Anorectal Melanoma: A Rare Cause of Large Bowel Obstruction.

Anorectal melanoma is a rare and aggressive malignancy with a challenging diagnosis and management. We present the case of a 69-year-old male with a history of chronic constipation and recent weight loss, who presented with symptoms suggestive of anorectal pathology. Despite initial diagnostic challenges, including an unsuccessful colonoscopy due to inadequate bowel preparation, the subsequent radiographic evaluation revealed a large bowel obstruction secondary to a protruding anorectal mass. Abdominal X-ray demonstrated significant colonic dilation while contrast-enhanced CT scan revealed a large hypodense mass protruding from the anal canal. Surgical intervention led to the excision of the mass, and histopathological examination confirmed malignant melanoma. Immunohistochemistry markers, including HMB 45, Melan A, and S100, supported the diagnosis. This case underscores the importance of considering anorectal melanoma in patients presenting with atypical anorectal symptoms, despite its rarity. Early recognition and intervention, supported by appropriate imaging modalities, are critical for optimizing patient outcomes in such cases.

Surgical Principles of Rectal Cancer.

This article reviews the oncological principles of rectal cancer surgery, beginning with an overview of the pertinent rectal and pelvic anatomy, followed by a discussion of the historical evolution in surgical management. Evidence supporting current practices with respect to proximal, distal, and circumferential margins are reviewed. Finally, operative approaches to restorative proctectomies and abdominoperineal resections are highlighted.

Prophylactic Mesh for Prevention of Parastomal Hernia Following End Colostomy: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: To evaluate the efficacy of prophylactic mesh placement during end colostomy formation at reducing rates of parastomal hernia using the most recently available data. BACKGROUND: Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have uniformly concluded that the use of prophylactic surgical mesh when fashioning an end colostomy reduces the risk of parastomal hernia. However, recent RCTs have failed to corroborate these findings. This study was designed to provide an updated systematic review and meta-analysis evaluating the efficacy of prophylactic mesh placement during end colostomy formation. METHODS: A search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they were RCTs that compared the use of prophylactic mesh to no prophylactic mesh during construction of an end colostomy following colorectal resection for benign or malignant disease. The primary outcome was parastomal hernia rate. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS: From 1,089 citations, 12 RCTs with 581 patients having prophylactic mesh placement and 671 patients not having prophylactic mesh placement met inclusion criteria. Incidence of parastomal hernia was significantly reduced in patients receiving prophylactic mesh (OR 0.60, 95% CI 0.46 to 0.80, p = 0.0003, I2 = 74%). Results were no longer significantly different when only studies conducted in the last 5 years were analyzed (p = 0.10). There was no significant difference in postoperative morbidity, postoperative mortality, colostomy-specific morbidity, or length of stay between groups. CONCLUSIONS: There remains a significant reduction in the risk of parastomal hernia with the use of prophylactic mesh at the time of end colostomy formation, despite recent evidence suggesting no difference. Further contemporary trials with the application of modern surgical technology are required.

Is pull-through an acceptable replacement for low anterior resection for rectal cancers in low-income setting? A case-control study.

BACKGROUND: Colorectal cancers are the second most common cancers overall and are the third deadliest cancers. Complete resection is the treatment of choice for rectal cancers and chemoradiotherapy (CRT) is strongly recommended in stage 2 and 3. Low anterior resection (LAR) is the most common procedure used, but it requires the use of stapler which might be very expensive as one study estimated the median cost of LAR inpatients to be over 13.000 USD. However, coloanal pull-through (PT) used to be the common procedure before introducing staplers in the twentieth century and can be less expensive, but with higher complication rates. MATERIALS AND METHODS: This is a retrospective case-control study from patients' records who underwent either LAR or PT for their rectal cancer in Syria. All patients had either stage 2 or 3 cancer and were treated by the same group of surgeons and received the same adjuvant and neoadjuvant CRT protocol. Patients from both groups had the same prognosis and stages. RESULTS: This study included 60 participants, of which, 30 had LAR and 30 had PT. They all had successful removal of the cancer and follow-ups were for 1 year after the surgery. There were no significant differences between the two procedures in post-operative leak, urinary retention, stricture, sexual function and recurrence (p > 0.05). However, post-operative incontinence was more frequent with PT (p = 0.027). CONCLUSION: PT can be an acceptable substitute of LAR in low income settings despite having higher incidence of incontinence.

Prone Versus Supine Position in Abdominoperineal Resection: Outcomes in the Laparoscopic Era.

Background: It is unclear whether the supine or prone approach for abdominoperineal resection (APR) influences outcomes. Methods: In a retrospective study of patients with rectal cancer who underwent curative laparoscopic APR from 2005 to 2018, we compared perioperative data, postoperative outcomes, oncological outcomes, and survival between the two approaches. Results: We recruited 123 patients (58 for the supine group and 65 for the prone group), with a median age of 72 (41-93) years. Mean follow-up was 67.4-45.7 months (28-169) in the supine group and 47.8-30.9 months (13-158) in the prone group (P = .026). Duration of surgery was longer in the prone group at 237 ± 52.3 minutes versus 210 ± 56.6 minutes in the supine group (P = .007). The incidence of tumor perforation during surgery was 9% in the supine group versus 3% in the prone group (P = .208). The incidence of perineal wound infection did not differ significantly between groups (supine 22% versus prone 20%, P = .93). The mesorectum was incomplete in 25% cases in the supine group and 14% cases in the prone group (P = .175). Circumferential resection margin positivity was 21% in the supine group and 14% in the prone group (P = .374). Local and distant recurrence was higher in patients with adenocarcinoma in the supine group at 10% and 31% versus 4% and 17% in the prone group (P = .177). Overall survival was higher in the prone group: 4% of patients died due to disease progression compared with 24% in the supine group (P = .034). Conclusions: Our results suggest that morbidity is similar with both laparoscopic techniques, but long-term outcomes seem better with the prone approach.

Estudio comparativo de los resultados del tratamiento del carcinoma anal escamoso en los pacientes HIV positivos y negativos / Comparative study of the results of the treatment of squamous anal carcinoma in HIV positive and negative patients

Introducción: El tratamiento del carcinoma anal escamoso (CAE) en los pacientes HIV positivos resulta controvertido. Si bien las guías actuales recomiendan realizar en los pacientes con buen estado inmunológico la quimiorradioterapia (QRT) concurrente estándar, algunos autores consideran que estos pacientes presentan mayor toxicidad y peores resultados a largo plazo, por lo que requerirían un abordaje diferente. El objetivo de este trabajo es comparar los resultados del tratamiento del CAE en los pacientes VIH positivos y negativos. Diseño: Estudio retrospectivo comparativo. Pacientes y métodos: Se revisaron retrospectivamente las historias clínicas de los pacientes tratados en el Sector Coloproctología, Hospital Fernández, entre 01/2007 y 10/2018. Los del conducto anal se dividieron en: Grupo I: VIH negativos y Grupo II: VIH positivos. Se compararon variables demográficas, factores de riesgo específicos, estadificación, QRT (drogas, toxicidad y respuesta), tratamiento quirúrgico curativo/paliativo, persistencia/recurrencia y supervivencia específica y global. Resultados: Se incluyeron 28 pacientes (18 mujeres); margen: 2, conducto: 26 (Grupo I: 15. Grupo II: 11). Los VIH positivos eran en su mayoría hombres que tienen sexo con hombres vs. 100% de mujeres VIH negativas (p<0,01), más jóvenes (45,2±0,9 vs. 63,6±8; p<0,01) y tabaquistas (82% vs. 27%; p=0,005). No hubo diferencia significativa en la estadificación, aunque el Grupo II tuvo tumores con complicaciones más severas. Pudieron completar el tratamiento: Grupo I: 93%, Grupo II: 64% (p<0,05). Tuvieron respuesta completa a la QRT 13/14 (93%) pacientes del Grupo I y 3/7 (43%) del Grupo II (p<0,01). Hubo 3 recurrencias, 2 locorregionales y 1 a distancia (p=NS). Los VIH positivos requirieron más cirugías (82% vs. 27%; p<0,01). A 5 pacientes (4 del Grupo II) se les realizó una resección abdominoperineal (RAP). Tuvieron colostomía definitiva, con o sin RAP, el 46% de los pacientes, la mayoría VIH positivos (82% vs. 27%; p=0,002). En los VIH positivos el RR de mortalidad por cáncer fue 4 (IC95%: 1,01-16,5; p=0,02) y el RR de mortalidad global fue 5,45 (IC95%: 1,42-20,8; p=0,002). Tuvieron menor supervivencia, tanto global (p=0,001) como libre de enfermedad (p=0,01). Mediana de seguimiento: 27 meses (4-216).Conclusiones: Los pacientes VIH positivos con CAE se diferenciaron de los VIH negativos en una menor tasa de respuesta completa a la QRT y una mayor necesidad de tratamiento quirúrgico. Además, tuvieron una supervivencia global y libre de enfermedad significativamente menor que los VIH negativos. (AU)

INTRODUCTION: The treatment of anal squamous cell carcinoma (SCC) in HIV-positive patients is controversial. Although current guidelines recommend performing standard concurrent chemoradiotherapy (CRT) in patients with good immune status, some authors believe that these patients have greater toxicity and worse long-term results, so they would require a different approach. The purpose of this study was to compare the results of SCC treatment in HIV-positive and HIV-negative patients.DESIGN: Comparative retrospective study.PATIENTS AND METHODS: The records of patients treated in the Coloproctology Section, Hospital Fernández, between 01/2007 and 10/2018 were retrospectively reviewed. Those of the anal canal were divided into: Group I: HIV-negative and Group II: HIV-positive. Demographic variables, specific risk factors, staging, CRT (drugs, toxicity, and response), curative/palliative surgical treatment, persistence/recurrence, and cancer-specific and global survival were compared.RESULTS: 28 patients (18 women), margin: 2, conduit: 26 (Group I: 15. Group II: 11). The HIV-positive were mostly men who have sex with men (vs. 100% HIV-negative women; p<0.01), younger (45.2 ± 0.9 vs. 63.6 ± 8; p<0.01) and smokers (82% vs. 27%; p=0.005). There was no significant difference in staging, although Group II had tumors with more severe complications. Completed the treatment: Group I: 93%, Group II: 64% of patients (p<0,05). Thirteen out of 14 (93%) patients in Group I, and 3/7 (43%) patients in Group II had a complete response to CRT (p<0.01). There were 3 recurrences, 2 loco-regional and 1 distance (p=NS). HIV-positive required more surgery (82% vs. 27%; p<0.01). 5 patients (4 of Group II) underwent an abdominal-perineal resection (APR). Forty six percent of patients had permanent colostomy, with or without APR, most of them were HIV-positive (82% vs. 27%; p=0.002). In HIV-positive patients, the RR of cancer mortality was 4 (95% CI: 1.01-16.5; p=0.02) and the RR of overall mortality was 5.45 (95% CI: 1.42-20, 8; p=0.002). They also had lower overall (p=0.001) and disease-free survival (p=0.01). Median follow-up: 27 months (4 - 216).CONCLUSION: HIV-positive patients with anal SCC were different from HIV-negative patients in that they had a lower complete response rate to CRT, and a greater need for surgical treatment. They had a significantly lower overall and disease-free survival than HIV-negative patients. (AU)

MRI of surgical flaps in pelvic reconstructive surgery: a pictorial review of normal and abnormal findings.

Surgical flaps are commonly used for pelvic reconstruction in a subgroup of patients with locally advanced or recurrent anorectal and gynecologic malignancies and following complications of pelvic irradiation. Surgical scenarios where flaps may be placed include (but are not limited to) extended or radical abdominal perineal resection (APR) and total pelvic exenteration (PE). Surgical flaps in pelvic reconstruction serve several functions, including reducing dead space and providing structural support, facilitating wound closure and cosmetic appearance, enhancing the postsurgical healing process, protecting anastomoses and helping to prevent adhesions of organs and viscera to adjacent structures and the pelvic side wall. The most commonly used surgical flaps in pelvic reconstruction surgery include the VRAM (Vertical Rectus Abdominis Muscle), MRAM (Modified Rectus Abdominis Myocutaneous flap), gracilis, sartorius and omental flaps. Surgical flaps can be mistaken for recurrent or residual tumor by radiologists who are not familiar with the appearance or surgical methods of flap placement, since flaps may have a mass-like appearance on cross sectional imaging, including CT and MRI. Recurrent neoplasm may be difficult to differentiate from postoperative changes of flap placement and associated postsurgical anatomic distortion. This review article focuses on understanding the nuances of surgically placed pelvic flaps and identifying their normal and abnormal appearances on magnetic resonance imaging (MRI) along a time continuum. Postsurgical complications, including hematoma, postoperative fluid collections, infection, ischemia, and necrosis as well as tumor recurrence on the initial and follow-up magnetic resonance imaging are illustrated and discussed.

Perineal hernia mesh repair: a fixation with glue, sutures and tacks. How to do it.

Introduction: Many different approaches for the repair of a perineal hernia (PH) after abdomino-perineal rectum amputation (APR) have been described throughout the years. Literature shows us that the use of a mesh had the best results with relatively low rates of recurrence compared to primary suture. Yet there is still no consensus on the best technique for fixation of the mesh in the perineal cavity. Methods: We want to introduce an addition to the surgical repair technique, using laparoscopic glue to ensure a solid fixation of the mesh. This is to prevent small bowel from sliding into the perineal area due to the high abdominal pressure when standing and to avoid the difficulties and risks of laparoscopical suturing in this area. Results: This use of glue for fixation of the mesh has been successful in the three cases described, with no recurrence after one-year follow-up. Conclusion: A recurrent PH can be prevented by a solid fixation of the mesh using the technique of a glued mesh repair. This technique shows to be easy, fast and without recurrence.

Amelanocytic anorectal malignant melanoma-Case report.

INTRODUCTION: Anorectal malignant melanoma (AMM), is a rare and aggressive form of melanoma. Accounts for <2% of melanomas, and <2% of anal tumors. It is more frequent at the 6th-7th decade, mostly in women. Surgery is the mainstay of treatment, but the extent is controversial. CASE PRESENTATION: 82-year-old male, presented with rectal mass in the Emergency Room (ER). After local excision, pathology observed that the mass corresponded to AMM. Despite being stage I (Local disease), a year later it presented with local recurrence and distant metastasis. The patient died 32 months after diagnosis. CONCLUSIONS: There is no optimal treatment, due to the lack of prospective studies. Wide local excision (WLE) has faster recovery, less post-operatory complications and similar survival rate compared to abdominal perineal resection (APR).

Surgical treatment of anorectal malignant melanoma from single tertiary center: A retrospective analysis of 91 cases / 中国实用外科杂志

OBJECTIVE:To investigate the surgical treatment of anorectal malignant melanoma(ARMM) and the prognostic factors that affect patients' overall survival(OS).METHODS:Theclinical and pathological data of 91 patients diagnosed as ARMM, who underwent surgery in the Gastrointestinal Cancer Center of Peking University Cancer Hospital from January 2003 to January 2018 were retrospectively analyzed. The effects of different clinicopathological factors on OS of the patients, and difference surgery, abdominal-perineal resection(APR) and wide local excision(WLE) on patients' survival were compared.RESULTS:Of the 91 patients with ARMM, 35(38.5%) were male, 56(61.5%) were female, and the ratio of male to female was 1:1.6. 12 patients(13.2%) underwent wide local excision and 79 patients underwent abdominal-perineal resection(86.8%); there were 19 cases(20.9%) diagnosed with distant metastasis and 72 cases(79.1%)without distant metastasis. The of 1-, 3-, and 5-year survival rates of ARMM patients in this cohort were 74%, 23% and9%; and the median survival of the patients was 18.7 months. The univariate analysis of the clinicopathological features of the patients demonstrated that the preoperative distant metastases, tumor diameters(>2 cm), tumor invasion depth(>2 mm) and lymph node metastasis were the prognostic factors of OS; multivariate analysis showed that preoperative distant metastasis and lymph node metastasis were independent factors affecting OS.The median survival of the patients admitted APR and WLE were both 21 months. There was no significant difference in survival between the WLE and APR group(P=0.94).CONCLUSION:Preoperative distant metastasis and lymph node metastasis are independent prognostic factors for overall survival of ARMM patients.Comparing with WLE, APR could not bring survival benefits.

How we do it: repair of large perineal hernia after abdominoperineal resection.

BACKGROUND: Symptomatic perineal hernia is a rare complication after abdominoperineal resection (APR). Management of these hernias is challenging. The recurrence rate after surgical repair is high because of the difficulty of prosthetic material fixation; there is no consensus regarding the best method of repair. METHODS: We introduced a novel combined laparoscopic-perineal dual fixation technique in the repair of perineal hernias after APR. This technique begins with a perineal approach under laparoscopic vision. After excision of the hernia sac, the mesh is introduced and fixed anteriorly to the urogenital diaphragm and laterally to the sacrotuberous ligament and the surrounding scar tissue. The perineal incision is then closed. Next, the mesh is fixed to the sacrum with ProTack® and is fixed again to the sacrotuberous ligament via a laparoscopic approach. RESULTS: The dual fixation repair method is successful and without difficulties, with no recurrence at 13-month follow-up. CONCLUSION: Our laparoscopic-perineal dual fixation method is a good alternative method for large perineal hernia repair after APR.

Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes.

BACKGROUND: The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes. METHODS: This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted. RESULTS: Seventeen cases were identified. Patient age was 61 (range 34-75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4-3.9). Post-operative length of stay was 4 (4-6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8-2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2-30). Follow-up was 9.7 months (range 20 days-23 months), during which one patient developed recurrent disease. CONCLUSIONS: This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.

Anorectal Melanoma: A Case Report and an Update of a Rare Malignancy.

Anal melanoma is an aggressive but rare malignancy. Patients commonly present with very advanced or even metastatic disease. Risk factors for anal melanoma are family history and an activating mutation of C-KIT. Surgical excision remains the mainstay of therapy. The presence of activating mutations of C-KIT has prompted use of C-KIT inhibitors such as imatinib and sunitini. Early diagnosis and treatment remain crucial. Abdominal perineal resection (APR) offers a higher rate of local control whereas wide local excision (WLE) can yield superior long-term survival.

Combination of pseudocontinent perineal colostomy and appendicostomy: a new approach in the treatment of low rectal cancer.

BACKGROUND: Abdominal perineal resection (APR) with applied colostomy remains the standard treatment for low rectal cancer; however, to date, a very high morbidity rate has been reported. AIMS: The aims of this study were to assess fecal continence, persistence of disease-related symptoms, and quality of life in patients with low rectal cancer after APR and pseudocontinent perineal colostomy and concomitant appendicostomy. METHODS: We included 17 patients with low rectal cancer who underwent APR at our hospital in this cross-sectional study. Following APR, pseudocontinent perineal colostomy and concomitant appendicostomy were performed. Patients then underwent antegrade colonic enema with tap water. Patients' symptoms, fecal continence, and quality of life were evaluated at regular time intervals. RESULTS: After a median follow-up of 12 months, 15 of 17 patients completed the study period. All patients were able to perform an antegrade enema by themselves. Mean continence score was 7 (out of 20) based on the Wexner Scale scoring system. Mean global health status score was 78, physical function was 93, and emotional function was 88. Minor morbidity was observed in 6 patients (40%). CONCLUSION: Pseudocontinent perineal colostomy with appendicostomy provides an acceptable level of continence and functional and emotional improvement in patients with low rectal cancer undergoing APR. Hence, this combinative method could be considered as an alternative for abdominal colostomy in selected patients.

The study of cylindrical abdominal perineal resection for rectal cancer and pelvic floor reconstruction improvement / 重庆医学

Objective To study the abdominal perineal resection for rectal cancer and clinical application of pelvic floor recon-struction .Methods 30 cases of rectal cancer patients from 2008-2011 were randomly divided into experimental group and the con-trol group ,30 cases in each group .Experimental group patients by columnar abdominal perineal resection of rectal cancer treatment , postoperative pelvic floor defect for dermal matrix reconstruction .The control group patients for colorectal cancer resection by lapa-rotomy .Results Compared with the traditional open resection ,the operation time ,intraoperative blood loss ,postoperative patholog-ical column T3 N0 M0 positive rate ,incidence of complications and incision aspect of cylindrical abdominal perineal resection were ob-vious advantages ,the difference was statistically significant (P< 0 .05) .Conclusion Compared with Miles surgery ,cylindrical ab-dominal perineal resection for rectal cancer can reduce the incidence of postoperative incisal edge positive rate and bowel perfora -tion .Human decellularized dermal matrix basin redevelopment can significantly reduce the surgical risk and difficulty of surgical op-erations .