Improved Outcomes in Colon and Rectal Surgery part 22. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | IMPROVED OUTCOMES IN COLON AND RECTAL SURGERY 155. Consten CJ Siors FJM Noten HJ et al. Anorectal surgery in human immunodeficiency virus-infected patients. Dis Colon Rectum 1995 38 1169-75. 156. Miles AJG Mellor CH Gazzard B et al. Surgical management of anorectal disease in HIV-positive homosexuals. Br J Surg 1990 77 869-71. 157. Munoz-Villasmil J Sands L Hellinger M. Management of perianal sepsis in immunosuppressed patients. Am Surg 2001 67 484-6. 158. Onerheim RM. A case of perianal mucinous adenocarcinoma arising in a fistula-in-ano a clue to the early pathologic diagnosis. Am J Clin Pathol 1988 89 809-12. 159. Seya T Tanaka N Shinji S et al. Squamous cell carcinoma arising from recurrent anal fistula. J Nippon Med Sch 2007 74 319-24. 160. Korelitz BI. Carcinoma of the intestinal tract in Crohn s disease results of a survey conducted by the National Foundation for Ileitis and Colitis. Am J Gastroenterol 1983 78 44-6. 161. Smith R Hicks D Tomljanovich PI et al. Adenocarcinoma arising from chronic perianal Crohn s disease case report and review of the literature. Am Surg 2008 74 59-61. 162. Sarani B Orkin BA. Squamous cell carcinoma arising in an unhealed wound in Crohn s disease. South Med J 1997 90 940-2. 198 20 Surgery and nonoperative therapy of anal fissure Jaime L Bohl and Alan J Herline CHALLENGING CASE A 35-year-old woman presents with a recurrent posterior anal fissure. She had a left lateral anal sphincterotomy 4 years ago for an unresponsive anal fissure. Her fissure healed until 6 months ago. She has had two previously vaginal deliveries. Exam reveals a posterior anal fissure with exposed sphincter muscle and a sentinel skin tag. Anal manometry revealed mildly decreased resting pressure and a hypertonic squeeze pressure. The patient s symptoms have not responded to stool softners and topical medication. CASE MANAGEMENT A repeat sphincterotomy is relatively contraindicated due to the decreased sphincter function. An acceptable surgical option is an .
