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Management of High-Grade Squamous Intraepithelial Lesion (Formerly Bowen Disease) and Paget Disease

Introduction Malignancies of the anus, anal canal, and perianal skin include epidermoid carcinoma, malignant melanoma, squamous cell carcinoma, adenocarcinoma, and basal cell carcinoma. From 2006 to 2010, the number of new cases of anal cancer was 1.7 per 100,000 men and women per year. The number of deaths was 0.2 per 100,000 men and women per year. This chapter focuses on perianal intraepithelial squamous cell carcinoma…

Anorectal Venereal Infections

Acknowledgment We thank Radu Clincea, MD, infectious disease consultant, for his assistance with this chapter. The anorectum is being used with increased frequency for sexual fulfillment. In both sexes this practice has resulted in an increase in the incidence and variety of sexually transmitted diseases (STDs). The lifestyle that is often associated with men who have sex with men (MSM) is a definite risk factor for…

Management of Anal and Perianal Warts

Background and Epidemiology Anal warts (condyloma acuminata) occur as a result of infection with the human papillomavirus (HPV). According to the Centers for Disease Control and Prevention, HPV infection affects approximately 20 million people and more than 50% of all sexually active individuals. High-risk populations such as homosexual men can have a prevalence of HPV approaching 95%. Overall, approximately 5 million new cases of anal or…

Cause and Management of Anal Stenosis

Introduction Anal stenosis (also referred to as anal stricture) is an abnormal narrowing of the anus that often occurs after colon and rectal surgery. The diagnosis of anal stenosis is suggested by a history of constipation and difficulty in passing stool. Patients often have a history of anal surgery, inflammatory bowel disease, radiation treatment, or anorectal infection. The diagnosis is confirmed by physical examination. Definition The…

Management of Pruritus Ani

Introduction Patients with pruritus ani experience symptoms of perianal itching, burning, or soreness. These symptoms may occur during the day or night, with higher intensity after bowel movements, and may even interfere with sleep. The prevalence may increase during the warm summer months with increased sweating and moisture. Pruritus ani afflicts 1% to 5% of the population, with men experiencing symptoms more often than women at…

Perianal Hidradenitis Suppurativa

Hidradenitis suppurativa (HS), which was first described by Alfred Velpeau in the early 1800s, is a chronic inflammatory condition of apocrine sweat glands affecting between 2% and 4% of young adults. HS results in significant morbidity in many patients. Although it most frequently involves the axillae and groin, perianal HS confronts the surgeon with a sometimes frustrating refractory inflammation that can mimic other types of perianal…

Pilonidal Sinus

Etiology Pilonidal disease is a common infection that occurs around hair-containing sinuses in the natal cleft. It usually presents in young men, and if it is not managed correctly, it tends to persist or recur. The disease and its treatments are a significant burden on patients, caregivers, and society, often resulting in significant loss of time from work with persistent symptoms, a continuing need for wound…

Rectovaginal Fistula

Definition Any communication between the rectum/anus and the vagina/perineal skin is classically referred to as a rectovaginal fistula (RVF). RVF is an accepted term for any fistula that originates in the distal rectum and anus and is connected to the vagina, perineal body, or labial area, because the evaluation and treatment are similar. In contrast, a fistula between the colon and vagina (such as may occur…

Anal Fistula

Introduction An anal fistula is an abnormal communication between the inside of the anus and epithelium outside the anus. The most common anal fistula is an anocutaneous fistula, which is the subject of this chapter. Etiology Anal glands have an opening in the anal crypts that are found at the dentate line. Infection in these glands spreads into the intersphincteric space, and from there it passes…

Anorectal Abscess

Abscesses in the anorectal region occur in all age groups and are a common, distressing problem. Predisposing factors include diabetes, Crohn disease, previous perianal surgery, and impairment of immunity, including human immunodeficiency virus (HIV); however, most abscesses occur spontaneously in healthy persons. Diagnosis is usually established by clinical examination, and adequate drainage is the treatment of choice. Drainage results in healing in more than half of…

Chronic Anal Fissure

Introduction An anal fissure is a linear tear in the lining of the anal canal that usually becomes symptomatic because it exposes the internal anal sphincter and causes painful spasms in that muscle. An anal fissure is a common condition that significantly disturbs the quality of life of persons who experience it. Most fissures are benign, primary, and idiopathic—that is, they are typical anal fissures. Atypical…

Hemorrhoids

Hemorrhoids are vascular cushions that lie close to the anus and are subject to the stresses and strains of defecation. They are normal structures that become symptomatic when thrombosis or prolapse develops as a result of either a congenital weakness in the area or because of excessive or repeated straining. The challenges of managing patients with symptomatic hemorrhoids include making a correct diagnosis, persuading patients to…

Anatomy and Physiology of the Colon, Rectum, and Anal Canal

Anatomy of the Colon and Rectum Colon The colon can be divided embryologically into the midgut (the transverse colon and portions proximal to it) and the hindgut (the distal half of the colon). The length of the colon is approximately 150 cm, and its diameter gradually diminishes from the cecum to the rectosigmoid junction. In appearance it is distinguished from the small bowel by its size…

Surgical Critical Care

COVID-19 and Health Care Delivery in a Pandemic Michael S. Burnim, MD Brian T. Garibaldi, MD BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in Wuhan, Hubei, China in December 2019. Within a matter of months, it caused the worst global pandemic since influenza in 1918. The following winter, the United States suffered at least 3400 deaths each day. Worldwide, by the summer of 2022,…

Preoperative and Postoperative Care

Eras Protocols for General Surgery Omaira Azizad, MD Girish P. Joshi, MBBS, MD INTRODUCTION Enhanced recovery after surgery (ERAS) pathways, introduced more than 25 years ago, represent a paradigm shift in perioperative care that involves integration of evidence-based, multimodal, multidisciplinary interventions that mitigate the undesirable effects of the surgical stress response. Traditional perioperative care has been fragmented with surgeons and anesthesiologists practicing in silos with significant variability in…

Trauma and Emergency Care

Initial Assessment and Resuscitation of the Trauma Patient Jessie Ho, MD Hasan B. Alam, MD INTRODUCTION According to the Centers for Disease Control and Prevention (CDC), unintentional injuries are the leading cause of death in Americans under the age of 45 years, with motor vehicle collisions, firearms, falls, cutting/piercing instruments, and burns among the leading mechanisms. Decreasing mortality in trauma requires an understanding of the trimodal distribution in…

Vascular Surgery

Open Repair of Abdominal Aortic Aneurysms Erin E. McIntosh, MD Richard P. Cambria, MD Abdominal aortic aneurysm (AAA) affects 15% of men over age 65 and accounts for up to 15,000 deaths annually in the United States. Average yearly growth is about 3 mm, though more rapid growth tends to occur in patients with risk factors such as active smoking, uncontrolled hypertension, and significant chronic obstructive pulmonary disease…

Chest Wall, Mediastinum, and Trachea

Management of Spontaneous and Secondary Pneumothorax Cameron D. Wright, MD PNEUMOTHORAX Spontaneous pneumothorax is described as a pneumothorax that occurs in the absence of trauma or significant lung disease. Secondary pneumothorax occurs in the setting of significant underlying lung disease, which predisposes the patient to a pneumothorax. Air in the pleural space typically occurs because of a communication between the lung or the tracheobronchial tree, although it…

Skin and Soft Tissue

Nonmelanoma Skin Cancers Nicholas Calotta, MD Paul N. Manson, MD Anthony Tufaro, MD, DDS Common nonmelanoma skin cancers (NMSCs) include basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The common forms of skin cancer arise, respectively, from the upper layers (epidermis) of the skin: ■ Basal cell: arises from the basal layer of the epidermis ■ Squamous cell: arises from the superficial layer of the epidermis ■ Melanoma:…

Endocrine Glands

Adrenal Incidentaloma Whitney Sutton, MD, MHS Shkala Karzai, MD Aarti Mathur, MD, PhD An adrenal incidentaloma is defined as an adrenal mass identified on imaging performed for an indication other than suspected adrenal disease. With increasing utilization of cross-sectional imaging over the past several decades, 40% of adrenal masses are now discovered incidentally. It is estimated that 1% to 8% of adults have an adrenal incidentaloma, and the incidence…