Miscellaneous Perianal Afflictions.

This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.

Experimental evaluation of a bovine pericardium-derived collagen matrix buttress in ileocolic and colon anastomoses.

BACKGROUND: Anastomotic leakage is a major complication of colorectal surgery. The purpose of this study was to evaluate and compare stapled ileocolic and colon-colon anastomoses with or without a collagen buttress derived from bovine pericardium in the immediate postoperative period. METHODS: Various stapling devices were used to create ileocolic and colon-colon anastomoses in a canine model. Ileocolic anastomoses were created by simulating two different techniques: "open" and "laparoscopic". Colon-colon anastomoses were created by using a double-stapled technique. A total of 27 colon anastomoses (13 left colon-colon, 8 right "laparoscopic", and 6 right "open") were created. Anastomoses buttressed with bovine pericardium (n = 15) were compared to anastomoses without any reinforcement (n = 12). Staple lines were evaluated 4 hours after operation. Evaluation included bursting pressure and bursting location. RESULTS: No stapler device malfunction occurred. Excision rings were complete in all colon-colon anastomoses. All non-buttressed anastomoses burst at the staple line, whereas with buttressed anastomoses the adjacent intestine burst (p = 0.0001). The intestinal bursting pressure of bowel segments with buttressed staple lines (mean, 362 mmHg) was significantly higher than the bursting pressure of non-buttressed staple lines (mean, 204 mmHg, p < 0.0001). CONCLUSION: The use of a collagen matrix buttress derived from bovine pericardium in stapled ileocolic and colon-colon anastomoses was safe. Buttressed anastomoses showed greater bursting strength as compared to non-buttressed anastomoses in the immediate postoperative period in a canine model.

Perianal Paget's disease treated with wide excision and gluteal skin flap reconstruction: report of a case and review of the literature.

BACKGROUND: Paget's disease of the anus is a rare perianal disorder. The condition is often associated with underlying invasive carcinoma and the prognosis is poor when underlying adenocarcinoma is present. METHODS: We report the case of a 72-year-old woman suffering from a two-year history of perianal itching, bleeding, and irritation. Perianal Paget's disease was confirmed by histopathologic demonstration of Paget's cells from a biopsy. Synchronous malignancy and metastasis were excluded. RESULTS: A first-stage operation consisted of a wide excisional biopsy with frozen section margin assessment. Permanent sections confirmed absence of invasive carcinoma and clear margins. Four days after wide excision, bilateral gluteal skin flap reconstruction was performed with a temporary diverting colostomy. No adjuvant therapy was necessary, and after one-year follow-up, the patient remains disease free. CONCLUSION: Perianal Paget's disease continues to pose problems in diagnosis and treatment. Our case report of perianal Paget's disease shows one method of management for advanced non invasive disease.

Fistula-associated anal adenocarcinoma: good results with aggressive therapy.

PURPOSE: To evaluate the clinical features, pathology, treatment, and outcome of patients with fistula-associated anal adenocarcinoma. METHODS: We identified 14 patients with histologically proven fistula-associated anal adenocarcinoma. We reviewed their medical records and pathology specimens to characterize their presentation, treatment, and clinical outcome. RESULTS: Nine patients presented with a persistent fistula, 3 with a perianal mass, 1 with pain and drainage, and 1 with a recurrent perianal abscess. The average age at time of diagnosis was 59 (range, 37-76) years. Eleven patients had preexisting chronic anal fistulas. Ten had Crohn's disease, and 1 had previously received pelvic radiation therapy. The diagnosis of cancer was suspected during physical examination in 6 of the 14 patients (43 percent). Twelve patients had extensive local disease at presentation. Primary abdominoperineal resection was performed in 11 patients, 7 following neoadjuvant chemoradiation. Six patients received postoperative chemotherapy, and 2 received postoperative radiation. Four patients died with metastatic disease. The remaining 10 patients are alive without evidence of disease at a mean follow-up of 64.3 (range, 14-149) months. CONCLUSIONS: The diagnosis of fistula-associated anal adenocarcinoma is often unsuspected. Most patients can be cured with aggressive surgical and adjuvant chemoradiotherapy.

Two experimental models for generating abdominal adhesions.

PURPOSE: To develop dependable rat models for generating abdominal adhesions that allow for objective evaluation and quantification. METHODS: Two adhesion models were devised and compared with conventional side-wall models involving cecal abrasion and peritoneal excision or abrasion. model T (tissue): removal of a 2.5 by 2.5 cm segment of full-thickness abdominal wall with overlying skin closure, exposing the viscera to subcutaneous tissue; model M (mesh): removal of an identical segment, replacing the defect with a 2.5 by 2.5 cm polypropylene mesh sewn to the cut edges. This exposed the viscera directly to the mesh surface. Seven days after operation, the character and extent of the adhesions were assessed at autopsy. Results were expressed as the percent area of subcutaneous tissue involved (T) or of mesh surface involved (M). For model T the percent involvement of the circumference of the defect edge was also recorded. The extent of omental and intestinal adhesions were evaluated individually. RESULTS: The classical side-wall models showed inconsistent patterns of adhesion formation and were difficult to evaluate. Every animal from both models M and T developed extensive adhesions. The mean coverage of mesh surface (M) was 93% and subcutaneous surface (T) 82%. In model T the mean involvement of the defect cut edge was 80% of the circumference. All model T animals had both intestinal and omental adhesions whereas there were no intestinal attachments in model M. Tenacity of adhesions did not differ significantly between animals or models. CONCLUSIONS: Adhesion models M and T are consistent, predictable, and dependable. They each yield extensive adhesion coverage to a defined site, which allow for standardized measurement.

Bovine pericardium buttress reinforces colorectal anastomoses in a canine model.

PURPOSE: The consequences of an anastomotic leak or disruption can be devastating, particularly in the colorectal surgery population. The purpose of this study was to evaluate and compare colon anastomoses with or without a collagen matrix buttress derived from bovine pericardium. METHODS: A circular stapler was used to create colon-colon anastomoses in a canine model. Twenty animals underwent two anastomoses each: one buttressed with bovine pericardium, and one without any reinforcement. Staple lines were evaluated at Days 0, 3, 7, 14, 42, and 84. Three animals were killed at each time interval, and evaluation included bursting pressure, bursting location, and histology. RESULTS: Colon segments with nonbuttressed anastomoses were more likely to burst at the staple line (63 percent), whereas buttressed anastomoses were more likely to burst at the adjacent intestine (74 percent; P=0.048). The burst pressure of nonbuttressed staple lines tended to be consistently, although not significantly, higher than the burst pressure of buttressed staple lines (P=0.651). At histologic analysis, the bovine pericardium buttress demonstrated an ability to allow cellular ingrowth at Day 3 and neovascularization at Day 7. There was no evidence of stenosis or infection. CONCLUSIONS: The use of a collagen matrix buttress in colorectal anastomoses was safe in a canine model. Our study indicates that true burst strength of the majority of buttressed anastomoses was greater than the adjacent intestine.