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Purpose: The aim of this study was to assess frequency and risk factors of severe bleeding after proctological surgery requiring hemostatic surgery observed after publication of the French guidelines for anticoagulant and platelet-inhibitor treatment.Methods: All patients who underwent proctological surgery between January 2012 and March 2017 in a referral center were included. Delay, severity of bleeding, and need for blood transfusion were recorded. Patients with severe postoperative bleeding were matched to controls at a 2:1 ratio adjusted on the operator, and the type of surgery.Results: Among the 8,890 operated patients, 65 (0.7%) needed a postoperative hemostatic procedure in an operating room. The risk of a hemostatic surgery was significantly increased after hemorrhoidal surgery compared with other procedures (1.9% vs. 0.5%, P–4) and was most frequent after Milligan-Morgan hemorrhoidectomy (2.5%). Mean bleeding time was 6.2 days and no bleeding occurred after day 15. Blood transfusion rate was 0.1%. Treatment with anticoagulants and platelet inhibitors were managed according to recommendations and did not increase the severity of bleeding. The risk of severe bleeding was significantly lower in active smokers vs. non-smokers in univariate (16.9% vs. 36.2%, P=0.007) and multivariate (odds ratio, 0.31; 95% confidence interval, 0.14–0.65) analysis whereas sex, age, and body mass were not significantly associated with bleeding.Conclusion: Severe postoperative bleeding occurs in 0.7% of patients, but varies with type of procedure and is not affected by anticoagulant or antiplatelet treatment. These treatments given in accordance with the new guidelines do not increase the severity of postoperative bleeding.

Purpose: Anal fistula is a common condition in proctology, usually requiring surgical treatment. Few risk factors have been clearly identified based on solid evidence. Our research objective was to determine whether history of anal surgery was a risk factor for subsequent anal fistula.Methods: We conducted a case-control study from January 1, 2012 through December 31, 2013 in our tertiary center, comprising 280 cases that underwent surgery for anal fistula and 123 control patients seeking a consultation for upper gastrointestinal symptoms. Patients with inflammatory bowel disease were excluded. For both cases and controls, the following variables were recorded: sex, any prior anal surgery, diabetes mellitus, infection with human immunodeficiency virus, and smoking status. For each variable, confidence interval and odds ratio (OR) were calculated.Results: In univariate analysis, male sex (73.2% vs. 31.7%, P < 0.0001), active smoking (38.1% vs. 22%, P = 0.0015), and prior anal surgery (16.0% vs. 4.1%, P = 0.0008) were associated with higher risk of anal fistula. In multivariate analysis, only male sex (OR, 5.5; 95% confidence interval [CI], 5.42 to 9.10; P < 0.0001) and previous anal surgery (OR, 4.48; 95% CI, 1.79 to 13.7; P = 0.0008) remained independently associated with anal fistula occurrence.Conclusion: The epidemiology of anal fistula is poorly assessed despite the high frequency at which it is diagnosed. Our findings suggest that history of any kind of anal surgery is a risk factor for further onset of anal fistula. Surgeons and patients must be informed of this issue.

Purpose Endorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas. Methods This retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms. Results Thirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%). Conclusion This study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.

Objective Anal high-grade squamous intraepithelial lesion (HSIL) may precede invasive cancer and can be detected clinically or during high-resolution anoscopy (HRA). The aims of this study were to compare the characteristics of HSIL discovered by HRA or in a surgical specimen without clinically visible lesion when diagnosed versus macroscopic HSIL when first diagnosed and then to compare their progression to invasive cancer. Patients and methods Clinical records of all patients with at least one HSIL lesion confirmed by histology and evaluated by HRA in a single center between September 1, 2009, and April 30, 2017, were retrospectively reviewed. The center's histological anal cancer data base was questioned in December 2017 to identify all cases. Results During a median (interquartile range) follow-up of 19.1 (5.6-40.2) months, 12 (2.9%) anal cancers were diagnosed in patients with a diagnosis of HSIL. Period of time between the first diagnosis of anal lesion and the cancer was 28.8 months (interquartile range = 15.4-65.6), and 11 (92%) of 12 were diagnosed as superficially invasive squamous cell carcinoma or T1N0M0. The rate of progression to anal cancer differed significantly between patients with macroscopic HSIL at diagnosis (5.4%) and patients with microscopic HSIL diagnosed during HRA (0.9%) (p = .01). Conclusions Patients with macroscopic histologically proven HSIL at first diagnosis of anal intraepithelial lesion have a significantly higher risk of anal cancer compared with patients with microscopic lesions diagnosed during HRA, but the duration between the first diagnosis of HSIL and cancer does not differ between the 2 groups.

Background Decision-making for pulse generator implantation for sacral nerve stimulation in the management of fecal incontinence is based on the results of a test phase. Its duration is still a matter of debate. Objective The purpose of this study was to determine whether an early positive response during the test phase could predict implantation of a permanent sacral nerve pulse generator. Design This was a short-term observational cohort study. A positive response was defined as a >50% decrease of fecal leaks compared with baseline. A multivariate logistic regression was computed to predict pulse generator implantation after the first week of the test phase. Settings The study was conducted in 3 national referral centers. Patients From January 2006 to December 2012, 144 patients with fecal incontinence enrolled in a prospectively maintained database completed a 2- to 3-week bowel diary, at baseline and during test phase. Main outcome measures The primary outcome was the clinical decision to implant a pulse generator. The primary predictor was a calculated score including the number of leak episodes, bowel movements, and urgencies and the time to defer defecation expressed in minutes during the first screening test week. Results After the first, second and third week of the test phase, 81 (56%) of 144, 96 (67%) of 144, and 93 (70%) of 131 patients had a positive test. A permanent pulse generator was implanted in 114. Time to defer defecation increased during the 3 weeks of screening. Urgencies were unchanged. The computed score was predictive of a permanent pulse generator implantation (Se = 72.6% (95% CI, 59.8-83.1); Sp = 100% (95% CI, 78.2-100); c-index = 0.86 (95% CI, 0.78-0.94)). Limitations No cost analysis or projection based on our proposal to reduce the test phase has been made. Conclusions Permanent pulse generator implantation can be safely proposed early (1-week screening) to fast responders. Nonetheless, permanent implantation may be decided as well in patients exhibiting a delayed response. Whether a rapid response to sacral nerve stimulation could be predictive of a long-term response remains to be determined. See Video Abstract at http://links.lww.com/DCR/A452.

Aim The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula. Method We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum. Results During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17–84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn’s disease (20). Of the 62 non-Crohn’s patients previous treatment was common and included surgery (42), antibiotics alone (41) and non-steroidal anti-inflammatory drugs (21). Conclusion Horseshoe extension in anal fistula is uncommon. With Crohn’s disease excepted, the majority had had previous treatment.

BACKGROUND: Anal incontinence is most often linked with sphincter rupture and/or stretching the pudendal nerves. OBJECTIVE: The aim of our study was to investigate the involvement of the puborectal part of the levator ani muscle in anal incontinence. PATIENTS AND MAIN OUTCOME MEASURES: Seventy-eight female patients were studied by anorectal manometry, 3-dimensional ultrasound examination, and concentric needle electromyography of the external anal sphincter, puborectal muscle, and bulbocavernous muscles, completing with the evaluation of the pudendal nerve terminal motor latencies. Damage to the puborectal muscle was defined by an abnormal ultrasound and/or abnormal electromyography. RESULTS: Rupture of the anal sphincter apparatus and puborectal muscle was found in 23% and 3.8%. The EMG showed damage to the puborectal part in 39 cases: this was isolated in 4 cases and combined with external anal sphincter damage in 35 patients. Unilateral or bilateral increase in the terminal motor latencies of the pudendal nerves was found in 36% (28/78) of the patients. The frequency of peripheral neurogenic lesions varied from 36% to 90% according to the electromyographic tests used. There was no correlation between puborectal part damage and resting pressure, perception threshold, and maximum tolerable rectal volume. The mean Wexner index score was not increased by the existence of a defect involving the puborectal part found by echography or by damage to the puborectal part shown by the EMG. Investigating puborectal muscle lesions reduced the percentage of idiopathic anal incontinence to 2.5%. CONCLUSION: Our study confirms the feasibility and usefulness of combined electromyography and 3-dimensional ultrasound examination of the puborectal muscle in anal incontinence.

Fistula arising from the glands of the anal crypts is the most common form of anoperineal sepsis. It is characterized by a primary internal orifice in the anal canal, a fistulous tract, and an abscess and/or secondary perineal orifice with purulent discharge. Antibiotics are not curative. The treatment of an abscess is urgent and consists, whenever possible, of incision and drainage under local anesthesia. Definitive treatment of the fistulous tract can await a second stage. The primary aim is to control infection without sacrificing anal continence. Fistulotomy is the basis for all treatments but the specific technique depends on the height of the fistula in relation to the sphincteric mechanism. Overall results of fistulotomy are excellent but there is some risk of anal incontinence. This explains the growing interest in sphincter sparing techniques such as the mucosal advancement flap, the injection of fibrin glue, and the plug procedure. However, results of these procedures are not yet good enough and leave much room for improvement.

Resume La fistule anale cryptoglandulaire est la plus frequente des suppurations anoperineales. Elle se caracterise par un orifice primaire dans le canal anal, un trajet fistuleux et un abces et/ou un orifice secondaire purulent. L’antibiotherapie n’est pas curative. Le traitement d’un abces est urgent et repose, quand elle est possible, sur l’incision sous anesthesie locale. Le traitement du trajet fistuleux peut se faire dans un second temps. Il vise a tarir la suppuration mais aussi a preserver la continence anale. Il repose habituellement sur les fistulotomies dont les modalites varient selon la hauteur du trajet fistuleux. Leurs resultats sont excellents mais il y a un risque d’incontinence anale sequellaire. Cela explique l’interet grandissant pour les techniques d’epargne sphincterienne, notamment l’avancement d’un lambeau de recouvrement, l’injection de colle biologique et la mise en place du plug. Cependant, leurs resultats sont encore insuffisants et doivent etre ameliores.

Aim Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique. Method Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn’s disease with proctitis, malignant or radiation-related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure-of-eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days. Results Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28–78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn’s disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow-up of 14 (2–67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre- and postoperatively were 1.3 (0–15) and 0.6 (0–6), respectively. Conclusion The success rate was promising with no deterioration of anal continence.

The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.

La proctalgie fugace est une algie ano-rectale intermittente evoluant en general de facon chronique. Sa prevalence dans la population generale varie entre 3 et 15 % avec une predominance feminine. L’âge moyen de survenue de la premiere crise douloureuse se situe entre 45 et 55 ans. Le diagnostic repose sur l’interrogatoire. Typiquement, la douleur est d’apparition brutale et inopinee sans facteur declenchant. Elle semble survenir plus volontiers la nuit. Elle est d’emblee paroxystique et en general intense. Elle siege au niveau du canal anal et/ou du bas rectum, et n’irradie pas. Elle est decrite comme une crampe, un spasme ou un coup de poignard. Sa duree est variable, mais elle cesse completement de facon spontanee. Les patients sont asymptomatiques entre les crises. L’examen clinique ainsi que les explorations complementaires sont normaux. Le mecanisme n’est pas clair mais l’hypothese d’un spasme du sphincter interne anal et/ou de la musculeuse rectale est le plus probable. Une simple explication sur la benignite de leurs douleurs suffit a rassurer l’immense majorite des patients.

La chirurgie des fistules anales est reconnue comme un facteur de risque majeur d'incontinence anale. Le mecanisme de cette incontinence reside principalement dans les lesions sphincteriennes chirurgicales, cependant un mecanisme neurogene par atteinte du nerf pudendal n'est pas exclu. L'objectif de notre etude etait d'evaluer l'influence de la chirurgie anale sur les latences distales anales motrices du nerf pudendal (LDANP). Materiel et methode: Les LDANP ont ete mesurees en pre- et postoperatoire chez respectivement 33 patients (28 hommes et cinq femmes) operes de suppuration anale et 34 patients (21 hommes et 13 femmes) operes d'hemorroidectomie pediculaire selon la technique de Milligan et Morgan. Resultats: L'âge moyen etait de 49,6 ans dans le groupe hemorroides et 45 ans pour le groupe fistule (p = 0,19). Le sex-ratio n'etait pas different entre les deux groupes (p = 0,06). Dans le groupe fistule anale, la moyenne de la LDANP en preoperatoire est de 2,42 ms (± 0,46) du cote infecte et de 2,40 ms (± 0,42) du cote sain, avec une difference significative avec les latences preoperatoires ipsi-laterales du groupe temoin: 2,73 ms (± 0,60) [p = 0,02, p = 0,01]. Les variations de la LDANP en postoperatoire du groupe fistule, aussi bien du cote sain (ALDANP = 0,06 ± 0,42 ms) que du cote pathologique (ALDANP = 0,03 ± 0,40 ms), sont comparables a celle du groupe hemorroides (ALDANP = 0,01 ± 0,48 ms, p = 0,63, p = 0,84). Conclusion: La conduction nerveuse des nerfs pudendaux ne semble pas etre alteree par la presence d'un processus infectieux de la fosse ischiorectale, non plus que par le geste chirurgical. Cependant, une etude electrophysiologique plus fine parait necessaire pour evaluer le retentissement sur l'innervation perineale.

Le diagnostic de fistule anale reste bien souvent clinique. Cependant, la connaissance du site, du ou des orifices primaires et secondaires, de la topographie du trajet fistuleux principal, et des eventuels trajets secondaires et collections associes ainsi que l’etat de l’appareil sphincterien est capitale pour une prise en charge optimale. Si toutes ces informations ne peuvent etre obtenues par l’examen clinique, il est indispensable de se tourner vers une technique d’imagerie en se souvenant que le choix d’sun radiologue ou d’un echographiste ayant une excellente connaissance de l’anatomie rectale importe davantage que le choix de la technique d’imagerie. L’endosonographie devrait cependant etre privilegiee en premiere intention du fait de sa facilite, de son cout modeste et de son accessibilite, et l’IRM reservee aux cas plus complexes. Enfin, meme si les prelevements a visee bacteriologiques ou histologiques sont souvent peu contributifs, ils ne dovient pas etre negliges et meritent d’etre realises au moins dans toutes les situations atypiques ou dans les recidives car ils peuvent orienter vers un diagnostic differentiel.

Anal epidermoid carcinoma is a rare malignant tumor, comprising less than 5% of all carcinomas of the colon, rectum, and anus. The primary therapy now includes radiotherapy, often in combination with chemotherapy. Radical surgery is now rarely indicated. Therapeutic indications are based on locoregional staging, the presence of visceral metastases and an evaluation of the medical history. Anorectal endosonography is helpful in evaluating locoregional extension. In addition, magnetic resonance imaging, positron emission tomography scanning and inguinal sentinel lymph node procedure should play a role in a more selective approach in patients with anal carcinoma.

This study evaluated the validity of endorectal ultrasonography in predicting rectal infiltration in patients with deep pelvic endometriosis.Patients were recruited consecutively in the Department of Surgical Gynecology of Diaconesses Hospital from April 1996 to July 2003. Inclusion criteria were the suspicion of deep pelvic endometriosis on the basis of outpatient history and/or clinical symptoms with a mass palpable on bimanual examination that might infiltrate the rectal wall. There were no exclusion criteria. Endorectal ultrasonography was performed by the same investigator with a 7.5-MHz to 10-MHz rigid probe, producing a 360 degrees view of the rectal wall and adjacent areas. We used surgical and histopathologic findings as the "gold standard" to evaluate the validity of endorectal ultrasonography.This study was based on 37 patients (mean age, 35.8 (range, 26-46) years) who underwent surgery. The time between endorectal ultrasonography and surgery ranged from 4 to 529 (mean, 88.7) days. Eight patients had endometriosis nodules penetrating the rectal wall. Endorectal ultrasonography showed sensitivity, specificity, a positive predictive value, and a negative predictive value of 87.5, 97, 87.5, and 97 percent, respectively, in the diagnosis of infiltration of the rectal wall by endometriosis.Endorectal ultrasonography is a reliable technique for visualizing rectal infiltration in patients with deep pelvic endometriosis. It should be more widely used by gynecologists because knowing about rectal infiltration before surgery is fundamental to defining the best possible surgical approach.

Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

Summary Introduction Primary anal actinomycosis of cryptoglandular origin, mainly due to Actinomyces israelii , a specific and rare cause of anal suppurative disease, needs to be recognized because it can be cured using specific treatments. Method Data were reviewed from 6 patients with actinomycotic anal abscesses of obvious cryptoglandular origin observed in a single proctology unit between 1983 and 2000. Therapeutic management included conventional surgical treatment of anal sepsis followed by a specific oral antibiotic therapy maintained until the surgical wound had completely healed. Results All but one of the patients were men (median age, 53 years). All abscesses, except one, were indolent. No patient presented macroscopic ″sulphur granules″ in the pus, but one presented ″watery pus″. The diagnosis was established by histological study of the surgically excised tissue or by anaerobic culture of the pus. In the one HIV-positive patient, an uncommon organism was isolated: Actinomyces meyeri . Two cases of recurrence were observed without evidence of Actinomyces infection. Conclusion Actinomycosis should be suspected particularly in indolent anal suppuration. The absence of macroscopic ″sulphur granules″ does not mean this diagnosis can be ruled out. Careful histological examination of the excised tissue and appropriate anaerobic cultures of pus should be carried out to achieve complete eradication of this rare, but easily curable disease.

Anal fistula surgery is recognized as a major risk factor for anal incontinence. This incontinence is mainly due to surgical sphincter lesions, although a neurogenic mechanism through damage to the pudendal nerve is not excluded. The objective of our study was to evaluate the influence of anal surgery on the anal terminal motor latency of the pudendal nerve (PNTML).The PNTML values were measured pre- and postoperatively, respectively, in 33 patients (28 men, 5 women) treated for anal suppuration and 34 patients (21 men, 13 women) undergoing pedicular hemorrhoidectomy using the Milligan and Morgan technique.The average age was 49.6 years in the hemorrhoid group and 45 years in the fistula group (p=0.19). There was no difference in the sex ratio between the two groups (p=0.06). In the anal fistula group, the preoperative mean PNTML was 2.42 (+/-0.46) ms on the infected side and 2.40 (+/-0.42) ms on the healthy side, with a significant difference from the control group's preoperative ipsilateral latencies: 2.73 (+/-0.60) ms (p=0.02, p=0.01). The variations in the postoperative PNTML of the fistula group, both on the healthy side (DeltaPNTML=0.06+/-0.42 ms) and on the diseased side (DeltaPNTML=0.03+/-0.40 ms), are comparable with those of the hemorrhoid group (DeltaPNTML=0.01+/-0.48 ms; p=0.63, p=0.84).The nervous conduction of the pudendal nerves does not seem to be altered by the presence of an infectious process in the ischiorectal fossa nor by the surgical procedure. However, a more refined electrophysiological study would seem to be necessary to assess the repercussions on the perineal innervation.

Introduction Malgre la revolution recente due a l’apparition de l’hemorroidopexie selon la technique de Longo dans le traitement chirurgical des hemorroides, l’hemorroidectomie selon la technique de Milligan et Morgan, decrite au Saint Mark's Hospital de Londres en 1937 [1], reste une intervention encore largement pratiquee en France. Elle garde en effet des indications specifiques ou ses resultats s’averent excellents : hemorroides internes completement prolabees (grade IV de Goligher), marisques hypertrophiques, pathologies hemorroidaires associees a une autre pathologie proctologique a operer (fissure, suppuration, condylomes, par exemple). Cette technique d’hemorroidectomie pediculaire consiste en l’exerese des trois paquets hemorroidaires principaux avec ligature haute de leur pedicule vasculaire, et laisse des plaies ouvertes entre lesquelles subsistent des ponts cutaneo-muqueux. Elle est simple et bien codifiee mais comporte une multitude de petits gestes minutieux qui permettent d’ameliorer la qualite du resultat postoperatoire.

Initialement destinee a explorer la prostate, l’echographie endocavitaire a ete progressivement modifiee pour l’etude du tube digestif. Elle a notamment connu un essor considerable en proctologie ces dix dernieres annees car cette technique d’acces aise, anodine, simple a realiser et peu couteuse, fournit une excellente image anatomique de la region anorectale. Elle a ainsi contribue a ameliorer la prise en charge therapeutique des suppurations anales car elle en fournit un bilan topographique precis (orifice primaire, trajet fistuleux principal, extensions secondaires et/ou collections) et car elle permet simultanement d’evaluer l’etat de l’appareil sphincterien. Une imagerie par resonance magnetique complementaire peut parfois s’averer utile pour completer le bilan loco-regional de certaines suppurations complexes (trajet principal haut situe, collections profondes, tissus cicatriciels, etc.).

L’echographie endocavitaire a connu un essor considerable en proctologie ces dix dernieres annees car cette technique indolore, simple a realiser, peu couteuse, fournit une excellente image anatomique du canal anal. Elle a eclaire la pathogenie de l’incontinence anale et occupe desormais une place preponderante au sein du bilan de cette affection. La mise en evidence des defects sphincteriens a en effet un impact therapeutique indeniable. Toutefois, il faut souligner que certaines images posent des problemes d’interpretation non negligeables incitant a la prudence dans les decisions therapeutiques.

Initialement destinee a explorer la prostate, l'echographie endocavitaire a ete progressivement modifiee pour l'etude du tube digestif. Elle a notamment connu un essor considerable en protologie ces dix dernieres annees car cette technique anodine, simple a realiser, peu couteuse, fournit une excellente image anatomique du canal anal. Elle a eclaire la pathogenie de l'incontinence anale et occupe desormais une place preponderante au sein du bilan de cette affection, la mise en evidence des defects sphincteriens ayant en effet un impact therapeutique indeniable. Toutefois, il faut souligner que certaines images posent des problemes d'interpretation non negligeables incitant a la prudence dans les decisions therapeutiques.

Fecal incontinence may be related to a neurogenic injury. Electrodiagnostic tests including pudendal nerve terminal motor latency (PNTML) and external anal sphincter electromyography (AEMG) have been proposed to reveal anal nerve damage. The aim of this study was to assess the respective value of PNTML and AEMG in the diagnosis of fecal incontinence. This study included 80 women (range 23-85 years) with fecal incontinence secondary to obstetrical and/or surgical trauma. They were evaluated by performing PNTML and AEMG. The electrophysiological results were compared and interpreted in the light of anorectal manometry (ARM) results. Electrodiagnostic test abnormalities were found in 64 of 80 patients (80%), including 28 patients with abnormal results for both tests and 36 patients with only one abnormal test. Overall, a neurogenic AEMG pattern was found in 64% of patients and a prolonged PNTML in 51%. No correlation was found between PNTML value and either AEMG grade or ARM parameters, while AEMG grade strongly correlated with squeeze pressure measured by ARM. This study showed that AEMG and PNTML did not give redundant information and allowed to explicit the mechanisms of neurogenic fecal incontinence. We found that AEMG was more sensitive and more closely related to the anal functional status (ARM parameters) than PNTML. These electrodiagnostic tests, particularly AEMG as performed in everyday practice, are useful in the assessment of neurogenic fecal incontinence.

OBJECTIVE High-resolution anoscopy (HRA) is a useful screening tool for anal intraepithelial neoplasia (AIN), although reputedly challenging for interpretation of suspected lesions. MATERIALS AND METHODS All consecutive patients who underwent biopsies for at least 1 lesion suspicious for AIN during HRA from November 2010 to March 2012 were prospectively included. The characteristics (borders, staining with acetic acid and Lugol iodine solution, and patterns of epithelium and vascularization) of the lesions detected during HRA were compared with histology. RESULTS A total of 168 suspicious anal lesions were biopsied and analyzed in 103 patients (68% men, mean age ± standard deviation = 49.8 ± 9 y, 57% positive status on human immunodeficiency virus infection). According to histology, 41.7% of the lesions were high grade, 34.5% were low grade, and 23.8% were nondysplastic. Lesions with irregular epithelial pattern (or irregular vascularization) were twice as likely to be high grade compared with lesions with regular epithelial pattern (or regular vascularization). The incidences of acetic acid-induced whitening were 91.4%, 94.8%, and 70% among the high-grade AIN, low-grade AIN, and nondysplastic samples, respectively. Among the high-grade AIN, 62.9% were not stained by Lugol solution (vs 31% of the low-grade AIN). The positive predictive value of a combination of these simple morphological criteria was 68.6%. CONCLUSIONS Several simple morphological criteria are significantly associated with high-grade AIN and are found less often in low-grade AIN. A combination of these morphological criteria provides sufficient positive predictive value to guide biopsy placement during HRA.

Background: Full thickness rectal prolapse in young adults with normal pelvic floor is a disease in which the rectum is exceedingly long and mobile. Surgical treatment should correct both anatomical defects by combined rectopexy and colonic resection, which is expected to be less constipating than rectopexy alone. The aim of this study was to describe an original procedure of rectopexy to the pelvic floor with prosthetic material combined with sigmoid resection, and to evaluate prospectively anatomical and functional results. Methods: Thirty-five patients (30 women) of median age 44 years (range 18 to 74) were operated on for full thickness rectal prolapse with normal pelvic floor. The rectum was mobilized posteriorly without division of the lateral ligaments and attached to the pelvic floor previously repaired with a nonabsorbable mesh. The sigmoid colon was resected with hand-sewn anastomosis. Clinical results were assessed by a questionnaire. Results: There were no deaths or any septic or anastomotic complications. Small bowel obstruction was corrected laparoscopically in 1 patient. Mean hospital stay was 8 days (range 6 to 14). Mean follow-up was 34 months (range 10 to 93). No recurrence was seen. Preoperatively, 33 patients (94%) complained of constipation mainly with emptying problems (21 patients) and 25 patients (71.5%) were incontinent. Postoperatively, no constipated or incontinent patient’s condition worsened. Rectal emptying was restored in 17 patients (81%). Eighteen incontinent patients (72%) regained full continence. On the other hand, 2 patients with normal bowel function worsened and 1 patient with an altered rectal compliance after Delorme’s operation became incontinent. Conclusions: In young adults with rectal prolapse and normal pelvic floor undergoing prosthetic rectopexy and sigmoid resection (a) morbidity was low, (b) anatomical control was obtained in all cases, (c) emptying problems were corrected, and (d) deleterious effects are likely to occur if they had no constipation before operation or if rectal compliance was previously altered.

Longtemps consideree comme secondaire et peu contributive, l’imagerie en proctologie a beaucoup evolue ces dix dernieres annees et contribue a ameliorer la prise en charge des troubles de la continence anale et des suppurations anorectales. En particulier, l’echographie endocavitaire (EE) et l’imagerie par resonance magnetique (IRM) prennent une place grandissante dans le cadre de la maladie de Crohn anoperineale (MAP). Elles ne sont pas indiquees de facon systematique mais s’averent utiles voire indispensables dans les situations difficiles: suppuration complexe et/ou multi-operee, retard de cicatrisation ou persistance d’un ecoulement postoperatoire, suspicion ou notion averee de doubles de la continence, douleurs anorectales inexpliquees. L’IRM semble globalement plus fiable que l’EE dans le reperage des orifices primaire(s) secondaire(s), des trajets fistuleux et des collection(s). Cela provient de sa meilleure resolution en contraste et de la possitilite d’une analyse tridimensionnelle sachant que de nombreuses ameliorations techniques vont encore ameliorer ses performances. Toutefois, l’EE est une technique fiable et bien codifiec pour l’evaluation de l’appareil sphincterien. En outre, elle presente l’avantage par raport a l’IRM d’etre facile d’acces, bon marche, de courte duree et simple a mettre en œuvre. Finalement, ces deux techniques semblent complementaires mais, s’il faut choisir, faire appel a un radiologue ayant une excellente connaissance de l’anatomie anorectale et de la maladie de Crohn importe actuellement davantage que le choix de la technique.

L’endosonographie est un outil performant, de mise au point recente, plus fiable que l’examen clinique et la tomodensitometrie, presentant de nombreux interets en pathologie tumorale anale. Elle permet d’obtenir un bilan, d’extension tumorale et ganglionnaire satisfaisant et la detection d’un residu tumoral ou une recidive eventuelle apres traitement. Elle devrait beneficer de l’apport des ponctions cytologiques et/ou biopsies echo-guidees. Son impact therapeutique peut etre majeur: chimiotherapie adjuvante a la radiotherapie en cas de tumeur volumineuse et/ou en cas d’adenopathies supposees envahies, contre-indication a une curietherapie en cas d’adenopathies envahies, radiotherapie de surdosage ou amputation abdomino-perineale en cas de residu tumoral ou de recidive.

Dear Editor: Chronic prolapse of intestinal mucosa appears to be the underlying mechanism behind a number of gastrointestinal conditions. We describe two cases of rectal prolapse in children aged 13 and 14 years presenting as recto-sigmoid polyposis. The underlying rectal prolapse remained undiagnosed for 3 and 4 years respectively. Rectopexy provided complete clinical and endoscopic healing in both cases.

BACKGROUND: The performance of cytologic screening and its correlation with histology and polymerase chain reaction (PCR) detection of human papillomavirus (HPV) DNA have not been evaluated in populations with a low prevalence of anal intraepithelial neoplasia (AIN). The objective of the current study was to analyze the significance of abnormal smears relative to the histology and PCR detection of HPV DNA. METHODS: A cytologic smear and a viral sample were taken in 300 consecutive patients undergoing surgery (Milligan-Morgan hemorrhoidectomy and/or fissurectomy) who gave their informed consent. RESULTS: The cytologic smear was normal in 216 of 290 patients (74.5%). Four high-grade and 19 low-grade intraepithelial neoplastic lesions were identified. In 5 patients, high-grade lesions could not be excluded, 30 lesions were of undetermined significance, and there were 16 cellular modifications with a non-neoplastic appearance. The PCR test for HPV was positive in 18.7% of patients, and a high-risk genotype was identified in 63.6% of positive samples. Histologic examination of the surgical samples was normal in 92.3% of patients. The 23 AIN samples were distributed as follows: 13 grade 1 AIN (AIN1), 6 AIN2, and 4 AIN3. The sensitivity of cytologic smears and PCR for detecting AIN was 56% and 60.8%, respectively, and specificity was 77% and 84.5%, respectively. Combining the 2 tests increased sensitivity to 78% but decreased specificity to 68%. CONCLUSIONS: Compared with a large surgical sample, anal cytologic Papanicolaou smears and HPV PCR exhibited sensitivity and specificity that varied, depending on the risk of HPV infection and AIN. Positive HPV DNA screening increased with AIN grade, and high-risk HPV testing was particularly helpful. Cancer 2012. © 2012 American Cancer Society.

Objective The study aimed to evaluate the efficacy of fibrin glue in the treatment of complex anal fistula. Method Thirty consecutive patients with a complex anal fistula underwent glue instillation after an 8 week period of seton drainage. Cure was defined as complete closure of any secondary opening, absence of fistula seepage, and no abscess formation. Results The mean age of the patients (15 males) was 40.5 (range, 22.8–69.1) years. The mean duration of follow-up was 11.7 (range, 0.2–33.5) months. Complete closure of the fistula was achieved in 17 patients at 1 month but in two patients a delayed abscess occurred. At the end of follow-up, 15 (50%) patients were considered to have been cured. The success rate was no different in cases of Crohn’s disease or when postoperative antibiotic therapy was given. There was, however, a significant difference in success following regional vs general anaesthesia (68.4 vs 18.2% success, P = 0.02). Conclusion Fibrin glue cured 50% of our first 30 patients, and regional anaesthesia was predictive of success.

Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis. Characteristically they have an endoanal primary opening, a fistula track and an abscess and/or an external purulent opening. Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia. Treating the fistula track occurs afterwards and aims to dry up the purulent discharge and avoid recurrence of the abscess by means of surgical fistulotomy. These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence. This explains the increasing interest in sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue.

A 55-year-old woman presented with chronic anal itching. She had a history of diffuse digestive polyposis with variant histological forms (hyperplastic and adenomatous polyps), and in …