Diathermy excision / contact destruction of anal condylomata acuminata

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  • Definition; Pathophysiology

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    Condylomata acuminata, also known as perianal warts, is a viral disease affecting certain parts of the body such as the anus with the anal canal, the external genitals and the cervix.

    This viral disease is one of the most common sexually transmitted diseases. The pathogen is the human papilloma virus (HPV).

    It infects epithelial cells of the skin/mucosa and may trigger tumor-like growth in the infected cells in the form of warts.

    More than 100 different subtypes of this HP virus exist, with certain subtypes having a particular risk potential for dysplasia and malignant transformation.

    Especially in immunosuppressed patients (e.g., HIV patients, patients under medical immunosuppression), HPV infection may lead to dysplasia and even malignant degeneration (anal carcinoma), of the skin/mucosa.

  • Anal canal

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    (1) Tunica muscularis, longitudinal sublayer, (2) Tunica muscularis, circular sublayer, (3) levator ani, (4) puborectalis, (5) external anal sphincter, deep part, (6) anal columns, (7) external anal sphincter, superficial part, (8) external anal sphincter, subcutaneous part, (9) Kohlrausch’s fold, (10) internal anal sphincter, (11) proctodeal gland, (12) corrugator cutis ani

    Anal canal

    The interaction of three muscles in the lower rectum creates a sphincter mechanism:

    1. The internal anal sphincter represents a thickening of the last annular fibers of the smooth colon muscles and is innervated by the sympathetic nervous system.

    2. The levator ani, however, has voluntary innervation (sacral plexus) and includes the puborectalis arising from the symphysis pubis. Since the course of the puborectalis creates a sling, deficient anteriorly, around the rectum, the latter becomes angulated.

    3. The external anal sphincter is also a striated muscle and extends from the center of the perineum (centrum perinei, perineal body) to the coccyx. Its somatic innervation is supplied by the pudendal nerve. With its contraction it terminates the anal canal.

    The different innervation of the three muscles involved in the sphincter mechanism provides additional protection against failure and resulting incontinence.

    The mucosa of the anal canal is plicated into numerous longitudinal folds (anal columns) displaying a dense arterial (!) plexus with venous drainage. When the sphincter muscles contract, these plexuses fill up quickly distending the mucosa and pushing the folds against each other, thereby ensuring gas-tight closure. Hemorrhoids and venous thromboses are well known vascular complications in this region.

    Defecation involves not only relaxation of the sphincter mechanisms (initiated by voluntary muscle action, drainage of the cavernous bodies) but also active abdominal press and intestinal peristalsis.

  • Herr Prof. Dr. med. Alexander Herold

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  • Indications

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  • Contraindications

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  • Diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 06.07.2014
  • Herr Prof. Dr. med. Alexander Herold

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  • Assessment of finding; specimen for histopathology

    152-5

    Expose the lesions and confirm diagnosis by sending specimen for histopathology. The easiest way to do this is through excision with scissors. All suspected malignant lesions must be studied separately.

  • Snare excision

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    Remove all lesions as small as possible and always in completely superficial epicutaneous fashion. Here, too, the wet-resection technique can be recommended, as it improves the conduction of the current and better protects the environment through cooling. The excision must not involve the entire skin. This is unnecessary, since without exception the location of each lesion is epicutaneous. If a lesion extends more deeply, infiltrative growth may be present, in which case a more extensive and deeper excision becomes necessary (see AIN and anal cancer).

  • Contact destruction with ball-tipped diathermy

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    Once again with wet-resection technique destroy each lesion with electric current and then completely remove with a swab or sharp spoon.

  • Excision of intra-anal condyloma

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    Here proceed in the same way as perianally. It is quite typical that the lesions will extend into the transition zone. These lesions may easily be removed atraumatically with bipolar forceps.

  • Finding at the end of the procedure

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  • Herr Prof. Dr. med. Alexander Herold

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  • Intraoperative complications

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  • Postoperative complications

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  • Städtisches Klinikum München Schwabing

    Dr. Anne Heiss

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  • Literature summary

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  • References on this topic

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  • Guidelines

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  • Current trials

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  • Literature search

    Literature search under: http://www.pubmed.com