Adenocarcinoma in a hemorrhoidectomy specimen: case report and review of the literature.

Our purpose is to report a case of unexpected anal adenocarcinoma found in a hemorrhoidectomy specimen. A review of the literature, with emphasis on extramucosal anal adenocarcinoma as a pathologic entity, is included. Our patient presented with a 2-year history of grade III prolapsing internal hemorrhoids. A hemorrhoidectomy was performed and gross examination of the specimen was unremarkable. The pathologic evaluation revealed microinvasive well-differentiated adenocarcinoma at the squamocolumnar junction. There was neither an apparent connection with the overlying mucosa nor an in situ component. A metastatic workup ruled out any other site of malignancy. At follow-up 18 months after surgery, no evidence of malignancy or recurrence was observed. An unexpected extramucosal anal adenocarcinoma in a hemorrhoidectomy specimen is a very exceptional finding. Review of the literature does not support routine histopathological examination of hemorrhoidectomy specimens.

Internal anal sphincter: advances and insights.

The internal anal sphincter, the smooth muscle component of the anal sphincter complex, has an ambiguous role in maintaining anal continence. Despite its significant contribution to resting anal canal pressures, even total division of the internal anal sphincter in surgery for anal fistulas may fail to compromise continence in otherwise healthy subjects. However, recently reported abnormalities of the innervation and reflex response of the internal anal sphincter in patients with fecal incontinence indicate its significance in maintaining continence. The advent of sphincter-saving surgery and restorative proctocolectomy has re-emphasized the major contribution of the internal anal sphincter to resting pressure and its significance in preventing fecal leakage. The variable effect of rectal excision on rectoanal inhibitory reflex has led to a reappraisal of the significance of this reflex in discrimination of rectal contents and its impact on anal continence. Electromyographic, manometric, and ultrasonographic evaluation of the internal anal sphincter has provided new insights into its pathophysiology. This article reviews advances in our understanding of internal anal sphincter physiology in health and disease.

Complete colonic obstruction caused by a sigmoid colon cancer incarcerated in an inguinal hernia sac.

An 85-year-old man with a clinical and x-ray picture consistent with a large bowel obstruction had a large left inguinal hernia with an incarcerated loop of sigmoid colon containing a small annular constricting colon carcinoma. Colonic obstruction due to inguinal hernia alone is so rare that a thorough evaluation should be done preoperatively in any patient believed to have colonic obstruction due to inguinal hernia.

Chronic pilonidal disease. An assessment of 150 cases.

During a four-year period, 150 consecutive patients were treated for chronic pilonidal disease by one of three different operative techniques. Patients with acute pilonidal abscesses or with complex or multiple recurrent pilonidal disease were excluded from this study. The average healing time was four weeks and the average length of hospital stay was one day. The overall recurrence rate was 8 percent (12 of 150 patients). The method of management most commonly used was fistulotomy with marsupialization of the sinus tract or cyst wall (125 of 150 patients). This simple and effective technique gave excellent results with a 6 percent recurrence rate (7 of 125 patients). On the basis of their experience, the authors propose that chronic pilonidal disease usually can be treated successfully on a same day surgery basis with fistulotomy, minimal excision, and marsupialization.

Preoperative bowel preparation. A survey of colon and rectal surgeons.

A survey of 500 clinically active, board-certified colon and rectal surgeons in the United States and Canada was conducted to obtain data regarding current methods of bowel preparation for elective colorectal surgery. A review of recent publications on preoperative bowel preparation was used to compare the current literature recommendations with the actual practice among the group surveyed. Responses were received from 352 of 500 colorectal surgeons to whom questionnaires were sent (70 percent response rate). All respondents used a mechanical preparation and some form of antibiotics. The favorite antibiotic regimen was oral antimicrobials combined with systemic antibiotics (88 percent). Concomitant administration of oral neomycin-erythromycin base and a systemic second generation cephalosporin active against both anaerobic and aerobic colonic bacteria, together with oral polyethelene glycol electrolyte mechanical colonic cleansing, was the most popular method of preoperative bowel preparation (58 percent). The second most frequent method of mechanical bowel cleansing consisted of conventional enemas, dietary restrictions, and cathartic preparations (36 percent). Mannitol solution (5 percent), and whole-gut irrigation per nasogastric tube (1 percent) were the least popular methods of mechanical bowel cleansing. The literature supports the current methods of preoperative bowel preparation used by the vast majority of surgeons surveyed.

Colonic resection in the treatment of complete rectal prolapse.

For the good risk patient, nearly all surgeons recommend an abdominal approach as the surest method of eliminating a complete rectal prolapse. The most commonly performed abdominal procedures are rectal suspension-fixation operations utilizing slings of synthetic material or suture without foreign material. Occasionally both of these procedures are combined with a segmental colorectal resection. Rectal mobilization with fixation of the rectum to the sacrum alone, by whatever means, has a high rate of success with a low mortality and morbidity. The wisdom of adding colorectal resection to rectopexy in the treatment of complete rectal prolapse remains controversial. The authors favor abdominal rectopexy with sigmoid resection because it avoids foreign material, eliminates the risk of volvulus, improves bowel management problems, and has low morbidity with a low recurrence rate. In our series of 102 patients treated by rectopexy and sigmoid resection, there were no deaths and only 4 per cent morbidity related to the anastomosis. After a mean follow-up period of four years, the recurrence rate was 1.9 per cent.

Primary retroperitoneal sarcomas.

A retrospective analysis of 20 adult patients with primary retroperitoneal sarcomas demonstrated that most patients presented with pain and a palpable abdominal mass. Liposarcomas and leiomyosarcomas were the most common tumors. Seven of the 20 patients (35 percent) had complete tumor excision. Operative morbidity was 18 percent with no mortality. After complete resection, the 5 year survival rate was 43 percent. Thirteen patients underwent partial excision of tumor, with an operative morbidity rate of 29 percent and a mortality rate of 15 percent. No patient in our series lived more than 2 years after only partial excision. Anatomic restrictions to wide resection and local recurrence were the most important factors determining survival. Aggressive, complete surgical resection in treating primary retroperitoneal sarcomas is strongly recommended.