Anorectal perineal teratoma is a congenital tumor, which is mostly asymptomatic in the early stage. It is mostly seen due to the stimulation of infection or the enlargement of the tumor to compress the rectum, causing anal drop and perianal pain as the main symptoms, which are easily misdiagnosed and mistreated clinically, delaying the disease and causing great pain and economic loss to patients. 1. Clinical data 1.1 General data
From 2008 to 2013, 16 patients with misdiagnosed perianal and sacrococcygeal teratoma were admitted to the Department of Anorectal Medicine of the First Affiliated Hospital of Henan College of Traditional Chinese Medicine, including 7 males and 9 females, the youngest being 22 years old and the oldest 67 years old, with an average age of 39 years. The duration of the disease ranged from 2 months to 10 years, mostly from half a year to one year. 1.2 Clinical manifestations
In the early stage, there were no obvious conscious symptoms, accompanied by infection of the swelling, sudden enlargement and anal drop, perianal swelling and pain, fever, poor defecation when the cyst was large, butter-like liquid or tofu sludge-like liquid or coffee-like liquid or rice swill-like liquid after the cyst ruptured, and painful swelling, difficult defecation or pus flow when combined with infection. 1.3 Previous diagnosis and treatment
All 16 patients had a history of outpatient treatment before admission to the hospital. 2 patients had painless masses around the rectum found during the examination of hemorrhoids, which were diagnosed as perianal masses and surgically removed; 9 patients had painful anal swelling due to infection, which were diagnosed as perianal abscesses and surgically treated; 5 patients were diagnosed as anal fistula due to ulceration of the masses and persistent purulent discharge around the anus; all 16 patients had a history of one or more surgeries All 16 patients had a history of one or more surgical procedures that did not heal, and two of them had eight surgical procedures. 1.4 Diagnostic tools
After careful clinical examination, 12 patients underwent fistulography and were found to have cystic masses around the rectum with smooth wall tissue; 4 patients underwent ultrasound, CT and perianal MRI and were found to have perianal cystic or cystic solid masses. 16 patients underwent surgical excision and the postoperative pathological diagnosis supported teratoma in 11 patients, including one case of malignant teratoma; 3 patients were found to have phosphorylated epithelial tissue and were diagnosed as dermatofibrosis. The pathological diagnosis was inflammatory tissue in 2 patients, and no teratoma or epithelial tissue was found. 1.5 Treatment method
Sixteen patients were treated surgically again with epidural anesthesia, and those with external orifices were injected with methylene blue dilution into the canal, and a C-shaped incision was used to avoid damaging the anal sphincter as much as possible, and the cyst wall tissue was sharply peeled along the canal and methylene blue colored tissue, and postoperative drainage was placed, and 5 cases were sutured in the first stage; 8 patients were treated with half sutures and semi-open dressing changes intraoperatively and postoperatively; 2 patients were located higher and communicated with the rectum. In two cases, the cyst wall was peeled off and drained by hanging threads and open drug exchange treatment; in one case, the patient had multiple cysts around the rectum, repeated infection, sclerosis of the anorectal ring, and the cyst wall could not be removed, so local scratching and electric knife cautery were used instead, and an abdominal fistula was performed, which was retracted after three months. 2.Treatment results The efficacy assessment criteria refer to the efficacy assessment criteria of anal fistula and perianal abscess in the Diagnostic and Efficacy Criteria of Chinese Medicine Evidence. Cured: the symptoms disappeared, the wounded surface healed, and no recurrence in the follow-up period of six months. Improvement: symptoms basically disappeared, but the wound surface healed poorly, or recurred within six months after the operation. Ineffective: no significant change or improvement before and after treatment. The result is that 14 out of 16 cases were cured, with a cure rate of 87.5%, 2 cases were improved, and 2 cases were relapsed within six months after surgery. 3. Discussion 3.1 Pathogenesis Teratoma originates from primitive embryonic tissue and belongs to abnormal developmental disease, which has all the characteristics of true tumor. Teratoma can occur in various parts of the midline of human fetogenic body cavity, with gonads being the most frequent, followed by the thoracic cavity and sacrococcygeal region. For the site of occurrence, it is an abnormal mixture of foreign tissues fixed with mature tissues in the lesion area, and this abnormality itself shows excessive continuous growth before puberty 3.2.1
Lack of diagnostic experience: the misdiagnosis rate of sacrococcygeal teratoma is high, which is mainly due to the low incidence of this disease, the lack of awareness of the disease among primary care physicians, narrow diagnostic thinking, and once a painful perianal swelling and perianal pus are found, the first diagnosis is based on experience as common perianal diseases: perianal abscess and anal fistula, which often leads to misdiagnosis. In our group, 9 of 16 patients were diagnosed as perianal abscess and 5 were diagnosed as anal fistula, and some patients had multiple operations, which made the preoperative differential diagnosis more difficult. 3.2.2
Detailed rectal diagnosis and routine ultrasound examination were not performed: rectal diagnosis and endorectal ultrasound examination are extremely important in this group, and all patients in this group were diagnosed by routine rectal diagnosis and endorectal ultrasound examination, and if cystic masses were found, further imaging examination was performed to confirm the diagnosis. If cystic masses were found, further imaging was performed to confirm the diagnosis. When asked for medical history, all 14 cases did not have previous endoluminal ultrasound examination. 3.2.3
Imaging examination was neglected: for the diagnosis of sacrococcygeal teratoma, imaging examination is crucial. If cystic masses were found by finger diagnosis and ultrasound, further imaging examinations such as imaging, CT and MRI were performed to confirm the diagnosis. However, the cost of imaging is high, and clinicians often do not recommend CT examination for patients with financial difficulties, which is also one of the reasons for misdiagnosis. 3.3 Pre-operative and post-operative examinations will help to improve the diagnostic accuracy, and there are many clinical cases such as “high complex anal fistula”, “low complex anal fistula”, “penetrating buttock fistula”, “post-rectal fistula”, “post-rectal fistula” and “post-rectal fistula”. “, “retrorectal abscess”, “posterior horseshoe perianal fistula”.
“What is the reason for the failure to heal after multiple surgeries? All patients with anal fistulas and perianal abscesses that do not heal after multiple surgeries should undergo further fistulogram, ultrasound, CT, MRI and other examinations before surgery to clarify the diagnosis as much as possible before surgical treatment. In fistulogram, fistula tip or the very end is enlarged and thickened with clear borders and the presence of cystic masses; rectal CT examination or MRI examination shows cystic masses with round or oval edges, all of which should be considered teratomas. Focusing on routine preoperative and postoperative examinations will help to improve the diagnostic accuracy of dermatomal cysts and reduce the incidence of misdiagnosis and mistreatment. 3.4 Some experiences of clinical diagnosis and treatment Rectal palpation is the simplest and most effective method to diagnose this disease, and most of them can be palpated, manifesting as round or ovoid masses, mostly in women, rare in adults, and extremely rare in the elderly; for long untreated high anal fistula or complex anal fistula, attention should be paid to examinations, such as fistulography, magnetic resonance imaging, CT, etc., to avoid misdiagnosis again, and the tissue of the canal wall should also be routinely examined pathologically after anal fistula surgery If there is a “cystic mass without obvious swelling and pain” around the perianal or rectal area, cystic teratoma or dermatomal cyst should be considered while excluding perianorectal abscess; if the cyst can be palpated on finger palpation, a perianal approach can be taken, taking a folding knife position, and the incision is mostly made with an inverted “V” or C shape. The separation should be mainly blunt, and the adhesion of part of the cyst wall to the surrounding tissues can be combined with electric knife, which should be peeled off and excised thoroughly, otherwise it will recur soon.