Anorectal complications in patients with haematological malignancies.

BACKGROUND: Anorectal complications are common in patients with haematological malignancies. OBJECTIVES: The objectives are to characterize anorectal complications in these patients, identify risk factors and shed light on treatment, morbidity and mortality rates. PATIENTS AND METHODS: A retrospective, observational study that included 83 inpatients with haematological malignancies and proctological symptoms from January 2010 to September 2015 was conducted. Clinical outcomes were obtained through a detailed review of medical records. RESULTS: The median age was 56 years, and 52 (62.7%) patients were men. Fifty-six (67.5%) patients had nonseptic anorectal complications and 27 (32.5%) patients had septic anorectal complications. RISKS FACTORS: Patients with septic anorectal complications were more commonly male, older, and had lower absolute neutrophil counts, but the differences were not statistically significant (P=0.79, 0.67 and 0.89, respectively). In positive blood cultures [23/70 (32.9%)], Enterococcus faecium, Klebsiella pneumonia, and Escherichia coli were the most common isolated agents. TREATMENT: In nonseptic anorectal complications, conservative treatments/minor proctological procedures were adopted, and patients with septic anorectal complications were treated with antibiotics±major proctological procedures and/or surgical drainage/debridement. RESULTS OF TREATMENT: Forty-eight (85.7%) patients in the nonseptic complications group improved compared with 23 (85.2%) patients in the septic complications group. The overall mortality rate was 2.4% (n=2), with one (1.2%) death related to perianal sepsis. CONCLUSION: Enterococcus spp. were more commonly identified in this study and can be increasing in this specific population. In contrast to other reports, we did not identify an association between septic anorectal complications and possible risk factors such as male sex, younger age or a low absolute neutrophil count. Most patients had nonseptic anorectal complications. A major proctological procedure/surgical debridement should always be applied in septic complications, which have better prognoses now than in the past.

Natural history of perianal Crohn's disease after fecal diversion.

BACKGROUND: Temporary fecal diversion has been used to allow severe perianal Crohn's disease (CD) to heal. Most data on intestinal reconnection rates precede the biological era with limited patient follow-up after reconnection. We, therefore, sought to evaluate the natural history of perianal CD after fecal diversion. METHODS: We identified 49 patients with CD and perianal involvement who underwent fecal diversion between 1991 and 2011 at a tertiary referral care center. Demographics, medication use, onset and extent of disease, and surgical interventions were abstracted. We determined the percentage of patients who were able to restore intestinal continuity and assessed the sustainability of this reversal. Time to intestinal reconnection and subsequent procedures were determined. We also examined temporal trends in the proportion of patients with perianal CD undergoing diversion or management with seton/EUA/fistulotomy between 2000 and 2011. RESULTS: Fifteen of 49 patients (31%) reestablished intestinal continuity during the study follow-up period. Ten of 15 patients (67%) who had reestablished intestinal continuity required an additional procedure to divert the fecal stream. Of the 5 patients who remained reconnected, 3 patients required further procedures to control sepsis. The proportion of patients with CD requiring perianal surgical interventions declined between 2000 and 2011. CONCLUSIONS: Severe perianal CD remains a challenging problem. In patients with CD with perianal disease requiring fecal diversion, the likelihood of sustained intestinal continuity remains low, despite greater biological use. However, there has been a temporal decline in the rate of surgical interventions required for perianal CD from 2000 to 2011.

Necessity of preventive colostomy for Fournier's gangrene of the anorectal region.

BACKGROUND: The aim of this study was to evaluate the necessity of preventive colostomy for Fournier's gangrene of the anorectal region. METHODS: The medical records of 37 patients with perianal Fournier's gangrene were evaluated retrospectively. Debridement(s) alone was performed in 18 patients (Group D), while debridement(s) plus Hartmann colostomy was performed in 19 patients (Group D&HC). RESULTS: There were no statistically significant differences between the D and D&HC groups with respect to mean age (p=0.73), sex ratio (p=1.00), diabetes mellitus (p=0.88), concomitant diseases (p=0.57), and number of debridements (p=0.75). The medical and surgical complication and mortality rates and duration of hospital and intensive care unit stays were also not significantly different between the D and D&HC groups (p>0.05). Fecal diversion was done at the initial operation in 11 patients, at second operation in 6 patients, and at third operation in 2 patients. When compared, morbidity rates were similar, but mortality rates were statistically different (p=0.031). CONCLUSION: Fournier's gangrene remains a difficult surgical problem. Despite aggressive multidisciplinary treatment, it still has a high mortality rate. Fecal diversion in the treatment of Fournier's gangrene is controversial. If necessary, preventive colostomy should be performed during the initial debridement.

[Experiences in surgery of proctologic diseases in patients with HIV infection]. / Erfahrungen in der Chirurgie proktologischer Erkrankungen HIV-Infizierter.

Individuals who are seropositive for the human immunodeficiency virus (HIV) often suffer from disorders affecting the anorectum, but unfortunately the best kind of treatment frequently seems questionable. In a retrospective investigation we reviewed 29 HIV-positive patients with anorectal lesions who had experienced a proctologic operation. Our impression correlates with other findings according to which HIV-positive patients in advanced stages have a poorer post-operative outcome in terms of morbidity and survival than patients in an early CDC disease stage. This implies that the indication for a proctologic operation in an immunocompromised state has to be considered carefully.

Perianal manifestations of human immunodeficiency virus infection: experience with 260 patients.

PURPOSE: Individuals infected with the human immunodeficiency virus often have disorders affecting the anorectum. These disorders may be complex and difficult to treat. We reported our early experience with 40 human immunodeficiency virus-positive patients with perianal disorders in 1990. We now present our series of 260 consecutive human immunodeficiency virus-positive patients with perianal disorders who underwent evaluation between 1989 and 1996 to examine the distribution of disorders, their treatments, and outcomes. METHOD: Patients were identified at initial presentation and followed prospectively. RESULTS: Two-hundred forty-nine (96 percent) of 260 patients were male, with an average age of 34.9 (range, 19-58) years. Average duration of human immunodeficiency virus positivity was 5 years, 5 months, with a maximum of 11 years, 5 months. Median CD4 count was 175 (range, 2-1,100) cells/mm3. Only 89 (34 percent) patients satisfied the criteria of the Centers for Disease Control and Prevention's for acquired immunodeficiency syndrome at presentation. The most frequent major presenting symptoms were anorectal pain (55 percent), a mass (19 percent), and blood in the stool (16 percent). Risk factors included homosexuality (75 percent) and a prior history of sexually transmitted disease (45 percent). Forty different perianal disorders were identified, which were categorized as benign noninfectious (18), infectious (14), neoplastic (6), and septic (2). The most common disorders were condyloma (42 percent), fistula (34 percent), fissure (32 percent), and abscess (25 percent). Neoplasms were present in 19 patients (7 percent). One hundred seventy-one patients (66 percent) had more than one disorder, with an average of 2.9 disorders among these patients. Four hundred eighty-five procedures were performed on 178 patients (2.7/patient), with no mortalities and a 2 percent complication rate. Thirty-one patients (12 percent) died during the course of follow-up, but anorectal disease was the cause of death in only two patients. CONCLUSIONS: Perianal manifestations of human immunodeficiency virus infection are common, often multiple, and varied. Patients with perianal disorders seek treatment throughout the course of the human immunodeficiency virus infection, and a perianal condition may be this disease's initial manifestation. Although recurrence is common and healing delayed, improved overall management of human immunodeficiency virus infection and a healthier human immunodeficiency virus-positive patient population have improved the outcome of surgical intervention in human immunodeficiency virus-infected patients with perianal disorders.

Surgical management of anorectal disease in HIV-positive homosexuals.

One thousand and ninety human immunodeficiency virus (HIV)-positive homosexual or bisexual males were seen in one hospital for management of HIV disease over a 9-year period. One hundred and fifty-five patients were referred by acquired immunodeficiency syndrome (AIDS) physicians for general surgical management. The most frequent reason for surgical referral (64 patients) was anorectal disease which occurred in 5.9 per cent of all HIV-positive patients. One or more diagnoses were reached in 61 of the 64 patients referred with anorectal disease: warts (38 per cent of diagnoses), anorectal ulceration (26 per cent), perianal sepsis (15 per cent), neoplasia (14 per cent) and haemorrhoidal disease (8 per cent). Anorectal symptoms were relieved in 68 per cent of patients and the median survival of those treated was 17.5 months from the time of surgical referral. Both warts and perianal sepsis were associated with in situ neoplasia, but no case of progression from in situ to invasive anal squamous carcinoma was detected. The aetiology of anorectal ulcers was not clear, but surgical excision of anal ulcers and skin tags can produce healing. Palliation of anorectal symptoms in HIV-positive homosexual patients is possible but some conditions are unusual and surgeons should be familiar with their presentation and management.