.093). Only patients in the nefopam group who underwent hemorrhoidectomy under TIVA or spinal anesthesia significantly required fewer additional opioids (P = 0.016, 60% mean difference). Similarly, the 24-h postoperative morphine consumption was lower in the nefopam group (mean difference = -3.4, 95%CI: 0.72,6.08). Furthermore, significantly lower NRPS were reported in the nefopam group during the 12-18 h postoperative period (P = 0.009). On the other hand, analgesic drugs related side effects were similar in both groups. Conclusions: The administration of nefopam after major anorectal surgery is beneficially evident in reducing postoperative opioid requirements. (AU)

Síndrome de Currarino incompleto. Presentación de un caso

El síndrome de Currarino es una enfermedad hereditaria y de baja incidencia, compuesta por una tríada: estenosis anal, malformación sacro coccígea y masa presacra. Puede cursar desapercibido hasta la adultez y generar subdiagnósticos. Se describe un paciente de 75 años, masculino, piel negra, de procedencia urbana y con antecedentes de hipertensión arterial, quien acudió al hospital por presentar hematuria, dolor en fosa lumbar izquierda y estreñimiento. Se realizaron estudios imagenológicos, como ultrasonido, tomografía de abdomen y resonancia magnética lumbosacra, los cuales condujeron al diagnóstico de tumor renal, síndrome de Currarino incompleto (dado por dos elementos de la triada: malformación sacro coccígea y masa presacra) asociado a otra enfermedad malformativa raquimedular, médula anclada. Son pocos los casos reportados en el mundo (casi 300), por lo que se considera una entidad rara, pero de fácil diagnóstico debido al advenimiento de las nuevas tecnologías en el campo de la imagenología.

Currarino syndrome is a hereditary disease with a low incidence, composed of a triad: anal stenosis, sacrococcygeal malformation and presacral mass. It can go unnoticed until adulthood and generate subdiagnoses. A 75-years-old male, black-skinned, urban origin patient with a history of arterial hypertension is described, who attended the hospital presenting hematuria, pain in the left lumbar fossa, and constipation. Radiological studies such as ultrasound, abdominal tomography and lumbosacral magnetic resonance were performed, which led to the diagnosis of a renal tumor, incomplete Currarino syndrome (given by two elements of the triad: sacrococcygeal malformation and presacral mass) associated with another spinal cord malformation disease, tethered cord. There are few cases reported in the world (almost 300), so it is considered a rare entity, but easy to diagnose due to new imaging technologies.

Predictors of long-term healing for endorectal advancement flap for anorectal fistulas

Introduction: Anorectal fistulas are some of the commonest surgical proctologic disorders treated by surgeons. Despite the recent introduction of various sphincter preserving techniques, the search for the optimal operation continues. The purpose of this study was to determine the predictors of long-term healing for the endorectal advancement flap. Methods: A retrospective review of a single surgeon experience with the endorectal advancement flap for anorectal fistulas over an 18-year period. The impact of various patient and fistula related factors were analyzed for their impact on the primary endpoint of long-term fistula healing. Results: 87 patients underwent endorectal advancement flap (Male/Female 42.5/57.5%). Median age was 41 years. Sixty-nine patients (79.3%) had anal fistula while 18 patients had rectal fistula (20.7%). An anterior based fistula was noted in 45 patients (51.7%). The most common etiology was cryptoglandular disease (87.4%). The median operative time was 75minutes (range 36-250). Postoperative septic complications were noted in 4 patients (4.6%). Fistula healing was documented in 80 patients (93%). During a median follow-up of 4 months (range 1-38, 1 patient lost to follow-up), recurrence was noted in 8 patients (9.3%), yielding an overall long-term success rate of 83.7%. The long-term healing rate was higher in patients with fistulas from cryptoglandular etiology (86.6%) compared to fistulas from other etiologies (63.6%) [p = 0.027]. Conclusions: The endorectal advancement is associated with a high healing rate, a low postoperative septic complication rate, and infrequent risk for recurrence. Long-term healing without recurrence is achieved more frequently in patients with cryptoglandular etiology of the fistula compared to patients with non-cryptoglandular etiology. (AU)

Eficácia da reabilitação perineal combinada com biofeedback e diatermia por radiofrequência (RDF) em síndromes de dor funcional anorretal associadas à contração paradoxal dos músculos elevadores do ânus. Um estudo prospectivo / Effectiveness of perineal pelvis rehabilitation combined with biofeedback and radiofrequency diathermy (rdf) in anorectal functional pain syndromes associated with paradoxical contraction of the levator ani muscles. a prospective study

ABSTRACT Background: Anorectal functional pain syndrome, also called chronic proctalgia, represents a neglected clinical entity and often confused with other syndromes such as vulvodynia or acute proctalgia. It is a very often disabling disease with a consequent significant negative impact on the patient's quality of life. Chronic proctalgia, in many patients, is secondary to the paradoxical contraction of the pelvic floor and associated with a dissynergy between the thorax-abdomen and the pelvic floor. To improve symptoms in functional anorectal pain syndromes, various rehabilitation techniques are used with the aim of promoting relaxation of the pelvic floor; however, to improve defecatory dynamics in patients with levator ani syndrome, only biofeedback has shown efficacy in a randomized study. The aim of this work is to evaluate whether a rehabilitation protocol with manometric biofeedback and radiofrequency diathermy (mt100 Fremslife emotion Tecar) reduces pain and paradoxical contraction of the levator ani and improves the quality of life in patients with anorectal pain syndromes. functional. Methods: This was a prospective study on 30 patients (20 women and 10 men) with anorectal functional pain syndrome and paradoxical contraction of the pelvic floor enrolled at the UOC of General, Minimally Invasive, Oncological and Obesity Surgery of the AOU "Luigi Vanvitelli" of Naples, Italy, from September 2021 to May 2022. All patients were evaluated with a coloproctological specialist visit followed by anorectal manometry and evaluation of altered clinical physiatric parameters (Brusciano Score). The protocol consisted of 10 rehabilitation sessions of the pelvic floor once a week and lasting approximately 45 minutes. During the sessions the patients were subjected to diathermy / radiofrequency treatment (10 minutes) with a static resistive electrode on the diaphragm, during which they were required to breathe diaphragmatically and to become aware of the perineal muscles, under the supervision of a physiotherapist; followed by application of diathermy with static capacitive (5 minutes) and resistive (10 minutes) electrode at the lumbar level. This was followed by the use of manometric biofeedback (15 minutes of tonic / phasic exercises) in order to instruct the patient on the reflex mechanism to obtain a voluntary relaxation of the external anal sphincter. The variables evaluated were Pain (VAS 0-10) and the questionnaire on the impact of colorectal and anal pathologies on the quality of life (CRAIQ-7) at the beginning, after 3 months and at the end of the treatment. Results: After 10 weeks, the rehabilitation treatment combined with diathermy and manometric biofeedback proved effective in the short term with a reduction in the scores of the Vas scale and CRAIQ-7 questionnaire and an increase in the percentage of release of the anal muscles on anorectal manometry. Conclusion: The use of radiofrequency diathermy with a system of static electrodes associated with biofeedback represents a valid rehabilitation option for those patients suffering from anorectal functional pain syndrome because it reduces pain and paradoxical contraction of the levator ani and improves quality of life of the patient.

RESUMO Contexto: A síndrome de dor funcional anorretal, também conhecida como proctalgia crônica, representa uma entidade clínica negligenciada e frequentemente confundida com outras síndromes, como vulvodinia ou proctalgia aguda. Trata-se de uma doença frequentemente incapacitante, com um consequente impacto negativo significativo na qualidade de vida do paciente. A proctalgia crônica, em muitos pacientes, é secundária à contração paradoxal do assoalho pélvico e está associada a uma dissinergia entre o tórax-abdômen e o assoalho pélvico. Para melhorar os sintomas em síndromes de dor anorretal funcional, são utilizadas diversas técnicas de reabilitação com o objetivo de promover o relaxamento do assoalho pélvico. No entanto, para melhorar a dinâmica de evacuação em pacientes com síndrome do elevador do ânus, apenas o biofeedback demonstrou eficácia em um estudo randomizado. Objetivo: O objetivo deste trabalho é avaliar se um protocolo de reabilitação com biofeedback manométrico e diatermia por radiofrequência (mt100 Fremslife emotion Tecar) reduz a dor e a contração paradoxal do elevador do ânus e melhora a qualidade de vida em pacientes com síndromes de dor anorretal funcional. Métodos: Realizado estudo prospectivo com 30 pacientes (20 mulheres e 10 homens) com síndrome de dor anorretal funcional e contração paradoxal do assoalho pélvico inscritos na UOC de Cirurgia Geral, Minimamente Invasiva, Oncológica e de Obesidade da AOU "Luigi Vanvitelli" de Nápoles, Itália, de setembro de 2021 a maio de 2022. Todos os pacientes foram avaliados com uma consulta especializada em coloproctologia, seguida de manometria anorretal e avaliação dos parâmetros fisiátricos clínicos alterados (Escore de Brusciano). O protocolo consistiu em 10 sessões de reabilitação do assoalho pélvico, uma vez por semana, com duração aproximada de 45 minutos. Durante as sessões, os pacientes foram submetidos a tratamento de diatermia / radiofrequência (10 minutos) com um eletrodo resistivo estático no diafragma, durante o qual foram solicitados a respirar através do diafragma e a tomar consciência dos músculos perineais, sob a supervisão de um fisioterapeuta; seguido pela aplicação de diatermia com eletrodo capacitivo estático (5 minutos) e resistivo (10 minutos) no nível lombar. Isso foi seguido pelo uso de biofeedback manométrico (15 minutos de exercícios tônicos /fásicos) com o objetivo de instruir o paciente sobre o mecanismo reflexo para obter um relaxamento voluntário do esfíncter anal externo. As variáveis avaliadas foram Dor (EVA 0-10) e o questionário sobre o impacto das patologias colorretais e anais na qualidade de vida (CRAIQ-7) no início, após 3 meses e no final do tratamento. Resultados: Após 10 semanas, o tratamento de reabilitação combinado com diatermia e biofeedback manométrico mostrou-se eficaz a curto prazo, com uma redução nos escores da escala VAS e do questionário CRAIQ-7, e um aumento na porcentagem de relaxamento dos músculos anais na manometria anorretal. Conclusão: O uso de diatermia por radiofrequência com um sistema de eletrodos estáticos associado ao biofeedback representa uma opção de reabilitação válida para pacientes que sofrem com a síndrome de dor anorretal funcional, pois reduz a dor e a contração paradoxal do elevador do ânus, melhorando a qualidade de vida do paciente.

Clinical study of cupping combined with acupoint application on acute urinary retention and its influences on detrusor function after anorectal surgery / 国际中医中药杂志

Objective:To explore the effect of cupping combined with acupoint application on acute urinary retention (AUR) and its influences on detrusor function after anorectal surgery.Methods:Randomized controlled trial. A total of 120 patients in the hospital were enrolled as the observation objects between April 2020 and April 2022. According to random number table method, they were divided into two groups, 60 in each group. The control group was given acupoint application, while observation group was additionally given cupping. All were continuously treated for 3 days. Before and after treatment, urination function symptoms were scored. The pain degree was assessed by VAS. C-reactive protein (CRP) was detected by ELISA, and white blood cell count (WBC) was detected by blood routine analyzer. The bladder volume (CC), maximum flow rate (Q max), average flow rate (AFR) and residual urine volume (PVR) were evaluated by urodynamics analyzer. The adverse reactions were recorded, and clinical curative effect was evaluated. Results:The difference in total response rate between observation group and control group was statistically significant [91.67% (55/60) vs. 80.00% (48/60); χ2=4.90, P=0.027]. After treatment, scores of dysuria, frequency of urination, urgency of urination and VAS in observation group were significantly lower than those in the control group ( t=22.83, 8.70, 8.70, 17.26, P<0.01). After treatment, Q max [(10.85±3.49) ml/s vs. (8.13±2.74) ml/s, t=4.75], AFR [(5.40±1.42) ml/s vs. (3.68±1.51) ml/s, t=19.44] and CC [(352.69±51.75) ml/s vs. (396.57±58.16) ml/s, t=4.37] in observation group were significantly higher than those in the control group ( P<0.01), while PVR [(36.73±6.54) ml/s vs. (51.04±10.32) ml/s, t=9.07] was significantly lower than that of the control group ( P<0.01). The levels of serum CRP and WBC in observation group were significantly lower than those in the control group ( t=23.50, 5.05, P<0.01). The difference in the incidence of adverse reactions between observation group and control group was not statistically significant [6.67% (4/60) vs. 5.00% (3/60); χ2=0.15, P=0.697]. Conclusion:Cupping combined with acupoint application can improve detrusor function, relieve abnormal urination symptoms and improve curative effect in AUR patients after anorectal surgery, which is safe and reliable.

Research and application of anorectal manometry in Parkinson's disease with constipation / 临床神经病学杂志

Parkinson's disease(PD)is the most common neurodegenerative disease in middle-aged and elderly people.Constipation is one of the most common non-motor symptoms of PD.Anorectal manometry can objectively reflect anorectal movement and sensory function,and is one of the necessary tests to check anorectal function,judge the type of constipation,and evaluate the effect of constipation treatment.This paper expounds the detection indicators and significance of anorectal manometry,and summarizes the characteristics of anorectal manometry in PD patients with constipation:decreased maximum anal systolic pressure,insufficient rectal propulsion,decreased rectal sensitivity,and the type of constipation in PD patients is mainly outlet obstruction with contradictory anal contraction or insufficient relaxation during defecation.

The potential value of ultrasound shear wave elastography in assessing functional defecation disorders / 中华消化杂志

Objective:To preliminary explore the potential application value of ultrasound shear wave elastography (SWE) in assessing functional defecation disorders compared with anorectal manometry and X-ray defecography.Methods:From July 2022 to December 2022, the results of SWE, anorectal manometry and X-ray defecography of 39 patients with functional defecation disorders visited Sir Run Run Shaw Hospital, School of Medicine of Zhejiang University were retrospectively analyzed. Non-parametric tests were used to analyze the changes in elastic modulus values of anorectal muscle groups at different phase.Chi-square test and Bland-Altman plots were used to assess the consistency between SWE, X-ray defecography and anorectal manometry in evaluating spastic pelvic floor syndrome, as well as the changes in the anorectal angle measured by SWE and X-ray defecography (from resting phase to contraction phase, resting phase to strain phase (Valsalval maneuver).Results:The elastic modulus values measured by SWE of the puborectalis muscle, internal anal sphincter, and external anal sphincter of patients with functional defecation disorders during strain phase were 32.4 kPa (19.1 kPa, 60.3 kPa), 25.3 kPa (17.0 kPa, 53.8 kPa), and 28.6 kPa (21.3 kPa, 55.1 kPa), respectively, which had no statistically significant differences compared to elastic modulus values in resting phase (33.5 kPa (22.1 kPa, 44.9 kPa), 28.9 kPa (22.4 kPa, 45.1 kPa), and 32.4 kPa (23.1 kPa, 49.4 kPa), all P>0.05). The consistency between SWE and X-ray defecography in the diagnosis of spastic pelvic floor syndrome was poor (Kappa=0.190). The consistency between SWE and anorectal manometry in the diagnosis of dyssynergic defecation was poor (Kappa=0.160). The differences in the changes of anorectal angle detected by SWE and X-ray defecography were within the 95% consistency limit ( P=0.429 and 0.582). Conclusion:SWE is sensitive in evaluating changes in anorectal angle, and it shows good consistency with defecography in assessing angle changes.

Pathogenesis, clinical diagnosis and treatment of anorectal malignant melanoma: a review / 预防医学

Abstract@#Anorectal malignant melanoma (ARMM) is a subtype of malignant melanoma with low incidence and high invasion, and has a poor prognosis due to its hidden location and rapid progression. In terms of pathogenesis, the molecular landscape and potential carcinogenic driver gene characteristics of ARMM are significantly different from those of cutaneous melanoma, manifested by a lower rate of somatic mutations, no ultraviolet exposure-related mutation characteristics, a high incidence of cell structural variation, and high genomic instability. The tumor-driving genomic mutations are mainly KIT, NRAS, and NF1 mutations, and the incidence of SF3B1 mutations is significantly higher than that in other sites of mucosal melanoma. Surgery is still the main treatment for ARMM, while immunotherapy and targeted therapy need further development. This article reviews the characteristics of carcinogenic driver gene mutations and clinical diagnosis and treatment of ARMM, providing a reference for the prevention and treatment of ARMM.

Clinicopathological features and prognosis of anorectal melanoma: A report of 68 cases / 北京大学学报(医学版)

OBJECTIVE@#To investigate the clinicopathological characteristics of anorectal mucosal melanoma (ARMM), and to evaluate the prognostic factors.@*METHODS@#A total of 68 primary ARMM surgical specimens from 2010 to 2018 were retrospectively studied. Slides were reviewed to evaluate pathological features. Slingluff staging method was used for staging.@*RESULTS@#(1) Clinical features: The median age at diagnosis in this group was 61.5 years, with a male-to-female ratio 1 ∶1.62. The most common complaint was blooding (49 cases). For anatomic site, anorectum was the prevalent (66.2%), followed by rectum (20.6%). At the time of diagnosis, 28 cases were stage Ⅰ (localized stage, 41.2%), 25 cases were stage Ⅱ (regional lymph node metastasis, 36.8%), and 15 cases were stage Ⅲ (distant metastasis, 22.1%). Five patients underwent wide local excision, the rest abdominoperineal resection, and 48 patients received adjuvant therapy after surgery. (2) Pathological features: Grossly 88.2% of the tumors were exophytic polypoid masses, with the median tumor size 3.5 cm and the median tumor thickness 1.25 cm. Depth of invasion below lamina muscularis mucosae ranged from 0-5.00 cm (median 1.00 cm). The deepest site of tumor invasion reached muscular layer in 27 cases, and perirectal tissue in 16 cases. Melanin pigmentation was absent or not obvious in 67.6% of the cases. The predominant cytology was epithelioid (45 cases, 66.2%). The rate for ulceration, necrosis, lymphovascular invasion, and perineural invasion was 89.7%, 35.3%, 55.9%, and 30.9%, respectively. The median mitotic count was 18/mm2. The positive rate of S100, HMB-45 and Melan-A were 92.0%, 92.6% and 98.0%, respectively. The median of Ki-67 was 50%. The incidences of mutations within CKIT, BRAF and NRAS genes were 17.0% (9 cases), 3.8% (2 cases) and 9.4% (5 cases), respectively. (3) Prognosis: Survival data were available in 66 patients, with a median follow-up of 17 months and a median survival time of 17.4 months. The 1-year, 2-year and 5-year overall survival rate was 76.8%, 36.8% and 17.2%, respectively. The rate of lymphatic metastasis at diagnosis was 56.3%. Forty-nine patients (84.5%) suffered from distant metastasis, and the most frequent metastatic site was liver. Univariate analysis revealed that tumor size (>3.5 cm), depth of invasion below lamina muscularis mucosae (>1.0 cm), necrosis, lymphovascular invasion, BRAF gene mutation, lack of adjuvant therapy after surgery, deep site of tumor invasion, and high stage at diagnosis were all poor prognostic factors for overall survival. Multivariate model showed that lymphovascular invasion and BRAF gene mutation were independent risk factors for lower overall survival, and high stage at diagnosis showed borderline negative correlation with overall survival.@*CONCLUSION@#The overall prognosis of ARMM is poor, and lymphovascular invasion and BRAF gene mutation are independent factors of poor prognosis. Slingluff staging suggests prognosis effectively, and detailed assessment of pathological features, clear staging and genetic testing should be carried out when possible. Depth of invasion below lamina muscularis mucosae of the tumor might be a better prognostic indicator than tumor thickness.

Clinical study on Sanhuang Qingre Fuming and Washing Decoction combined with Chinese medical excision in the treatment of horseshoe perianal abscess after high position / 国际中医中药杂志

Objective:To observe the clinical effect of Sanhuang Qingre Fuming and Washing Decoction combined with Chinese medical excision in the treatment of horseshoe-shaped perianal abscess after high position and to explore its mechanism of action.Methods:Randomized controlled trial. Sixty surgical patients in our hospital from April 2020 to February 2021 were selected as observation objects. The patients were divided into two groups according to the random number table, with 30 patients in each group. Both groups were treated with Traditional Chinese Medicine drainage. On the second day after operation, the control group was treated with potassium permanganate sitz bath fumigation and washing, and the observation group was treated with Sanhuang Qingre Fuming and Washing Decoction. The wound healing time was observed in the two groups, serum TNF-α, IL-1β, IL-6, VEGF, bFGF, and EGF levels were detected by ELISA on the 1st and 7th d after operation, respectively. Serum SOD level was detected by the chemiluminescence method, and serum MDA level was detected by thiobarbituric acid method.Results:The wound healing time in the observation group was shorter than that in the control group ( t=3.37, P<0.01). The recovery rate was 93.3% (28/30) in the observation group and 76.7% (23/30) in the control group. The difference was statistically significant between the two groups ( χ2=4.32, P=0.038). Seven days after surgery, the levels of serum TNF-α, IL-1β and IL-6 in the observation group were significantly lower than those in the control group ( t values were 2.01, 2.05 and 4.88, respectively, P<0.05 or P<0.01), the level of SOD was significantly higher than that of the control group ( t=-2.13, P=0.038), the level of MDA water was significantly lower than that of the control group ( t=3.26, P=0.002), and the levels of VEGF, bFGF and EGF were significantly higher than those in the control group ( t values were -2.02, -3.33, -3.77, respectively, P<0.05). Conclusion:Sanhuang Qingre Tuming and Washing Decoction combined with Chinese medical excision in the treatment could shorten the healing time of the wound surface of horseshoe-shaped perianal abscess after high elevation and improve the recovery rate. The Sanhuang Qingre Fuming and Washing Decoction may reduce inflammatory reaction and oxidative stress damage, improve the level of growth factors and facilitate the postoperative tissue repair.

Influences of Dixon anus preserving surgery on curative effect, anorectal function and stress response in patients with low rectal cancer / 中国医师进修杂志

Objective:To investigate the influences of Dixon anus preserving surgery on the curative effect, anorectal function and stress response of patients with low rectal cancer.Methods:A total of 150 patients with low rectal cancer admitted to Zhangjiakou Fifth Hospital from May 2016 to March 2019 were retrospective analysis as the study subjects. According to the different surgical methods, the patients were divided into the study group (75 cases) and the control group (75 cases). The patients in the study group received Dixon operation, and the patients in the control group received Miles operation. The general condition of operation, postoperative urination function, stress response [C reactive protein (CRP), interleukin-6 (IL-6), cortisol (Cor) and adrenocorticotropic hormone (ACTH)], anorectal function [anal resting pressure (ARP), maximal squeeze pressure (MSP), anal longest contraction time (ALCT)], quality of life (PAC-QOL score), postoperative complications, local recurrence rate, distant metastasis rate, 3-year tumor free survival rate and 3-year overall survival rate were compared between the two groups.Results:The operation time, intraoperative blood loss and postoperative drainage volume in the study group were lower than those in the control group: (172.28 ± 23.45) min vs. (189.57 ± 23.68) min, (177.39 ± 21.23) ml vs. (191.35 ± 22.67) ml, (342.36 ± 52.89) ml vs. (489.42 ± 63.33) ml, there were statistical differences ( P<0.05). The levels of CRP, IL-6, Cor and ACTH in the study group were lower than those in the control group: (22.35 ± 4.75) mg/L vs. (35.65 ± 5.28) mg/L, (58.74 ± 15.11) μg/L vs. (79.63 ± 20.23) μg/L, (145.36 ± 27.48) ng/L vs. (156.48 ± 32.55) ng/L, (44.58 ± 5.27) ng/L vs. (49.62 ± 5.68) ng/L, there were statistical differences ( P<0.05). The urination function and anorectal function of the patients in the study group were obviously better than those in the control group 6 months after operation, and the PAC-QOL score was obviously lower than that in the control group: (22.53 ± 2.86) scores vs. (27.54 ± 3.21) scores ( P<0.05); there was no obvious difference between the study group and the control group in the incidence of postoperative complications, local recurrence rate, distant metastasis rate, 3-year tumor free survival rate and 3-year total survival rate ( P>0.05). Conclusions:Dixon operation is effective in the treatment of low rectal cancer. It can preserve the anorectal function of patients to the greatest extent, protect urination function, reduce stress reaction of patients, and it is more conducive to rapid rehabilitation of patients.