AIM: Retrospective analysis of 23 cases of persistent ano-rectal abscesses and fistulas with an unusual clinical presentation (absent external opening in all cases) resulting in modification of treatment modalities to prevent the dreaded complications of recurrence and incontinence. METHODS: 23 patients presenting with ano-rectal sinus disease from January 2012 to June 2013 were retrospectively reviewed. Patients were collected from two different institutions of Kanpur. Intra-operatively the probe was introduced from the internal opening and extended outwards towards the skin taking the shortest route followed by incising the tip of the probe. This converted the sinus tract into a fistula after which either of the two techniques was employed: (a) Surgery (fistulotomy) alone in cases where small chunk of sphincteric muscle mass was to be cut. Here the internal opening was below the ano-rectal ring. (b) Surgery along with placement of kshar-sutra in cases where internal opening was too near to the ano-rectal ring or above it. Sphincteric part of the tract was saved from cutting by encircling it with kshar-sutra during surgery. RESULTS: All our patients had symptomatic relief and we achieved complete healing of the wound in all of them with no incidence of persistence of the disease after six months of follow-up, no incidence of recurrence and no incidence of anal incontinence. CONCLUSIONS: Thorough clinical examination resulted in identifying the peculiarity of our cases and also helped us in establishing the etiological factors along with the involved anatomy. Special procedure adopted in our study helped us in preventing complications and ensuring complete healing of the wounds. INTRODUCTION:More than 95% of all ano-rectal abscesses are caused by infections arising in the anal glands that communicate with the anal crypts (cryptoglandular disease). 1, 2 As the abscess enlarges, it escapes the confines of the inter-sphincteric plane and spreads in any one of several possible directions. The most common of all ano-rectal abscesses is a peri-anal abscess, which presents as a tender, erythematous bulge at the anal verge. Incision and drainage alone will result in complete resolution of the infection in about half of patients. 3 The drainage should be performed as close to the anus as possible to shorten the length of any possible subsequent fistula tract. In addition to adequate drainage, one should endeavour to prevent acute recurrence of an abscess by either excising the overlying skin, inserting a drainage catheter, or placing a loose seton. 3, 4 Acute abscesses recur in about 10% of patients and in about 50% of patients, an anal fistula occurs, which consists of a chronically infected tract with an internal opening located in a crypt at the level of the dentate line, and an external opening located at the drainage site of the earlier abscess. The appropriate treatment for an anal fistula is dependent upon the anatomy and the location of the fistula tract. 5,6,7
We report a post-traumatic case of tendoachilles injury with an overlying skin defect. Following debridement, tendon reconstruction was done by using vascularised peroneus brevis musculotendinous unit and proximal part of the same muscle provided the skin cover. Postoperative recovery was uneventful. At 2 years follow-up, he had a near-normal gait. The main advantage of this flap is not being only a local flap but also providing a vascularised tendon.
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