Non- Malignant Strictures

1. Congenital. i) Strictures at the level of anal valves, due to incomplete obliteration of proctodeal memebrane ii) Spasmodic: Anal fissure causing spasm of the internal sphincter, with time becomes fibrotic

3. Organic: i) Postoperative stricture incorrectly performed haemorrhoidectomy ii) Irradiation stricture: strictures following radiations iii) Senile anal stenosis: seen in elderly, in which there is chronic internal sphincter contraction

iv) Lymphogranuloma inguinale: most common cause of tubular inflammatory stricture. 80% are women. v) Inflammatory bowl disease: stricture of anorectum occurs following ulcerative proctocolitis and large bowl Crohns disease. Stricture is annular vi) Endometriosis: recto vaginal septum may present as stricture.

 Clinical Features a) Difficulty in defecation b) Pipe-stem shaped stool. c) In inflammatory srtricture, tenemus, bleeding and passage of muco-pus. d) Acute or chronic intestinal obstruction sometimes may occur

 Rectal Examination Sharply defined shelf like interruption of the the lumen. Biopsy of the stricture is necessary.

TREATMENT
1.Prophylactic passage of anal dilator during convalescence of hemorroidectomy greatly reduces the incidence of postoperative stricture. 2. Dilatation by bougies for anal and many rectal strictures dilatation by bougies at regular interval is sufficient

 Incision and primary Free skin Graft: for post- operative and senile strictures, this procedure gives better results 4) Colostomy : when stricture is causing intestinal obstruction 5) Rectal excision and colo-anal anastomosis when stricture is at or just above the ano-rectal junction and associated with normal anal canal

ANAL canal CANCER

Incidence
1.5%-2% of all digestive system malignancies in the US increasing incidence over the last 30 years from 10 to 20 million cases(5000 in year) Carefully conducted epidemiologic studies showed that cure of anal CA can be possible in majority of patients with preservation of the anal sphincter

Having anal fistulas

Female gender Multiple sex partners(Having many sexual partners) Cigarette smoking a Receptive anal intercourse HIV Age( Being over 50 years old.) IBD

 hemorrhoids, fissures, fistulae case reports of anal CA in patients with IBD led to conclusion that it was result of sexual activity Increased risks with 10 or more lifetime partners

Epidemiology

annual incidence among men & women

1994 and 2000 (2.04 and 2.06)

1973 and 1979 (1.06 and 1.39)

Anatomy

Lymphatic drainage
above dentate line drains to the perirectal & perivertebral nodes

below dentate line drains to inguinal &

femoral nodes

Histology
74% Epidermoid Carcinoma Squamous Basaloid Mucoepidermoid 19% Adenocarcinoma 4% Melanoma 3% Neuroendocrine/carcinoid/

sarcoma(leiomyosarcoma/lymphoma sarcoma)

Location
Anal canal tumors Pathologic classification of tumors in this area is difficult no easily identifiable landmarks between rectum and anus & transition zone has widely variable histologic appearance some have abrupt transition from glandular rectal tissue to anal squamous tissue others have intervening segment of junctional mucosa (basaloid or cloacogenic mucosa)

Neoplasms of the anal canal :

1. distal to the dentate line 2. proximal to the dentate line

Clinical presentation
45% rectal bleeding 30% pain/sensation of rectal mass 20% no symptoms Mass in anus

Itching
A change in bowel habits.

Diagnosis
History P.E(T.R..) Anoscopy..Rectoscopy Endoscopy C.T MRI

Biopsy:

Treatment of localized SCC

Anal margin tumors Local surgery wide local excision with 1 cm margins of normal tissue & primary closure if tumor involves > of anal circumference APR 5 year survival rate > 80% for tumors < 2cm in greatest dimension

Follow up : Preop chemoradiation therapy and subsequent APR if there is Residual tumor in postradiation biopsy Combined chemoradiation therapy results in local failure 14-37%, 5 year survival rates 72-89%, and 5 year colostomy free survival rates of 70-86% after confirmation through multiple

Anal canal tumour APR (with permanent colostomy) 5 year survival rate 40-70% with 3% perioperative mortality rate

Combined modality therapy

5-FU, mitomycin, and intermediate dose radiation

Treatment of anal adenocarcinoma

Principles same as those for rectal CA APR is the primary treatment adjuvant therapy may include chemoradiation

Anal Intraepithelial Neoplasia (Bowen's Disease)

Bowen's disease refers to squamous cell carcinoma in situ of the anus. This increase is thought to result from increased rates of HPV infection along with immunosuppression

Treatment of AIN is aimed at either resection or

ablation. Extensive resection with flap closure may occasionally be required. Because of a high recurrence and/or reinfection rate, these patients require extremely close surveillance.

Epidermoid Carcinoma
Epidermoid carcinoma of the anus includes squamous cell carcinoma, cloacogenic carcinoma,

Epidermoid Carcinoma
transitional carcinoma, and basaloid carcinoma. Wide local excision is usually adequate treatment for these lesions.

Epidermoid carcinoma occurring in the anal canal or invading the sphincter cannot be excised locally First-line therapy relies upon chemotherapy and radiation. (the Nigro protocol: 5-fluorouracil, mitomycin C, and 3000 cGy external beam radiation). More than 80% of these tumors can be cured by using this

Recurrence usually requires radical resection (abdominoperineal resection). Metastasis to inguinal lymph nodes is a poor prognostic sign.

Verrucous Carcinoma (Buschke-Lowenstein Tumor, Giant Condyloma Acuminata)

Verrucous carcinoma is a locally aggressive form of condyloma acuminata

Wide local excision is the treatment of

choice when possible, but radical resection

may sometimes be required.

Basal Cell Carcinoma

This is a slow-growing tumor that rarely metastasizes. Wide local excision is the treatment of choice, but recurrence occurs in up to 30% of patients.

Radical resection and/or radiation therapy may be required for large lesions.

Paget's disease.
Wide local excision is usually adequate treatment for perianal Paget's disease.

Melanoma
prognosis for patients with anorectal disease remains poor Local resection with free margins does not increase the risk of local or regional recurrence and APR offers no survival advantage over local excision