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Introduction: Robotic-assisted complete mesorectal excision (RATME) is increasingly being used by colorectal surgeons. Most surgeons consider RATME a safe method, and believe it can facilitate total mesorectal excision (TME) in rectal cancer, and may potentially have advantages over intersphincteric resection (ISR) and anus preservation. Therefore, this trial was designed to investigate whether RATME has technical advantages and can increase the ISR rate compared with laparoscopic-assisted TME (LATME) in patients with middle and low rectal cancer. Methods and analysis: This is a multicenter, superiority, randomized controlled trial designed to compare RATME and LATME in middle and low rectal cancer. The primary endpoint is the ISR rate. The secondary endpoints are coloanal anastomosis (CAA) rate, conversion to open surgery, conversion to transanal TME (TaTME), abdominoperineal resection (APR) rate, postoperative morbidity and mortality within 30 days, pathological outcomes, long-term survival outcomes, functional outcomes, and quality of life. In addition, certain measurements will be conducted to ensure quality and safety, including centralized photography review and semiannual assessment. Discussion: This trial will clarify if RATME improves ISR and promotes anus preservation in patients with mid- and low-rectal cancer. Furthermore, this trial will provide evidence on the optimal treatment strategies for RATME and LATME in patients with mid- and low-rectal cancer regarding improved operational safety. Trial registration: ClinicalTrials.gov NCT06105203. Registered on October 27, 2023. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To compare the risk profiles, anatomical, and functional outcomes between obese and non‐obese women who experienced obstetric anal sphincter injury (OASI).A retrospective electronic database study was conducted at Cork University Maternity Hospital (CUMH). Women with missing data/repairs conducted outside CUMH were excluded. Participants were categorized into obese (BMI ≥30 kg/m2) and non‐obese (BMI <30 kg/m2) groups. Primary measure was a composite adverse outcome assessed 6 months post‐delivery, including one or more of the following: resting pressure <40 mmHg, squeezing pressure <100 mmHg, defects in the internal and/or external anal sphincter. Statistical analyses were performed using SPSS version 28.Among the 349 women included in the study, 285 (81.7%) had a BMI <30 kg/m2 and 64 (18.3%) had a BMI ≥30 kg/m2. Gestational diabetes was significantly higher in obese women. No significant differences were observed in newborn weight or mode of delivery. The majority of tears were classified as grade 3B in both groups. Attendance rates at the OASI clinic did not differ between the groups. Among those attending, no statistical differences were noted in manometry results, which were reduced in both groups. Rates of internal anal sphincter defects were lower in the obese group (7.0% vs 15.6%, P = 0.15) and external anal sphincter defects were significantly lower in obese women (0% vs 9.1%, P = 0.04). No difference was found in the rates of composite adverse outcomes between the groups.Functional outcomes and manometry results did not differ, but non‐obese women had higher rates of anatomical defects in OASI, requiring further study. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To investigate the association between coronavirus disease 2019 (COVID‐19) infection during the peripartum period and obstetric anal sphincter injuries (OASIS).A retrospective cohort study was conducted, including all singleton vaginal deliveries and cesarean deliveries due to failed vacuum extraction, between June 2020 and January 2022 at a large tertiary medical center. OASIS complication during childbirth was compared between women with and without peripartum diagnosis of COVID‐19, defined as a positive polymerase chain reaction test obtained within 1 week before delivery or up to 3 days after delivery. Universal screening for COVID‐19 was implemented. A logistic regression model was used to adjust for confounding variables.The study included 22 911 women, among whom 468 (2.0%) tested positive for COVID‐19 and 22 443 women had no COVID‐19 diagnosis. After adjusting for confounding variables, peripartum infection with COVID‐19 was found to be independently associated with OASIS (adjusted odds ratio 4.38, 95% confidence interval 2.00–9.61; P < 0.001).Infection with COVID‐19 during the peripartum period significantly increases the risk for OASIS by more than fourfold. These findings emphasize the importance of understanding the impact of COVID‐19 on birth complications, such as OASIS, to improve public health measures and enhance obstetric outcomes during pandemics. [ABSTRACT FROM AUTHOR]

Although observational clinical studies have established an association between Intestinal Diseases (IDS) and Anal Diseases (ADS), the causal relationship is still not fully understood due to the limitations of observational studies. Genome-wide association study (GWAS) statistical data for IDS and ADS were obtained from publicly available databases. To assess the causal effects of IDS on ADS, we conducted Mendelian randomization analysis. The inverse variance weighted method indicated that Inflammatory bowel disease (IBD) had a significant causal relationship with three kinds of ADS: Anorectal abscess (ARB), Haemorrhoidal disease (HEM), and Fissure and fistula of anal and rectal regions (FISSANAL). Crohn's disease (CD) and Ulcerative colitis (UC) also showed significant causal effects with three ADS: ARB, HEM, and FISSANAL. Furthermore, a potential link between CD and BNA(Benign neoplasm of anus and anal canal), Irritable bowel syndrome (IBS) and HEM, Colorectal cancer (CRC) and BNA, and Celiac disease and MNA (Malignant neoplasm of anus and anal canal) was observed. This comprehensive MR analysis highlight the significant and increased risk of common Anal Diseases (ARB, FISSANAL, and HEM) in patients with IBD, CD, and UC. Additionally, potential positive causal associations emerged between IBS and HEM, CRC and BNA, as well as between celiac disease and MNA. [ABSTRACT FROM AUTHOR]

Background: Conjoined twins are a rare congenital anomaly with various types, depending on the connection site. Managing these cases requires a structured approach leading to separation surgery. This report provides a detailed description of the anesthetic strategies and challenges of pygopagous conjoined female twins who underwent 2 surgeries before separation at 17 weeks of age. Case Report: The female twins were conjoined at the sacral level (S4), with fused thecal sacs at L5 and cord tethering, with the conus terminating below L3 in both patients. They had separate rectal ampullae that fused into a single anal canal in the midline in a Y formation. The babies underwent 2 surgeries prior to separation: meningocele repair for twin B and anal canal dilation and sphincter mapping for both twins, followed by a ventriculoperitoneal shunt insertion for twin B. The separation surgery included dividing the bony vertebral fusions and dural sacs, untethering the spinal cords and nerves, and correctly allocating the intrapelvic muscles, guided by sphincter muscle mapping. Anesthesia was managed by 2 distinct teams each time, with duplicated equipment and color-coded medications to prevent errors. Due to the critical condition of twin B, general anesthesia was administered to her first. The report also addresses the challenges faced during the 3 surgical procedures. Conclusions: Anesthetic management for pygopagus twins presents complex challenges. Despite limited experience with similar cases, successful management was achieved through planning, effective communication, and rehearsal of unfamiliar setups. Attention to detail and involvement of highly experienced teams were crucial to the success of the procedures. [ABSTRACT FROM AUTHOR]

Concomitant with the rupture of the cloacal membrane, the perineal skin epithelium thickens (see accompanying article). In this study, we establish in female embryos and foetuses that the thick skin area divides into ventral and dorsal areas at ~14 weeks and gradually becomes restricted to the vaginal vestibule and anal canal thereafter. The dense mesenchymal core of the labia minora, which forms at ~8 weeks, extends dorsally to the anal canal as a midline reinforcement. The skin epithelium overlying this reinforcement is much thinner than the flanking ‘thick skin’, and is supported by an interrupted basement membrane, which implies epithelial–mesenchymal transformation of the thin midline epithelium and the subsequent establishment of the perineal raphe by the merging of the adjacent thick epithelium. Meanwhile, the anogenital distance in the perineum increases rapidly in length. Perhaps as a consequence, the labia minora cover only the ventral third of the vaginal vestibule at 20 weeks. The endodermal ducts of Bartholin's glands are identifiable at 7 weeks, while acini form at ~12 weeks. The vestibular bulbs become identifiable at ~10 weeks and form vascular networks after ~14.5 weeks. After the rupture of the cloacal membrane, the diameter of the junction of the dorsal cloaca with the anal canal is just a pinhole but widens dorsoventrally after the 7th week. The cutaneous muscles of the perineal area form as a ventrally open U‐shaped mesenchymal mass, from which the anal sphincter and bulbospongiosus muscle develop. In conclusion, our findings show that thick skin epithelium persists in the vaginal vestibule and anal canal. [ABSTRACT FROM AUTHOR]

Concomitant with the rupture of the cloacal membrane in the 6th week of development, the intermediate layer of the perineal‐skin epithelium thickens. We investigated its distribution and the development of the corresponding subcutaneous compartments in serial sections of female human embryos and foetuses and prepared 3D reconstructions to establish topographic relations. The thick‐skin area becomes restricted to the outlets of the genital and intestinal tracts. The clitoris and labia majora become identifiable at ~7 weeks. The mesenchymal mass inside the clitoris soon divides into the glans and the cavernous bodies. The clitoral hood forms between 10 and 14 weeks as a fold of tissue that extends from proximal to distal over the glans. Due to the caudal bending of the clitoral shaft, the labia majora gradually cover the clitoris after ~14 weeks. The labia minora form at ~8 weeks from the ridges of thick‐skin epithelium that flank the genital exit. They are continuous ventrolaterally with the clitoral hood and ventromedially with the apex of the cavernous body. Dorsally, their dense subcutaneous mesenchymal core extends to the anal canal. Between 8 and 14 weeks, the urethra lengthens axially, while the vaginal vestibule extends ventrally. In this period, the urethral plate of female embryos is mitotically active but does not increase in volume, which suggests that it contributes to vestibular growth. In conclusion, we observed a temporal correlation between the development of the thick‐skin epithelium and that of the external genitals, with a distribution that is reminiscent of the dihydrotestosterone‐sensitive skin. [ABSTRACT FROM AUTHOR]

Anorectal diseases are a major health threat in the field of health sciences. Fistula‐in‐ano is one of the treatable complex benign lesions of the rectum and anal canal. Complex high anal fistulas can reoccur even after surgical treatment. Establishing a cure for cryptoglandular fistula‐in‐ano is problematic, as a significant percentage of these diseases persist or recur if the internal opening of the anal fistula is left untreated. Here, we report a case of complex left anterolateral supralevator anal fistula with communication to the prostate gland that forms a prostatic abscess, as it is very rare. After following Ksharasutra (Ayurvedic medicated seton) treatment with regular wound care, significant regression in the condition was observed. A follow‐up scan showed no evidence of fistula‐in‐ano. A 50‐year‐old businessman presented with complaints of discomfort deep inside the rectum and perineum associated with pain at the base of the scrotum and pus discharge from the perianal region for 1 year. He was diagnosed to have a complex left anterolateral supralevator anal fistula with communication to the prostate substance after a thorough clinical examination and transrectal ultrasonography. After undergoing Ksharasutra treatment for 4 months, pus discharge completely stopped, and sonofistulogram report showed no evidence of fistula‐in‐ano. Images of the sonofistulogram report were documented before and after the treatment. This article highlights the unique feature of Ksharasutra therapy where the fistula extending to the prostate was treated with no loss of function of the anal sphincter. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusion Rectal intussusception (RI) and external rectal prolapse (ERP) are associated with anal sphincter dysfunction. The aim of this study was to examine sphincter function with anal acoustic reflectometry (AAR) in RI and two distinct phenotypes of ERP termed high and low “take‐off”.A prospective study of patients with RI and ERP attending a tertiary pelvic floor unit. Clinical data, AAR, and conventional anal manometry were analysed according to the Oxford prolapse grade.A total of 108 (102 [94%] female, median age 62 years [range: 26–95]) patients were recruited into three groups according to prolapse grade: Oxford grades I and II (intrarectal RI, n = 34), Oxford grades III and IV (intra‐anal RI, n = 35) and Oxford grade V (ERP, n = 39). As the grade of prolapse increased, resting AAR measurements of opening pressure, opening elastance, closing pressure, and closing elastance decreased (p < 0.001). Maximum resting pressure with manometry was reduced in ERP and intra‐anal RI compared to intrarectal RI (p < 0.001). However, incremental squeeze function was not different between the three groups with either AAR or manometry (p > 0.05).There were no differences in AAR or manometry variables between grade IV RI (n = 18) and high take‐off ERP (n = 20) (p > 0.05). By contrast, opening pressure (p = 0.010), closing pressure (p = 0.019) and elastance (p = 0.022) were reduced in low take‐off ERP (n = 19).Increasing rectal prolapse grade is associated with reduced anal sphincter function at rest indicating internal anal sphincter dysfunction. Physiological differences exist between high and low take‐off ERP with sphincter function in the former similar to that seen in grade IV RI. [ABSTRACT FROM AUTHOR]

Introduction: Perianal fistula is a rare condition, however causes substantial morbidity due to its chronicity. Recently, preoperative magnetic resonance imaging (MRI) has become an essential tool for doing a thorough investigation of the fistulous tract, grading of the fistula, concomitant abscess and secondary tracts, and to reduce chances of recurrence after surgery. Methods: A prospective observational hospital based study was done for a duration of 18 months. Patients with suspected perianal fistula were evaluated using MRI and the fistulous tracts were evaluated using the St. James University Hospital Classification. Results: The study confirmed a higher incidence of perianal fistulas among males and predominantly in the 41-50 age demographic. Most fistulas exhibited straightforward anatomical features, with single external and internal openings, and were concentrated at the 5-7 o'clock position, which could influence surgical approaches and outcomes. Based on the St. James University Hospital Classification, the most prevalent fistula was found to be Grade I. MRI was also useful in evaluating associated complications, if present. Conclusion: The incorporation of MRI fistulogram which is a simple and noninvasive method, into standard diagnostic protocols for perianal fistulas not only enhances diagnostic accuracy but also significantly contributes to optimized therapeutic strategies and improved patient care outcomes. [ABSTRACT FROM AUTHOR]

Background: In placebo‐controlled clinical trials, reboxetine, a selective noradrenaline reuptake inhibitor, increases urethral pressure and relieves stress urinary incontinence symptoms in women. Considering the close connection in neural regulation of the external urethral and anal sphincters, we hypothesized that reboxetine may also enhance anal sphincter pressure. Conversely, it is believed that selective serotonin reuptake inhibitors may contribute to fecal incontinence by reducing anal sphincter pressure. In this study, we investigated the effect of reboxetine and citalopram on anal opening pressure in healthy female volunteers. Methods: In a double‐blind, three‐way crossover trial, 24 female participants received single doses of 40 mg citalopram, 8 mg reboxetine, and matching placebos, with a minimum of 8‐day washout between sessions. Using anal acoustic reflectometry, we measured anal opening pressure during both resting and squeezing conditions at the estimated time of peak plasma concentration for both study drugs. Key Results: Compared with placebo, reboxetine increased anal opening pressure with 23.4 cmH2O (95% confidence interval [CI] 16.5–30.2, p < 0.001) during rest and with 22.5 cmH2O (95% CI 15.2–29.8, p < 0.001) during squeeze. Citalopram did not change anal opening pressure statistically significantly compared to placebo. Conclusions & Inferences: An 8‐mg dose of reboxetine increased anal opening pressure substantially in healthy women, suggesting potential benefits for fecal incontinence symptoms. In contrast, a 40‐mg dose of citalopram showed a marginal and statistically insignificant effect on anal opening pressure, indicating that selective serotonin reuptake inhibitors do not contribute to fecal incontinence by reducing anal sphincter tone. [ABSTRACT FROM AUTHOR]

Simple Summary: The study evaluated the long-term outcomes of chemoradiotherapy (CRT) with S-1 after limited surgery for T1 or T2 lower rectal cancer. The 3-year and 5-year relapse-free survival rates were 90.17% and 85.87%, respectively, showing favorable outcomes for T1 cancer patients, with effective anal function preservation. However, further treatment is needed to improve outcomes for T2 cancer patients. Background: The short-term outcomes of chemoradiotherapy (CRT) with S-1 (a combination of tegafur, gimeracil, and oteracil) following limited surgery for patients with T1 or T2 lower rectal cancer have shown encouraging results. Objectives: This study was designed to delve deeper into the long-term outcomes of CRT with S-1 after limited surgery, with the goal of evaluating both the long-term efficacy and potential risks associated with this treatment approach in patients diagnosed with T1 or T2 lower rectal cancer. Methods: This was conducted as a multicenter, single-arm, prospective phase II trial. The patient population consisted of individuals clinically diagnosed with either T1 or T2 lower rectal or anal canal cancer, with a maximum tumor diameter of 30 mm and classified as N0 or M0. Patients underwent local excision or endoscopic resection. After surgery, CRT with S-1 was administered to patients meeting several criteria, including the confirmation of well-differentiated or moderately differentiated adenocarcinoma, negative surgical margins, submucosal invasion depth of ≥1000 µm, and high tumor-budding grade (2/3). The primary endpoint of this study was relapse-free survival, while secondary endpoints included local recurrence-free survival, overall survival, anal sphincter preservation rate, and safety. Results: A total of 52 patients were included, with pathological diagnoses revealing T1 in 36 patients and T2 in 16 patients. The 3-year and 5-year relapse-free survival rates were 90.17% and 85.87%, respectively. The 3-year and 5-year local recurrence-free survival rates were 90.17% and 88.07%, respectively, while the 3-year and 5-year overall survival rates were 94.03% and 91.94%, respectively. Conclusions: CRT with S-1 after limited surgery for T1 lower rectal cancer demonstrated favorable outcomes in terms of recurrence, survival, and local control rates while effectively maintaining anal function in patients. However, further treatment approaches may be necessary to improve outcomes for patients diagnosed with stage T2 lower rectal cancer [ABSTRACT FROM AUTHOR]

Objective: To compare mean post-operative pain in stapled haemorrhoidectomy versus open haemorrhoidectomy. Study Design: Randomized Control Trial. Setting: Department of Surgery, Allied Hospital Faisalabad. Period: 18-04-2021 to 17-10-2021. Methods: There are 94 patients that fill the concert form that agree in this study. The presenting complaints that included such as bleeding per anus, prolapsed of the mucosal membrane, hardening of stool and itching of rectum that were noted. Complete history was taken and physical examination was done as per rule. There are two groups arranged where patients are divided in this group with a well-mannered numerical method. Patients having the group that labeled as Group A underwent open haemorrhoidectomy that compare with the patients that labelled with as Group B with stapled heamorrhoidectomy. All operations were done by same surgical team. All patients were retained in surgical ward in surgical department of Allied hospital Faisalabad. there are several post-operative therapies were taken for reducing the pain and recommend the analgesic NASIDS in the form of Intravenous rout. In the first post-operative day of treatment I/v Paracetamol were administered for 08 hours. NSAIDS and other pain killers were administered in the form of Diclofenac 50mg for the next five post-operative days. However, these medications were administered in both groups that labeled as Group a and Group B of the patients. Results: Comparison of post-operative pain in both groups shows 2.28+0.45 pain in Group-A and 1.26+0.49 in Group-B, p value is 0.0001. Conclusion: The conclusion that showed post-operative pain is significantly lower in stapled haemorrhoidectomy when compared with open haemorrhoidectomy in 3rd and 4th degree of haemorrhoids. [ABSTRACT FROM AUTHOR]

This study aimed to describe the prevalence of high‐risk human papillomavirus (HR‐HPV) types in the anal canal in a cohort of people living with HIV (PLWHIV) with a history of malignancy. Setting: Referral tertiary care hospital for adult patients with cancer. Methods: We reviewed data of patients from the AIDS Cancer Clinic on antiretroviral therapy in chronic control who were consecutively referred for high‐resolution anoscopy (HRA), where they underwent anal evaluation, collection of specimens for anal cytology and anal human papillomavirus (HPV) followed by HRA with directed biopsy if needed. Results: A total of 155 patients were included; 149 (96.1%) were men, all of them men who have sex with men (MSM); the median age was 39 (IQR 32‐47) years; 105 (67.7%) with Kaposi sarcoma, 40 (25.8%) with non‐Hodgkin lymphoma and 10 (6.4%) with other neoplasms; only 7 (4.5%) had active cancer. The prevalence of HR‐HPV infection was 89% (n=138) (95% CI 83–93) with at least one HR‐HPV infection, and 62% (96) had coinfection with at least two types; the median HR‐HPV types of coinfection were 3 (IQR 2–4). The number of patients infected with HPV 16 was 64 (41.3%, 95% CI 33.8–49.3), HPV 18 was 74 (47.7%, 95% CI 39.9–55.7) and with both 35 (22.6%). Some 59 patients (38%) had high‐grade squamous intraepithelial lesions (HSIL) and 49 (31.6%) had low‐grade squamous intraepithelial lesions (LSIL). The prevalence of HR‐HPV and HSIL among patients aged ≤35 and >35 years was the same. Conclusions: In this cohort of PLWHIV with a history of malignancy we found a high prevalence of HR‐HPV 16 and 18 and anal HSIL, even in persons aged ≤35 years. These data highlight the importance of anal cancer screening in PLWHIV and history of malignancy. [ABSTRACT FROM AUTHOR]

Bursaphelenchus parasaudi n. sp., isolated in Ningbo, P.R. China, from loblolly pine logs imported from the USA is described. It is characterised by a slim body (a = 32-43), lateral field with four lines, excretory pore located at the level of metacorpus, vulva at 76% of total body length, a distinct vulval flap in lateral view, post-uterine branch ca half to two-thirds of the vulva to anus distance long, female tail conical, slightly ventrally curved, with a finely rounded terminus, male spicules with weakly developed rostrum and condylus and cross-striped in their central part, a single precloacal papilla and three pairs of ventro-sublateral papillae. It belongs to the africanus group of the genus Bursaphelenchus and is most similar to B. saudi. Detailed phylogenetic analysis based on the partial 18S region, ITS and 28S D2-D3 region confirmed the status of this nematode as a new species. [ABSTRACT FROM AUTHOR]

Objectives: To introduce a two‐dimensional sonographic method to assess the fetal anus, and to evaluate the feasibility of this method to diagnose anal atresia prenatally and identify the presence or absence of anoperineal fistula (in males) and anovestibular fistula (in females). Methods: This was an observational study of suspected cases of anal atresia referred to a single center in Israel between August 2018 and October 2023. In addition to conventional evaluation of the perineum in the axial plane, fetuses referred to our center for suspected malformation were scanned with a new method termed the 'infracoccygeal/transperineal window'. This window consisted of a midsagittal view of the fetal pelvis, including the distal rectum and the anal canal. Normal anatomy was confirmed when the anal canal was continuous with the rectum and terminated at the expected location on the perineum. In female fetuses, the normal anal canal runs parallel to the vaginal canal and diverges posteriorly, terminating at the perineal skin, distant from the vestibule. In male fetuses, the normal anal canal diverges posteriorly in relation to the corpora cavernosa, terminating at the perineal skin, distant from the scrotum. High anal atresia was identified when a blind‐ending rectal pouch was demonstrated in the pelvis without a fistula to the perineum or vestibule. Low anal atresia was determined when a rectal pouch was continuous with an anteriorly deflected fistula. In females, the fistula converges with the vaginal canal, terminating at the vestibule; in males, the fistula deflects anteriorly, terminating at the base of the scrotum. Postnatally, the diagnosis and type of anal atresia were confirmed through physical examination with direct visualization of the fistula, radiographic studies, surgical examination and/or postmortem autopsy. Results: Of the 16 fetuses diagnosed prenatally with anal atresia, eight were suspected to have low anal atresia and eight were suspected to have high anal atresia. The median gestational age at diagnosis was 23 (range, 14–37) weeks. All cases showed additional structural malformation. Eleven patients opted for termination of pregnancy, of which four had low anal atresia and seven had high anal atresia. Postnatal confirmation was not available in four cases due to curettage‐induced mutilation or in‐utero degradation following selective termination of the affected twin, leaving 12 cases for analysis, of which seven were diagnosed with low anal atresia and five with high anal atresia. In these 12 cases, all prenatal diagnoses were confirmed as correct, rendering 100% sensitivity and 100% specificity in this high‐risk fetal population. Conclusions: The infracoccygeal/transperineal window is an effective method to detect and classify the level of anal atresia prenatally. This may improve prediction of postnatal fetal continence and optimize prenatal counseling. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Introduction: Anal fissure is a common proctological condition characterized by painful lesions caused by hyper- tonia of the internal anal sphincter smooth muscle. Despite its impact, conventional treatments available may be limited in terms of reproducibility, efficacy, and long-term tolerability. Therefore, exploring new pharmacological therapies, in sync with nanocarriers enabling their specific targeting to the site of action, offers a potential alternative to improve its treatment. Method: This study adopts a retrospective and longitudinal approach. Results: Different therapeutic approaches are applied, ranging from hygienic-sanitary measures and non-invasive pharmacological treatments to surgery, most of them aimed at reducing hypertonia. The most commonly used drugs in hospitals are lidocaine, diltiazem, nifedipine, nimodipine, isosorbide nitrate, and botulinum toxin. Lever- aging the advantages of pharmaceutical nanotechnology to enhance therapeutic efficacy, reduce adverse effects from systemic administration, and increase healing rates, studies have been found on the application of polymeric nanoparticles, vesicular nanoparticles, and micro-nano emulsions to deliver drugs for the symptomatic treatment of anal fissure. Some formulations are already authorized for use, while others are still under research. Conclusions: It has been demonstrated that new formulations, especially those based on nanotechnology, show significant potential in improving the healing of fissures compared to conventional treatments. However, further studies on the safe use of these systems are necessary before their widespread clinical implementation. [ABSTRACT FROM AUTHOR]

Objective: Obesity and maternal age are increasing among pregnant patients. The understood effect of body mass index (BMI), advanced maternal age (AMA), and second stage of labor on obstetric anal sphincter injury (OASIS) at delivery is varied. The objective of this study was to assess whether incorporating BMI, second stage of labor length, and AMA into a model for predicting OASIS among forceps‐assisted vaginal deliveries (FAVD) had a higher predictivity value compared to models without these additions. Method: This was an IRB‐approved retrospective cohort study of singleton gestations who underwent a FAVD between 2017 and 2021. The primary outcome was prediction of OASIS via established models versus models including the addition of new predictive factors. Results: A total of 979 patients met inclusionary criteria and were included in the final analysis. 20.4% of patients had an OASIS laceration, 11.3% of neonates had NICU admissions, 23.7% had a composite all neonatal outcome, and 8% had a composite subgaleal/cephalohematoma outcome. Comparisons of known factors that predict OASIS (nulliparity, race, episiotomy status) to known factors with additional predictors (BMI, AMA, and length of second stage in labor) were explored. After comparing each model's AUC to one another (a total of 3 comparisons made), there was no statistically significant difference between the models (all P > 0.62). Conclusion: Including BMI, AMA, and second stage of labor length does not improve the predictivity of OASIS in patients with successful FAVD. These factors should not impact a provider's decision to perform a FAVD when solely considering increased odds of OASIS. Synopsis: We attempted to improve established models predicting OASIS in FAVDs. However, we did not find a significant difference in predictive ability when including additional factors. [ABSTRACT FROM AUTHOR]

A variety of tumors involve the anal canal because the anal canal forms the transition between the digestive system and the skin, and this anatomical region is made of a variety of different cells and tissues. Magnetic resonance imaging (MRI) is the modality of choice for diagnosis and local staging of the anal canal and perianal neoplasms. In this pictorial review, we demonstrate the MRI anatomy of the anal canal and perianal region and display the imaging spectrum of tumors in the region along with an overview of its management. Imaging appearances of many tumorlike lesions that can cause diagnostic dilemmas are also demonstrated with pointers to differentiate between them. [ABSTRACT FROM AUTHOR]

Introduction Postoperative constipation (PC) in patients with imperforate anus and perineal fistula (PF) has been reported in up to 60%. Histological studies of PF revealed innervation anomalies which seem to be one of the reasons for PC. Perioperative histologically controlled fistula resection (PHCFR) allows appropriate resection of PF and pull-down normoganglionic rectum at the time of posterior sagittal anorectoplasty (PSARP). Materials and Methods A total of 665 patients with anorectal malformations underwent surgery between 1991 and 2021. Of these, 364 presented PF; 92 out of them (41 F) were studied. Patients with sacral and spinal cord anomalies, neurological disorders, and cut-back anoplasty were excluded. PSARP was done on all patients. Hematoxylin-eosin staining and NADH Tetrazolium-reductase histochemical method were used. Four and more ganglion cells in the myenteric plexus represented a sufficient length of the resection. The continence was scored according to the modified Krickenbeck scoring system. Final scores ranged from 1 to 7 points. Values are given as median. Results A total of 65 (70.7%) patients presented an aganglionic segment in PF, and 27 patients presented hypoganglionosis. The median length of the resected fistula was 25 mm (interquartile range [IQR]: 20–30). The median total continence score was 7 (IQR: 6–7). Post-op constipation was observed in 6/92 (6.5%) patients. Conclusion PHCFR diminished PC to 6.5% of patients. [ABSTRACT FROM AUTHOR]

Objective The purpose of the study was to determine if antegrade continence enema (ACE) alone is an effective treatment for patients with severe functional constipation and segmental colonic dysmotility. Methods A retrospective study of patients with functional constipation and segmental colonic dysmotility who underwent ACE as their initial means of management. Data was collected from six participating sites in the Pediatric Colorectal and Pelvic Learning Consortium. Patients who had a colonic resection at the same time as an ACE or previously were excluded from analysis. Only patients who were 21 years old or younger and had at least 1-year follow-up after ACE were included. All patients had segmental colonic dysmotility documented by colonic manometry. Patient characteristics including preoperative colonic and anorectal manometry were summarized, and associations with colonic resection following ACE were evaluated using Fisher's exact test and Wilcoxon rank-sum test. p -Values of less than 0.05 were considered significant. Statistical analyses and summaries were performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, United States). Results A total of 104 patients from 6 institutions were included in the study with an even gender distribution (males n = 50, 48.1%) and a median age of 9.6 years (interquartile range 7.4, 12.8). At 1-year follow-up, 96 patients (92%) were successfully managed with ACE alone and 8 patients (7%) underwent subsequent colonic resection for persistent symptoms. Behavioral disorder, type of bowel management, and the need for botulinum toxin administered to the anal sphincters was not associated with the need for subsequent colonic resection. On anorectal manometry, lack of pelvic floor dyssynergia was significantly associated with the need for subsequent colonic resection; 3/8, 37.5% without pelvic dyssynergia versus 1/8, 12.5% (p = 0.023) with pelvic dyssynergia underwent subsequent colonic resection. Conclusion In patients with severe functional constipation and documented segmental colonic dysmotility, ACE alone is an effective treatment modality at 1-year follow-up. Patients without pelvic floor dyssynergia on anorectal manometry are more likely to receive colonic resection after ACE. The vast majority of such patients can avoid a colonic resection. [ABSTRACT FROM AUTHOR]

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Background Methods Results Conclusion Anal fissures are a debilitating benign condition, thought to be due to the hypertonicity of the internal anal sphincter resulting in localized ischaemia inhibiting healing. There are several surgical and non‐surgical treatment options for chronic anal fissures. Clinical practice surveys report a trend toward sphincter‐sparing options, reserving the more successful treatment of lateral sphincterotomy, with an incontinence rate up to 10%, for refractory fissures.A search of MEDLINE, Cochrane Database of Systematic Reviews and EMBASE for studies assessing sphincter‐sparing treatment with botulinum toxin and fissurectomy was performed following PRISMA guidelines. Outcomes assessed included healing rate, persistence, recurrence, re‐intervention and incontinence rates.Fifteen non‐randomized studies assessed 978 patients managed with botulinum toxin and fissurectomy. The mean age was 40.8 years with a female predominance of 58.9%. Healing rate was reported on 14 of the 15 studies, with a healing rate of 81% (95% CI:0.67, 0.90). Persistence rate was reported as 15% (95% CI:0.07, 0.28) and a recurrence rate of 6% (95% CI: 0.01, 0.19). Re‐intervention was required in 8% of patients with 55.1% requiring a repeat dose of botulinum toxin with or without fissurectomy. Incontinence appears to be transient with studies reporting a rate of 1% with median long‐term follow up 23 months (range: 5–60 months).Combination fissurectomy and botulinum toxin is a safe and viable sphincter sparing treatment option, with moderate success rate and negligible complications. Randomized controlled trials are required to further strengthen the evidence for its use in chronic anal fissures. [ABSTRACT FROM AUTHOR]

Biofeedback therapy is useful for treatment of functional defecation disorders but is not widely available and is labor intensive. We developed an Internet-of-Medical-Things (IoMT) device, enabling self-guided biofeedback therapy. This study assesses the safety and efficacy of self-guided biofeedback therapy using the IoMT device in comparison to standard operator-led therapy. Patients experiencing urge or seepage fecal incontinence (≥1 episode/week) were randomly assigned to either our IoMT system or to the conventional anorectal manometry-based therapy. Both interventions comprised six weekly sessions, focusing on enhancing anal strength, endurance, and coordination. The novel device facilitated self-guided therapy via visual instructions on a companion app. Primary outcomes included safety/tolerability, changes in Vaizey severity scores, and alterations in anorectal pressure profiles. Twenty-five patients (22 females, 3 males) participated, with 13 in the novel device group and 12 in the standard therapy group. Both groups showed significant reductions in symptom severity scores: IoMT device group -4.2 (95% CI: -4.06, -4.34, p = 0.018), and the standard therapy group -4.8 (95% CI: -4.31, -5.29, p = 0.028). Anal sphincter resting pressure and sustained squeeze time improved significantly in both groups, and the novel device group demonstrated an increase in maximum sphincter squeeze pressure. There were no significant differences between the therapy groups. Importantly, the experimental device was well-tolerated compared with standard therapy, with no serious adverse events observed. This study demonstrates the comparable efficacy of self-administered biofeedback using the IoMT device with traditional biofeedback therapy. The results demonstrates the potential of the IoMT device as a safe, self-guided method for FI therapy, offering convenience and effectiveness in fecal incontinence management. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID19) can cause gastrointestinal complications as well as respiratory tract disease. Coagulation abnormalities and thrombosis frequently occur in COVID19, especially in cases with severe clinical outcome. The relationship between gastrointestinal perforation and coagulopathy due to COVID19 remains unclear. Case presentation: A 49-year-old female received Chimeric antigen receptor T (CAR-T) therapy for an early recurrence of diffuse large B-cell lymphoma (DLBCL) that was refractory to chemotherapy. She was diagnosed with cytokine release syndrome (CRS) because of a fever and oxygen desaturation, and administered tocilizumab. Forty days after completing CAR-T therapy, she was infected with COVID19 and transferred to our hospital. Her general condition worsened and she developed COVID19 pneumonia, and then steroid pulse therapy was started. While her respiratory condition improved, she experienced pain in the anal region and computed tomography (CT) revealed a rectal perforation. An emergency surgery was undertaken, and the lower rectum wall was found to be completely necrotic. Removal of the necrotic part of the rectum tissue, and drainage and lavage of necrotic tissue in the pelvic cavity were performed. The remaining rectum was resected with partial sigmoidectomy, but we could not make the anal stump closed. In addition, an end colostomy in the sigmoid colon was performed. Histopathological findings showed thromboses in the rectal mesentery veins. After the first surgery, the pelvic abscess cavity persisted and her high-grade fever continued. Reoperation was laparoscopically performed, and she underwent a resection of anal canal with residual necrotic rectal and mesorectal tissue, and a drainage of the pelvic abscess. After the reoperation, her general condition improved and CT showed that the abscess cavity had significantly improved. Conclusions: Gastrointestinal perforation, especially rectal necrosis due to coagulopathy caused by severe COVID19 infection, is a rare but life-threatening complication. Physicians should have a high degree of clinical suspicion for timely diagnosis and management, and surgical intervention is necessary in cases of rectal necrosis. [ABSTRACT FROM AUTHOR]

Necrotizing fasciitis (NF) is a rare and life-threatening serious infectious disease, characterized by acute onset and rapid progress, leading to extensive necrosis of skin, soft tissue as well as fascia by a variety of aerobic and anaerobic bacteria, localized on external genitalia, scrotum, groin and perianal areas in males. There exist numerous common etiologies for NF, yet NF induced by malignant neoplasms is exceedingly rare. Several studies have reported that NF may be associated with tumor site (rectal/sigmoid colon cancer) and blood supply dysfunction caused by targeted therapy drugs (bevacizumab, aflibercept, ramucirumab). The perforation of colorectal cancer poses a unique risk factor for NF. However, in our two cases, the patient with rectal cancer received CapeOX (oxaliplatin + capecitabine) + bevacizumab + tislelizumab for 3 cycles without perforation but did develop NF. One month after debridement, the patient continued immunotherapy with tislelizumab alone for the fourth cycle and maintained for an additional 3 cycles without any recurrence of NF. Therefore, does the occurrence of NF correlate with the tumor site (rectum) and targeted immunotherapy? Another patient with hepatocellular carcinoma also developed NF after receiving 2 cycles of lenvatinib + sintilimab treatment. The third cycle of sintilimab immunotherapy was administered on the 13th day after operation, which was subsequently maintained for an additional 2 cycles without recurrence of NF. The absence of a direct correlation between hepatocellular carcinoma and rectal tumor location as well as immunotherapy, suggests that NF may be closely linked to targeted therapy. [ABSTRACT FROM AUTHOR]

Polyploid Giant Cancer Cells (PGCCs) have been recognized as tumor cells that are resistant to anticancer therapies. However, it remains unclear whether their presence in the bloodstream can be consistently detected and utilized as a clinical marker to guide therapeutic anticancer regimens. To address these questions, we conducted a retrospective study involving 228 patients diagnosed with six different types of carcinomas (colon, gastric, NSCLC, breast, anal canal, kidney), with the majority of them (70%) being non-metastatic. Employing a highly sensitive liquid biopsy approach, ISET®, and cytopathological readout, we isolated and detected circulating PGCCs in the patients' blood samples. PGCCs were identified in 46 (20.18%) out of 228 patients, including in 14.47% of 152 non-metastatic and 29.85% of 67 metastatic cases. Patients were subsequently monitored for a mean follow up period of 44.74 months (95%CI: 33.39–55.79 months). Remarkably, the presence of circulating PGCCs emerged as a statistically significant indicator of poor overall survival. Our findings suggest that circulating PGCCs hold promise as a reliable prognostic indicator. They underscore the importance of further extensive investigations into the role of circulating PGCCs as a prognostic marker and the development of anti-PGCC therapeutic strategies to improve cancer management and patient survival. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions The establishment of midwife‐led birth centers (MLBCs) is still being debated. The study aimed to compare severe adverse outcomes and mode of birth in low‐risk women according to their birth planned in MLBCs or in obstetric‐led units (OUs) in France.We used nationwide databases to select low‐risk women at the start of care in labor in MLBCs (n = 1294) and in OUs (n = 5985). Using multilevel logistic regression, we compared severe adverse maternal and neonatal morbidity as a composite outcome and as individual outcomes. These include severe postpartum hemorrhage (≥1000 mL of blood loss), obstetrical anal sphincter injury, maternal admission to an intensive care unit, maternal death, a 5‐minute Apgar score <7, neonatal resuscitation at birth, neonatal admission to an intensive care unit, and stillbirth or neonatal death. We also studied the mode of birth and the role of prophylactic administration of oxytocin at birth in the association between birth settings and severe postpartum hemorrhage.Severe adverse maternal and neonatal outcome indicated a slightly higher rate in women in MLBCs compared to OUs according to unadjusted analyses (4.6% in MLBCs vs. 3.4% in OUs; cOR 1.36; 95%CI [1.01–1.83]), but the difference was not significant between birth settings after adjustment (aOR 1.37 [0.92–2.05]). Severe neonatal morbidity alone was not different (1.7% vs. 1.6%; aOR 1.17 [0.55–2.47]). However, severe maternal morbidity was significantly higher in MLBCs than in OUs (3.0% vs. 1.9%; aOR 1.61 [1.09–2.39]), mainly explained by higher risks of severe postpartum hemorrhage (2.4 vs. 1.1%; aOR 2.37 [1.29–4.36]), with 2 out of 5 in MLBCs partly explained by the low use of prophylactic oxytocin. Cesarean and operative vaginal births were significantly decreased in women with a birth planned in MLBCs.In France, 3 to 4% of low‐risk women experienced a severe adverse maternal or neonatal outcome regardless of the planned birth setting. Results were favorable for MLBCs in terms of mode of birth but not for severe postpartum hemorrhage, which could be partly addressed by revising practices of prophylactic administration of oxytocin. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions The artificial anal sphincter is a device used to treat patients with fecal incontinence who are unable to control their bowel movements on their own. Long‐term morphological changes in the tissue surrounding the artificial anal sphincter can cause biomechanical compatibility problems, which seriously affect the clinical application of the artificial anal sphincter.In this paper, the superelasticity of shape memory alloys was utilized to design and fabricate a biomechanically compatible constant force clamping artificial anal sphincter. An in vitro simulation system was constructed to verify the effectiveness, safety, and constant force characteristics of the artificial anal sphincter.The experimental results demonstrated that the artificial anal sphincter could be effectively closed with no leakage of the liquid‐like intestinal contents, which are most likely to leak. The pressure of the artificial anal sphincter on the intestinal tube gradually increased and eventually became constant during closure, and the pressure value was always less than the intestinal blood supply pressure threshold.In this paper, we designed an artificial anal sphincter based on biomechanical compatibility and the corresponding in vitro simulation experimental program and preliminarily verified the effectiveness, safety, and constant force characteristics of the artificial anal sphincter. [ABSTRACT FROM AUTHOR]

The relationship between psoriasis and site-specific cancers remains unclear. Here, we aim to investigate whether psoriasis is causally associated with site-specific cancers. We use observational and genetic data from the UK Biobank, obtaining GWAS summary data, eQTL analysis data, TCGA data, and GTEx data from public datasets. We perform PheWAS, polygenic risk score analysis, and one-sample and two-sample Mendelian randomization analyses to investigate the potential causal associations between psoriasis and cancers. In the unselected PheWAS analysis, psoriasis is associated with higher risks of 16 types of cancer. Using one-sample Mendelian randomization analyses, it is found that genetically predicted psoriasis is associated with higher risks of anal canal cancer, breast cancer, follicular non-Hodgkin's lymphoma and nonmelanoma skin cancer in women; and lung cancer and kidney cancer in men. Our two-sample Mendelian randomization analysis indicates that psoriasis is causally associated with breast cancer and lung cancer. Gene annotation shows that psoriasis-related genes, such as ERAP1, are significantly different in lung and breast cancer tissues. Taken together, clinical attention to lung cancer and breast cancer may be warranted among patients with psoriasis. The relationship between psoriasis and cancer remains unclear. Here, the authors use PheWAS, polygenic risk scores, and Mendelian randomization analyses to demonstrate that psoriasis is causally associated with lung and breast cancer. [ABSTRACT FROM AUTHOR]

Nematode surveys in natural environments in the Iberian Peninsula detected three unidentified Xenocriconemella populations that closely resembled the X. macrodora-species complex, but utilization of integrative taxonomy confirmed that they comprised a new taxon described in this paper as X. andreae sp. nov. Only females were detected in the new species (considered parthenogenetic) and delineated with a bare body (274–353 µm); lip region with two annuli, continuous with body delineation; second lip annulus enclosed by the first one. Flexible and thin stylet (88.0–99.0 µm), representing 30.4–47.8% of total body length. The excretory pore is positioned 2–3 annuli posterior to the level of stylet knobs, at 101.5 (87–107) µm from the lip region. Female genital tract: monodelphic, prodelphic, large, and representing 34.4–52.4% of the body length; vagina slightly ventrally curved. The anus is located at (6–9) annuli from the rear end. Tail short, conoid, and blunt round terminus. Ribosomal and mitochondrial markers (D2-D3 expansion domains of 28S, ITS , partial 18S rRNA, and COI), as well as molecular phylogenetic analyses of sequences, confirmed this new taxon, and it was clearly delineated from X. macrodora and species within the species complex (X. costaricense, X. iberica, X. paraiberica, and X. pradense). [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: Despite the high prevalence of fecal incontinence, existing treatment options may be inadequate. Drugs that enhance the tone of the anal sphincter complex could potentially be an effective pharmacological approach. This study investigated the effect of the tricyclic antidepressant imipramine on anal sphincter tone in healthy women, employing anal acoustic reflectometry as the evaluating method. Methods: In a double-blind, randomized, placebo-controlled crossover study, 16 healthy female volunteers were randomized to one of two treatment sequences. The participants attended two study visits separated by at least 7 days' washout. At each visit, they received a single dose of 50 mg imipramine or matching placebo, in alternating order. We assessed the anal opening pressure under the resting state and during voluntary squeezing of the pelvic floor. Measurements were performed pre-dose and 1 h after drug administration, corresponding to the estimated time of peak plasma concentration of imipramine. Results: All participants completed the study. In total, 44% of the participants reported at least one adverse effect, primarily anticholinergic. Compared with placebo, imipramine increased anal opening pressure by 15.2 cmH2O (95% confidence interval [CI] 2.0–28.2 cmH2O, p = 0.03) in the resting state and 15.1 (95% CI 4.2–26.0 cmH2O, p = 0.01) cmH2O during squeezing. Conclusions: The findings indicate that imipramine increases anal sphincter tone in healthy women. However, further research is required to evaluate its clinical impact on individuals with fecal incontinence. This research also demonstrates the effectiveness of using anal acoustic reflectometry for assessing pharmacological effects on anal sphincter function. [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy. Methods: This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening. Results: Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups. Conclusions: In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Perianal alveolar rhabdomyosarcoma is a rare sarcoma that requires a high index of suspicion along with tissue biopsy for accurate diagnosis. Successful treatment, even in the setting of recurrence, requires a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Primary signet‐ring cell carcinoma of the anal canal and rectum is an extremely rare and aggressive malignancy. The present case underscores the importance of considering primary signet‐ring cell carcinoma in differential diagnoses for young patients with chronic anorectal symptoms. It highlights the need for a multidisciplinary treatment approach (including surgery, chemotherapy, and radiotherapy) and comprehensive follow‐up for managing this challenging condition and improving long‐term patient outcomes. Primary signet‐ring cell carcinoma of the anal canal and rectum is an exceedingly rare subtype of colorectal adenocarcinoma, often originating as an extension of rectal adenocarcinoma. This malignancy constitutes a small fraction of colorectal cancers and is scarcely reported in medical literature. We present the case of an 18‐year‐old male with a three‐year history of progressively worsening hematochezia, anorectal pain, and defecation‐associated prolapse. Initial conservative treatments failed, leading to further investigations that revealed a palpable, nodular anorectal mass. Imaging studies (including CT and MRI), and biopsy confirmed poorly differentiated adenocarcinoma with signet‐ring cell morphology. The tumor exhibited extensive lymphovascular invasion and involved perirectal lymph nodes, and was staged as pT3, N2a. Immunohistochemical staining was positive for CK 7, CK 20, and SATB2, supporting the primary anorectal origin. The treatment regimen included initial diversion colostomies for symptom relief, followed by neoadjuvant chemotherapy with a modified 5‐fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) regimen and concurrent chemoradiation with Xeloda. The patient subsequently underwent an abdominoperineal resection (APR), which confirmed the diagnosis and achieved curative resection. Postoperative complications included transient ileus and wound infection, which were managed with supportive care. This case underscores the diagnostic and therapeutic challenges posed by primary signet‐ring cell carcinoma of the anorectal region, highlighting the need for a high index of suspicion and comprehensive diagnostic workup in atypical presentations. The multimodal treatment approach, incorporating surgery, chemotherapy, and radiotherapy, was crucial in managing this locally advanced tumor. The rarity and aggressiveness of this carcinoma necessitate a tailored treatment strategy to improve patient outcomes. Long‐term follow‐up, including regular imaging and surveillance, is vital for monitoring disease recurrence and evaluating treatment effectiveness. [ABSTRACT FROM AUTHOR]

Tailgut cysts are rare lesions which are found in the rectorectal space. They develop in the final section of the intestine from which the rectum and anus extend and vary from being asymptomatic to symptomatic due to pressure on organs or nerves. Tailgut cysts are more common in females, usually between 30 and 60 years of age. They are thought to be benign, with variable malignancy risks. Surgical excision followed by histological examination is the gold standard of treatment, but access and approach to tailgut cysts depend on the location and morphology of the lesion. We present two symptomatic cases of this very rare pathology. In both cases, the cyst and coccyx bone were successfully excised using different approaches. The first patient was a 40-year-old woman with a large cyst which caused morning tenesmus, urinary outflow disorders and painful ovulation. Due to the cyst size, laparotomy was performed, and a combined approach was used. The second patient is a 36-year-old woman with co-existing endometriosis and a cyst causing pain in the sacral spine, constipation and tenesmus. The tumor was excised using a Kraske approach, and due to the infiltration of the coccyx bone it was removed using an osteotome. In this patient, perforation of the cyst was also observed. Both patients completed follow-ups involving regular surgical check-ups and MRI scans. Descriptions of different symptoms and surgical approaches make our study an important source of knowledge for diagnosing and treating these very rare tumors. [ABSTRACT FROM AUTHOR]

Third- and fourth-degree anal sphincter injuries are among the most severe traumas women can experience during childbirth, often leading to lifelong continence issues. Despite extensive research, current repair techniques are often inadequate, failing to provide long-term efficiency. The repair of OASIS tends to worsen with time as fecal or anal incontinence increases. This article presents the risk factors for primary repair failure differently from those previously described in the literature, specifically focusing on avoidable risk factors related to obstetricians and surgeons who perform OASIS repair. After reviewing the literature, the following risk areas were identified and described: recurrent OASIS, pitfalls of the current WHO classification, surgical techniques, place in which the repair should be performed, surgical training, factors related to low volumes of patients with grade III-IV injuries, timing of the repair, and failure of primary repair. [ABSTRACT FROM AUTHOR]

The internal anal sphincter (IAS) functions to maintain continence. Previous studies utilizing mice with cell-specific expression of GCaMP6f revealed two distinct subtypes of intramuscular interstitial cells of Cajal (ICC-IM) with differing Ca2+ activities in the IAS. The present study further examined Ca2+ activity in ICC-IM and its modulation by inhibitory neurotransmission. The spatiotemporal properties of Ca2+ transients in Type II ICC-IM mimicked those of smooth muscle cells (SMCs), indicating their joint participation in the "SIP" syncytium. Electrical field stimulation (EFS; atropine present) abolished localized and whole cell Ca2+ transients in Type I and II ICC-IM. The purinergic antagonist MRS2500 did not abolish EFS responses in either cell type, whereas the nitric oxide synthase (NOS) inhibitor NG-nitro- l -arginine (l -NNA) abolished responses in Type I but not Type II ICC-IM. Combined antagonists abolished EFS responses in Type II ICC-IM. In both ICC-IM subtypes, the ability of EFS to inhibit Ca2+ release was abolished by l -NNA but not MRS2500, suggesting that the nitrergic pathway directly inhibits ICC-IM by blocking Ca2+ release from intracellular stores. Since inositol (1,4,5)-trisphosphate receptor-associated cGMP kinase substrate I (IRAG1) is expressed in ICC-IM, it is possible that it participates in the inhibition of Ca2+ release by nitric oxide. Platelet-derived growth factor receptor α (PDGFRα)+ cells but not ICC-IM expressed P2Y1 receptors (P2Y1R) and small-conductance Ca2+-activated K+ channels (SK3), suggesting that the purinergic pathway indirectly blocks whole cell Ca2+ transients in Type II ICC-IM via PDGFRα+ cells. This study provides the first direct evidence for functional coupling between inhibitory motor neurons and ICC-IM subtypes in the IAS, with contractile inhibition ultimately dependent upon electrical coupling between SMCs, ICC, and PDGFRα+ cells via the SIP syncytium. NEW & NOTEWORTHY: Two intramuscular interstitial cells of Cajal (ICC-IM) subtypes exist within the internal anal sphincter (IAS). This study provides the first evidence for direct coupling between nitrergic motor neurons and both ICC-IM subtypes as well as indirect coupling between purinergic inputs and Type II ICC-IM. The spatiotemporal properties of whole cell Ca2+ transients in Type II ICC-IM mimic those of smooth muscle cells (SMCs), suggesting that ICC-IM modulate the activity of SMCs via their joint participation in a SIP syncytium (SMCs, ICC, and PDGFRα+ cells). Listen to this article's corresponding podcast at https://ajpgi.podbean.com/e/got-guts-the-micro-version-inhibitory-neurotransmission-in-the-internal-anal-sphincter/. [ABSTRACT FROM AUTHOR]

Squamous cell carcinoma of the anus (SCCA) incidence has been rising in the United States, particularly among older adults (≥65 years). We estimated the impact of this rise on future burden (through 2035) using age-period-cohort modeling. The SCCA burden (cases/year) is expected to rise, reaching approximately 2700 among men and approximately 7000 among women in 2031-2035 (burden during 2016-2020 among men and women was approximately 2150 and approximately 4600), with most cases 65 years of age or older (61% in men and 70% in women in 2031-2035; from 40% and 46% in 2016-2020). SCCA incidence (per 100 000) is projected to rise among older men aged 65-74, 75-84, and 85 years or older (5.0, 4.9, and 4.3 in 2031-2035 vs 3.7, 3.8, and 3.4 in 2016-2020, respectively) and women (11.2, 12.6, and 8.0 in 2031-2035 vs 8.2, 6.8, and 5.2 in 2016-2020, respectively). The projected rise in SCCA burden among older adults is troubling and highlights the importance of improving early detection and clinical care. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether perineal wound complications in the first birth, alone or in conjunction with obstetric anal sphincter injury (OASI), is associated with an increased risk of OASI in the second birth. Design: Nationwide population‐based cohort study. Setting: Sweden. Population: Women (n = 411 317) with first and second singleton vaginal births in Sweden, 2001–2019. Methods: Data on diagnostic codes and surgical procedures were retrieved from the Swedish Medical Birth Register and the Swedish Patient Register. A perineal wound complication was defined as wound infection, dehiscence or perineal haematoma within 2 months of childbirth. Main outcome measures: Associations between wound complications in the first birth and OASI in the second birth were investigated with logistic regression and presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). Results: In total, 2619 (0.6%) women had a wound complication in the first birth, and 5318 (1.3%) had an OASI in the second birth. Women with a wound complication but no OASI in the first birth had more than doubled odds of OASI in the second birth (aOR 2.73, 95% CI 2.11–3.53). Women with OASI and a wound complication in the first birth had almost tenfold odds (aOR 9.97, 95% CI 6.53–15.24) of recurrent OASI. Conclusions: Perineal wound complication in the first birth increases the likelihood of OASI in a subsequent birth. [ABSTRACT FROM AUTHOR]

Objective: Endoscopic submucosal dissection (ESD) is a specific procedure that uses an electrosurgical knife for en-bloc resectioning large tumors. However, no study has examined the effect of ESD on the defecation function of patients with rectal tumors. We aimed to investigate the potential effects caused by ESD by analyzing changes in the morphology and movement of the anorectum pre- and post-ESD. Methods: This prospective observational study included 11 patients with anorectal tumors who underwent ESD between April 2020 and February 2022. Pre-ESD assessments included anorectal manometry and defecography. Post-ESD assessments were conducted 2 months later, including anorectal manometry, defecography, and proctoscopy for ulcer and stenosis evaluation. Results: The median patient age was 73 years, including seven males and four females. Eight patients (73%) had a tumor in the lower rectum, and the extent of resection was less than 50% of the rectal lumen. Resection reached the dentate line in six cases (55%). In the patients with post-ESD mucosal defects involving the dentate line, the median of functional anal canal length significantly decreased from (3.4 cm pre-ESD to 2.8 cm post-ESD, p = 0.04). Defecography revealed one case with incomplete evacuation (<50%) and incontinence post-ESD. Interestingly, patients with pre-existing rectoceles noted resolution of lesions post-ESD. None of the patients reported daily constipation or fecal incontinence. Conclusions: While rectal ESD is unlikely to cause significant real-world defecation difficulties, alterations in rectal and anal canal morphology and function may occur if the dentate line is involved in the resection range. [ABSTRACT FROM AUTHOR]

Introduction: In clinical experience, occiput posterior (OP) position is associated with longer labor duration than occiput anterior (OA) position, but few studies have investigated the association between labor duration and fetal position. We aimed to compare duration of the active phase of labor in OP deliveries with OA deliveries in a contemporary population using survival methods. Secondary aims were to compare the frequencies of operative interventions, obstetric anal sphincter injuries (OASIS), postpartum hemorrhage, and newborn outcomes in OP with OA deliveries. Material and Methods: We did a historical cohort study in three university hospitals in Norway from 2012 to 2022. Women with a single fetus in cephalic presentation, no previous cesarean section and gestational age ≥37 weeks were eligible and stratified into the first four groups of the Robson ten‐group classification system (TGCS). We estimated the mean duration and calculated the hazard ratio (HR) for delivery using survival analyses. Cesarean sections and instrumental vaginal deliveries were censored. Results: The study population comprised 112 019 women, 105 571 (94.2%) were delivered in OA and 6448 (5.8%) in OP position. The estimated mean duration of the active phase of labor was longer in women with the fetus in OP position in all four TGCS groups. The estimated duration was longer in the OP groups in analyses stratified with respect to epidural analgesia and oxytocin augmentation. The graphical abstract illustrates the probability of delivery in OP compared with OA position in merged TGCS groups 1 and 2a, as a function of time. The unadjusted HR was 0.33 (95% CI 0.31–0.36) for fetuses delivered in OP position compared with OA position in TGCS group 1, 0.25 (95% CI 0.21–0.27) in group 2a, 0.70 (95% CI 0.67–0.73) in group 3, and 0.61 (95% CI 0.55–0.67) in group 4a, respectively. Neither maternal age, gestational age, BMI nor birthweight had confounding effect. Operative delivery rates and OASIS rates were higher in OP position in all four groups. Conclusions: We found longer duration of the active phase of labor in women with the fetus delivered in OP position in all four TGCS groups. [ABSTRACT FROM AUTHOR]

Objectives: To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. Methods: Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off‐line image quality as "inadequate," "adequate," or "ideal" using the Point‐of‐Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra‐ and interrater agreement on those findings. Results: Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two‐dimensional (2D) and three‐dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra‐ and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80–0.94)] and moderate [ICC = 0.72 (0.63–0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. Conclusion: TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects. [ABSTRACT FROM AUTHOR]

Background: Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women's lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs. Aim: To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries. Design and setting: A qualitative study investigating women's experiences with their GP, and GPs' perspectives about providing such care. Method: This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries (n = 41); and second, focus groups with GPs (n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined. Results: Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication. Conclusion: The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting. [ABSTRACT FROM AUTHOR]

The purpose of this study is to examine the effect of pelvic floor muscle training on faecal incontinence. Faecal incontinence is a condition in which stool leaks from the anus involuntarily or uncontrollably. Faecal incontinence is common in elderly people and patients with underlying diseases, but the pathophysiology of faecal incontinence is diverse, and treatment methods must be varied accordingly. Among the known treatment methods, in this study, we focused on pelvic floor muscle training, which can be performed in daily life. The literature was searched for papers that present existing knowledge and address current perspectives. Extracted studies included papers that report scientific consensus. After reviewing the literature, it appears that it is possible to effectively train patients to defecate twice a day, approximately 30 min after breakfast and dinner, by having them attempting to defecate, even when there is no such urge. Pelvic floor muscle training can improve urinary and faecal incontinence by strengthening the contractile force of the pelvic floor muscles such as the external anal sphincter and levator ani. However, the specific types of faecal incontinence patients that can effectively benefit from pelvic floor muscle training is unclear. It is important for patients to understand the pelvic floor muscle training program and to develop sufficient motivation to continue training at home. [ABSTRACT FROM AUTHOR]

Background: Obstetric Anal Sphincter Injuries (OASI) are associated with significant morbidity. Data regarding induction of labor (IOL) and risk of OASI is conflicting. The objective of this study is to evaluate if IOL increases the odds of OASI when compared to spontaneous labor. Methods: This is a retrospective case–control study in women with term, singleton pregnancies, who had a vaginal delivery at a single, academic center in an urban setting from October 2015 to December 2021. Individuals with the primary outcome, OASI, were identified and matched with controls (no OASI) by delivery date. Results: 303 OASI individuals were identified and matched with 1106 controls. Women with OASI were more likely to be White or Asian, have commercial insurance, and have a previous cesarean delivery (CD). IOL increased the likelihood of OASI by 49% compared to spontaneous labor (OR 1.49, 95% CI [1.138, 1.949]). IOL was no longer significant when adjusting for confounding variables and known risk factors. Conclusion: IOL was not associated with OASI when accounting for known antepartum and intrapartum risk factors. Further investigation of modifiable and non-modifiable risks during labor is imperative to decrease the risk of OASI and associated pelvic floor disorders. [ABSTRACT FROM AUTHOR]

Purpose: We investigated the effects of mouse-derived DFAT on the myogenic differentiation of a mouse-derived myoblast cell line (C2C12) and examined the therapeutic effects of rat-derived DFAT on anal sphincter injury using a rat model. Methods: C2C12 cells were cultured using DMEM and DFAT-conditioned medium (DFAT-CM), evaluating MyoD and Myogenin gene expression via RT-PCR. DFAT was locally administered to model rats with anorectal sphincter dysfunction 3 days post-CTX injection. Therapeutic effects were assessed through functional assessment, including anal pressure measurement using solid-state manometry pre/post-CTX, and on days 1, 3, 7, 10, 14, 17, and 21 post-DFAT administration. Histological evaluation involved anal canal excision on days 1, 3, 7, 14, and 21 after CTX administration, followed by hematoxylin–eosin staining. Results: C2C12 cells cultured with DFAT-CM exhibited increased MyoD and Myogenin gene expression compared to control. Anal pressure measurements revealed early recovery of resting pressure in the DFAT-treated group. Histologically, DFAT-treated rats demonstrated an increase in mature muscle cells within newly formed muscle fibers on days 14 and 21 after CTX administration, indicating enhanced muscle tissue repair. Conclusion: DFAT demonstrated the potential to enhance histological and functional muscle tissue repair. These findings propose DFAT as a novel therapeutic approach for anorectal sphincter dysfunction treatment. [ABSTRACT FROM AUTHOR]

Background: Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence. Methods: We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs. Results: Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs. Conclusions: Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress. [ABSTRACT FROM AUTHOR]

Anal cancer is uncommon, comprising 2.2% of gastrointestinal cancers. Squamous cell carcinoma (SCC) is the most common; while perianal basal cell carcinoma (BCC) is rare, representing only 0.2% of anorectal malignancies. BCC, associated with sun exposure and immunosuppression, often resembles benign conditions and manifests as perianal ulcers or masses. Histologically, BCC exhibits basaloid tumor cells with distinct patterns. Despite its rarity, accurate diagnosis is crucial. We expose a case study of a 59-year-old male, previously healthy, that presented with hematochezia and perianal pain, leading to a diagnosis of lower gastrointestinal bleeding. Colonoscopy was needed, and a biopsy revealed an ulcerated, indurated lesion involving the left lateral hemorrhoidal bundle, diagnosed as pigmented basaloid carcinoma. Microscopic examination showed malignant nests of cells with peripheral nuclear palisading, melanocytes, and melanin pigment. Immunohistochemistry confirmed positivity for p63, CK5/6, and BCL2. Respect the treatment, due to the involvement of the anal sphincteric muscle, radiotherapy was chosen. [ABSTRACT FROM AUTHOR]

Background: The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line. Methods: We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed. Results: We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions. Conclusion: ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice. [ABSTRACT FROM AUTHOR]