We present a case of benign anal adenomas arising from the anus, an extremely rare diagnosis. A year-old white man presented with rectal bleeding of several months duration. Examination revealed a 4 cm friable mass attached to the anus by a stalk. At surgery, the mass was grasped with a Babcock forceps and was resected using electrocautery. Microscopic examination revealed a tubulovillus adenoma with no areas of high grade dysplasia or malignant transformation.
External colorectal anastomosis with two planes of absorbable suture. A copy Anal vilis adenoma the written consent is available for review by the Editor-in-Chief of this journal. But they were proctectomies, one of which was an actual LAR for an upper rectal lesion and the rest of them were proctectomies with coloanal pouches, some of those done by mucosectomy because the lesion extended very low in the rectum. Avoiding surgery in patients with colorectal polyps. This form of presentation of rectal villous adenomas may require surgical Anal vilis adenoma for removal. The complication rate was significantly lower in transanal compared with transabdominal Anal vilis adenoma 3. Gastrointest Endosc Clin North Am. Prevalence of adenomas and colorectal cancer in average risk adenom a systematic review and meta-analysis. As far as our follow-up plan, I have the viliss come back every 3 to 4 months for the first year and every Aal months thereafter until they have reached 5 years.
Mature woman hair styled. INTRODUCTION
They are commonly described as secreting large amounts of mucus, resulting in hypokalaemia in patients. In the present case, the clients declined to castrate the dog to take further opportunity for breeding; therefore, we decided to provide only medical treatment with cyclosporin A, for its anti-proliferative effects. The presence of an inflammatory component, however, cannot be ruled out since not all of the mass was excised. Is this seen in neutered males also? He was transfused with packed red blood cells and the lesion was amputated at the bedside. He measured this new mass at about 4cm. The purpose of Mature woman in silk pantie case report is to determine whether administration of cyclosporin A systemically can reduce the proliferative activity of perianal gland tumors in a dog. Study supervision Anal vilis adenoma Herzig and Deveney. It does bleed sometimes but i have not got any money to have this done they would not let me pay money every month so should i have him put down he does not seem to be in pain just it does not look very nice as its so big. Thank you so much. Our mean follow-up period was 25 months, which Anal vilis adenoma relatively short.
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- The perianal glands are sebaceous-like structures in the perianal skin of dogs, located close to the anus.
- An adenoma is a benign tumor of epithelial tissue with glandular origin, glandular characteristics, or both.
- Primary neoplasms arising in the anal canal are relatively unusual.
- Language: English French.
Arch Surg. Theodore X. Villous adenomas are considered premalignant and should be removed to prevent the development of invasive carcinoma. However, the second reason to remove them is that in spite of random biopsies of the lesions that are reportedly benign, the lesion may still harbor cancer.
Random preoperative biopsies have a high degree of sampling errors, and complete excision is the only accurate diagnostic and adequate therapeutic approach to villous adenomas of the rectum. Villous adenomas are usually sessile and are not easily removed by endoscopic snare polypectomy. Obviously, in the right colon and cecum a formal colectomy is done. However, in the rectum, except for high rectal lesions, an effort should be made to remove these transanally to prevent the morbidity of the abdominal operation and loss of sphincter control and to maintain proper bowel movements.
While this paper emphasizes all these points quite well, I have several questions for the authors. Extent of resection. If the patients had APR what is the explanation for this?
Were some of these cases in which the villous adenoma's distal edge was at or just above the dentate line but its proximal extent was high, eg, 10 cm or above, so that the entire lesion could not be removed completely by transabdominal approach or by a low anterior resection? In this circumstance, I have combined the procedures doing TAE for the lower portion and LAR for the upper portion with reanastomosis to the mucosally resected distal rectum.
Have you ever used this approach? Transabdominal vs TAE. It was proven quite well that transabdominal resection has a significantly higher complication rate than TAE, but isn't this an apples and oranges comparison? Isn't the characteristics of the tumor, ie, distance from the anal verge, size, etc, that [which] drives the selection rather than surgeon's choice? Selection of patients. What are your criteria for distance from the anal verge for attempting a TAE?
Do you have a definite cut-off point? Also do you avoid TAEs in midrectal lesions in the anterior positions in the female for fear of perforating into the peritoneal cavity? Do you think that this is a long enough follow-up to conclude that you have seen all the benign recurrences which may be slow to recur? What is the time to recurrence? Is it relatively early or late?
Occurring before or after 25 months? This will give some idea whether 25 months is an adequate time to judge the complete status of recurrence. Margin status. I am concerned that in 9 of 40 excisions there was no information regarding resection margins.
Also 2 of the patients had positive margins on pathology, but there is no mention of re-excision to obtain a negative margin. Why was reexcision not attempted in these patients? Carcinoma in villous adenoma. Current data suggest that recurrence rate[s] with T2 lesions treated with simple excision alone are high and that additional therapy is warranted.
What would be your recommendation for further treatment in T2 lesions if the patient did not have any contraindications? Endoscopic ultrasound. Ten of the lesions were called invasive carcinoma on EUS but only 5 patients actually had invasive carcinoma on final pathology. Also, I teach my residents not to order a test unless it directly benefits the patient or changes what you are going to do.
With this data, are you still recommending preoperative EUS in rectal villous adenomas? Also have you looked into a simpler, less costly test and its correlation to postoperative pathology, that is, a rectal examination and the surgeon's finger?
Villous adenomas that are benign are characteristically soft and velvety and may even be missed on digital rectal examination. The presence of hard areas in the villous adenomas, in my experience, correlates with the presence of cancer. Is this your experience? How can you get this probability from such small numbers? In general, the number of data points in the various comparisons is quite small leading to the possibility of [[beta]] or type II errors in the reported probabilities.
For example, in comparing patients with benign recurrence vs no recurrence with only 4 patients recurring , it is stated that the average size of tumor that occurred was 5 cm and the average size with no recurrence was 2. Even here a probability of 0. Although it cannot be proved that these are statistically different, at the same time, it cannot be stated that they are statistically the same.
Dr Deveney: First, the comment regarding the extent of resection. Actually, that comment regarding APR was an error in the first draft. But they were proctectomies, one of which was an actual LAR for an upper rectal lesion and the rest of them were proctectomies with coloanal pouches, some of those done by mucosectomy because the lesion extended very low in the rectum.
The selection of the procedure was indeed driven by the characteristics of the tumor as well as the suitability of the patient to undergo that procedure because of their comorbidities. In the patients in whom a proctectomy needed to be done, a TAE just was not deemed feasible.
And again men vs women, anterior vs posterior lesions make a difference. Being able to predict exactly how low the cul de sac extends and where the peritoneal cavity is, particularly in women in whom it extends lower, difficult and so maybe something that leads us to caution in attempting to resect lesions that are anterior.
Our follow-up is definitely not long enough. The recurrences that we had, which were all benign lesions, were early and some of the cases have had long enough follow-up to be able to be reasonably certain that recurrence will be unlikely.
However, one of the patients who had been referred to us with a recurrence of a benign lesion had his initial resection done 25 years before. So I think that the length of time for recurrence may be extremely variable and that is a limitation of our paper. We need longer follow-up. As far as our follow-up plan, I have the patients come back every 3 to 4 months for the first year and every 6 months thereafter until they have reached 5 years.
This patient group did include a number of elderly people who were lost to follow-up after a few years. With regard to the margin status not being available on some of the patients, it was really a matter of this being a retrospective study.
The pathologists sometimes did not mention it in their final report. Regarding the treatment of the T2 tumors, indeed these patients were very elderly and they had a lot of comorbidities. If they were young and fit patients with a T2 lesion, I would favor transabdominal resection with a low anastomosis, and if they were not physically fit, then chemotherapy and radiation or observation.
The comment regarding EUS is a point I think very well taken. We always do a digital rectal examination, and I agree totally with Dr O[[rsquo]]Connell that the finding of any area in the tumor that is hard makes it likely that that might be a cancer. Any of our patients who had a villous adenoma who were found preoperatively to have a hard area or a biopsy of cancer were not included in this series because this series included only patients in whom a benign villous adenoma was the preoperative diagnosis.
There are some patients, however, whose lesions were above the digital examination or extended high enough that you could not feel the entire lesion, and as the experience with EUS increased in our hospital, I think that it is worthwhile to evaluate those patients who have a higher lesion with an EUS to have as much information as possible ahead of time. Regarding the comments about the statistics, the Mann-Whitney U Test was used for comparisons per the advice of our statisticians, and I think in general our numbers are too small in some cases to reach statistical significance when you break it down into the small subgroups.
We would need a larger number of patients to show true differences, but we did not have them. Mean age was 66 years range, years and mean follow-up was 25 months range, 0.
Mean tumor size was 3. Tumor size did not correlate with malignancy. The complication rate was significantly lower in transanal compared with transabdominal excisions 3. There were 4 Transanal excision with negative margins is associated with low recurrence and complication rates and is the preferred approach, even with large lesions.
Villous adenoma is a premalignant polyp of the gastrointestinal tract. Up to two-thirds of these lesions occur in the rectum.
They have an equal distribution between sexes and a peak incidence in the sixth and seventh decades of life. Surgical options for resection of villous adenoma of the rectum include local treatments, such as transanal excision TAE , transanal endoscopic microsurgery, and mucosal resections, or radical resections, such as proctectomy. Whenever possible, local excision and sphincter preservation is the procedure of choice for accessible lesions with favorable characteristics.
Ongoing challenges in managing these lesions continue to be identifying risk factors for failure of local therapy and identifying diagnostic techniques that may aid in deciding appropriate surgical therapy. The broad range of reported recurrence rates for treatment of villous adenoma of the rectum indicates a need for additional data. Therefore, we analyzed the year experience of a single surgeon in the management of these tumors with respect to the oncologic outcome of different surgical techniques, complication rates, and concordance of preoperative and postoperative diagnoses.
We hypothesized that TAE of rectal villous adenoma would provide good oncologic outcome with acceptable complication and recurrence rates. The operative log of a single surgeon K. Institutional review board approval was obtained before medical record review. Patients who had a preoperative diagnosis of malignancy using biopsy were excluded.
All patients were preferentially considered for TAE unless the extent of the tumor precluded this procedure eg, nearly or totally circumferential or carpeting of the entire rectum. Statistical analyses were performed using SPSS, version Forty procedures were performed in 36 patients during this period. Mean age was 66 years, and the male to female ratio was An attempt at excision, either endoscopically or surgically, was made in 20 Two patients died during the study period: one received a subsequent diagnosis of cholangiocarcinoma; the other, breast cancer and Parkinson disease.
A mean follow-up of 25 months was possible in 32 of 36 patients Patient characteristics are presented in Table 1. Preoperative pathology reports were available in all 40 cases and were divided into 3 categories: no or low-grade dysplasia; high-grade dysplasia; or no comment on dysplasia made. No tumor was found to harbor invasive adenocarcinoma preoperatively.
We examined the proportion of tumors that were either upgraded or downgraded by definitive excision.
Anal vilis adenoma. Jump to Section
Villous adenomas are dubiously benign lesions, which are difficult to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge.
Giant adenomas are not amenable for endoscopic or transanal resection. Only few isolated cases have been reported by laparoscopic resection. We present our case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis with a review of literature in regard to their malignant potential.
A year-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with mucus discharge.
Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy.
Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia. Large size, villous content, and distal location are all associated with severe dysplasia in colorectal adenomas.
Large villous rectal tumors, particularly of circumferential type pose a great challenge for endoscopic or transanal removal.
Henceforth, open or laparoscopic surgery is required for these cases. Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. Laparoscopic colorectal resection is safe and effective. A recent meta-analysis puts the pooled prevalence in average-risk individuals of adenomas, colorectal cancer, non-advanced adenomas, and advanced adenomas at As giant adenomas are difficult for endoscopic removal and malignant potential is not known, laparoscopic colectomy offers safe and effective management of these lesions with the benefits of accelerated postoperative recovery [ 4 ].
We present a case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis and review of literature in terms of malignant potential and optimal treatment of such tumors.
A year-old lady presented to our outpatient department with complaints of painless bleeding per rectum from 8 months and a fleshy mass protruding from the anal canal from 3 months. The mass was reducible on manual palpation and associated with profuse mucus discharge.
The hydration status of the patient was adequate, she had mild pallor and abdominal examination was essentially normal. The upper extent of the lesion could not be reached.
The laboratory investigations revealed hemoglobin 8. Initial biopsy revealed villous adenoma with focal moderate dysplasia. A colonoscopy was done which showed irregular, friable, edematous mucosa in rectum extending for 15 cm nearly circumferentially with no other lesions in the entire colon.
Contrast-enhanced computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall max thickness 2. Surrounding fat planes were normal and there were no enlarged lymph nodes. In view of the large size of the lesion with associated moderate dysplasia, a decision was made to perform a laparoscopic low anterior resection. The rectum and sigmoid colon were mobilized with high ligation of the inferior mesenteric artery, total mesorectal excision with circumferential radial margin up to the dentate line and divided beyond the lesion.
The patient recovered well and was discharged on the fourth post-op day. At the time of discharge, digital rectal examination revealed a preserved anal sphincter tone and no troublesome mucus discharge.
Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia Figs. Both the resected ends were free of tumor. Fourteen lymph nodes were isolated, all of which showed reactive changes. The patient underwent restoration of bowel continuity after 5 months and is healthy up to 1 year of follow-up. The natural history of colorectal carcinomas has been extensively studied in correlation with the underlying accumulation of genetic alterations as understood by the adenoma-carcinoma sequence.
Adenomas are precursor lesions defined by the presence of intraepithelial neoplasia, characterized by varying degrees of nuclear stratification and loss of polarity. Polyps develop as mucosal excrescence as a consequence of accelerated crypt fission resulting from APC gene mutation [ 5 ]. They described very large broad-based rectal tumors associated with secretory diarrhea [ 6 ]. Histologically, polyps are classified as neoplastic adenomas or non-neoplastic.
Non-neoplastic polyps have no malignant potential and include hyperplastic polyps, hamartomas, lymphoid aggregates, and inflammatory polyps. Neoplastic polyps or adenomas have malignant potential and are classified according to the World Health Organization as tubular, tubulovillous, or villous adenomas, depending on the presence and volume of villous tissue [ 8 ].
Villous adenomas are classically sessile with a velvety or hairy surface and microscopically leaf-like projections lined by dysplastic glandular epithelium. Villous architecture is defined arbitrarily by the length of the glands exceeding twice the thickness of normal colorectal mucosa [ 8 , 9 ]. The risk of malignant degeneration is related to both the size and type of polyp [ 2 , 9 , 10 ].
This fact forms the basis for secondary prevention strategies to eliminate colorectal cancer by targeting the neoplastic polyps for removal before malignancy develops [ 2 , 3 ]. This analysis suggests that endoscopically unresectable polyps or giant polyps of villous type are best treated by radical oncologic resection. In a study that analyzed adenomatous polyps to determine risk factors for high-grade dysplasia or invasion, the size was the strongest predictor.
Large size, villous content and distal location are all associated with severe dysplasia in colorectal adenomas [ 3 , 8 , 9 , 10 ].
Hematochezia and anemia are common presenting features due to bleeding from the tumor. Rectosigmoid lesions can present with protrusion of mass or tenesmus. Other symptoms include fever, malaise, weight loss, and abdominal pain. An important fact is that the giant villous adenomas may excrete large quantities of mucus and potassium, which can produce mucus diarrhea and electrolytic alterations.
McKittrick-Wheelock syndrome, which is a disorder characterized by fluid and electrolyte depletion, is caused by a secretory colorectal tumor [ 32 ]. Endoscopic polypectomy is the mainstay of polyp management because the majority of lesions are protuberant. Polyp size, position, and access can make this very taxing and a great challenge for endoscopic or transanal endoscopic microsurgery TEMS removal.
Large villous tumors of the low and mid rectum can be treated by per-anal resection with recurrence rates equivalent to transanal endoscopic microsurgery; however, the mean length of the tumor was 5.
TEMS can be employed in lesions up to 6 cm in carefully selected patients but owing to giant size, location, circumferential, and diffuse villous lesion, it has not been indicated for such lesions.
Such big lesions may approach the dentate line and pose an increased risk of perforation with serious complications. Another unfavorable point of endoscopic resection of circumferential rug like mucosa is the development of stricture [ 36 , 37 , 38 , 39 ]. Carditello et al. A recent study found that the incidence of cancer in patients undergoing colectomy for an irretrievable polyp is Open or laparoscopic colorectal resection is the procedure of choice for lesions not eligible for endoscopic resection and for large sessile villous tumors [ 4 , 23 , 26 , 39 ].
It has been demonstrated a mortality rate of 0. Troublesome mucus discharge and bleeding may result in severe hemodynamic alterations. Epidemiology of colorectal polyps. Tech Coloproctol. Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. Large size, Villous content and Distal location are associated with severe dysplasia in colorectal adenomas.
Anticancer Res. Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection. Surg Endosc. Early alteration of cell cycle-regulated gene expression in colorectal neoplasia. Am J Pathol. Rev de Gynec et de Chi Abdom.
Polyps and cancer of the large bowel: a necropsy study in Liverpool. Histological typing of intestinal tumours. In: International histological classification of tumours, No. Geneva: World Health Organization; Shussman N, Wexner SD. Colorectal polyps and polyposis syndromes. Gastroenterol Rep Oxf. The National Polyp Study. Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas.
High-grade dysplasia and invasive carcinoma in colorectal adenomas: a multivariate analysis of the impact of adenoma and patient characteristics.
Eur J Gastroenterol Hepatol. Sequential endoscopic and surgical removal of giant rectal adenomas extending to the dentate line. Endoanal resection of a giant villous adenoma in the middle rectum—a video vignette. Colorectal Dis. McKittrick Wheelock syndrome treated by transanal minimally invasive surgery: a single-center experience and review of the literature. A case report of a giant rectal adenoma causing secretory diarrhea and acute renal failure: McKittrick-Wheelock syndrome. BMC Surg.
The McKittrick-Wheelock syndrome: a rare cause of curable diabetes. Endocrinol Diabetes Metab Case Rep. A case of large rectal villous adenoma associated with tenesmus and body weight loss.
Gan To Kagaku Ryoho. McKittrick-Wheelock syndrome: a rare case report of acute renal failure. Clujul Med.