Anal Sphincter Research Articles

The Administration of Spinal or Local Anesthesia in Anal Fissure and Hemorrhoidectomy: A Comparative Literature Review

The purpose of this review is to consider the risks, benefits, and prospective benefits of spinal and local anesthetic. Comparing the safest and most suitable anesthetic to utilize with each surgical technique also helps. An extremely sensitive area of the human body is the anorectal region. Although it is normally shorter than the remainder of the gastrointestinal system, measuring between 2.5 and 4 cm, it is extremely complex physically and functionally. The anal canal's only purpose is to serve as a link between the rectum and the digestive system. It is crucial for maintaining fecal continence and safeguards the body against foreign bacteria that may utilize the rectum as a possible entrance point into the anal canal. Anorectal anal fissures are a typical, benign disorder. It is an extremely painful disease that, in certain extreme situations, may also cause per rectal hemorrhage. Usually an ulcer, it develops longitudinally in the anus's epithelial lining immediately distal to the dentate line. A fissure-in-ano is characterized by indurated margins, visible internal anal sphincter fibers, and a polyp or skin tag close to the fissure's distal end. Hemorrhoids are little clusters of arteriovenous, fibrovascular, and submucosal sinusoids that are located in the anorectal area. Hemorrhoids are shown to be related with new per rectal bleeding in the patients shortly after they defecate, which is a highly distinctive pattern. In circumstances where medical therapy is ineffective, surgery has been suggested for both of these disorders. Any time surgery is scheduled, the question of selecting anesthetic arises. Although both local and spinal anesthesia are advised, studies and expert views have shown that local anesthetic has a clear advantage over spinal anesthesia. It is a popular option for many surgeons since it is successful in terms of the patient's health and is also economical.

Impact of Internal Anal Sphincter Division on Continence Disturbance in Female Patients.

Few studies measured the pre- and postoperative anatomic and functional anal canal using 3-dimensional endoanal ultrasound and anal manometry and correlated sphincter division with fecal incontinence, severity, and function. To assess the incidence of fecal incontinence in patients who underwent internal anal sphincter division for anal fissure or intersphincteric anal fistula and correlate severity of symptoms with percentage of divided muscle, anatomical measurements, and anal pressures. Prospective cohort study. Colorectal surgery unit, tertiary referral center. Patients underwent clinical assessment using the Cleveland Clinic Florida Fecal Incontinence score for severity of symptoms, manometry, and ultrasound. Ultrasound measurements of length, percentage, and angle of divided internal anal sphincter, anterior external anal sphincter, posterior external anal sphincter plus puborectalis, and gap lengths. Sixty-three women (mean age, 44 years) were divided into 2 groups: 30 (48%) underwent fistulotomy for intersphincteric anal fistula and 33 (52%) underwent sphincterotomy for chronic anal fissure with high anal resting pressure. Forty-six percent experienced some measure of fecal incontinence after internal anal sphincter division. Incidence of fecal incontinence, severity of symptoms, and angle of the divided internal anal sphincter were similar between the groups. Length and percentage of the divided internal anal sphincter were significantly higher in the intersphincteric anal fistula. External anal sphincter and external anal sphincter plus puborectalis lengths were similar in both groups. Gap length was significantly longer in chronic anal fissures with high anal resting pressure. Single-institution, exclusion of males. Fecal incontinence was reported in half of the patients who underwent internal anal sphincter division. Despite the greater length and percentage of internal anal sphincter division in patients who underwent fistulotomy, incidence and severity of fecal incontinence were similar in both groups. Three-dimensional endoanal ultrasound showed greater gap length in the sphincterotomy group, which may be functionally significant after the division of the shorter internal anal sphincter but with a similar impact on fecal incontinence in both groups. ANTECEDENTES:Pocos estudios han medido el canal anal anatómico y funcional antes y después de la cirugía mediante ecografía endoanal tridimensional y manometría anal, y correlacionado la división del esfínter con la incontinencia fecal, la gravedad y la función.OBJETIVO:Evaluar la incidencia de incontinencia fecal en pacientes sometidos a división del esfínter anal interno por fisura anal o fístula anal interesfinteriana, y correlacionar la gravedad de los síntomas con el porcentaje de músculo dividido, las medidas anatómicas y las presiones anales.DISEÑO:Estudio de cohorte prospectivo.AJUSTE:Unidad de cirugía colorrectal, centro de referencia de tercer nivel.PACIENTES:Pacientes sometidos a una evaluación clínica utilizando la puntuación de incontinencia fecal de Cleveland Clinic Florida para la gravedad de los síntomas, la manometría y la ecografía.PRINCIPALES MEDIDAS DE RESULTADO:Mediciones por ultrasonido de la longitud, el porcentaje y el ángulo del esfínter anal interno dividido y el esfínter anal externo anterior, el esfínter anal externo posterior más el puborrectal y las longitudes del espacio.RESULTADOS:Sesenta y tres mujeres (edad media, 44 años) se dividieron en 2 grupos: 30 (48%) sometidos a fistulotomía por fístula anal interesfinteriana y 33 (52%) sometidos a esfinterotomía por fisura anal crónica con alta presión anal en reposo. El 46% experimentó algún grado de incontinencia fecal después de la división del esfínter anal interno. La incidencia de incontinencia fecal, la gravedad de los síntomas y el ángulo del esfínter anal interno dividido fueron similares entre los grupos. La longitud y el porcentaje del esfínter anal interno dividido fueron significativamente mayores en la fístula anal interesfinteriana. Las longitudes del esfínter anal externo y del esfínter anal externo más el puborrectal fueron similares en ambos grupos. La longitud del espacio fue significativamente mayor en la fisura anal crónica con alta presión anal en reposo.LIMITACIONES:Institución única, exclusión de varones.CONCLUSIÓN:La incontinencia fecal se reportó en la mitad de los pacientes sometidos a división del esfínter anal interno. A pesar de la mayor longitud y porcentaje de división del esfínter anal interno en los pacientes sometidos a fistulotomía, la incidencia y gravedad de la incontinencia fecal fue similar en ambos grupos. La ecografía endoanal tridimensional mostró una mayor longitud del espacio en el grupo de esfinterotomía, lo que puede ser funcionalmente significativo después de la división del esfínter anal interno más corto, pero con un impacto similar en la incontinencia fecal en ambos grupos. (Traducción-Dr. Fidel Ruiz Healy ).

Maternal obesity and the risk of postpartum infections according to mode of delivery

Objective The aim of the present study was to assess the impact of different maternal Body Mass Index (BMI) classes on the risk of postpartum endometritis, wound infection, and breast abscess after different modes of delivery. Secondly to estimate how the risk of postpartum infection varies with different maternal BMI groups after induction of labor and after obstetric anal sphincter injuries. Methods A population-based observational study including women who gave birth during eight years (N = 841,780). Data were collected from three Swedish Medical Health Registers, the Swedish Medical Birth Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. Outcomes were defined by ICD-10 codes given within eight weeks postpartum. The reference population was uninfected women. Odds ratios were determined using Mantel–Haenszel technique. Year of delivery, maternal age, parity and smoking in early pregnancy were considered as confounders. Results There was a dose-dependent relationship between an increasing maternal BMI and a higher risk for postpartum infections. Women in obesity class II and III had an increased risk for endometritis after normal vaginal delivery aOR 1.45 (95% CI: 1.29–1.63) and for wound infections after cesarean section aOR 3.83 (95% CI: 3.39–4.32). There was no difference in how maternal BMI affected the association between cesarean section and wound infection, regardless of whether it was planned or emergent. Women in obesity class II and III had a lower risk of breast abscess compared with normal-weight women, aOR 0.47 (95% CI: 0.38–0.58). The risk of endometritis after labor induction decreased with increasing maternal BMI. The risk of wound infection among women with an obstetrical sphincter injury decreased with increasing BMI. Conclusion This study provides new knowledge about the impact of maternal BMI on the risk of postpartum infections after different modes of delivery. There was no difference in how BMI affected the association between cesarean section and wound infections, regardless of whether it was a planned cesarean section or an emergency cesarean section.

Magnetic resonance imaging of pilonidal sinus disease: interobserver agreement and practical MRI reporting tips

ObjectiveTo evaluate the interobserver agreement for the features of natal cleft pilonidal sinus disease (PSD) on magnetic resonance imaging (MRI) and propose a standardized checklist for reporting PSD on MRI.Materials and methodsForty MRI studies of 39 discrete patients with PSD were retrospectively evaluated by five independent radiologists using a standardized checklist. Fleiss’ Kappa (k) coefficients of agreement were used to test the agreement between categorical variables. The MRI features of the natal cleft sepsis associated with PSD were classified into four main categories: morphology, branching and extensions, external skin openings, and the relationship of the PSD to the coccyx. A survey was created and disseminated online among general surgeons who treat patients with PSD to assess the relevance of the MRI features proposed in the standardized checklist.ResultsThe overall agreement regarding the identification of morphology of the natal cleft sepsis was moderate (k = 0.59). Lateral and caudal extensions interobserver agreement was substantial (k = 0.64 and 0.71, respectively). However, the overall agreement regarding the individual parts of anal sphincter involved was moderate (k = 0.47). Substantial interobserver agreement was found in assessing the proximity of the PSD to the coccyx (k = 0.62).ConclusionPreoperative MRI can delineate the extensions and branching of PSD with substantial agreement. MRI is superior in describing the deep extensions of PSD with better reliability than assessing the number and locations of the external openings. Expert consensus agreement is needed to establish the MRI features necessary for optimal reporting of PSD.Clinical relevance statementMRI can offer valuable information about the extent of sepsis associated with pilonidal sinus disease, particularly in cases with involvement of critical anatomical structures such as the coccyx and anal triangle. MRI can potentially contribute to more accurate patient stratification and surgical planning.Key Points• The interobserver agreement for assessing PSD’s lateral and caudal extension on MRI is substantial.• MRI can describe deep extensions and branching of PSD with superior reliability than assessing the number and site of external openings.• Reporting the relationship between natal cleft sepsis in PSD and the anal region may influence the surgical approach and postoperative healing.

Management of postpartum perineal wound complications.

Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications. There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing. Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications.

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs). Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge. Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052). Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial

BackgroundCervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone.MethodsThis is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results).DiscussionWe anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care.Trial registrationIRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021).

Results of a Systematic Intensive Follow-Up of 259 Cases of Obstetric Anal Sphincter Injury

BACKGROUND:Obstetric anal sphincter injury (OASI) is a complication of childbirth. Some women will develop symptoms, which may appear in the short or long term. In most clinical practice guidelines, follow-up is only recommended in women with anal incontinence (AI). In our hospital, follow-up is offered to all women who suffer an OASI: Anorectal manometry (ARM) and endoanal ultrasound (EAUS) are scheduled for all patients. The aim of this study was to determine if a symptom-based or systematic follow-up was better for these patients. To do so, we compared the results of investigations (EAUS and ARM) between asymptomatic and symptomatic women.METHODS:A retrospective analysis of prospectively collected data from 259 women who suffered an OASI in a single tertiary hospital in Barcelona (Spain) between May 2008 and May 2018.RESULTS:Seventy-seven percent of women attended the first follow-up visit at the perineal clinic, and 40.5% of women completed the 12-month follow-up. At initial evaluation, 60% of the patients had a Wexner score of 0. Seventy-two percent of women had an abnormal result on one or both investigations (EAUS and ARM).CONCLUSIONS:Attendance and adherence to our follow-up protocol are low. Although the incidence of AI symptoms is low at early follow-up in women after OASI, they show a high rate of functional dysfunctions on manometry. If follow-up is offered only to symptomatic patients, it could lead to an underestimation of their true condition.

In vivo measurement of the elastic properties of pelvic floor muscles in pregnancy using shear wave elastography.

We aimed to investigate changes in the elastic properties of levator ani muscle (LAM) and external anal sphincter (EAS) during pregnancy using shear wave elastography (SWE). Our secondary objective was to examine the association between the elastic properties of pelvic floor muscles (PFM) and perineal tears at childbirth. This was a prospective monocentric study, including nulliparous women. Three visits were planned (14-18, 24-28, and 34-38weeks) with a SWE assessment of the LAM and EAS at rest and during Valsalva maneuver. Then, we collected data about the delivery's characteristics. Assessments were performed using an Aixplorer V12® device (SL 18-5 linear probe) using a transperineal approach, reporting the shear modulus in kPa. We looked for changes in PFM's elastic properties during pregnancy using one-way ANOVA for repeated measures. We compared the mean shear modulus in late pregnancy for each muscle and condition between women with an intact perineum at delivery and those with a perineal tear using Student's t test. Forty-seven women were considered. Forty-five women had vaginal delivery of which 38 (84.4%) had perineal tears. We did not report any significant changes in the elastic properties of PFM during pregnancy. Women with an intact perineum at delivery had a stiffer EAS at Valsalva maneuver in late pregnancy (27.0kPa vs. 18.2kPa; p < 0.005). There were no significant changes in the elastic properties of the PFM in pregnancy. Stiffer EAS in late pregnancy appears to be associated with a lower incidence of perineal tears.

A pilot study on staged surgery by delta video-assisted anal fistula treatment (dVAAFT) for complex anal fistula

Complex anal fistulas (CAF) present a challenge in achieving healing while preserving anal sphincter function. This study aims to introduce a novel staged approach for CAF treatment, combining video-assisted anal fistula treatment (VAAFT), seton placement, and other staged approaches. Consecutive patients with CAF underwent the staged approach involving VAAFT and seton placement. Data on patient demographics, fistula characteristics, and operative findings were collected. Pre-operative work-up included clinical evaluation, endoanal ultrasonography (EAUS), and magnetic resonance imaging (MRI). Surgical techniques and outcomes were evaluated. Eighteen patients (median age 38 years) were included. Misplacement of a previously placed seton was observed in 64% of cases. VAAFT combined with seton placement achieved simplification and healing of secondary tracts in 66% of cases. Operative times significantly decreased across interventions. At a median follow-up of 14 months, complete healing was achieved in 2 patients, with 1 patient demonstrating persistence of the fistula. Post-operative complications were observed in 11% of patients, with no deterioration in continence. The staged approach combining VAAFT, seton placement, and staged procedures offers a potential solution for treating CAF. VAAFT provides diagnostic and therapeutic benefits, simplifying the fistula anatomy and optimizing seton placement. The approach allows subsequent procedures based on individual fistula characteristics.

Obstetric anal sphincter injuries: are defunctioning colostomies required?

The incidence of obstetric anal sphincter injury in the UK is rising. This condition leads to significant morbidity in otherwise healthy women. Significant long-term complications of obstetric anal sphincter injury include anal incontinence, ano-vaginal or recto-vaginal fistula and psychological distress. Current management of third and fourth degree perineal tears post-vaginal birth is primary repair. This article discusses the role of a defunctioning colostomy in women with severe perineal tears in the immediate postnatal period. A defunctioning colostomy is a surgical procedure to open a section of colon (large bowel) onto the abdominal wall; a stoma bag is then worn over this to collect faeces. The rectum and anal canal are not used (defunctioned), while the stoma is in place and the perineum is healing. This article describes the purpose and operative steps of colostomy formation and reviews current published evidence of outcomes in those with colostomy formation for obstetric anal sphincter injury. It also addresses the difference in clinical approach between obstetricians and colorectal surgeons in relation to the management of severe obstetric anal sphincter injury and highlight the need for multidisciplinary input.

CLINICAL STUDY OF CHRONIC FISSURE-IN-ANO AND COMPARATIVE STUDY OF DIFFERENTMODALITIESOF ITS TREATMENT IN NMCH&amp;RC

Anal fissure is a most common painful condition whichcauses considerable morbidity and affects the patients quality of life to a greater extent. The majority of acute anal fissures heal spontaneously. However, some of the acute anal fissures do not resolve but become chronic. Thiswarrantsprompttreatmentof the condition with appropriatemethods.Selecting a better method of treating this condition that can achieve optimal clinical results and getting the least pain and inconvenience to the patient has always posed a challenge to the surgeons. This has led to the innovation of a number of surgical and pharmacological methods that relaxes the anal sphincter. Aimof The Study:To study the different clinical presentations and etiological factors of the fissure in ano&amp; different modalities of treatment of fissure in ano i.e., application of 2% Diltiazem ointment, Lords Anal Dilatation and Subcutaneous Lateral Internal Sphincterotomy. &amp;to evaluate the efficacy Subcutaneous Lateral Internal Sphincterotomyas a treatment modality in the management of chronic anal fissure in comparison with application of 2% Diltiazem ointment &amp; with Lords Anal Dilatation. Materials &amp; Methods: The material for the study was taken from the cases attending thesurgery OPD and admitted In-patients of all the units of the Department of General Surgery, Navodaya Medical College Hospital &amp; Research Centre,whowerediagnosed to haveChronicanal fissure. This study was a prospective study which included 90 patients presenting with chronic anal fissure over a period of 18 months from November 2019 to May 2021.Thesepatientswererandomly selectedandclassifiedintothree groups(A,B,C) eachconsistingof30 patients &amp; each group with one type of treatment modality, like group A for 2% diltiazem, B for lords anal dilatation &amp; C for LIS. Follow-up of the patients was done by history and per-rectalexamination to assess the efficacy of the treatment and the complications like pain,bleeding,sphincter spasm, dischargeperanum and incontinence. Results :This study showed the results in favour of Lateral Internal Sphincterotomywith a healing rate of 100% with faster pain-relief and minimal or no complications ifperformedbythehands of an experienced surgeon, whereas latency in the clearance of symptoms and lesions was seen with 2% Diltiazem and Lords Anal Dilatation with adverse effects as well. With the healingrate of 100% of Fissure-in-ano in LIS therapy group, 81% in Lords Anal Dilatation and 71% with topical 2% Diltiazem therapy, &amp; adverse effects or complications being maximum in 2% Diltiazem therapy group, 13 patients (46%) when compared to Lords Anal Dilatation (41% , 11 patients) and LIS group (32%, 09 patients), weconcludethatLateralinternalsphinterotomy(LIS) appearstobethebetterlineoftreatmentasthereis 100%healingrate, minimal complications and no recurrence.

CLINICAL STUDY OF CHRONIC FISSURE-IN-ANO AND COMPARATIVE STUDY OF DIFFERENTMODALITIESOF ITS TREATMENT IN NMCH&amp;RC

Anal fissure is a most common painful condition whichcauses considerable morbidity and affects the patients quality of life to a greater extent. The majority of acute anal fissures heal spontaneously. However, some of the acute anal fissures do not resolve but become chronic. Thiswarrantsprompttreatmentof the condition with appropriatemethods.Selecting a better method of treating this condition that can achieve optimal clinical results and getting the least pain and inconvenience to the patient has always posed a challenge to the surgeons. This has led to the innovation of a number of surgical and pharmacological methods that relaxes the anal sphincter. AimofThe Study:To study the different clinical presentations and etiological factors of the fissure in ano&amp; different modalities of treatment of fissure in ano i.e., application of 2% Diltiazem ointment, Lords Anal Dilatation and Subcutaneous Lateral Internal Sphincterotomy. &amp;to evaluate the efficacy Subcutaneous Lateral Internal Sphincterotomyas a treatment modality in the management of chronic anal fissure in comparison with application of 2% Diltiazem ointment &amp; with Lords Anal Dilatation. Materials &amp; Methods: The material for the study was taken from the cases attending thesurgery OPD and admitted In-patients of all the units of the Department of General Surgery, Navodaya Medical College Hospital &amp; Research Centre,whowerediagnosed to haveChronicanal fissure. This study was a prospective study which included 90 patients presenting with chronic anal fissure over a period of 18 months from November 2019 to May 2021.Thesepatientswererandomly selectedandclassifiedintothree groups(A,B,C) eachconsistingof30 patients &amp; each group with one type of treatment modality, like group A for 2% diltiazem, B for lords anal dilatation &amp; C for LIS. Follow-up of the patients was done by history and per-rectalexamination to assess the efficacy of the treatment and the complications like pain,bleeding,sphincter spasm, dischargeperanum and incontinence. Results :This study showed the results in favour of Lateral Internal Sphincterotomywith a healing rate of 100% with faster pain-relief and minimal or no complications ifperformedbythehands of an experienced surgeon, whereas latency in the clearance of symptoms and lesions was seen with 2% Diltiazem and Lords Anal Dilatation with adverse effects as well. With the healingrate of 100% of Fissure-in-ano in LIS therapy group, 81% in Lords Anal Dilatation and 71% with topical 2% Diltiazem therapy, &amp; adverse effects or complications being maximum in 2% Diltiazem therapy group, 13 patients (46%) when compared to Lords Anal Dilatation (41% , 11 patients) and LIS group (32%, 09 patients), weconcludethatLateralinternalsphinterotomy(LIS) appearstobethebetterlineoftreatmentasthereis 100%healingrate, minimal complications and no recurrence.

Risk indicators for obstetrical anal sphincter injury in vaginal birth after caesarean section compared to first vaginal delivery

ObjectivesComparison of the rate of obstetric anal sphincter injury (OASI) between women having their first vaginal birth after caesarean section (CS) and true nulliparous women with a vaginal delivery. Assessment of risk indicators for OASI in women with vaginal birth after one CS (VBAC). Study design28 535 women with their first VBAC and a cohort of 275 439 nulliparous women with a vaginal delivery of a liveborn infant in a cephalic position from the Dutch perinatal registry were analyzed. We compared the OASI rate with univariate and multivariate analysis. In women with VBAC possible risk indicators for OASI were assessed using univariate and multivariate logistic regression analysis. ResultsThe rate of OASI was 5.2% in women with vaginal birth after CS and 4.0% in women with a first vaginal delivery. The adjusted OR (aOR) for vaginal birth after an elective CS was higher (aOR 1.34, 95% CI 1.23–1.47) compared to vaginal birth after an emergency CS (aOR 1.16, 95% CI 1.08–1.25). In women with vaginal birth after emergency CS, the aOR for the indication non-progressive labor was 1.18 (95% CI 1.08–1.29), whereas CS for suspected fetal distress was not significantly associated with obstetric anal sphincter injury in VBAC.In the 28 535 women with a VBAC, mediolateral episiotomy (MLE), birth weight < 3000 g and maternal age < 25 years were associated with a significantly lower rate of OASI. A gestational age of 42 weeks, birth weight ≥ 3500 g, operative vaginal delivery and duration of the 2nd stage of labour of ≥ 60 min were associated with a significantly higher rate of OASI. ConclusionsWomen with a VBAC have a higher rate of OASI in comparison with women with a first vaginal delivery, with the exception of women with a vaginal birth after an emergency CS for suspected fetal distress. Factors associated with a significantly lower rate for OASI were MLE, maternal age < 25 and birth weight < 3000 g. A gestational age of 42 weeks, birth weight between 3500 and 4000 g and ≥ 4000 g, operative vaginal delivery and duration of the 2nd stage of delivery longer dan 60 min were associated with a significantly higher rate of OASI.

Evaluation of perfusion index as a predictor of successful caudal block in pediatric patients: A prospective randomized study.

Caudal block is among the most widely administered regional anesthesia in pediatric patients. The clinical signs and objective assessments are not fast and reliable enough to provide a good feedback. Perfusion index (PI) is considered as a sensitive marker to assess the efficacy of caudal block. We aim to assess PI as an indicator for success of caudal block in pediatric patients. Sixty pediatric patients scheduled for elective surgery of lower abdomen and below were included. Patients were randomly allocated into two groups (n = 30): Group 1 received caudal block after general anesthesia and Group 2 only received general anesthesia. PI, heart rate, mean arterial pressure, and anal sphincter tone (AST) were recorded at 5, 10, 15, and 20 min following induction of anesthesia. A persistent increase in the PI value was observed in Group 1 starting from 5 min till 20 min, as compared to Group 2, at all the time intervals. When mean PI was statistically compared between both the groups, it was found to be highly significant (P = 0.001). Group 1 patients have progressive laxity of AST which was found to be significantly different from Group 2 (P < 0.001). We have found that both PI and AST are good indicators for assessing success of caudal block onset in pediatric patients but AST took slightly longer time (~20 mins). Therefore, we conclude that PI is simple, economical, and noninvasive monitor that predicts the caudal onset much earlier than AST.

Diagnosis, management and training in perineal trauma: a UK national survey of obstetricians

Introduction and hypothesisPerineal trauma during vaginal delivery is very common. Training in diagnosis and repair of trauma, including obstetric anal sphincter injuries, varies in the UK. We aimed to investigate the current knowledge and training received by obstetric physicians.MethodsA national, validated survey was conducted online, using Qualtrics. The National Trainees Committee distributed the survey. It was also sent directly to consultants via email.ResultsA total of 302 physicians completed the survey and were included in the analysis. 3.9% of participants described their training in obstetric perineal trauma as “very poor” or “poor”. 20.5% said they have not received training. 8.6% of physicians practising for more than 10 years had not had training for over 10 years. 70.5% responded “somewhat agree” or “strongly agree” when asked if they would like more training. Identification of first, second, third-, and fourth-degree tears from images and descriptions was very good (more than 80% correct for all categories). Classification of other perineal trauma was less consistent, with many incorrectly using the Sultan Classification. “Manual perineal support” and “Controlled or guided delivery” were the most frequently selected methods for the prevention of obstetric anal sphincter injury (OASI).ConclusionsTraining experience for physicians in obstetric perineal trauma varies. Further improvement in training and education in perineal trauma, particularly in OASI, is needed for physicians. Perineal trauma that is not included in the Sultan Classification is often misclassified.

Pelvic floor muscle length changes with breathing in males: A preliminary report

The study aimed to identify whether pelvic floor muscles modulate length with breathing, and if any length changes induced by breathing relate to abdominal cavity displacement and intra-abdominal pressure. To investigate these relationships, displacement of pelvic landmarks that related to pelvic floor muscle length using transperineal ultrasound imaging, breath volume, intra-abdominal pressure, abdominal and ribcage displacement, and abdominal and anal sphincter muscle electromyography were measured during quiet breathing and breathing with increased dead-space in ten healthy men. Pelvic floor muscle landmark displacement modulated with ribcage motion during breathing. This relationship was stronger for: i) motion of the urethrovesical junction (puborectalis muscle length change) than the mid-urethra landmark (striated urethral sphincter muscle length change), and ii) dead-space breathing in standing than dead-space breathing in supine or quiet breathing in standing. In most (but not all) participants, the urethrovesical junction descended during inspiration and elevated during expiration. Striated urethral sphincter length changes during the respiratory cycle was independent of intra-abdominal pressure. In summary, breathing involves pelvic floor muscle length changes and is consistent with the role of these muscles during respiration to aid maintenance of continence, lung ventilation and/or provision of support to the abdominal cavity. Clinicians who train pelvic floor muscles need to be aware that length change of pelvic floor muscles is expected with breathing.

Robot-Assisted Sacrocolpopexy versus Trans-Vaginal Multicompartment Prolapse Repair: Impact on Lower Bowel Tract Function.

This study evaluated the effectiveness, safety, and possible changes in bowel symptoms after multicompartment prolapse surgery by comparing two different surgical approaches, transvaginal mesh surgery with levatorplasty (TVMLP) and robot-assisted sacrocolpopexy (RSC). All patients underwent pelvic (POP-Q staging system) and rectal examination to evaluate anal sphincter tone in the lithotomy position with the appropriate Valsalva test. The preoperative evaluation included urodynamics and pelvic magnetic resonance defecography. Patient Global Impression of Improvement (PGI-I) at follow-up measured subjective improvement. All patients completed Agachan-Wexner's questionnaire at 0 and 12 months of follow-up to evaluate bowel symptoms. A total of 73 cases were randomized into the RSC group (36 cases) and TVMLP group (37 cases). After surgery, the main POP-Q stage in both groups was stage I (RCS 80.5% vs. TVMLP 82%). There was a significant difference (p < 0.05) in postoperative anal sphincter tone: 35%. The TVMLP group experienced a hypertonic anal sphincter, while none of the RSC group did. Regarding subjective improvement, the median PGI-I was 1 in both groups. At 12 months of follow-up, both groups exhibited a significant improvement in bowel symptoms. RSC and TVMLP successfully corrected multicompartment POP. RSC showed a greater improvement in the total Agachan-Wexner score and lower bowel symptoms.

Hubungan Antara Paritas dengan Kejadian Ruptur Perineum (Literature Review)

Perineal tears occurs either spontaneously with vaginal or instrument delivery, or as a result of an episiotomy. Severe perineal tears can involve damage to the anal sphincter and anal mucosa. Perineal tears is caused by several factors which are classified into three groups. Such as maternal factors, delivery procedures, and mothers where parity is a factor in perineal tears. This study used a literature review study design. Research article searches were sourced from the Pubmed, Google Scholar, SCOPUS, scientificdirect, and BMC electronic databases. Search articles using keywords, namely perineal tears, parity, obstetric sphincter anal injuries. The results of a review of nine journals that have been carried out show that parity with a small number can cause perineal tears with a high degree, and vice versa parity with a high number further reduces the degree of perineal tears. But it is also affected by physical activities such as gymnastics and sports which can help to reduce the risk of perineal tears regardless of existing parity. The data that we reviewed can be concluded that there is a relationship between parity and perineal tears.

Malnutrition and Developmental Delay Presenting as Complications of Late Onset Hirschprung’s disease : A Case Report

Background: Hirschsprung’s Disease is a congenital disorder characterized by the absence of ganglionic cells in the colon, causing loss of peristaltic movement in the bowel. Most cases are diagnosed before the age of one and marked by the delayed passage of meconium, vomiting, and distended abdomen. Here, we present a case of a 2-year-old boy with an atypical presentation of malnutrition and developmental delay as a complication of Hirschsprung’s Disease. Case Presentation: A 2-year-old boy who presented with abdominal distention and chronic constipation was referred to our hospital. Past personal history revealed that he frequently suffered from the symptoms but was previously diagnosed with regular constipation and only consumed symptomatic medication. On admission, his vital signs were all normal, but his appearance was pale and weak. Growth and developmental screening showed poor growth status and developmental delay in all four domains. From the physical examination, gross abdominal distention was found and the rectal examination demonstrated a tight anal sphincter, empty rectal vault, and a green-colored stool with no forceful expulsion. Radiologic and histopathological findings suggested Hirschsprung’s disease. Conclusion: Chronic abdominal distention followed by malnutrition and developmental delay can present as a complication of hirschsprung’s diseasein older children. Due to these subtle signs and symptoms, a thorough examination and proper diagnostic algorithm are