Giant condyloma acuminata (GCA), or Buschke-Löwenstein tumor, is a rare exophytic cauliflower-like growth in the anogenital region. The spectrum of treatment options is wide, ranging from the application of topical ointments to the performance of an abdominoperineal resection. Currently, wide local excision is the most common approach and may entail the creation of a protective loop ileostomy or implementation of flaps or grafts that facilitate closure. We describe a unique surgical approach for the management of circumferential GCA void of the use a protective loop ileostomy, flaps, or grafts. Our report highlights that the implementation of a radical, circumferential, wide excision resulting in “free-floating anus” and healing via secondary intention can ultimately lead to excellent functional and cosmetic results and therefore may be considered a minimally invasive surgical option for patients afflicted with a large, circumferential GCA

Comer, Lydia H.

Guillem, José G.

Hoang, Van

Luo, William Y.

Varvoglis, Dimitrios N.

English

Carolina Digital Repository

Brief ReportThe American Surgeon™2023, Vol. 89(12) 6389–6392© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/00031348231199173journals.sagepub.com/home/asu“Free-Floating Anus”: A Flap-FreeApproach for Definitive Excision ofCircumferential Giant CondylomaAcuminataWilliamY. Luo,MD,MAS1,, VanHoang,MD1,, DimitriosN.Varvoglis, MD1,, Lydia H. Comer, BA1,, and José G.Guillem, MD, MPH, MBA1AbstractGiant condyloma acuminata (GCA), or Buschke-Löwenstein tumor, is a rare exophytic cauliflower-like growth in theanogenital region. The spectrum of treatment options is wide, ranging from the application of topical ointments to theperformance of an abdominoperineal resection. Currently, wide local excision is the most common approach and mayentail the creation of a protective loop ileostomy or implementation of flaps or grafts that facilitate closure. We describea unique surgical approach for the management of circumferential GCA void of the use a protective loop ileostomy, flaps,or grafts. Our report highlights that the implementation of a radical, circumferential, wide excision resulting in “free-floating anus” and healing via secondary intention can ultimately lead to excellent functional and cosmetic results andtherefore may be considered a minimally invasive surgical option for patients afflicted with a large, circumferential GCA.Keywordsgiant condyloma acuminata, Buschke-Löwenstein tumor, free-floating anus, ileostomy-freeCase PresentationThe patient was an otherwise healthy 30-year-old malewith a history of tobacco and alcohol-use disorder whopresented with a 7-month history of what he described asanal warts that caused daily bleeding and constant painexacerbated by bowel movements or straining. He denieda history of same-sex intercourse or sexually transmitteddiseases. His physical exam was remarkable for a cir-cumferential fleshy anal condyloma with internal com-ponents spanning just distal to the dentate line andextending radially 5 centimeters (cm) beyond the analverge with the anterior perineal portion of the lesionextending 2 cm into the scrotal base. The remainder of hisexam was within normal limits. Following an informeddiscussion, the patient consented for a wide local excisionof the mass with plans for closure via secondary intention.Operative TechniqueFollowing induction with general anesthesia, the patientwas placed in the lithotomy position and an examinationrevealed stable findings from his initial clinic visit(Figure 1A). The procedure began by using a number 15blade to excise a representative sample which on frozensection confirmed the presence of condyloma acuminatawithout evidence of carcinoma. Electrocautery was thenused to demarcate a 1 cm circumferential excisionborder around the lesion. This incision was extendedinto the subcutaneous fatty plane and continued ina circumferential fashion, while taking great care toavoid violating the perianal musculature. The peripheralen bloc circumferential excision included a 4 × 2 cmportion of the posterior scrotal skin while the internalcircumferential excision margin in the anal canal wasproximal to all visible disease. The remaining “free-floating” anal mucosa within the anal canal was securedto the surrounding subcutaneous tissue and internalsphincter using interrupted 2-0 chromic sutures1Department of Surgery, University of North Carolina at Chapel Hill,Chapel Hill, NC, USAWilliam Y. Luo, Van Hoang, Dimitrios N. Varvoglis and Lydia H. Comercontributed equally to this work.Corresponding Author:José G. Guillem, MD, MPH, MBA, Division of GastrointestinalSurgery, UNC Department of Surgery, CB #7081, Chapel Hill, NC27599-7081, USA.Email: Jose_guillem@med.unc.edu(Figure 1B). To facilitate drainage, a .5-inch Penrosedrain was placed in the anal opening and secured to theskin with 2-0 silk sutures (Figure 1C). Figure 1D showsthe excised specimen with the anal mucosa at its center.Notably, the perineal defect included a scrotal compo-nent with exposed dartos fascia just anterior to theperineal body. The scrotal skin was advanced over theexposed dartos fascia and secured to the perineal bodyusing 3-0 braided absorbable and chromic sutures. Theremainder of the wound was irrigated and after hemo-stasis was achieved, it was left open to close via sec-ondary intention and wet-to-dry dressings. The patientwas extubated in the operation room (OR) and trans-ferred to the post-anesthesia care unit without incidentand subsequently admitted for observation. Followingevaluation by occupational and physical therapy andwound care teaching, the patient was discharged onpostoperative day 2. Final pathology of the specimenrevealed a condyloma acuminatum of the anus mea-suring 7.5 cm in its greatest dimension, without theevidence of high-grade dysplasia or carcinoma. Allmargins, including circumferential, internal, and pe-ripheral external, were grossly and histologically free ofdysplasia.Subsequent Follow-UpAt the patient’s first postoperative visit (day 31), he wasdoing well overall but experiencing some anal discomfortwith fecal evacuation. Examination revealed a well-healing perineal wound with mild stenosis of the neo-anus (Figure 2A and B). He was discharged from clinicand recommended to begin daily dilations with a com-mercially available anal dilator and a bowel regimen ofdaily docusate and mineral oil to minimize discomfort. Hereturned to clinic for routine follow-up on postoperativeday 57 with difficulty evacuating and examination re-vealed worsened neoanal stenosis. The wound was oth-erwise healing well. Because of impressive neo-analstenosis and worsening symptoms, the patient underwentFigure 1. (A) Image of preoperative perianal region; (B) perianal region following the excision of lesion with “free-floating” analmucosa secured to internal anal sphincter; (C) placement of Penrose drain within anal canal; (D) excised specimen demonstratingcircumferential GCA and gross negative margins.6390 The American Surgeon™ 89(12)an anorectal examination under anesthesia (EUA) onpostoperative day 59. His anal canal was found to beseverely strictured, prohibiting full passage of the sur-geon’s fifth digit beyond the neoanus. A 1 cm thickcircumferential band of granulation tissue at the level ofthe neoanus was released with cautery. Gentle dilation ofthe neoanus was performed first digitally and then fol-lowed with Hegar dilators. At the conclusion of the case,the surgeon’s full index finger was able to traverse theneoanus with ease. He was discharged home with plans tocontinue home digital anal dilations. He continued to dowell and had regular bowel movements ranging from oneto two per day. A representative image from postoperativeday 81 (from index procedure) is shown in Figure 2C.On postoperative day 92 (from index procedure), heunderwent a repeat EUA and digital dilation and the scartissue encountered within the neoanus was gently re-leased. No masses or lesions were found on examination.The patient was discharged with instructions to continuehome dilations with a Hegar dilator kit.At his most recent clinic visit on postoperative day 329(from the index procedure), he reported regular bowelmovements without constipation or incontinence, withonly minor bleeding from the operative site associatedwith wiping. Examination revealed that the site washealing well, with no signs of stricturing (Figure 2D).ConclusionEn bloc resection of a large GCA with healing by sec-ondary intention has not been widely adopted, as reflectedin the paucity in publications including isolated casereports1,2 and a case series published in 2015.3 We per-formed a radical resection that left an area of anal mucosawithout its normal anatomic circumferential attachments,thereby creating a “free-floating anus.” Compared to priorpublished techniques that involved extensive flap cov-erage and multiple serial procedures, at times includingfecal diversion, our approach relied on healing by sec-ondary intention and resulted in minimal scarring, optimalcosmesis, with minimal to no impact on the patient’ssphincter function at 1 year follow-up. Furthermore, wewere able to avoid many of the feared complicationsassociated with graft or flap failure, such as ischemia,Figure 2. (A) Perianal region on postoperative day 31 demonstrating a healthy, granulating wound and closure via secondary in-tention; (B) digital rectal examination on postoperative day 31 demonstrating mild stenosis; (C) perianal region on postoperative day81 demonstrating further closure via secondary intention; (D) perianal region on postoperative day 329 demonstrating a well-healedneo-anus without signs of stricturing.Luo et al 6391necrosis, or infection. Although our patient did experienceminor stenosis of the neoanus, after serial dilations he wasnoted at last clinic visit to have well-formed bowelmovements without fecal incontinence and apparent goodquality of life. Because of fears of long-term anal stenosisand incontinence, neither of which occurred in our patient,this technique has not been widely adopted. We believethat the “free-floating anus” approach void of flap cov-erage and/or proximal ileostomy is an effective and de-sirable surgical alternative for carefully selected patientspresenting with large, circumferential GCA.Author ContributionsW.Y.L., V.H., D.N.V., and L.H.C.: Writing-Original Draft;Writing-Review and Editing. J.G.G.: Writing-Original Draft;Writing-Review and Editing; Supervision; Conceptualization.Declaration of Conflicting InterestsThe author declared the following potential conflicts of interestwith respect to the research, authorship, and/or publication ofthis article: Dr. Guillem had a role as a Consultant for IntuitiveSurgical, Inc.FundingThe author(s) received no financial support for the research,authorship, and/or publication of this article.Ethical ApprovalThis study (Ref ID: 392321) was examined by the UNCOffice ofHuman Ethics (Study #: 23-0762) and was determined that thiscase report does not constitute human subjects research as de-fined by federal regulations and therefore does not require IRBapproval.Informed ConsentThe patient has consented to the submission of the case report forpublication, and the authors affirm that the patient providedinformed consent for publication of the de-identified images inFigures.ORCID iDDimitrios N. Varvoglis https://orcid.org/0000-0002-9439-6530References1. Qian G, Yu H. Giant condyloma acuminata of Buschke–Lowenstein: Successful treatment mainly by an innovativesurgical method. Dermatol Ther. 2013;26(5):411-414.2. Altinay-Kirli E, Güçer S, Karnak I. Perianal giant condylomaacuminata in an infant: An alarming lesion for a pediatricsurgeon. Turk J Pediatr. 2011;53(3):333-336.3. Guttadauro A, Chiarelli M, Macchini D, et al. Circumfer-ential anal giant condyloma acuminatum: A new surgicalapproach. Dis Colon Rectum. 2015;58(4):e49-e52.6392 The American Surgeon™ 89(12)

“Free-Floating Anus”: A Flap-Free Approach for Definitive Excision of Circumferential Giant Condyloma Acuminata

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“Free-Floating Anus”: A Flap-Free Approach for Definitive Excision of Circumferential Giant Condyloma Acuminata

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