The Optimal Primary Treatment for Pediatric Perianal Abscess and Anal Fistula: A Systemic Review and Meta-Analysis

BackgroundPerianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients.MethodsUsing PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis.ResultsThirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615–2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109–0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761–10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information.ConclusionStrong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence.Level of evidenceType of study: Systemic review; Evidence level: Level II.     

Características y resultados oncológicos del carcinoma epidermoide de ano: análisis comparativo entre los pacientes inmunocompetentes y los inmunodeprimidos

ObjectiveMost evidence, including recent randomized controlled trials, analysing anal squamous cell carcinoma (SCC) do not consider immunocompromise patient population. The aim of this study was to compare clinical and oncological outcomes among immunocompetent and immunocompromised patients with anal squamous cell carcinoma.MethodMulticentric retrospective comparative study including 2 cohorts of consecutive patients, immunocompetent and immunocompromised, diagnosed with anal SCC. This study evaluated clinical characteristics, clinical response to radical chemoradiotherapy (CRT) and long-term oncological results including both local and distant recurrence, overall survival (OS) and disease-free survival (DFS).ResultsA total of 84 patients, 47 (55.6%) female, diagnosed with anal SCC from January 2012 to December 2017 were included, 22 (26%) and 62 (74%) patients in immunocompromised and immunocompetent groups respectively. Patients in immunocompromised group were significantly younger (53 vs. 61 years; P=0.001), with smaller tumoral size (P=0.044) and reported higher rates of substance abuse.including tobacco use (P=0.034) and parenteral drug consumption (P=0.001). No differences were found in administered therapies (P=301) neither in clinical response to chemoradiotherapy (83 vs. 100%). Moreover, similar 5-year OS (60 vs. 64%; P=0.756) and DFS (65 vs. 68%; P=0.338) were observed.ConclusionThe present study shows no significant differences in long-term oncological results among immunocompetent and immunocompromised patients diagnosed with anal SCC, with a similar oncologic treatment. This evidence might be explained due to the close monitoring and adequate therapeutic control of HIV positive patients.     

Clinical,radiological and physiological assessment of anorectal function

The maintenance of anorectal continence and defaecation is complex. The disruption of these mechanisms can result in symptoms of either faecal incontinence or obstructive defaecation. Both conditions can have significant impact on quality of life. This article details the clinical assessment of presenting patients to establish potential causes, grade the severity of the symptoms and to assess the impact on their quality of life. The appropriate specialized radiological and physiological investigations aim to evaluate the structural integrity and function of the anal sphincter, the anorectal and pelvic floor musculature and measure the transitory function of the colon.     

复方黄柏液涂剂联合吲哚美辛栓治疗PPH术后肛门下坠

目的:观察复方黄柏液涂剂灌肠联合吲哚美辛栓纳肛治疗吻合器痔上黏膜环切术(Procedure for Prolapse and Hemorrhoids,PPH)术后肛门下坠的临床效果。方法:收集40例PPH术后1个月后出现肛门下坠患者并随机分为两组,治疗组20例,给予复方黄柏液涂剂灌肠联合吲哚美辛栓纳肛;对照组20例,单独给予吲哚美辛栓纳肛。7天为1个疗程,连续治疗2个疗程,观察治疗后的症状积分及治疗有效率。结果:两组患者治疗前肛门下坠评分比较,差异无统计学意义(P> 0.05);两组患者经过2个疗程的治疗,治疗前与治疗后的症状积分均有改善(P <0.05),2个疗程后治疗组的肛门下坠评分低于对照组(P <0.05)。治疗组总有效率为94.7%(18/19),低于对照组的78.9%(15/19),差异有统计学意义(P <0.05)。结论:复方黄柏液涂剂灌肠联合吲哚美辛栓治疗PPH术后肛门下坠比单独使用吲哚美辛栓效果明显,尤其是对肛门坠胀不适疼痛不明显者。     

Sexual Anal Pain in Gay and Bisexual Men: In Search of Explanatory Factors

BackgroundSexual anal pain—or anodyspareunia—in gay and bisexual men is a scientifically and clinically neglected topic. More understanding of its origins and correlates is needed.AimTo search for correlates of painful anal intercourse with the inclusion of minority stress processes.MethodsThe analysis is based on data collected in an Internet study on the sexuality of Polish gay, bisexual, and straight men. Multiple ordinal regression analysis was used to search for the correlates of painful receptive anal intercourse in a group of 1,443 nonheterosexual men who declared practicing this type of intercourse within the last 12 months. The investigated correlates included demographics, sexual patterns and experiences, experiencing minority stress, sexual problems, and mental and physical health. To assess the level of minority stress, we used the Sexual Minority Stress Scale based on Ilan Meyer's Minority Stress Model, with its subscales relating to internalized homophobia, expectation of rejection, concealment, and sexual minority negative events. Sexual problems were measured with single-item questions adapted from the National Health and Social Life Survey. Data on the remaining correlates were obtained using a survey that we developed.Main Outcome MeasuresThe intensity of pain during receptive anal sexual intercourse as rated on a 5-point Likert scale was a dependent variable.ResultsAge (odds ratio [OR]: 0.97; P < .001), performance anxiety (OR: 1.94; P < .001), and internalized homophobia (OR: 1.04; P < .001) were the only statistically significant predictors of the intensity of pain during receptive anal sexual intercourse.Clinical ImplicationsClinicians addressing sexual anal pain should consider performance anxiety, internalized homophobia, and younger age as possible operating factors.Strengths & LimitationsThe major strengths of the study include the provision of additional data on this neglected topic derived from a large sample of participants from the little recognized Central European cultural context and the major limitations are the nonrepresentative sampling, retrospective data collection, cross-sectional design, Internet methodology, and lack of information on the clinical relevance of experienced pain, that is, distress or help-seeking, as well as its recurrent or persistent character.ConclusionPainful sexual anal activity requires further investigation.Grabski B, Kasparek K. Sexual Anal Pain in Gay and Bisexual Men: In Search of Explanatory Factors. J Sex Med 2020;17:716–730.     

改良Soave术治疗先天性直肠肛管狭窄的疗效分析

目的总结分析改良Soave术治疗先天性直肠肛管狭窄的临床疗效,探讨准确诊断和一期治愈的手术方法。方法回顾性分析郑州大学第一附属医院2015年1月至2018年1月采用改良Soave术治疗5例先天性直肠肛管狭窄患儿的疗效。其中男3例,女2例,年龄4个月至6岁,病程1个月至6年,均足月出生,5例大肠气钡双重造影提示均合并继发性巨结肠,临床表现可排细条状大便。结果5例患儿术后手术切口一期愈合,排便通畅,术后1个月无小肠结肠炎、吻合口出血、吻合口漏、肌鞘感染、泌尿系统感染、腹膜炎;随访12~37个月,远期无便秘,无梗阻综合征、吻合口狭窄,无二次入院。其中1例远期出现Ⅰ°直肠脱垂,随访该患儿停止扩肛3个月后直肠黏膜脱垂频率较扩肛期间逐渐减少,截至术后15个月时已无直肠黏膜脱垂,排便正常,平均1次/d。1例远期夜间偶有污便,随访该患儿术后1年夜间偶有污便,日间控便正常,可保证生活质量。结论小儿先天性直肠肛管狭窄治疗方法尚无统一标准,常合并继发性巨结肠,改良Soave术为一期手术治愈先天性直肠肛管狭窄提供可能。准确诊断主要依据大肠气钡双重造影,狭窄段主要位于耻尾线(PC线)与I线之间。