Anal Sphincter Defects In Patients Research Articles

Simple Anal Reinforcement with Anal Encirclement Using an Artificial Ligament in Patients with fecal Incontinence: A Single-center Observational Study

Objectives: Surgical repair of anal sphincter defects in patients with fecal incontinence (FI) has been associated with excellent or good short-term results; however, its benefits have been shown to deteriorate over long-term follow-up. When sphincteroplasty fails or is not feasible, the subsequent surgical options are limited. This study aimed to evaluate the efficacy of anal encirclement using the Leeds-Keio ligament in patients with FI. Methods: The inclusion criteria for the procedure were failure of or unsuitability for sphincteroplasty and the presence of a patulous anus (diameter, ≥35 mm). The artificial ligament was routed outside the external anal sphincter at the depth of the middle anal canal under caudal epidural anesthesia. Results: Fourteen patients (mean age, 79.4 years; 8 females) with FI were included. Of these, seven (50%) showed a ≥50% reduction in the Cleveland Clinic Florida Fecal Incontinence Score (CCFIS). The mean CCFIS of 13.6 at baseline significantly improved to 7.9 3 months after surgery. The mean maximal anal resting pressure significantly increased from 16.8 mmHg to 22.6 mmHg. Postoperatively, temporary fecal impaction was observed in one patient (7%). None of the cases required removal of the artificial ligament or additional operative interventions for FI during the mean follow-up period of 31.9 months. Conclusions: Anal encirclement using the Leeds-Keio ligament was technically simple and safe and achieved good short-term outcomes. Therefore, this technique appears to be a simple solution for sphincter defects and may become an important surgical option for patients with FI and a patulous anus.

Sa1372 Can 3D High Resolution Anorectal Manometry Detect Anal Sphincter Defects in Patients With Fecal Incontinence?

Sa1372 Can 3D High Resolution Anorectal Manometry Detect Anal Sphincter Defects in Patients With Fecal Incontinence?

Mo2019 Three-Dimensional High-Resolution Manometry in the Assessment of Anal Sphincter Defects in Patients With Incontinence: Correlation With Symptom Scores and Endoanal Ultrasonography

Carcinoma of the prostate is a significant cause of mortality and morbidity worldwide and is the most common non-cutaneous malignancy in American men. External beam radiotherapy (EBRT) for locally advanced prostate carcinoma is associated with a halving of the 10-year prostate cancer mortality. A frequent complication of EBRT is fecal incontinence, which significantly impairs quality of life for patients. Pelvic nerve damage as a result of the radiotherapy has been implicated as a possible cause of fecal incontinence. The aim of this study was to determine if fecal incontinence severity and pudendal nerve dysfunction were more commonly associated with men that had undergone EBRT for prostate cancer than in men with fecal incontinence with no history of prostate cancer or pelvic floor radiotherapy. Methods: At Flinders Medical Centre 1305 patients underwent anorectal physiology testing between January 1998 andNovember 2013. 114men were investigated for fecal incontinence with pudendal nerve terminal motor latency (PNTML) testing and anal manometry. Men with evidence of sphincter injury on endoanal ultrasound (EUS) (n=34), a missing EUS result (n=2) or who had received radiotherapy for causes other than prostate cancer (n=4) were excluded. Of the remaining 74 men, 17 had previously undergone radiotherapy for prostate carcinoma (presenting for anorectal testing on average 8.8 years post EBRT) and 57 had no reported prostate cancer. Pudendal nerve function, mean resting pressures (MRP), squeeze pressures (MSP) and Wexner incontinence scores, were compared between the two groups. Results The non-radiotherapy group (62±17 yrs; range 18-85) and a mean Wexner incontinence score of 8 ± 4 which was significantly less (p<0.005) than the mean score of 13 ± 3 in the radiotherapy group (77 ± 6 yrs; range 67-86). In the non-radiotherapy group, 21.7% had abnormal bilateral PNTML compared to 87.5% in the radiotherapy group (p<0.001, Chi-Square). 15.2% in the non-radiotherapy group had delayed bilateral or unilateral PNTML compared to 25.1% in the radiotherapy group (p<0.001). 6.5% of patients in the non-radiotherapy group had no unilateral or bilateral pudendal nerve response (no sphincter contraction in response to stimulus) compared to 62.6% in the radiotherapy group (p<0.001). MRP was 83 ± 40 cmH20 (normal range 54-124 cmH20) in the nonradiotherapy group compared to 55 ± 29 cm H20 in the radiotherapy group (p<0.05). MSP was 246 ± 74 cm H20 (normal range 179-317 cmH20) in the non-radiotherapy group compared to 190 ± 90 cm H20 in the radiotherapy group (p<0.05). Conclusions. Abnormal pudendal nerve function is associated with incontinent males who have received radiotherapy for prostate cancer. This study suggests that pelvic nerve damage as a result of radiotherapy may play a role in the fecal functional disorders experienced by many post-EBRT men.

Detection of Anal Sphincter Defects in Female Patients With Fecal Incontinence

Endoanal ultrasound is widely used for the detection of external and internal anal sphincter defects in patients with fecal incontinence. Recently, 3-dimensional transperineal ultrasound has been introduced as a noninvasive imaging method for the detection of these sphincter defects. This study was designed to assess agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects in women with fecal incontinence. This study was designed as a prospective observational study. The study took place in a university hospital. Between October 2008 and June 2009, all women with concerns of fecal incontinence underwent 2-dimensional endoanal ultrasound as well as 3-dimensional transperineal ultrasound. The main outcome measures are the presence of external and internal anal sphincter defects. Fifty-five patients were included. External and internal anal sphincter defects were observed with 2-dimensional endoanal ultrasound in 27 (49%) and 15 (27%) patients. Three-dimensional transperineal ultrasound detected an external and internal sphincter defect in 19 (35%) and 16 (29%) patients. The Cohen κ coefficient for the detection of external (κ = 0.63) and internal (κ = 0.78) anal sphincter defects was good. This study's limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. This study shows good agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects. Based on these data, 3-dimensional transperineal ultrasound might be considered as a valuable alternative noninvasive investigation method.

Three‐dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry

Anal sphincter anatomy on two-dimensional endoanal -ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three-dimensional (3D) measurements yield a better correlation. The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2-year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF-FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. Sixty-one patients of median age 53 years (range 15-82) were evaluated. Thirty-two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF-FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact-sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF-FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.

Clinical, sonographic and manometric characteristics and impact on quality of life of anal incontinence in 92 men referred for endoanal ultrasonography

Anal incontinence (AI) is a frequent symptom with considerable impact on quality of life. The aim of this study was to describe the clinical, sonographic and manometric characteristics of a male population with AI. Endoanal ultrasonography (EAU) was performed in 92 men referred for exploration of AI. Anal incontinence severity was evaluated by the Jorge and Wexner score (JW). The gastrointestinal quality-of-life index (GIQLI) was determined in 57% of patients. Anorectal manometry was performed in 62.6% of patients. The average JW score was 11+/-1. Anal incontinence had considerable impact on quality of life: average GIQLI=81+/-4. Seventeen patients presented an anal sphincter defect on EAU, 16 of whom had a history of coloproctological surgery. Prior surgery was significantly more common among patients who had a defect on ultrasonography; manometry showed significantly lower resting anal pressure. Our study confirms the severity of AI in a male population and its impact on quality of life. It also highlights the high prevalence of anal sphincter defects in patients with a history of anal surgery.

External Anal Sphincter Defects in Patients with Fecal Incontinence: Comparison of Endoanal MR Imaging and Endoanal US

To prospectively compare in a multicenter study the agreement between endoanal magnetic resonance (MR) imaging and endoanal ultrasonography (US) in depicting external anal sphincter (EAS) defects in patients with fecal incontinence. The study was approved by the medical ethics committee of all participating centers. A total of 237 consenting patients (214 women, 23 men; mean age, 58.6 years +/- 13 [standard deviation]) with fecal incontinence were examined from 13 different hospitals by using endoanal MR imaging and endoanal US. Patients with an anterior EAS defect depicted on endoanal MR images and/or endoanal US scans underwent anal sphincter repair. Surgical findings were used as the reference standard in the determination of anterior EAS defects. The Cohen kappa statistic and McNemar test were used to calculate agreement and differences between diagnostic techniques. Agreement between endoanal MR imaging and endoanal US was fair for the depiction of sphincter defects (kappa = 0.24 [95% confidence interval: 0.12, 0.36]). At surgery, EAS defects were found in 31 (86%) of 36 patients. There was no significant difference between MR imaging and US in the depiction of sphincter defects (P = .23). Sensitivity and positive predictive value were 81% and 89%, respectively, for endoanal MR imaging and 90% and 85%, respectively, for endoanal US. In the selection of patients for anal sphincter repair, both endoanal MR imaging and endoanal US are sensitive tools for preoperative assessment, and both techniques can be used to depict surgically repairable anterior EAS defects.

External Anal Sphincter Defects in Patients with Fecal Incontinence: Comparison of Endoanal MR Imaging and Endoanal US

External Anal Sphincter Defects in Patients with Fecal Incontinence: Comparison of Endoanal MR Imaging and Endoanal US

Anal Sphincter Defects in Patients with Fecal Incontinence: Endoanal versus External Phased-Array MR Imaging

To prospectively compare external phased-array magnetic resonance (MR) imaging with endoanal MR imaging in depicting external and internal anal sphincter defects in patients with fecal incontinence and to prospectively evaluate observer reproducibility in the detection of external and internal anal sphincter defects with both MR imaging techniques. The medical ethics committees of both participating hospitals approved the study, and informed consent was obtained. Thirty patients (23 women, seven men; mean age, 58.7 years; range, 37-78 years) with fecal incontinence underwent MR imaging with both endoanal and external phased-array coils. MR images were evaluated by three radiologists with different levels of experience for external and internal anal sphincter defects. Measures of inter- and intraobserver agreement of both MR imaging techniques and of differences between both imaging techniques were calculated. Both MR imaging techniques did not significantly differ in the depiction of external (P > .99) and internal (P > .99) anal sphincter defects. The techniques corresponded in 25 (83%) of 30 patients for the depiction of external anal sphincter defects and in 28 (93%) of 30 patients for the depiction of internal anal sphincter defects. Interobserver agreement was moderate to good for endoanal MR imaging and poor to fair for external phased-array MR imaging. Intraobserver agreement ranged from fair to very good for both imaging techniques. External phased-array MR imaging is comparable to endoanal MR imaging in the depiction of clinically relevant anal sphincter defects. Because of the weak interobserver agreement, both MR imaging techniques can be recommended in the diagnostic work-up of fecal incontinence only if sufficient experience is available.

Incidence des ruptures sphinctériennes dans l’incontinence anale : étude échographique

Study aim: To assess the incidence of endosonographic anal sphincter defects in a population of patients complaining of anal incontinence. Patients and methods: Seventy two consecutive patients (10 men, 62 women, mean age: 55 years) with anal incontinence underwent transanal sonography. In this series, 22 patients had a history of anal surgery (group I), while 50 patients (46 parous women, 4 men) had not been previously operated (group II). Results: Fifty patients (69.4%) had an anal sphincter defect identified on transanal sonography: 6 isolated internal sphincter defects (12%), 18 isolated external sphincter defects (36%) and 26 combined sphincter defects (52%). The incidence of sphincter defects was similar in the surgical and medical group (81.8% vs 64%, p > 0.05). All but one of the isolated internal sphincter defects were observed in group I. Among the 46 parous women of group II, the use of forceps was not associated with a significantly higher frequency of anal sphincter defects (72% vs 64%, p > 0.05). Conclusion: This study confirms the high incidence of endosonographic anal sphincter defects in patients with anal incontinence. Isolated lesions of the internal sphincter are mainly seen after anal surgery. In our group of parous women, the use of forceps did not increase the incidence of anal sphincter lesions.

Imaging of the anorectal region

Imaging of anorectal region has drastically changed during the last decade. Transrectal ultrasound and transrectal MRI can be used for staging the rectal tumours. Endoanal sonography can be applied for the classification of perianal fistulae and identification of anal sphincter defects in patients with faecal incontinence. Due to the limitations of endoanal sonography, endoanal MRI was introduced to assess the pathology related to the anal sphincter complex. Endoanal MRI seems superior to endoanal sonography. This paper describes the new developments of the imaging techniques and presents new insights in anatomy and pathology of the anorectum.