Rectal Granular Cell Carcinoma Requiring Abdominoperineal Resection

Background Granular cell tumors, derived from neural crest cells, are rare tumors infrequently located in the colon or rectum. We will discuss a patient with a rectal granular cell tumor invading the anal sphincters requiring an abdominoperineal resection. Methods A 56-year-old male, with anal pain, was found to have a perirectal mass. Pathology from ultrasound-guided transrectal biopsy demonstrated low grade granular cell tumor. The patient underwent a laparoscopic abdominoperineal resection with perineum reconstruction. Results Pathology demonstrated a granular cell tumor of 4.5 centimeters with tumor invasion of the anal sphincters. Surgical margins were free of neoplasm. Discussion This is the only documented case of a colorectal granular cell tumor that has required an abdominoperineal resection. On histology, it was considered low grade but its behavior was more consistent with a malignant process. Additional research on malignant granular cell tumors is necessary to help improve treatment options, prevent recurrence, and improve overall survival. His medical course will be followed for disease progression or metastasis.

Traumatic posterior anal injury requiring a sphincteroplasty without diversion.

The anal sphincters may be divided by direct anal trauma or by severe pelvic injuries. The preoperative clinical assessment may correlate well with intra-operative assessment. As long as about half the sphincter ring remains active there is a good chance of restoring satisfactory faecal continence following a sphincteroplasty.

Is an empirical approach to performing access in pediatric surgery in children safe?

Objective: to determine the topical localization of the structural components of the anal sphincter and to formulate the basic postulates of the formation of safe anatomical access in pilonidal disease surgery in children. Materials and methods: the study was conducted on the corpses of 10 children who had no lifelong pathology of the sacrococcygeal region and pelvis aged 12 to 17 years, including 5 girls and 5 boys. Soft tissue columns 1 cm wide and up to 5 cm long were prepared at a distance of 1 cm from the anus by 12 h, 3 h, 6 h and 9 h according to the dial in the back position. After preparation and fixation of the drugs, their staining was performed and cross-sections of anal sphincters 5–7 μm thick were made. The analysis of the received morphometric data is carried out. The results of the study: it was found that the cross-sectional area of the bundle of muscle fibers of the external sphincter of the anus on average in adolescents ranged from 448±32 μm2 to 412±24 μm2. The diameter of its muscle fibers was 13.02±1.56 μm, and the bulk density of muscle fibers is 96.12±1.34%. Regarding the length of the internal anal sphincter, it was found that it is almost the same in different areas and is 1.3±0.03 at the level of 3 and 12 hours, 1.3±0.07 at the level of 6 hours and 1.2±0.03 at the level of 9 hours. In the study of the linear dimensions of the length of different portions of external anal sphincter in certain places of the biopsy revealed a predominance of parameters that were determined at 6 hours, respectively, 5.7±0.06 cm against 4.3±0.04 cm at 3 hours, and 12 hours, respectively 5.1±0.06 cm against 4.3±0.03 cm at 9 years. The thickness of the external sphincter of the anus at 6 hours, respectively 26.7±0.61 mm against 18.5±0.19 mm at 3 hours, (<0.01) and 12 hours, respectively 23.9±0.33 mm against 18.4±0.19 mm at 9 hours. Diameters of separate muscular fibers and bundles were explored. It is established that the average diameter of a muscle fiber makes 13.7±0.18 microns, and the average diameter of a muscular bundle is equal to 435.9±5.15 microns. Conclusions. 1. Existing anatomical descriptions of anal sphincters need in the modern world more thorough research to prevent their injury during surgery. 2. The external anal sphincter has the spatial form of the three-storeyed oval structure extended in the front-back direction with dominance of the caudal muscular portion. 3. When performing radical surgical interventions for pilonidal disease in children by cleft-lift method, it is necessary to complete the edge of surgical access at a distance of not less than 3 cm to the edge of the anal sphincter. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: pilonidal disease, children, morphometry, surgical intervention.

Gluteal protuberance as a first symptom of branched pilonidal sinus with anal fistula – case report

The authors present the case of a patient who underwent a surgery due to a branched pilonidal sinus with branching to anal sphincters and a purulent cistern in the left buttock. The lesion was diagnosed accidentally. The patient’s main ailments were non-specific buttock pains experienced for several months, which were followed by periodic febrile states. Advanced diagnostics of this region was planned and carried out. The patient was qualified for Bascom II procedure with simultaneous excision of the anal fistula tract and opening of the left buttock fluid cistern. No complications were observed in the postoperative course. The follow-up after 2 months showed no recurrence. The authors emphasize the fact that the lesions of the gluteal cleft are difficult to diagnose, diagnosed late and often asymptomatic. Proper diagnostics and proper surgical technique allow for complete cure.

A novel template for anorectal fistula reporting in anal endosonography and MRI – a practical concept

Anorectal fistula surgery is associated with risks of recurrence and/or faecal incontinence due to anal sphincter injuries. In order to minimise these complications, preoperative evaluation of the anatomy of the fistula tract and morphology of the anal sphincters is mandatory. Anal endosonography (AES) and Magnetic Resonance Imaging (MRI), due to high resolution of images and ability to identify a number of fistula elements which are important for surgeons in treatment planning, are the methods of choice in the diagnosis of anorectal fistulas.In this paper, a new template for endosonographic and MRI report, systematically describing all anorectal fistula’s characteristics, is presented. This template provides practical information for the surgeon, useful in preoperative assessment and postoperative follow-up.

Deep infiltrating endometriosis of the rectovaginal septum – an interdisciplinary problem

Endometriosis refers to the ectopic localization of the uterine glandular epithelium, which can infiltrate all peritoneal cavity organs as well as, though less commonly, distant locations. One of its most severe forms is deep infiltrating endometriosis (DIE) of the rectovaginal septum. In cases of DIE, the infiltration may involve the vagina, uterus, rectum, and the area of anal sphincters and pelvic floor muscles. The condition causes a variety of pain symptoms, including dyspareunia and dyschezia, and other intestinal complaints, significantly impairing the quality of a woman’s life. Important elements of the diagnostic work-up include obtaining the patient’s detailed history followed by transvaginal and transrectal examinations. Additional examinations recommended in patient assessment are transvaginal and transrectal ultrasonography, and MRI. The sensitivity and specificity of the methods may reach 91 and 98%, respectively. The combination of these diagnostic modalities significantly increases the rate of diagnosis, reducing the time to the start of treatment which, at present, is on average 7 years. The main management methods for DIE include pharmacotherapy and surgical treatment complemented by an appropriate diet, physiotherapy and psychotherapy. Hormone treatment markedly reduces pain, contributing to an improvement in the quality of life, and causes slight changes in the size of endometriotic lesions, which is associated with the relapse of symptoms after the discontinuation of medication. Surgical methods allow radical removal of lesions, but may cause significant complications, adversely affecting the function of the intestine, bladder, anal sphincters, and other body organs. In each case, the choice of optimum treatment should be adjusted individually to the patient based on the experience of the multidisciplinary team.