End-to-end stapled technique for Kono-S anastomosis.

PURPOSE: Our aim was to develop a Kono-S anastomotic technique using surgical staplers. METHODS: Two patients underwent stapled Kono-S anastomosis, one via abdominal and one transanal approach. RESULTS: The approach for an abdominal and transanal stapled Kono-S anastomosis is detailed. CONCLUSION: The Kono-S anastomosis can be safely configured using common surgical staplers.

Increasing experience with the LIFT procedure in Crohn's disease patients with complex anal fistula.

BACKGROUND: Surgical management of anal fistulas in Crohn's disease (CD) is associated with high failure rates, and treatment options are limited due to ongoing proctitis, multiple tracts, and concern for incontinence and non-healing wounds. The aim of this study was to investigate the healing rate of ligation of the inters-sphincteric fistula tract (LIFT) for anal fistulas in Crohn's disease and identify prognostic factors for healing. METHODS: This prospective analysis compared long-term healing rates of CD patients undergoing LIFT for anal fistulas. Consecutive patients with CD who underwent LIFT procedure at our institution, in the period from March 2012 to September 2019 were included. The main outcome was anal fistula healing rate. RESULTS: The study cohort of 46 patients (mean age of 34.2 ± 13.0 years, 18 (40%) males). After a mean follow-up time of 33 ± 28 months, fistula healing was seen in 30 (65%) patients. A total of 8 patients were noted to have inter-sphincteric recurrence and 8 patients had trans-sphincteric recurrence. Smoking at the time of surgery was significantly associated with LIFT failure (HR 3.18, 95% CI 1.18-8.61, p = 0.02). Other factors, such as age, sex, race, disease duration and location, type of fistula history of proctitis, preoperatively use of biologics or a seton, and previous repair attempts, did not appear to influence LIFT healing. Although not statistically significant, there was a trend toward increase in failure among patients with active proctitis at the time of surgery (HR 1.97, 95% CI 0.71-5.42, p = 0.19). CONCLUSION: Our increasing experience with LIFT for anal fistula in CD demonstrates a higher rate of healing (65%) than previously reported (48%). Smoking appears to negatively influence healing of LIFT in CD.

Long-term healing after complex anal fistula repair in patients with Crohn's disease.

BACKGROUND: Complex anal fistula in Crohn's disease (CD) poses a challenging problem. We sought to evaluate long-term surgical healing of complex anal fistula in CD through the two robust repair options-ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF). METHODS: A single-center retrospective study was conducted evaluating long-term healing rates in patients with CD with complex anal fistula undergoing LIFT or AF in 2008-2018. Fistula healing was defined as closure of external wounds, cessation of drainage and absence of pain. Short-term and long-term healing rates were compared. Cox proportional hazards model was performed to identify independent predictors of fistula healing. RESULTS: The study cohort included 60 CD patients undergoing LIFT (n = 38) or AF (n = 22). The AF group included 8 dermal flaps. Patients having LIFT were younger (35 years vs 43 years; p = 0.007), more likely to have a seton at the time of repair (92% vs 68%; p = 0.03) and less likely to have had prior repair attempts (34% vs 68%; p = 0.02). Short-term fistula healing occurred in 65% (n = 39) of the overall study cohort. However, at final follow-up, median 36 months (range 6-192 months), only 46% (n = 28) of repaired fistulas were healed. Considering the overall status of the cohort's perianal health at final follow-up, including both repaired, secondary or novel anal fistulas, only 50% (n = 30) of all patients in the cohort had all fistula sites healed and maintained bowel continuity at final follow-up. On Cox proportional hazards analysis, LIFT independently predicted long-term fistula healing (hazard ratio 2.3; 95% confidence interval 1.1-4.9; p = 0.03). Only a small number of patients (n = 5; 8%) required fecal diversion (n = 3) and/or proctectomy (n = 2). CONCLUSIONS: Repair of complex anal fistula in CD results in modest healing rates. LIFT independently predicts long-term healing. However, these results must be taken in context, considering differences in patient and fistula characteristics between groups. These results ought to be kept in mind when counseling CD patients with complex anal fistula.

Does external beam radiation therapy to the pelvis portend worse ileal pouch outcomes? An international multi-institution collaborative study.

AIM: Short-term morbidity and long-term functional outcome of patients with an ileal pouch-anal anastomosis (IPAA) exposed to pelvic external beam radiation therapy (EBRT) remains unknown. We report the largest series to date regarding the effects of pelvic EBRT on: (i) 30-day postoperative outcomes; and (ii) long-term functional outcome following IPAA. METHOD: A retrospective chart review was conducted of patients who received EBRT before or after IPAA between 1980 and 2017 across three international inflammatory bowel disease referral centres. RESULTS: Nineteen patients were included. Indications for EBRT were rectal adenocarcinoma (n = 13), prostate adenocarcinoma (n = 4) or anal squamous cell carcinoma (ASCC) (n = 2). EBRT was given prior to IPAA in 12 (63%) patients and after IPAA in seven (37%). In EBRT before IPAA, patients had a median of 5 (range: 4-8) daytime bowel movements, 1 (range: 0-5) night-time bowel movement, no daytime incontinence, and only one patient used pads at a median follow up of 25 (range: 11-163) months; one patient underwent pouch excision 15 months after IPAA. In EBRT after IPAA, patients reported a median of 8 (range: 5-10) daytime and 2 (range: 0-5) night-time bowel movements, 80% had either daytime or night-time incontinence and 80% used pads at a median follow up of 90 (range: 25-315) months. CONCLUSION: Pelvic EBRT administered prior to IPAA is associated with acceptable long-term function outcome. However, when pelvic EBRT is given to an IPAA in situ, most patients experience poor long-term pouch function without pouch failure.

Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.

PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.

Increasing experience of ligation of the intersphincteric fistula tract for patients with Crohn's disease: what have we learned?

AIM: Ligation of the intersphincteric fistula tract (LIFT) has been proposed as a treatment of trans-sphincteric fistula in perianal Crohn's disease (CD). The aim of this study was to look at our experience of the LIFT procedure in CD patients on long-term follow-up. Specifically, we aimed to determine the fistula healing rate after the LIFT procedure after more than 12 months follow-up and to identify any prognostic factors. METHOD: Retrospective study of patients with trans-sphincteric Crohn's fistula tracts treated with the LIFT procedure between January 2011 and October 2015. Complete fistula healing as well as clinical outcomes were analysed. RESULTS: Data were available for 23 patients. After a median follow-up of 23 months, LIFT site healing was 48%. Patients with healed LIFT had a median follow-up time of 10.5 months, while patients with failed LIFT had a median follow-up time of 31 months (P = 0.04). Median time to failure was 9 months for patients with follow-up > 1 year. Most patients failed within 1 year (9/12; 75%) of the procedure. In multi-site CD, the LIFT procedure was more likely to be successful in those with small bowel disease (P = 0.04) compared with colonic disease (P = 0.02). Other factors such as preoperative use of biological therapies, presence of a seton, previous repair attempts, fistula position, type or number of fistulas, multiple fistula tracts, smoking status and other associated perianal disease did not appear to influence LIFT healing rates. CONCLUSION: The LIFT procedure offers reasonable long-term success in the treatment of perianal trans-sphincteric fistulas associated with CD. LIFT is more likely to fail in patients with concurrent colonic CD than in patients with small bowel CD.

Can three-dimensional high-resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence?

AIM: Endoanal ultrasound (EAUS) is the gold standard for detecting anal sphincter defects in patients with faecal incontinence (FI), while anorectal manometry evaluates sphincter function. Three-dimensional high-resolution anorectal manometry (3D HRAM) is a newer modality with the potential to assess both sphincter function and anatomy. The purpose of the present study was to compare 3D HRAM with 3D EAUS for the detection of anal sphincter defects in patients with FI. METHOD: A linkage analysis was performed between the 3D HRAM and 3D EAUS databases of a tertiary referral centre to identify patients with FI who underwent both 3D EAUS and 3D HRAM. With 3D HRAM, a defect was defined as any pressure measurement below 25 mmHg at rest with at least 18° of continuous expansion. The 3D HRAM findings were compared with those of 3D EAUS. RESULTS: The study cohort included 39 patients with a mean age of 64.7 ± 15.2 years (SD); and 31 (79%) were female. Eight (21%) patients had an anal sphincter defect on EAUS with a median size of 93° (range 40°-136°). Fourteen (36%) had a defect shown by 3D HRAM with a median size of 144° (36°-180°). The sensitivity, specificity and positive and negative predictive values of 3D HRAM in detecting a sphincter defect were 75%, 74%, 43% and 92%, respectively. CONCLUSION: With a negative predictive value of 92%, 3D HRAM may be a useful screening method for ruling out a sphincter defect in patients with FI, thereby avoiding both EAUS and manometry in selected patients.

Cathelicidin suppresses lipid accumulation and hepatic steatosis by inhibition of the CD36 receptor.

BACKGROUND AND OBJECTIVES: Obesity is a global epidemic which increases the risk of the metabolic syndrome. Cathelicidin (LL-37 and mCRAMP) is an antimicrobial peptide with an unknown role in obesity. We hypothesize that cathelicidin expression correlates with obesity and modulates fat mass and hepatic steatosis. MATERIALS AND METHODS: Male C57BL/6 J mice were fed a high-fat diet. Streptozotocin was injected into mice to induce diabetes. Experimental groups were injected with cathelicidin and CD36 overexpressing lentiviruses. Human mesenteric fat adipocytes, mouse 3T3-L1 differentiated adipocytes and human HepG2 hepatocytes were used in the in vitro experiments. Cathelicidin levels in non-diabetic, prediabetic and type II diabetic patients were measured by enzyme-linked immunosorbent assay. RESULTS: Lentiviral cathelicidin overexpression reduced hepatic steatosis and decreased the fat mass of high-fat diet-treated diabetic mice. Cathelicidin overexpression reduced mesenteric fat and hepatic fatty acid translocase (CD36) expression that was reversed by lentiviral CD36 overexpression. Exposure of adipocytes and hepatocytes to cathelicidin significantly inhibited CD36 expression and reduced lipid accumulation. Serum cathelicidin protein levels were significantly increased in non-diabetic and prediabetic patients with obesity, compared with non-diabetic patients with normal body mass index (BMI) values. Prediabetic patients had lower serum cathelicidin protein levels than non-diabetic subjects. CONCLUSIONS: Cathelicidin inhibits the CD36 fat receptor and lipid accumulation in adipocytes and hepatocytes, leading to a reduction of fat mass and hepatic steatosis in vivo. Circulating cathelicidin levels are associated with increased BMI. Our results demonstrate that cathelicidin modulates the development of obesity.

Does a history of postoperative ileus predispose to recurrent ileus after multistage ileal pouch-anal anastomosis?

BACKGROUND: Although postoperative ileus (POI) is a common complication after major abdominal colorectal surgery, it is unknown whether a history of POI predisposes to recurrent POI in subsequent surgeries. In the present retrospective case-control study, conducted at the colorectal surgery division of a tertiary care center, we attempted to identify factors that may predict recurrent POI in ulcerative colitis (UC) patients undergoing three-stage ileal pouch-anal anastomosis (IPAA). METHODS: Charts of UC patients undergoing three-stage IPAA were reviewed. All patients received a standardized accelerated postoperative care pathway. Patients were assigned to one of 3 categories: Group A patients did not have POI after either initial subtotal colectomy (STC) or subsequent IPAA, Group B patients developed POI only after initial STC, and Group C patients developed POI after both STC and IPAA. RESULTS: The study group consisted of 91 patients. There were 71 (78 %) patients in Group A, 14 (15 %) patients in Group B, and 6 (7 %) patients in group C. There was no significant difference in any demographic or clinical features among patients that developed no POI, those that developed POI only after STC, and those that developed POI after both STC and IPAA. CONCLUSIONS: POI is difficult to predict after first- and second-stage IPAA. Clinical factors and a history of POI from first-stage IPAA do not predict POI after second-stage IPAA. Patients with a history of POI after STC do not have an increased risk of developing recurrent POI.

Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease.

BACKGROUND: In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD. METHODS: A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes. RESULTS: The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042). CONCLUSION: Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

Inhibition of hormone-induced cyclic AMP production and steroidogenesis in interstitial cells by deglycosylated lutropin.

We have investigated the ability of chemically deglycosylated ovine pituitary lutropin (DGLH) to stimulate cyclic AMP accumulation in rat interstitial cells in vitro. In sharp contrast to the native hormone which brought about a large increase in cyclic AMP levels, no significant response was indiced by DGLH even in the presence of the phosphodiesterase inhibitor, isobutyl methylxanthine. On the contrary, all preparations of DGLH tested were potent inhibitors of the action of the native hormone. The concentration of DGLH for inhibition of LH-induced cyclic AMP response was significantly lower than that required for inhibition of steroidogenesis. While inhibition of hormone-induced cyclic AMP response was complete, the inhibition of steroidogenesis in testicular cells by DGLH approached about 70-80%. Accumulation of cycli AMP induced by hCG was also effectively inhibited by DGLH suggesting that its inhibitory action is mediated via its binding to lutropin receptor(s) on interstitial cells. A recombinant of deglycosylated subunits, DG alpha + DG beta, had properties identical to that of DGLH.

Infliximab in the treatment of medically refractory indeterminate colitis.

AIM: To examine the outcome of infliximab intervention in refractory indeterminate colitis. METHODS: Twenty patients with severe, medically refractory indeterminate colitis were treated with infliximab. All patients initially received infliximab, 5 mg/kg, intravenously and, in some patients, the dose was subsequently increased to 10 mg/kg. The number of infusions ranged from one to 16 per patient. Indeterminate colitis was defined as colitis that could not be classified with certainty as Crohn's disease or ulcerative colitis based on traditional clinical, endoscopic and histopathological criteria. The clinical response to infliximab was classified as complete response, partial response or non-response. RESULTS: Fourteen of the 20 patients (70%) showed a complete response to infliximab treatment, two showed a partial response and four showed no response. The four non-responders underwent colectomy with ileal pouch-anal anastomosis. The resected colon specimen was consistent with ulcerative colitis in all four cases, although two were subsequently re-classified as Crohn's disease. Eight additional patients were subsequently re-classified as having Crohn's disease on longer follow-up evaluation, whilst eight continued to have features of indeterminate colitis. The response rate to infliximab treatment was similar in both groups. CONCLUSIONS: Infliximab is effective in approximately two-thirds of patients with indeterminate colitis, and thus may be considered for patients with refractory disease prior to colectomy. The follow-up time afforded by infliximab treatment may allow for more accurate classification of the disease in a significant proportion of patients whose colitis has indeterminate features at initial presentation.

Significance of extramucosal residual tumor at the bronchial resection margin.

Extramucosal microscopic residual disease (MRD) at the bronchial resection margin was identified in 45 (1.6%) of 2,890 patients who underwent resection of primary non-small cell lung cancer between 1975 and 1985. In 9 of these patients, residual tumor was confined to submucosal lymphatics, whereas in the other 36, MRD was found in peribronchial soft tissue. All patients underwent complete mediastinal lymphadenectomy. Three patients had stage I disease, 3 had stage II, 33 had stage IIIa, 4 had stage IIIb, and 2 had stage IV. Recurrent disease developed in 34 (81%) of the evaluable patients; the recurrence was local in 11 (32%). Median time from operation to diagnosis of local recurrence was 8 months. Sixty percent of the recurrences in the N0 group were local, and only 23% of those in the N2 group were local. Extramucosal MRD is most frequently associated with advanced-stage disease. Postoperative therapy had no effect on the development of recurrent disease. We found no difference in survival between patients whose initial site of recurrence was local as opposed to distant. Median survival after the identification of either local or distant recurrence was 5 months. The finding of extramucosal MRD identifies a subset of patients with a poorer prognosis compared with those with clear resection margins.

A 27-year experience with splenectomy for Gaucher's disease.

Gaucher's disease is an inherited metabolic disorder caused by the defective activity of acid beta-glucosidase and the resultant accumulation of glucosyl ceramide-laden macrophages in the liver, bone, and spleen. Splenectomy is the preferred treatment for patients with Gaucher's disease who develop massive splenomegaly with accompanying hypersplenism and/or mechanical pressure symptoms. The charts of 48 patients with Gaucher's disease undergoing splenectomy at our institution between January 1963 and December 1989 were analyzed to determine the short- and long-term results of this procedure. Thirty-five (73%) patients had total splenectomy, whereas 13 (27%) patients had partial splenectomy. There was one postoperative death (after total splenectomy), and 13 patients (27%) had postoperative complications. Eleven patients (23%) presented with accelerated bone disease after total splenectomy (mean follow-up: 96 months). No patients having partial splenectomy (mean follow-up: 25 months) developed progressive bone disease. Eight patients have died since surgery. All four deaths due to malignant disease occurred in patients after total splenectomy. The results of this largest-ever reported series of splenectomy for Gaucher's disease confirm that while either total or partial splenectomy can be performed with minimal morbidity and mortality, total splenectomy is accompanied by more aggressive bone disease and a predisposition to malignancy. Prospective, randomized trials are needed to substantiate whether partial splenectomy is indeed the treatment of choice for splenomegaly associated with Gaucher's disease.

A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction.

BACKGROUND: Many cases of acute adhesive small-bowel obstruction (SBO) can be successfully treated with intestinal tube decompression. There is considerable controversy, however, regarding whether a short nasogastric tube (NGT) or a long nasointestinal tube (LT) is the best method of intestinal tube decompression. PATIENTS AND METHODS: A prospective, randomized trial was conducted to compare NGT and LT decompression with respect to the success of nonoperative treatment and morbidity of surgical intervention in 55 patients with acute adhesive SBO. RESULTS: Twenty-eight patients were managed with NGT and 27 with LT. There were 44 cases of partial SBO (23 NGT, 21 LT) and 11 cases of complete SBO (5 NGT, 6 LT). Twenty-one patients ultimately required operation, including 13 managed with NGT (46%) and 8 with LT (30%) (P = 0.16). The mean period between admission and operation was 60 hours in the NGT group versus 65 hours in the LT group. At operation, 3 patients in the NGT group had ischemic bowel that required resection. Postoperative complications occurred in 23% of patients treated with NGT versus 38% of patients treated with LT (P = 0.89). Postoperative ileus averaged 6.1 days for NGT patients versus 4.6 days for LT patients (P = 0.44). There were no deaths. CONCLUSIONS: Patients with adhesive SBO can safely be given a trial of tube decompression upon hospital admission. There was no advantage of one type of tube over the other in patients with adhesive SBO.

Topical nitroglycerin in the management of anal fissure: an explosive outcome!

Anal sphincter spasm is a common finding in patients with anal fissure disease. It is postulated that spasm impedes mucosal blood flow and impairs healing. Topical nitroglycerin (NTG), a nitric oxide donor compound, has been shown to cause relaxation of the anal sphincter and may have treatment efficacy in the management of anal fissure. The purpose of this study was to assess the usefulness of NTG for anal fissure. We performed a retrospective review of patients with anal fissure treated with various concentrations of topical NTG ointments over an 18-month period ending July 1997. Of the 81 patients studied, 44 (54%) were male. There were 42 acute and 39 chronic fissures. NTG preparations included 1 per cent isosorbide (n = 37), 0.2 per cent NTG (n = 38), and 0.5 per cent NTG (n = 6). Healing with NTG therapy occurred in 29 acute (69%) and 21 chronic fissure (54%) patients. There was no difference in the incidence of healing of acute or chronic fissure between the various NTG treatment preparation groups. When acute and chronic fissure therapy was subdivided by time of NTG treatment (immediate versus post-conservative therapy failure (PCF)), 14 (74%) of acute PCF and 5 (42%) of chronic PCF patients healed. We conclude that no single formula was superior. When patients were subdivided into a PCF group, NTG therapy demonstrated a significant salvage rate, thus avoiding surgery.

Gaucher disease: fate of the splenic remnant after partial splenectomy--a case of rapid enlargement.

In Gaucher disease, partial splenectomy has been suggested for alleviating the complications of splenomegaly as well as for avoiding the immunologic compromise and potential acceleration of bony and hepatic involvement that may follow total splenic resection. However, the fate of the splenic remnant has been reported rarely. A subtotal splenectomy (85%) was performed in a 19-month-old girl with rapidly progressing Gaucher disease and massive splenomegaly (12% of body weight). Within 3 months, the splenic remnant had increased four-fold in size. Previous reports indicated only three Gaucher patients had significant enlargement of the splenic remnant after partial splenectomy. These findings indicate that splenomegaly may recur rapidly in Gaucher disease following partial splenectomy.

Adjuvant interferon for anal condyloma. A prospective, randomized trial.

PURPOSE: The aim of this study was to determine whether interferon combined with surgical excision and fulguration could reduce the unacceptably high rate of recurrence of anal condyloma seen after surgical extirpation. METHODS: Forty-three patients with anal condyloma were prospectively randomized into two groups. Group I (n = 25) patients underwent surgical excision and fulguration immediately followed by an injection of 500,000 IU (0.1 ml) of interferon alfa-n3 into each quadrant of the anal canal. Group II (n = 18) patients underwent surgical excision and fulguration but then received four injections (0.1 ml) of saline into each quadrant of the anal canal. RESULTS: After a mean follow-up of 3.8 months, 10 of 43 (23 percent) patients developed recurrent anal condyloma. Only 3 of 25 (12 percent) interferon-treated patients had recurrences vs. 7 recurrences in 18 (39 percent) saline-treated patients (P = 0.046). Interferon was particularly effective in reducing recurrences in patients whose condylomata were present for more than six months (P = 0.04) and those condylomata that contained human papillomavirus DNA subtype 6/11 (P = 0.05). CONCLUSION: Adjuvant interferon treatment can reduce the high recurrence rate of anal condyloma seen after surgical extirpation.