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

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

Role of the seton in the management of anorectal fistulas

PURPOSE: To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton. METHODS: A five-year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow-up ranged from 2 to 61 months (mean, 23 months). RESULTS: Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long-term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent). CONCLUSIONS: Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.     

Surgical management of anorectal fistulas in Crohn's disease

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated. Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988. Read at the XIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Glasgow, Scotland, July 10 to 14, 1988.     

Reconstructive perineoplasty in the management of non-healing wounds after anorectal surgery

Non-healing wounds (NHW) following anorectal surgery cause great distress to the patient and may be followed by a retracting scar causing anal deformity and incontinence. The management of NHW is controversial. The aim of this study was to review our experience with reconstructive perineoplasty in the treatment of such condition. From January 1992 to June 2000, we treated 12 patients affected by NHW (4 men and 8 women, mean age 47 years), not responding to conservative treatment. None had Crohn's disease or HIV infection. Pre- and postoperative anal manometry and ultrasound were carried out in 8 patients. All had microspinal anesthesia, mechanical preparation of the intestine, and perineal wound cleansing. Reconstructive perineoplasty was performed by means of local flaps (i. e. cutaneous, fasciocutaneous, myocutaneous). Median follow-up was 13 months (range, 1 to 70). Postoperative complications were as follows: 5 perineal suture dehiscences (1 total, 4 partial), the flap being resutured in one case under local anesthesia; one patient required dilatations for mild anal stricture. No case of gross fecal incontinence, retracting scar or perineal ulcer was observed. Among those patients who had disordered anal continence prior to surgery, all but one improved continence score following perineoplasty from 2.8±2.2 to 1.8±1.2 (mean ± sdm, not significant). Following reconstructive perineoplasty, no significant change was observed in functional and morphologic patterns of the anal sphincters either at manometry or by ultrasound. Reconstructive perineoplasty resulted in a good functional and clinical outcome in most cases and, therefore, may be considered an effective procedure in the managment of NHW. Received: 20 December 2000 / Accepted: 15 February 2001     

The use of corticosteroid ointments in the management of postoperative anorectal wounds

Conclusions When applied to anorectal wounds, 9-alpha-fluorohydrocortisone in 0.1 per cent and 0.2 per cent concentration and triamcinolone acetonide in 0.1 per cent concentration effectively minimizes edema, fibrosis, tab formation and postoperative pain. Smoother healing and reduced disability are accomplished in a higher percentage of cases with 0.2 per cent 9-alpha-fluorohydrocortisone than with preparations containing 0.1 per cent of the corticosteroid. Benefits achieved with 0.1 per cent triamcinolone acetonide or 0.2 per cent 9-alpha-fluorohydrocortisone are roughly equivalent to those observed with 2.5 per cent hydrocortisone. Addition of antibacterial and antifungal agents to corticosteroids is considered helpful but not essential to treatment. When neomycin, gramicidin and nystatin were combined with triamcinolone acetonide, no clear-cut advantage was apparent, and an undesirable amount of granulation tissue sometimes developed during the reparative process. Prompt topical application of corticosteroids in the postoperative period is a rational therapeutic measure which minimizes edema of perianal tissues, reduces pain and prevents other undesirable sequelae.     

The value of muscle relaxants in the postoperative management of anorectal operations

Summary Results are reported on the effect of striated muscle fiber relaxants, in decreasing reflex muscle contracture of the anal sphincter muscles caused by the first postoperative evacuation of the rectum, in patients having undergone hemorrhoidectomy or combined fissurectomy and hemorrhoidectomy. Twenty patients were given tubocurarine chloride injections in a repository vehicle, while three groups of 15 patients each were treated with meprobamate, methocarbamol and chlormezanone, respectively. A comparative study was made of another group of 20 patients who had undergone the same surgical treatment and who received the same care, excepting administration of muscle relaxants. Patients treated with tubocurarine or meprobamate reacted favorably and pain was reduced. The conclusion was reached that both drugs are valuable in lessening pain intensity after anorectal surgery. Methocarbamol and chlormezanone did not render favorable results according to the observations made in this study. Read at the meeting of the Mexican Proctologic Society and the American Proctologic Society, Mexico City, Mexico, April 29 to May 1, 1960.     

Advances in pathogenesis and management of sepsis

PURPOSE OF REVIEW: The rationale for therapeutic targets in sepsis has arisen from the concept of pathogenesis. This review focuses on recent advances in pathogenesis of sepsis that can aid in management of sepsis patients. RECENT FINDINGS: Cellular survival in sepsis is related to the magnitude of the stimulus, the stage of the cell cycle and the type of microbe. While phenotypic modification of the endothelium (procoagulant and proadhesive properties, increased endothelial permeability, endothelial apoptosis and changes in vasomotor properties) leads to vasoplegia as a direct correlate to septic shock mortality, phenotypic changes in the epithelium cause activation of the virulence of the opportunistic pathogens and loss of mucosal barrier function, the latter causing a vicious circle in severe sepsis. Early identification of sepsis with protocolized screening, triggering evidence-based protocolized care, is anticipated to reduce sepsis morbidity and mortality. Current treatment of sepsis includes early antibiotic therapy, early aggressive goal-directed resuscitation targeting tissue hypoperfusion, steroids (for refractory shock), activated protein C (for high risk of death) and maintaining support of organ systems. SUMMARY: A better understanding of pathogenesis of sepsis has led to specific proven management tools that are likely to improve clinical outcome once incorporated into protocolized care.     

Incidence of fistulas after drainage of acute anorectal abscesses

PURPOSE: The aim of this study was to assess the incidence of anal fistulas and factors related to this incidence after incision and drainage of acute cryptoglandular anorectal abscesses. METHODS: Of 170 patients without previous anal fistulas, 146 were followed up for an average of 99 (range, 22–187) months after abscess drainage or until a fistula appeared. RESULTS: Fifty-four (37 percent) patients developed a fistula, and 15 (10 percent) patients developed a recurrent abscess. The incidence of fistulas was higher in females than in males (50vs. 31 percent;P=0.0403), especially regarding anterior abscesses (88vs. 33 percent). Abscesses growingEscherichia coli were more prone to fistula formation than those growing other bacteria (46vs. 27 percent;P=0.0368). CONCLUSION: Incision and drainage alone of acute anorectal abscesses is recommended, because an unnecessary primary fistulotomy can be avoided in more than half of the patients by this approach. For superficial anterior abscesses in females, however, primary fistulotomy may be considered.     

Sacropelvic resection and intraoperative electron irradiation in the management of recurrent anorectal cancer

PURPOSE: To provide local control and palliation of pain, a multimodality approach, including external beam radiation therapy, surgical resection, and intraoperative electron irradiation (IOERT), has been used for patients with locally advanced anal or recurrent rectal cancers involving the sacrum. METHODS: Sixteen consecutive patients (11 males; 5 females; ages, 44–76) underwent surgical exploration, sacrectomy, and IOERT, between 1990 and 1994. RESULTS: Proximal extent of resection was S2–3 in four patients, S3–4 in five, and S4–5 in five. Two patients had resection of the anterior table of the sacrum. Margins were clear in 11, close in 3, and microscopically involved in 2 patients. Operative times ranged from 6 to 17 (median, 12.5) hours, and blood loss ranged from 300 to 12,600 (median, 3,350) ml. No operative deaths resulted. Major postoperative complications occurred in eight patients (50 percent): posterior wound infections and dehiscence, urinary leak, and ileal fistula. Five (31 percent) and 3 (19 percent) patients developed no or minor complications, respectively. Intensive Care Unit stay was one night for all patients, and overall hospital stay ranged from 11 to 30 (median, 16.5) days. Follow-up was available on all 16 patients. Kaplan-Meier survival was 68 percent at one year and 48 percent at two years. At the time of analysis, 9 of 16 patients were alive. Of the nine alive patients who responded to a questionnaire, eight reported a reduction in pain and improved quality of life postoperatively. CONCLUSIONS: Sacropelvic resection, in conjunction with IOERT, provides palliation and offers potential for cure in patients with locally advanced or recurrent anorectal cancer.Supported in part by a grant from the Centro Nazionale Ricerche, (National Institute of Scientific Research), Rome, Italy and American Cancer Society Career Development Award.Read at meeting of The American Society of Colon & Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

活化蛋白C治疗感染中毒症及其所致急性肺损伤的研究进展

近来的研究表明活化蛋白C（APC）在感染中毒症中具有抗凝、促纤溶和抗炎作用。重组人活化蛋白C（rhAPC）可显著降低感染中毒症患者的病死率。但rhAPC在临床应用中的适应证及其有效性仍存在争议。细胞学研究提示APC可通过与细胞表面受体结合,激活细胞内的各种蛋白酶,使其磷酸化或去磷酸化,诱导细胞内信号转导,调节炎症相关基因的表达,从而调节参与感染中毒症的多个重要病理生理过程。此外,APC可能对感染中毒症所致急性肺损伤起到保护性作用。