Use of 3D Anorectal Ultrasonography in the Preoperative Assessment of Complex Anal Fistulas and Patterns of Healing, Failure, and Recurrence After Ligation of the Intersphincteric Fistula Tract (LIFT).

OBJECTIVES: To use three-dimensional anorectal ultrasonography (3D-US) to evaluate the outcome of ligation of the intersphincteric fistula tract (LIFT) in patients with crypto-glandular transsphincteric fistula and describing the patterns of healing, failure, and recurrence rate. METHODS: After classifying the fistula and determining the length of the sphincter muscle to be transected, the patients were submitted to LIFT. The accuracy of pre- and postoperative 3D-US with 360° endoprobe (16 MHz) with automatic scanning and clinical findings was evaluated against surgical findings. Three outcomes were considered: healing, failure (persistent anal fistula through the original external opening or intersphincteric), and recurrence (reappearance of the anal fistula). RESULTS: Sixty-three patients of both sexes were evaluated. The 3D-US assessment revealed primary healing in 50 (79.3%) patients, although in 6 (9.5%) cases healing was delayed and the cavity was without communication with the anal canal. The procedure failed in 9 (15.9%) and fistula recurred in 4 (6.3%), all of whom underwent a second surgery based on a new 3D-US, resulting in a 92.3% (12/13) healing rate on 3D-US. CONCLUSIONS: A 3D-US was found to be useful in the preoperative assessment of fistulas by quantifying the percentage of muscle to be transected, and in the postoperative assessment by identifying healing, types of failure, and recurrence. The 3D-US was accurate and consistent with surgical findings.

Clinical utility of trans-sacral magnetic stimulation-evoked sphincter potentials and high-density electromyography in pelvic floor assessment: Technical evaluation.

AIM: Faecal incontinence is common and of multifactorial aetiologies, yet current diagnostic tools are unable to assess nerve and sphincter function objectively. We developed an anorectal high-density electromyography (HD-EMG) probe to evaluate motor-evoked potentials induced via trans-sacral magnetic stimulation (TSMS). METHOD: Anorectal probes with an 8 × 8 array of electrodes spaced 1 cm apart were developed for recording HD-EMG of the external anal sphincter. These HD-EMG probes were used to map MEP amplitudes and latencies evoked via TSMS delivered through the Magstim Rapid2 (MagStim Company). Patients undergoing pelvic floor investigations were recruited for this IDEAL Stage 2a pilot study. RESULTS: Eight participants (median age 49 years; five female) were recruited. Methodological viability, safety and diagnostic workflow were established. The test was well tolerated with median discomfort scores ≤2.5/10, median pain scores ≤1/10 and no adverse events. Higher Faecal Incontinence Severity Index scores correlated with longer MEP latencies (r = 0.58, p < 0.001) and lower MEP amplitudes (r = -0.32, p = 0.046), as did St. Mark's Incontinence Scores with both MEP latencies (r = 0.49, p = 0.001) and MEP amplitudes (r = -0.47, p = 0.002). CONCLUSION: This HD-EMG probe in conjunction with TSMS presents a novel diagnostic tool for anorectal function assessment. Spatiotemporal assessment of magnetically stimulated MEPs correlated well with symptoms and offers a feasible, safe and patient-tolerable method of evaluating pudendal nerve and external anal sphincter function. Further clinical development and evaluation of these techniques is justified.

Postoperative results and complications of fecal diversion for anorectal Crohn's disease.

PURPOSE: Fecal diversion is a less-invasive technique that can alleviate symptoms in patients with refractory anorectal Crohn's disease. However, complications, including recurrence of residual anorectal Crohn's disease, may develop. We aimed to evaluate the postoperative results and complications associated with fecal diversion in patients with refractory anorectal Crohn's disease. METHODS: We enrolled 1218 Crohn's disease patients who underwent laparotomy at our institute. We retrospectively analyzed the clinical features of 174 patients who underwent fecal diversion for refractory anorectal Crohn's disease, complications of the diverted colorectum, and the incidence and risk factors for proctectomy after fecal diversion. RESULTS: After fecal diversion, 74% of patients showed improved symptoms. However, bowel continuity restoration was successful in four patients (2.2%), and anorectal Crohn's disease recurred in all patients. Seventeen patients developed cancer with a poor prognosis. The rate of conversion to proctectomy after fecal diversion was 41.3%, and the risk factors included rectal involvement (p = 0.02), loop-type stoma (p < 0.01), and the absence of treatment with biologics after fecal diversion (p = 0.03). CONCLUSION: Fecal diversion for refractory anorectal Crohn's disease can improve clinical symptoms. Patients with rectal involvement or loop-type stoma have a greater risk of requiring proctectomy following fecal diversion. The administration of biologic may decrease the rate of proctectomy.

Treatment of faecal incontinence with autologous expanded mesenchymal stem cells: results of a pilot study.

AIM: Management of faecal incontinence (FI) remains challenging because no definitive optimal treatment for this condition has yet been determined. Regenerative medicine could be an attractive therapeutic alternative for treating FI. Here, we aimed to determine the safety and feasibility of autologous expanded mesenchymal stem cells derived from adipose tissue (AdMSCs) in the treatment of patients diagnosed with structural FI. METHOD: This was a randomized, multicentre, triple-blinded, placebo-controlled pilot study conducted at four sites in Spain with 16 adults with FI and a sphincter defect. Autologous AdMSCs were obtained from patients from surgically excised adipose tissue. These patients were intralesionally infused with a single dose of 4 × 107 AdMSCs or a placebo while under anaesthesia. We assessed the safety and feasibility of the treatment as the cumulative incidence of adverse events and the treatment efficacy using the Cleveland Clinic Faecal Incontinence Score, Faecal Incontinence Quality of Life score and Starck criteria to classify sphincter defects and anorectal physiology outcomes. RESULTS: Adipose tissue extraction, cell isolation and intralesional infusion procedures were successful in all the patients. There was only one adverse event connected to adipose tissue extraction (a haematoma), and none was associated with the injection procedure. There were no significant differences in any of the assessed clinical, manometric or ultrasonographic parameters. CONCLUSION: This study indicates that this infusion procedure in the anal sphincter is feasible and safe. However, it failed to demonstrate efficacy to treat patients with structural FI.

LIFT: a feasible option for primary and recurrent fistulas.

BACKGROUND: The development of a surgical solution for anal fistulas with minimal recurrence and morbidity remains a challenge. Ligation of the intersphincteric fistula tract (LIFT), however, is a sphincter sparing technique that provides complete resolution of the transsphincteric fistula as well as minimizing recurrence and fecal incontinence. Our goal is to evaluate the efficacy of fistula tract ligation for primary and recurrent fistulas. METHODS: A retrospective single-center case study was conducted from data between 2015 and 2019 in a large district hospital in Antwerp, Belgium. Patients who underwent LIFT were included. Demographic patient data as well as primary outcome during the follow-up period were collected. A systematic literature review and analysis was conducted with terms [ANAL FISTULA] [TREATMENT] [LIFT] [LIGATION OF INTERSPHINCTERIC FISTULA]. Primary healing and recurrence associated with surgical modifications were investigated. RESULTS: 4 out of 25 patients presented with early failure (84% primary success rate) after a median follow-up period of 7 months. The median time until recurrence was 105 days. The success rate after a redo ligation was 100%. Twenty-eight studies were included for review and divided into three groups depending on the technical variation of the used technique. The success rate was 74.2% for the LIFT group, 72.9% in the LIFT + group, and 77.5% in the mLIFT group p = .92. CONCLUSION: LIFT is a feasible treatment option for primary and recurrent fistulas, with excellent success rates where fistula characteristics rather than chosen technique dictate the surgical outcome.

The Controversy of Surgical Intervention for Anal Canal Duplication in Children.

OBJECTIVE: Since the first definition of anal canal little has been discovered about the etiology of this rare condition. We present four asymptomatic cases of anal canal duplication with diverse clinical and surgical findings. METHODS: A retrospective chart review was performed on four infants presenting with asymptomatic anal canal duplication, born between 2014 and 2016. Clinical characteristics and pathologic findings of patients either by radiological imaging or pathology were evaluated. The primary outcome measure was the complications. RESULTS: All patients were followed-up with physical examination and ultrasound for a mean of 3.5±1.0 years, lastly seen at the beginning of 2018. The female to male ratio was 3:1. Duplicate anal canal length varied between 12-20mm, and two of the four patients had a presacral cystic mass confirmed as a tail gut cyst following surgery. At follow-up, none of the patients had developed symptoms related to anal canal duplication, regardless of whether they had surgical intervention. CONCLUSION: Though surgical management is the preferred treatment for anal canal duplication, it seems that patients who do not undergo surgery might remain free of symptoms, suggesting that surgical intervention may be unnecessary.

Cortico-anorectal, Spino-anorectal, and Cortico-spinal Nerve Conduction and Locus of Neuronal Injury in Patients With Fecal Incontinence.

BACKGROUND & AIMS: The neuropathophysiology of fecal incontinence (FI) is incompletely understood. We examined the efferent brain-anorectal and spino-anorectal motor-evoked potentials (MEP) to characterize the locus of neuronal injury in patients with FI. METHODS: We performed bilateral transcranial, translumbar, and transsacral magnetic stimulations in 27 patients with FI (19 female) and 31 healthy individuals (controls, 20 female) from 2015 through 2017. MEPs were recorded simultaneously from the rectum and anus using 4 ring electrodes. The difference in MEP latencies between the transcranial (TMS) and translumbar transsacral magnetic stimulations was calculated as cortico-spinal conduction time. MEP data were compared between patients with FI and controls. Patients filled out questionnaires that assessed the severity and effects of FI. RESULTS: The MEP latencies with TMS were significantly longer in patients with FI than controls at most sites, and on both sides (P < .05). Almost all translumbar and transsacral MEP latencies were significantly prolonged in patients with FI vs controls (P < .01). The cortico-spinal conduction time were similar, on both sides, between patients with FI and controls. Ninety-three percent of patients had 1 or more abnormal translumbar and transsacral latencies, but neuropathy was patchy and variable, and not associated with sex or anal sphincter function or defects. CONCLUSIONS: Patients with FI have significant neuropathy that affects the cortico-anorectal and spino-anorectal efferent pathways. The primary loci are the lumbo-rectal, lumbo-anal, sacro-rectal, and sacro-anal nerves; the cortico-spinal segment appears intact. Peripheral spino-anal and spino-rectal neuropathy might therefore contribute to the pathogenesis of FI.

Complete rectal prolapse in wild anubis baboons (Papio anubis).

This report describes two cases of rectal prolapse in wild anubis baboons (Papio anubis), with one spontaneous resolution. Both occurred after individuals consumed low-water, high-fibre dried maize during provisioning prior to capture, while one also experienced distress during capture.

Perianal abscess in infants: Amenable to conservative treatment in selected cases.

BACKGROUND: Perianal abscess is a common surgical condition in daily pediatric practice. Management is a subject of controversy and a variety of approaches are practiced. While the most frequent approach is drainage with/without fistulotomy, the superiority of this approach and the place of conservative approach has not been established. The aim of this study was to evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants. METHODS: Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed. RESULTS: Criteria for a conservative approach were: spontaneous drainage into the anal canal (n = 8) or perianal skin (n = 4), and phlegmonous infiltrate with fluid collection detected on ultrasound (n = 7). Mean age at symptom onset was 8.4 months. Twelve patients were managed for the first time. Previous care in seven patients included 1-4 drainage procedures (n = 4), spontaneous drainage (n = 1) and antibiotics (n = 2). Five patients were on oral antibiotics at presentation. After diagnosis, 18 patients received i.v. antibiotics and one, oral antibiotics. Three patients (15.7%) ultimately required surgical drainage; two were lost to follow up. During follow up (mean, 22.4 months) four patients (28.5%) had a single recurrent episode; abscess in three (managed conservatively in two and surgically in one) and fistula-in-ano in one patient that healed spontaneously. Thus, surgical intervention was prevented in 13/17 patients (76.4%) available for follow up. CONCLUSIONS: Perianal abscess in infants is amenable to conservative management in selected cases. Avoiding surgical intervention is advantageous, especially given the high recurrence rate.

Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment.

BACKGROUND: Treatment of a perianal fistula is difficult due to the risk of fecal incontinence and recurrence. The ligation of intersphincteric tract (LIFT) procedure is a sphincter-saving procedure associated with success rates ranging from 57 to 94%. The aim of our study was to find predictors for a favorable outcome of the LIFT procedure, evaluation of postoperative fecal incontinence, quality of life, and subsequent treatment with long-term follow-up. METHODS: This study was performed in patients who underwent LIFT between 2013 and 2015 at our institution. Their medical data were retrieved from the electronic patient files. The fistula characteristics were described by physical examination, three-dimensional endoanal ultrasound, and perioperative evaluation. Recurrence rate, postoperative fecal incontinence, and quality of life were assessed with the Patient-Reported Outcome Measurement (PROM). Thirty-two months later, long-term follow-up including subsequent procedures was evaluated. RESULTS: Forty-five patients [17 men, mean age 40 years (range 24-67 years)] were included. In 41 (84%) patients, the fistula was classified as complex; 32 (71%) were referrals with a history of previous fistula surgery. The initial success rate was 18 (40%). Only the height of the internal fistula opening (≥ 15 mm p < 0.03) was associated with recurrence. The LIFT procedure did not affect the occurrence of fecal incontinence or soiling. Recurrence showed a trend with a lower PROM (p = 0.07). Twenty-four months later, further surgery leads to cure in 34 (75%), asymptomatic fistulas in 7 (16%), and persisting active fistulas in 4 (9%) patients. CONCLUSIONS: Initial LIFT had a success rate of 40% and with subsequent surgical treatment 75%. Recurrence after LIFT is related to the height of the internal fistula opening and is associated with diminished quality of life. Continence was not affected by initial LIFT.

Long-term efficacy and safety of a nitinol closure clip system for anal fistula treatment.

INTRODUCTION: Treatment failure of anal fistula results in high re-occurrence rate. MATERIAL AND METHODS: Efficacy and safety of a nitinol closure clip system (bear-claw clip) were evaluated for anal fistulae treatment in a 36-month long-term follow-up study. RESULTS: Twenty-two patients were included. No patient had been treated with a bear-claw clip system before. All patients were fully continent before treatment. Follow-up time was 36 months (range 19-48 months). We observed a re-occurrence rate of 41% (nine patients) with presence of an active fistula. Time to recurrence was on average 6.9 months (range 3-11 months). Thirteen patients (59%) showed a complete healing of the fistula. Placed clip was removed in all patients on average after almost 5.8 months (3-12 months), in three cases the clip was left in situ. We did not observe any incontinence; one patient reported recurrent burning after defecation once the clip system was removed. DISCUSSIONS: Clip placement is a minimally invasive sphincter-preserving procedure with minimal complications and with an acceptable recurrence rate in the long term. However, bear-claw clip placement should probably be offered patients as a treatment option before more invasive procedures with higher perioperative morbidity are taken into consideration.

Rectal bleeding and implications for surgical care in Nepal.

BACKGROUND: Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world's population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries such as Nepal. The aim of this study was to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. METHODS: A countrywide survey using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged >18 y were included in this analysis. RESULTS: A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%). CONCLUSIONS: The Nepal health care system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a health care professional and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.

Rectal prolapse in the pediatric population-a narrative review of medical and surgical management.

Background and Objective: Although more frequent in the adult population, rectal prolapse is a common anorectal condition that can occur in children and adolescents. While many cases spontaneously resolve without the need for intervention, the advent of newer minimally invasive procedures and operations have provided options for pediatric patients. Here, we review the pathophysiology, etiology, presentation, diagnosis and principles of management of rectal prolapse in the pediatric population as it has evolved over the past several decades. Methods: The literature was queried from free databases available to the public including the National Institute of Health National Library of Medicine MEDLINE and PubMed for manuscripts published from January 1, 1975 to December 1, 2023. Manuscripts without an accompanying English translation or those written entirely in foreign languages were excluded. Key Content and Findings: Numerous conditions contribute to rectal prolapse in children, including constipation, gastrointestinal infectious and non-infectious etiologies, cystic fibrosis, malnutrition, neurogenic, anatomic, lead points, and abuse. Initial management of rectal prolapse is medical management, addressing the underlying condition associated with rectal prolapse along with attempted manual reduction. For patients with recurrent rectal prolapse, a variety of noninvasive and procedural management options are available including injection sclerotherapy and anal encirclement in addition to surgical rectopexy by open and newer minimally invasive methods. Conclusions: Despite significant advances in the evaluation, procedural and surgical management of pediatric anorectal conditions in the last few decades, there continues to be substantial variation in clinicians' and surgeons' practice for the treatment of rectal prolapse in children and adolescents. Much remains to be studied in the future to improve clinical outcomes for this patient population.

Current Status and Role of Artificial Intelligence in Anorectal Diseases and Pelvic Floor Disorders.

Background: Anorectal diseases and pelvic floor disorders are prevalent among the general population. Patients may present with overlapping symptoms, delaying diagnosis, and lowering quality of life. Treating physicians encounter numerous challenges attributed to the complex nature of pelvic anatomy, limitations of diagnostic techniques, and lack of available resources. This article is an overview of the current state of artificial intelligence (AI) in tackling the difficulties of managing benign anorectal disorders and pelvic floor disorders. Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed database to identify all potentially relevant studies published from January 2000 to August 2023. Search queries were built using the following terms: AI, machine learning, deep learning, benign anorectal disease, pelvic floor disorder, fecal incontinence, obstructive defecation, anal fistula, rectal prolapse, and anorectal manometry. Malignant anorectal articles and abstracts were excluded. Data from selected articles were analyzed. Results: 139 articles were found, 15 of which met our inclusion and exclusion criteria. The most common AI module was convolutional neural network. researchers were able to develop AI modules to optimize imaging studies for pelvis, fistula, and abscess anatomy, facilitated anorectal manometry interpretation, and improved high-definition anoscope use. None of the modules were validated in an external cohort. Conclusion: There is potential for AI to enhance the management of pelvic floor and benign anorectal diseases. Ongoing research necessitates the use of multidisciplinary approaches and collaboration between physicians and AI programmers to tackle pressing challenges.

Two Rings, Two Recoveries: Exploring the Thiersch Method in Complicated Cases.

Rectal prolapse, characterized by the protrusion of rectal mucosa or full-thickness tissue through the anal canal, significantly impacts quality of life, necessitating prompt intervention upon diagnosis. This case report presents the management of rectal prolapse in two cases admitted to our institution presenting with complaints of a prolapsing anal mass and many associated comorbidities and their subsequent surgical management using the Thiersch procedure. Following the procedure, both patients were monitored postoperatively, discharged once vitally stable, and kept on regular follow-up. Surgery is the primary therapy for rectal prolapse, and while various surgical techniques address rectal prolapse, anal encirclement procedures like the Thiersch procedure have been largely replaced by newer abdominal or perineal approaches. However, it is a valuable option for select patient populations. The Thiersch procedure is an ideal modality for treating high-risk patients with rectal prolapse or those patients with poor compliance for more extensive procedures. It can also be used temporarily until a further definitive treatment is planned later in the future.

Painful Anal Ulcers in an HIV-Negative Young Woman: An Atypical Presentation of Syphilis.

Anorectal syphilis is relatively uncommon and diagnostically challenging given the wide differential diagnosis for anal lesions. Risk factors, such as men who have sex with men or HIV-positive status, are especially important to elicit from patients during the clinical history. In this report, we present a rare case of painful anal syphilis diagnosed in an HIV-negative woman by tissue biopsy.

Prevalence of perianal diseases and associated factors in primigravida women: A hospital-based cross-sectional study.

OBJECTIVES: To define the incidence of anorectal diseases in primigravida women as well as in the first month after delivery and the factors affecting the development of anorectal diseases. METHODS: The sample size was determined as 328 primigravida women. Research data were collected from pregnant women who applied to Gynecology and Obstetrics Polyclinic, Kars Harakani State Hospital Gynecology and General Surgery Polyclinic, Kafkas University, Kars, Turkey, between November 2020 and August 2021.The pregnant women were examined and surveyed 4 times; in the second and third trimesters, on the day after delivery, and in the first month after delivery. Chi-square test was used in the analysis of the data determined by counting. Variables which were statistically significant (p<0.05) in the Chi-square test were included in the backward logistic regression analysis. RESULTS: Perianal disease was observed in 103 (38.6%) of the pregnant women. The incidence of perianal disease was found to be 4.917 times (confidence interval [CI]: [2.134-11.327]) higher in those with perianal disease compared with those without, 2.936 times (CI:[1.584-5.439]) higher in those who did not consume fiber-rich foods compared with those who did, 9.512 times (CI: [4.583-19.742]) higher in those with constipation compared with those without, and 23.721 times (CI: [5.363-104.915]) higher in those whose pushing stage duration was above average compared with that in those whose pushing stage duration was below average. CONCLUSION: In primigravida pregnants, the risk of perianal disease increases in those who have perianal disease before pregnancy, those who do not consume fibrous food, those who have constipation, and those who have a long pushing period.

Anorectal pathology in the HIV population: a guide for radiologists.

Patients with human immunodeficiency virus (HIV) can present with a wide range of different acute and chronic pathologies. Anorectal conditions are particularly common in this unique patient population, including pathologies, such as proctitis, anorectal abscess, anorectal fistula, and anal squamous cell carcinoma. The radiologist plays a critical role in the assessment of these common forms of anorectal disease, as these conditions can present with various findings on imaging assessment. Pelvic CT, MRI, and FDG-PET/CT are among the most common modalities used for assessment of anorectal disease in the HIV patient population. Knowledge of the fundamental clinical and imaging findings associated with these pathologies in HIV patients is critical for radiologists.

Insights into the management of anorectal disease in the coronavirus 2019 disease era.

Coronavirus 2019 disease (COVID-19) has created major impacts on public health. The virus has plagued a large population requiring hospitalization and resource utilization. Knowledge about the COVID-19 virus continues to grow. It can commonly present with gastrointestinal symptoms; initially, this was considered an atypical presentation, which led to delays in care. The pandemic has posed serious threats to the care of anorectal diseases. Urgent surgeries have been delayed, and the care of cancer patients and cancer screenings disrupted. This had added to patient discomfort and the adverse outcomes on healthcare will continue into the future. The better availability of personal protective equipment to providers and standard checklist protocols in operating rooms can help minimize healthcare-related spread of the virus. Telehealth, outpatient procedures, and biochemical tumor marker tests can help with mitigation of anorectal-disease-related problems. There is limited literature about the clinical management of anorectal diseases during the pandemic. We performed a detailed literature review to guide clinicians around management options for anorectal disease patients. We also highlighted the health challenges seen during the pandemic.

Benign anorectal disease: hemorrhoids, fissures, and fistulas.

Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients' lives. They are primarily encountered by primary care providers, including internists, gastroenterologists, pediatricians, gynecologists, and emergency care providers. Most complex anorectal disease cases are referred to colorectal surgeons. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical. The aim of this review is to examine the etiology, diagnosis, medical, and surgical treatment for these benign anorectal diseases.