Anal Canal Duplication Associated with Presacral Cyst in an Adult.

Anal canal duplication (ACD) is a rare congenital malformation, usually detected early in life. We report a case of a 67-year-old female with symptomatic ACD associated with a presacral cyst. Physical examination revealed an accessory opening located in the midline, posterior to the true anus. Imaging examinations, including fistulography, endoanal ultrasonography, and magnetic resonance imaging, revealed a blind-ending fistulous tract without connecting with the rectum and a presacral cyst posterior to the rectum. Complete surgical excision of the tract with cyst was performed through a posterior sagittal approach. Histologic examination revealed squamous epithelium lining and smooth muscle bundles, thereby confirming ACD. The postoperative course was uneventful, and the patient was doing well; no recurrence was observed 4 years after surgery. ACD can present for the first time in infants, children, and adults. Imaging examinations are useful for the diagnosis and preoperative assessment of ACD. Therefore, ACD should be considered in the differential diagnosis, even in adults, when a posterior perineal orifice is encountered, particularly in female patients. Once ACD is suspected, intense imaging inspection is recommended to visualize the ACD and associated anomalies, and surgical removal is warranted to prevent inflammatory complications or malignant changes.

Endoanal Ultrasonography of Mucinous Adenocarcinoma Arising from Chronic Fistula-in-ano: Three Case Reports.

Mucinous adenocarcinoma arising in chronic fistula-in-ano is rare, and diagnosing it at an early stage is difficult. The role of endoanal ultrasonography in diagnosing the condition has not been discussed in the study. Herein, we report three cases of mucinous adenocarcinoma arising from anal fistulas in which endosonography played an important role in diagnosing malignant change. Three male patients with a 5- to 20-year history of anal fistula were referred to our hospital due to perianal induration, progressive anal pain, or mucopurulent secretion. In all three patients, endosonography revealed a multiloculated complex echoic mass with isoechoic solid components communicating with a trans-sphincteric fistula and sonography-guided biopsy under anesthesia revealed mucinous adenocarcinoma. All patients underwent abdominoperineal resection with lymph node dissection. One patient with a local recurrence died 3 years after surgery and two have remained disease-free for >6 years. These observations suggest that endosonography may be a reliable technique for the diagnosis of mucinous adenocarcinoma arising from chronic fistula-in-ano. Sonography-guided biopsy is useful for the definitive diagnosis of malignancy. Therefore, periodic endosonography assessment should be recommended for patients with persistent anal fistula, especially those with progressive clinical symptoms. Once malignancy is suspected, aggressive sonography-guided biopsy under anesthesia should be performed, which may enable an early diagnosis, curative treatment, and favorable long-term results.

Non-sphincter splitting fistulectomy vs conventional fistulotomy for high trans-sphincteric fistula-in-ano: a prospective functional and manometric study.

PURPOSE: This study compared the clinical and physiological results of non-sphincter splitting fistulectomy (N-SSF) with those of sphincter splitting fistulotomy (SSF) for treatment of high trans-sphincteric fistula-in-ano. MATERIALS AND METHODS: A prospective, observational study was undertaken in 70 consecutive patients with high trans-sphincteric fistula treated by SSF (n = 35) or N-SSF (n = 35). Anal manometry was performed before and 3 months after surgery. Anal continence was assessed using the Cleveland Clinic Florida Incontinence Score. RESULTS: There was no difference between the two groups in age, gender, presence of horseshoe extension, preoperative incontinence score and manometric values. The incidence of recurrence was similar between the two groups. The postoperative incontinence score of the SSF group was significantly higher than that of the N-SSF group (1.9 +/- 2.9 vs 1.1 +/- 2.9, P = 0.0347). Maximum resting pressure showed significant decrease after surgery in both groups (83.2 to 56.1 mmHg, P = 0.0001 and 85.1 to 58.4 mmHg, P = 0.0001). Voluntary contraction pressure and functional anal canal length did not change after N-SSF (137.6 to 138.2 mmHg, P = 0.9524 and 4.06 to 4.07 cm, P = 0.9524), but significantly decreased after SSF (120.2 to 96.7 mmHg, P = 0.0085 and 4.12 to 3.74 cm, P = 0.0183). CONCLUSION: Non-sphincter splitting fistulectomy for high trans-sphincteric fistula provided better functional results than fistulotomy. Less impairment of anal continence was achieved possibly not only by maintenance of the external anal sphincter function but also by preservation of the length of the high-pressure zone.

Factors affecting continence after fistulotomy for intersphincteric fistula-in-ano.

BACKGROUND AND AIMS: This study was undertaken to determine the incidence of and risk factors for anal incontinence after fistulotomy for intersphincteric fistula-in-ano. We also evaluated the role of anal manometry in preoperative assessment of intersphincteric fistula. MATERIALS AND METHODS: A prospective, observational study was undertaken in 148 patients who underwent fistulotomy for intersphincteric fistula between January and December 2004. Functional results were assessed by standard questionnaire and anal manometry. Possible factors predicting postoperative incontinence were examined by univariate and multivariate regression analyses. RESULTS: The mean follow-up period was 12 months. Postoperative anal incontinence occurred in 30 patients (20.3%), i.e., soiling in 6, incontinence for flatus in 27, and incontinence for liquid stool in 4. Fistulotomy significantly decreased maximum resting pressure (85.9 +/- 20.4 to 60.2 +/- 18.4 mmHg, P < 0.0001) and length of the high pressure zone (3.92 +/- 0.69 to 3.82 +/- 0.77 cm, P = 0.035), but it did not affect voluntary contraction pressure (164.7 +/- 85.2 to 160.3 +/- 84.8 mmHg, P = 0.2792). Multivariate analysis showed low voluntary contraction pressure and multiple previous drainage surgeries to be independent risk factors for postoperative incontinence. CONCLUSION: Fistulotomy produces a satisfactory outcome in terms of eradicating sepsis and preserving function in the vast majority of patients with intersphincteric fistula with intact sphincters. However, sphincter-preserving treatment may be advocated for patients with low preoperative voluntary contraction pressure or those who have undergone multiple drainage surgeries. Preoperative anal manometry is useful in determining the proper surgical procedure.

Microbiological analysis and endoanal ultrasonography for diagnosis of anal fistula in acute anorectal sepsis.

BACKGROUND AND AIMS: Treatment of anorectal sepsis requires prompt surgical drainage, but it is important to identify any associated anal fistula for preventing recurrence. We evaluated whether microbiological analysis and/or endoanal ultrasonography could be used to predict anal fistula in patients with acute anorectal sepsis. METHODS: Five hundred fourteen consecutive patients with acute anorectal sepsis were studied. Clinical data, digital examination findings, endosonographic findings, and results of microbiological analysis were compared with definitive surgical findings of the presence or absence of anal fistula. RESULTS: Anorectal abscess with anal fistula was found in 418 patients, and anorectal abscess without anal fistula was found in 96 patients. Microbiological examination showed that Escherichia coli, Bacteroides, Bacillus, and Klebsiella species were significantly more prevalent in patients with fistula (P<0.01), and coagulase-negative Staphylococci and Peptostreptococcus species were significantly more prevalent in patients without fistula (P<0.01). Results of endoanal ultrasonography were concordant with the definitive surgical diagnosis in 421 (94%) of 448 patients studied. CONCLUSION: Acute anorectal sepsis due to colonization of "gut-derived" microorganisms rather than "skin-derived" organisms is more likely to be associated with anal fistula. When the microbiological analysis yields gut-derived bacteria, but no fistula has been found in the initial drainage operation, repeat examinations during a period of quiescence, including careful digital assessment and meticulous endosonography, are warranted to identify a potentially missed anal fistula.

Postoperative urinary retention after surgery for benign anorectal disease: potential risk factors and strategy for prevention.

PURPOSE: This study was undertaken to determine the incidence of and risk factors for urinary retention after surgery for benign anorectal disease. METHODS: We reviewed 2,011 consecutive surgeries performed under spinal anesthesia for benign anorectal disease from January through June 2003 to identify potential risk factors for postoperative urinary retention. In addition, we prospectively investigated the preventive effect of perioperative fluid restriction and pain control by prophylactic analgesics on postoperative urinary retention. RESULTS: The number of procedures and the urinary retention rates were as follows: hemorrhoidectomy, 1,243, 21.9%; fistulectomy, 349, 6.3%; incision/drainage, 177, 2.3%; and sliding skin graft/lateral subcutaneous internal sphincterotomy, 64, 17.2%. The overall urinary retention rate was 16.7%. With hemorrhoidectomy, female sex, presence of preoperative urinary symptoms, diabetes mellitus, need for postoperative analgesics, and more than three hemorrhoids resected were independent risk factors for urinary retention as assessed by multivariate analysis. With fistulectomy, female sex, diabetes mellitus, and intravenous fluids >1,000 ml were independent risk factors for urinary retention. Perioperative fluid restriction, including limiting the administration of intravenous fluids, significantly decreased the incidence of urinary retention (7.9 vs 16.7%, P<0.0001). Furthermore, prophylactic analgesic treatment significantly decreased the incidence of urinary retention (7.9 vs 25.6%, P=0.0005). CONCLUSIONS: Urinary retention is a common complication after anorectal surgery. It is linked to several risk factors, including increased intravenous fluids and postoperative pain. Perioperative fluid restriction and adequate pain relief appear to be effective in preventing urinary retention in a significant number of patients after anorectal surgery.

Blockade of constitutively activated Janus kinase/signal transducer and activator of transcription-3 pathway inhibits growth of human pancreatic cancer.

Constitutive activation of signal transducer and activator of transcription (Stat) proteins has been demonstrated in a wide variety of malignancies. In this study, we elucidated the significance of Janus kinase (JAK) and the downstream transcription factor Stat3 signals on malignant potentials of pancreatic cancer. Electrophoretic mobility shift assay and immunohistochemical analysis revealed that Stat3 was constitutively activated in subsets of human pancreatic cancer tissues and cell lines (Panc1, Kp4, AsPC-1, BxPC-3). A JAK-specific inhibitor, tyrphostin AG490, markedly inhibited Stat3 activation and expression of cyclin D1, bcl-xL and vascular endothelial growth factor mRNAs estimated by RT-PCR, as followed by growth arrest (6.3-21.3% vs controls; P<0.001) of pancreatic cancer cells. Inactivation of Stat3 by dominant-negative Stat3 adenovirus partly suppressed the growth of pancreatic cancer cells on day 4 post-inoculation (P<0.05) but not the expression of these mRNAs. These results indicate that activation of the JAK/Stat3 signaling pathway plays an important role in the progression of pancreatic cancer and that blockade of JAK/Stat3 signals may provide a novel therapeutic strategy for pancreatic cancer.

Combination therapy of resection and intraoperative radiation for patients with carcinomas of extrahepatic bile duct and ampulla of Vater: prognostic advantage over resection alone?

BACKGROUND/AIMS: To investigate the therapeutic efficacy of intraoperative radiation for carcinomas of the bile duct and ampulla of Vater. METHODOLOGY: Postoperative morbidity, mortality and survival of patients undergoing surgical resection of ampullary cancer (n = 19) and bile duct cancer (n = 28) were retrospectively compared between two groups with and without intraoperative radiation. RESULTS: Background items (age, gender, preoperative laboratory data, operative time and bleeding volume, tumor stage) did not differ significantly between the two groups. The predominant postoperative complication was leakage of pancreatic juice, which occurred in similar rates in both groups. No significant differences were noted in the 3-year survival rates between the resection plus intraoperative radiation group and resection alone group (60.0% (n = 5) vs. 50.1% (n = 13) for ampullary cancer; 0% (n = 4) vs. 27.1% (n = 24) for bile duct cancer, respectively). The main causes of recurrence were distant metastasis for ampullary cancer and microscopic residue of carcinoma for bile duct cancer. CONCLUSIONS: The combination of intraoperative radiation and resection may add no significant benefit to patients with ampullary and bile duct cancer when compared with resection alone.

Completion radical surgery after cholecystectomy for accidentally undiagnosed gallbladder carcinoma.

Survival time of 73 patients with undiagnosed gallbladder carcinoma incidentally found after cholecystectomy treated between 1982 and 2000 was evaluated in relation to various variables, with special reference to the significance of the radical second resection. The most significant prognostic factor was the depth of tumor invasion as assessed by univariate and multivariate analyses (odds ratio 3.40, 95% CI 1.65-7.00, p < 0.001). None of the 23 pT1 patients received radical second resection, and all of them were doing well without recurrence at their last follow-up examination. The 3-year survival rate was 68% for patients with pT2 and 14% for patients with pT3. Patient characteristics for the 18 pT2 patients who underwent radical second resection were similar to the characteristics of the 25 pT2 patients who did not; nor did postoperative survival times differ significantly. Survival time was not correlated with the interval from initial to second surgery or the type of initial cholecystectomy (open vs laparoscopic). In 11 patients with pT2 whose surgical margin was judged positive at initial cholecystectomy, the radical second resection significantly lengthened survival time. Radical second resection tended to prolong the median survival period from 7 to 15 months in 7 patients with pT3, although the difference was not significant. In conclusion, patients with pT1 undiagnosed carcinoma need no further treatment. The redo surgery was found to prolong survival only in patients with pT2 with positive surgical margin at initial cholecystectomy.

Case of a bleeding pseudoaneurysm of the middle colic artery complicating acute pancreatitis.

Massive bleeding from a pseudoaneurysm is rare, but it can be a life-threatening complication in patients with acute pancreatitis. We present a case in which massive bleeding from a pseudoneurysm in the middle colic artery complicating acute pancreatitis was successfully treated by transcatheter embolization and by continuous regional arterial infusion of a protease inhibitor and antibiotic. We also discuss the clinical features, diagnosis and treatment of such lesions in light of the literature. We emphasize the value of computed tomography in the early diagnosis of mesenteric hematoma in cases of acute pancreatitis and the value of angiography for control of bleeding from the complicating pseudoaneurysm.