Does HIV status influence the anatomy of anal fistulas?

PURPOSE: Although anorectal disease is common in human immunodeficiency virus-positive patients, little is known about the type and anatomic distribution of anal fistulas in this patient group. The aim of this study was to compare anatomic characteristics of anal fistulas in human immunodeficiency virus-positive patients with those in human immunodeficiency virus-negative patients by use of a retrospective chart review. METHODS: The charts of 146 male patients younger than 50 years with an anal fistula were reviewed. Incomplete fistulas referred to those tracts arising from an internal opening into either a blind sinus or an undrained abscess cavity. RESULTS: There were 60 human immunodeficiency virus-positive patients and 86 human immunodeficiency virus-negative patients. Mean age of the human immunodeficiency virus-positive patient group was 37 years vs. 40 years for the human immunodeficiency virus-negative patient group. Thirty-one human immunodeficiency virus-positive patients (52 percent) were classified as having AIDS, and the remaining 29 patients (48 percent) were asymptomatic. Mean T helper cell count in the human immunodeficiency virus-positive patient group was 277 cells per microliter. Fistulous tracts were intersphincteric (n = 56), transsphincteric (n = 41), suprasphincteric (n = 2), and incomplete (n = 47). Incomplete fistulas were identified in 33 (55 percent) human immunodeficiency virus-positive patients vs. 14 (16 percent) human immunodeficiency virus-negative patients (P < 0.001). Of the 47 incomplete fistulas, 37 (79 percent) were found in association with an abscess cavity. All ten patients with an incomplete fistula into a blind sinus were human immunodeficiency virus-positive. The incidence of an incomplete fistula without an abscess was significantly higher in the human immunodeficiency virus-positive patient group (17 percent) compared with the human immunodeficiency virus-negative patient group (0 percent; P < 0.001). CONCLUSIONS: Anal fistulas in HIV-positive patients arise from the dentate line in similar locations to human immunodeficiency virus negative patients. However, human immunodeficiency virus-positive patients were more likely to have incomplete anal fistulas than human immunodeficiency virus-negative patients. Furthermore, human immunodeficiency virus-positive patients are predisposed to incomplete fistulas leading into a blind sinus.

Topical nitroglycerin in the management of anal fissure: an explosive outcome!

Anal sphincter spasm is a common finding in patients with anal fissure disease. It is postulated that spasm impedes mucosal blood flow and impairs healing. Topical nitroglycerin (NTG), a nitric oxide donor compound, has been shown to cause relaxation of the anal sphincter and may have treatment efficacy in the management of anal fissure. The purpose of this study was to assess the usefulness of NTG for anal fissure. We performed a retrospective review of patients with anal fissure treated with various concentrations of topical NTG ointments over an 18-month period ending July 1997. Of the 81 patients studied, 44 (54%) were male. There were 42 acute and 39 chronic fissures. NTG preparations included 1 per cent isosorbide (n = 37), 0.2 per cent NTG (n = 38), and 0.5 per cent NTG (n = 6). Healing with NTG therapy occurred in 29 acute (69%) and 21 chronic fissure (54%) patients. There was no difference in the incidence of healing of acute or chronic fissure between the various NTG treatment preparation groups. When acute and chronic fissure therapy was subdivided by time of NTG treatment (immediate versus post-conservative therapy failure (PCF)), 14 (74%) of acute PCF and 5 (42%) of chronic PCF patients healed. We conclude that no single formula was superior. When patients were subdivided into a PCF group, NTG therapy demonstrated a significant salvage rate, thus avoiding surgery.

Colorectal cancer: comparison of laparoscopic with open approaches.

PURPOSE: We compared laparoscopic with open colectomy for treatment of colorectal cancer. METHODS: We performed a retrospective review of patients undergoing colectomy for colorectal cancer between January 1991 and March 1996 at a large private metropolitan teaching hospital. Operative techniques included open (n=90) and laparoscopic (n=80) colectomy. Laparoscopic colectomy was further subdivided into the following groups: facilitated (n=62), with extracorporeal anastomosis; near-complete (n=9), with small incision for specimen delivery only; complete (n=3), with specimen removal through the rectum; and converted to an open procedure (n=6). Main outcome measures included operative time, blood loss, time to oral intake, length of postoperative hospitalization, morbidity, lymph node yield, recurrence, survival, and costs. RESULTS: Operative time was equivalent in the laparoscopic and open groups (laparoscopic, 161 minutes; open, 163 minutes; P=0.94). Blood loss was less for the laparoscopic group (laparoscopic, 104 ml; open, 184 ml; P=0.001), and resumption of oral intake was earlier (laparoscopic, 3.9 days; open, 4.9 days; P=0.001), but length of hospitalization was similar. Mean lymph node yield in the laparoscopic group was 12 compared with 16 in the open group (P=0.16). Rates of morbidity, recurrence, and survival were similar in both groups. No port-site recurrences occurred. CONCLUSIONS: Laparoscopic and open colectomy were therapeutically similar for treatment of colorectal cancer in terms of operative time, length of hospitalization, recurrence, and survival rates. The laparoscopic approach was superior in blood loss and resumption of oral intake.