ABSITE Focused on Anorectal Appraisal Exam Assessment Questions and Correct Answers with Rationales Latest Updates 2024/2025
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ABSITE
ABSITE Focused on Anorectal Appraisal Exam Assessment Questions and Correct Answers with Rationales Latest Updates 2024/2025
A 42-year-old female referred to your office with a fistula-in-ano. She reports occasional incontinence to flatus and urgency with liquid stool. She has no significant pas...
ABSITE Focused on Anorectal Appraisal Exam
Assessment Questions and Correct Answers
with Rationales Latest Updates 2024/2025
A 42-year-old female referred to your office with a fistula-in-ano.
She reports occasional incontinence to flatus and urgency with
liquid stool. She has no significant past medical history.
Examination confirms a fistula-in-ano anteriorly slightly off the
midline with the external opening 2.0 cm from the anal verge.
You believe the fistula to be transsphincteric. Which of the
following is the most appropriate management of this patient?
A. Draining seton
B. Cutting seton
C. Fibrin glue
D. Endorectal advancement flap
E. Primary fistulotomy - correct answer Endorectal
advancement flap
Rationale
The correct answer is D. This patient has impaired continence;
thus, a muscle-sparing approach is indicated. Endorectal
advancement flap is associated with published healing rates of
65 - 93%. Fibrin glue, while muscle sparing, is associated with
low healing rates. While a draining seton may control symptoms,
the fistula will persist. Cutting seton and primary fistulotomy
would be associated with significant risk of fecal incontinence
and should be avoided in this patient.
A 50-year-old mother of five has been treated several times for a
high transsphincteric anterior anal fistula with fibrin glue
therapy and seton placement. She returns to the ED with similar
complaints of purulent drainage and straining with bowel
,movements. She is hemodynamically stable and afebrile. She is
amenable to surgical repair. What procedure would be the best
choice for her?
A. Ligation of intersphincteric fistula tract (LIFT)
B. Fistulotomy
C. Anorectal advancement flap
D. Fistulectomy
E. Cutting seton placement - correct answer Anorectal
advancement flap
Rationale
The use of an anorectal advancement flap has been advocated in
patients with high transsphincteric and suprasphincteric fistulas,
multiple previous sphincter operations, and multiple and
complex fistulas.
The traditional lay-open technique (fistulotomy) (B) may be
inappropriate for women with anterior fistulas and patients with
inflammatory bowel disease.
Recent extensive literature search suggested that the use of
cutting setons (E) be abandoned because of high incontinence
rates of 12% since they ultimately damage the sphincters.
Fistulectomy (D), whether primary or secondary, was associated
with a clinically significant disturbance in anal function and is no
longer a recommended treatment.
A pitfall with the LIFT technique (A) may be the intersphincteric
approach for high tracts especially with horseshoe tracts. Also,
, exposure of the intersphincteric space may damage the internal
sphincter. Outcome data with LIFT are limited.
A 72-year-old man presents with biopsy-proven anal canal
squamous cell carcinoma 2 cm in size. Physical examination is
otherwise unremarkable and he has no inguinal
lymphadenopathy. CT of the chest/abdomen/pelvis showed no
evidence of metastatic disease. What is the appropriate course of
treatment?
A. Abdominoperineal resection
B. Wide local excision and local advancement flap
C. Trans-anal excision
D. Wide local excision and prophylactic superficial inguinal
lymph node dissection
E. Definitive chemoradiation with 5' Fluorouracil and Mitomycin
C - correct answer Definitive chemoradiation with 5'
Fluorouracil and Mitomycin C
Rationale
Nigro and associates demonstrated that combined radiation and
chemotherapy are definitive treatment for epidermoid anal canal
malignancies. The protocol includes external beam radiation
therapy to the pelvis, pelvic and inguinal nodes. Patients receive
chemotherapy with Mitomycin C and 5-FU. This regimen has
supplanted the need for abdominoperineal resection in anal
cancer cancers.
A 70-year-old female presents with a 5-month history of intense
pruritus in the perianal region. On examination, she has a 2-cm
area of erythematous and scaly rash that is well demarcated
around the perianal region. Biopsy of the lesion confirms Paget's
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