Sphincter Integrity Research Articles

Role of Trans perineal Ultrasound in Inflammatory Bowel Disease

Abstract Background Inflammatory Bowel Disease (IBD) is a medical terminology for a group of diseases that cause chronic intestinal inflammation. It is categorized into two subtypes: Ulcerative colitis and Crohn’s disease. Fistulae are frequently seen manifestations of perianal IBD, and their clinical course these consists of flare-ups with bouts of active drainage, followed by intervals of clinical remission. Improved prognosis, treatment, and assessments of perianal disease activity may all contribute to a better patient quality of life. Aim of the Work to explore the role of trans perineal ultrasound in assessment of disease activity and/or complications in patients with inflammatory bowel disease. Patients and Methods The Diagnostic Radiology Unit; Radiology Department, Ain Shams University Hospitals. For 6 months. We studied the relevance of 23 different ultrasound parameters and 6 indices in conjunction with clinical, endoscopic based scores. Sample size of at least 30 patients with IBD with affection of anal or perianal area were sufficient to achieve study objective. Results Rectal wall thickness and submucosal band thickness could be used as indicators for presence of disease in ulcerative colitis patients. TPUS could be used to assess the internal sphincter thickness, external sphincter integrity in Crohn’s disease. Partial Mayo clinical score showed significant correlation with Mayo endoscopic score; however, it couldn’t predict degree of severity. Internal sphincter thickening increased anal canal vascularity and perianal fistula is more common in Crohn’s disease than ulcerative colitis. Conclusion Trans perineal ultrasound is considered as a good tool that is noninvasive, cost effective and convenient and shows a potential in the assessment of disease activity and complications in inflammatory bowel disease.

Assessing lower esophageal sphincter integrity during peroral endoscopic myotomy: navigating the challenges of preservation versus division.

Assessing lower esophageal sphincter integrity during peroral endoscopic myotomy: navigating the challenges of preservation versus division.

Automatic anal sphincter integrity detection from ultrasound images via convolutional neural networks.

The anal sphincter complex comprises the anal sphincter and the U-shaped deep and superficial puborectalis muscle. As an important supporting structure of the posterior pelvic floor, together with its surrounding tissues and muscles, the anal sphincter complex maintains the normal physiological functions of defecation and continence. The plane required for diagnosing anal sphincter injury and the diagnosis of anal sphincter integrity through pelvic floor ultrasound are highly dependent on sonographers' experience. We developed a deep learning (DL) tool for the automatic diagnosis of anal sphincter integrity via pelvic floor ultrasound. A 2D detection network was trained to detect the bounding box of the anal sphincter. The pelvic floor ultrasound image and its corresponding oval mask were input into a 2D classification network to determine the integrity of the anal sphincter. The average precision (AP) and intersection over union (IoU) were used to evaluate the performance of anal sphincter detection. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the classification model. The Pearson correlation coefficients (r values) of the topmost and bottommost layers detected by the CNN and sonographers were 0.932 and 0.978, respectively. The best DL model yielded the highest area under the curve (AUC) of 0.808 (95% CI: 0.698-0.921) in the test cohort. The results from the CNN agreed well with the diagnostic results of experienced sonographers. We proposed, for the first time, a CNN to obtain the plane required for diagnosing anal sphincter injury on the basis of pelvic floor ultrasound and for preliminarily diagnosing anal sphincter injury.

Mathematical Model of Anal Canal for Anal Fistula Surgery

Abstract: Purpose: Surgery is necessary for the treatment of an anal fistula. However, excision of some sphincter muscle would compromise sphincter integrity or function, which is the cause of a reduced success rate in the long term. In order to develop an appropriate surgical plan, a mathematical model that describes the relationship between the internal pressure of the anal canal and the structure of anal sphincters is required.
 Methods: The anatomical structure of the anal canal and the corresponding sphincter pressure can be measured by endoanal ultrasound (EAUS) imaging and manometry, respectively. Length-tension relationships for skeletal and smooth muscles, two major components of the external and internal anal sphincter, respectively, were reviewed first. 
 Results: Based on the information about the internal and external sphincters, two mathematical models, the thick-wall cylinder model and the two-layer model, have been created, from which the influence of complete or partial excision of the sphincter muscle can be estimated.
 Conclusions: The proposed thick-wall cylinder and two-layer models could describe the relationship between the internal anal canal pressure and the structure of anal sphincters, from which the influence of complete or partial excision of the sphincter muscle may be estimated.

Use of endolumenal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders.

Investigating gastrointestinal (GI) motility disorders relies on diagnostic tools to assess muscular contractions, peristalsis propagation and the integrity and coordination of various sphincters. Manometries are the gold standard to study the GI motor function but it is increasingly acknowledged that manometries do not provide a complete picture in relation to sphincters competencies and muscle fibrosis. Endolumenal functional lumen imaging probe (EndoFLIP) an emerging technology, uses impedance planimetry to measure hollow organs cross sectional area, distensibility and compliance. It has been successfully used as a complementary tool in the assessment of the upper and lower oesophageal sphincters, oesophageal body, the pylorus and the anal canal. In this article, we aim to review the uses of EndoFLIP as a tool to investigate GI motility disorders with a special focus on paediatric practice. The majority of EndoFLIP studies were conducted in adult patients but the uptake of the technology in paediatrics is increasing. EndoFLIP can provide a useful complementary data to the existing GI motility investigation in both children and adults.

Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound.

To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle. This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal(IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard. In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference. This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Autologous adipose-derived stromal vascular fraction and platelet concentrates for the treatment of complex perianal fistulas

BackgroundComplex perianal fistulas are a major challenge for modern surgery since 10–35% of patients have functional problems after treatment. Sphincter-saving techniques have a wide range of efficacy (10–80%). We hypothesised that autologous adipose-derived stromal vascular fraction in combination with platelet rich plasma is a new therapeutic strategy with enhanced cure and function preservation rates.MethodsAdult patients with complex cryptoglandular perianal fistulas were treated with injection of autologous adipose-derived stromal vascular fraction in combination with platelet rich plasma around and inside the fistulous tract between May 2018 and April 2019 at the General and Emergency Surgery Operative Unit of the University Hospital “P. Giaccone” of Palermo. Fistulas were confirmed by magnetic resonance imaging. Patients completed the Short Form-36 score on quality of life and the Wexner and Vaizey scores on faecal incontinence, and they were functionally studied using a three-dimensional anorectal manometry. The clinical and functional follow-up was performed at 1 year and 2 years after surgery.ResultsNine patients (4 males, 5 females; median age 42 years [19–63 years]) with high trans-sphincteric or horseshoe fistulas were treated. The average number of previous surgeries per patient was 4.8. At 1 year follow-up, 77.7% of patients were cured, while at 2 years there was 1case of relapse. The variation in Short Form-36 score in cured patients was not significant (p = 0.0936). No statistically significant differences were found in continence scores.ConclusionsThe proposed treatment is a treatment option that preserves sphincter integrity and function, potentially avoiding postoperative incontinence and the need of repeated treatments.

Analysis of the efficacy of biofeedback for faecal incontinence after surgery for anorectal malformation

Objective To explore the therapeutic effects of biofeedback in the treatment of faecal incontinence (FI) after surgery for anorectal malformation (ARM). Methods Clinical data were collected from paediatric patients for postoperative biofeedback due to FI caused by ARM between May 2017 and November 2021. The data included the duration of symptoms, the integrity of the anal sphincter, anorectal manometry parameters, and FI scores. These patients were divided into the low ARM group (group A) and the high ARM group (group B). Results A total of 45 paediatric patients were enrolled in the study. There were 28 cases in group A and 17 cases in group B. The differences in age, gender, and body weight were not statistically significant between the two groups (p > 0.05). The differences in the clinical indicators were also not statistically significant between the two groups at the time of the initial evaluation. The duration of symptoms was 2.21 ± 0.71 years and 4.14 ± 1.89 years in groups A and B. There were 16 cases with an intact anal sphincter in group A and only two cases with an intact anal sphincter in group B. This difference was statistically significant between the two groups (p < .05). The anal resting pressure, initial sensitivity threshold, defaecation sensitivity threshold, defaecation urge threshold, and FI scores were significantly improved in both groups post-treatment compared to pre-treatment (p < .001). Strong impulses improved significantly in group A, while strong impulses did not improve significantly in group B. The multivariate logistic regression analysis with these variables further showed that symptom duration and anal sphincter integrity were the main factors influencing the therapeutic effects of biofeedback. Conclusion Biofeedback plays a positive role in the treatment of FI in paediatric patients following surgery for ARM. Symptom duration and anal sphincter integrity were found to be the main factors influencing the therapeutic effect of biofeedback.

Is there a role for transperineal ultrasound imaging of the anal sphincter immediately after primary repair of third degree tears?

ObjectiveWhen obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs). Study DesignThis is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair. Results21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear.8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair.Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant. ConclusionsWomen who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair.

Endoscopic Radiofrequency Ablation of Fistula in Ano (E-RaFisTura) in the Era of Surgical Innovation. A Serial Prospective Evaluation of 10 Patients

Background: Fistula in-ano is an abnormal chronic infected tunnel (tract) between the rectum or the anal canal and perianal skin usually, with granulation tissue which connecting a primary orifice (internal) to a secondary one (external). This morbid antity represents a dilemma for both, patients and surgeon-proctologists because of postoperative issues occurrence such as fecal incontinence. The surgical management of this infectious condition has emerged nowadays, by emphasing new surgical techniques that preserve anal sphincter's integrity and functional. Over the last decade, numerous techniques sparing anal sphinters have gained popularity such as endoscopic approach (VAAFT), Laser, fibrin glue, transanal advancement flap repair [1,6]. In the same perspective,we are presenting in this paper, our preliminary outcomes of a combination of endoscopic approach (VAAFT) with Radifrequency Ablation of the fistula's tract that we nicknamed with the acronym of E-RaFisTura). Methods: We enrolled 10 males patients with anal fistula, age groupe 50-70 years, without any comorbidity in the term of diabetes mellitus, bowel inflammatory disease. Preoperatively each of them underwent a digital rectal examination, pelvic MRI, colonoscopy to rule out any concomitant abscess, Crohn's disease. Fleet enema, subcutaneus lower molecular weight heparin as well as intravenous broad spectrum antibiotic were administered an hour prior the surgical procedure. All patients were shifted to endoscopic surgical treatment of anal fistula (VAAFT) by using the fistuloscope of Piercarlo Meinero combined to the device of Fistura (Radiofrequency Ablation) with its probe 6-7 F (Figure 1 a,b,c). Then we visualized the fistula's tract and we seal it with radiofrequency thermocoagulation without damaging the anal sphincters by closing the internal opening with a suture node (Vicryl Rapid 3-0). Taxinomically, 2 patients had intersphincteric fistula, 3 transphincteric and the 5 others had submucosal anal fistula. Outcomes: We are inthe third month of follow up, none of the aboved mentioned patients has presented any postoperative issue excepting some local discomfort in immediate postoperative day, relieved with voltaren. Furthermore, the orificial wound healing is successful. Conclusion: Focused on our preliminary results, despite the small volume of patients, this combination of endoscopic and radiofrequency ablation can be regarded with optimism in selected patients. We will perform a powerful prospective study with a huge sample to have more accurate opinion. Bioethics Considerations: All enrolled patients had given their written consent prior. Furthermore,this surgical trial was approved by the Ethical commitee of Our Clinic.

Assessment of sphincter integrity using intraoperative endoanal ultrasound after bull horn injury to the perianal area

Assessment of sphincter integrity using intraoperative endoanal ultrasound after bull horn injury to the perianal area

Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI)

Introduction and hypothesisEndoanal ultrasound (EAUS) and anal manometry are used in the assessment women with a history of obstetric anal sphincter injury (OASI), both postpartum and in a subsequent pregnancy, to aid counselling regarding mode of delivery (MOD).MethodsA prospective observational study between 2012 to 2020 was completed. Women were reviewed 3 months postpartum following OASI and in the second half of a subsequent pregnancy. Anorectal symptoms were measured using the validated St Mark’s Incontinence Score (SMIS: asymptomatic to mild symptoms = ≤ 4). Anal manometry (incremental maximum squeeze pressure [iMSP: normal = > 20 mmHg]) and EAUS (abnormal = sphincter defect > 1 h in size) were performed.ResultsOne hundred forty-six women were identified and 67.8% had an anal sphincter defect ≤ 1 h in size postnatally. In those with a defect ≤ 1 h, postpartum mean iMSP and SMIS significantly improved in a subsequent pregnancy (p = 0.04 and p = 0.01, respectively). In women with a defect > 1 h, there was no significant difference between the mean iMSP or SMIS score postnatally compared to a subsequent pregnancy. At both time points, significantly more women had an anal sphincter defect ≤ 1 h and SMIS of ≤ 4 (p = 0.001 and p < 0.001 respectively) compared to those with a defect < 1 h. In addition, significantly more women had an anal sphincter defect ≤ 1 h and iMSP ≥ 20 mmHg (p < 0.001). Overall, out of the 146 women included in this study, 76 (52.1%) with a defect ≤ 1 h also had an iMSP ≥ 20 mmHg and SMIS ≤ 4 at 3 months postpartum.ConclusionsWomen who remain asymptomatic with normal anal manometry and no abnormal sphincter defects on EAUS postnatally do not need to have these investigations repeated in a subsequent pregnancy and can be recommended to have a vaginal delivery. If our protocol was modified, over half of the women in this study could have had their MOD recommendation made in the postnatal period alone.

Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS)\u2014a nested case-controlled study

Introduction and hypothesisObstetric anal sphincter injury (OASI) is a significant risk factor for developing anal incontinence. It can therefore be hypothesised that recurrent OASI in a subsequent delivery may predispose women to further anal sphincter dysfunction.MethodsA nested case-controlled study based on data collected prospectively between 2006 and 2019. Women matched for age and ethnicity, with a history of one OASI and no sphincter damage in a subsequent delivery (control) were compared to women sustaining a second OASI. Assessment was carried out using the St Mark’s score (SMIS), anorectal manometry and endoanal ultrasound scan (findings quantified using the modified Starck score).ResultsEighty-four women were included and equally distributed between the two groups, who were followed up 12 weeks postnatally. No difference in SMIS scores was found. Maximum resting pressure (MRP, mmHg) and maximum squeeze pressure (MSP, mmHg) were significantly reduced in the study group. Median (IQR) MRP in the study group was 40.0 (31.3–54.0) versus 46.0 (39.3–61.5) in the control group (p = 0.030). Median (IQR) MSP was 73.0 (58.3–93.5) in the study group versus 92.5 (70.5–110.8) (p = 0.006) in the control group. A significant difference (p = 0.002) was found in the modified Starck score between the study group (median 0.0 [IQR 0.0–6.0]) and control group (median 0.0 [IQR 0.0–0.0]).ConclusionsWe have demonstrated that women with recurrent OASI do not have significant anorectal symptoms compared to those with one OASI 12 weeks after delivery, but worse anal sphincter function and integrity. Therefore, on long-term follow-up, symptoms may possibly develop. This information will be useful when counselling women in a subsequent pregnancy.

08: Regenerative medicine approach to augment surgical repair of anal sphincter injuries: Injection of purified exosome product may improve anorectal manometry parameters and sphincter integrity

08: Regenerative medicine approach to augment surgical repair of anal sphincter injuries: Injection of purified exosome product may improve anorectal manometry parameters and sphincter integrity

Role of Endoanal Ultrasonography in Grading Anal Sphincter Integrity in Rectal Prolapse and in Predicting Improvement in the Continence State After Surgical Treatment.

Rectal prolapse can be associated with fecal incontinence (FI) that may not completely resolve after surgical treatment. We aimed to examine the utility of endoanal ultrasonography (EAUS) in identifying the pattern of anal sphincter injury in rectal prolapse and in predicting the improvement in continence state after surgical treatment. Records of patients of rectal prolapse who underwent surgical treatment and were evaluated with EAUS before surgery were screened. According to the degree of anal sphincter injury preoperative EAUS, 4 grades of anal sphincter injury were recognized (0 to III). The preoperative patient characteristics and outcome of surgery in each group were compared. Fifty-nine patients (33 male), mean age 36.2 years, were included in the study. Forty-four (74.5%) patients complained of FI preoperatively. There were 12 (20.3%) patients with grade 0 injury, 29 (49.1%) with grade I, 7 (11.8%) with grade II, and 11 (18.6%) with grade III. Patients with grade III presented more with external rectal prolapse had a significantly longer duration of symptoms and had undergone previous surgery for rectal prolapse significantly more than the patients of the other 3 grades. Patients with grade II and grade III anal sphincter injury had significantly higher incontinence scores and lower anal pressures than grade 0 and grade I patients. Preoperative EAUS is a useful tool for the assessment of anal sphincter injury in patients with rectal prolapse and for predicting improvement in FI after surgical treatment as higher grades of sphincter injury were associated with less improvement in continence than lower grades.

Exo-anal imaging of the anal sphincter: a comparison between introital and transperineal image acquisition.

Three-dimensional exoanal ultrasound imaging of the anal sphincter may be obtained transperineally with a convex probe, or at the introitus with a transvaginal probe. We hypothesised that introital acquisition would yield better quality and more reproducible evaluation. We acquired three 3D volumes of the anal sphincter (one transperineal transverse with a 4- to 8-MHz convex probe and two introital with a 5- to 9-MHz probe in transverse and mid-sagittal view) in 20 representative women attending the gynaecology clinic. Each 3D dataset was anonymised and hence blinded for clinical data and for acquisition method. Images were analysed off-line by two expert specifically trained ultrasonographers in a random order to assess image quality, sphincter integrity and sphincteric measurements. We assessed the intra- and interrater agreement by the Cohen's kappa (κ) and by the intraclass correlation coefficient for categorical and continuous variables respectively. The mid-sagittal introital acquisition had most inconclusive images owing to unsatisfactory quality, on which raters agreed (К = 0.80). Subsequently, agreement in the anal sphincter evaluation between transverse introital and transperineal acquisitions was compared. Agreement on internal anal sphincter gap was excellent for both transverse introital (К = 0.87) and transperineal acquisition (К = 0.93). Agreement on external anal sphincter discontinuity was excellent for the transperineal acquisition (К = 0.87) and good for the transverse introital acquisition (К = 0.73). Intra- and interrater agreement of external and internal anal sphincteric measurements were best for transperineal acquisitions. In our hands, transperineal acquisition with a 4- to 8-MHz probe performed better than introital acquisition with a 5- to 9-MHz probe in the assessment of the anal sphincter complex.

Dynamic 2-dimensional transperineal ultrasound evaluation in labor room as a screening tool for anal sphincter injuries and anal incontinence in primiparous women

Early repair of obstetric anal sphincter injuries is crucial in the prevention of anal incontinence, but the diagnostic accuracy of the clinical examination after delivery is poor. Endoanal ultrasound imaging is now regarded as the gold standard for diagnosing anal sphincter injuries, and it improves the diagnosis of these lacerations. Four-dimensional transperineal ultrasound imaging has been proposed as an effective and less invasive alternative to endoanal ultrasound imaging in the diagnosis of anal sphincter injuries. The purpose of this study was to evaluate the feasibility and accuracy of the assessment of anal sphincter contraction by dynamic 2-dimensional transperineal ultrasound imaging immediately after delivery and its correlation with anal incontinence at the 4-month follow-up evaluation. A nonconsecutive series of nulliparous women with low-risk singleton term pregnancies were recruited in the labor room after vaginal delivery for the purpose of this study from January 2017 to July 2017. All enrolled patients had a clinical examination of the perineum by the caregiver that was repeated by an experienced research fellow. For each patient, a further dynamic 2-dimensional transperineal ultrasound imaging were carried out. Before the perineal repair, the women were asked to contract the anal sphincter during 2-dimensional transperineal ultrasound imaging; they were divided in 2 groups according to the sonographic findings: women with sonographic evidence of anal sphincter contraction (group A) and women with no evidence of contraction at ultrasound imaging (group B). A follow-up examination of anal sphincter integrity with 4-dimensional transperineal ultrasound imaging was carried out 4 months after delivery. At this time, the levator ani integrity was evaluated with the use of 4-dimensional transperineal ultrasound imaging, as previously described. Over the study period 69 women were enrolled. In 55 women (80%), there was evidence of proper anal sphincter contraction (group A); in 14 cases (20%), it was not possible to identify anal sphincter contraction with dynamic 2-dimensional transperineal ultrasound imaging (group B). Obstetric anal sphincter injuries that were detected through clinical examination were significantly more frequent in group B than in group A (13/14 [93%] vs 7/55 [12%]; P<.001). At the 4-month postpartum follow up, the previously recognized obstetric anal sphincter injuries were found to be repaired correctly; a third-degree perineal tear that had not been reported previously was diagnosed by 4-dimensional transperineal ultrasound imaging . Anal incontinence was reported in 8 of 69 patients (11%); it was more frequent in group B when compared with group A (4/14 [29%] vs 4/55 [7%]; P=.047). Dynamic 2-dimensional transperineal ultrasound imaging is a feasible technique and a useful supporting tool for the assessment of anal sphincter integrity in the labor room before suturing. Anal incontinence at the 4-month follow-up evaluation is more frequent among women with no evidence of anal sphincter contraction at dynamic 2-dimensional transperineal ultrasound imaging after delivery.

Efficacy of Plug Treatment for Complex Anorectal Fistulae: Long-term Danish Results.

PurposeBioprosthetic plugs are appealing, allow simple, repeatable applications, preserve sphincter integrity, minimize patient discomfort, and allow subsequent surgical options when needed. However, success rates vary widely. This study assessed the healing rate in our department when both the Cook-Surgisis and the Gore fistula plugs were used and the long-term effectiveness of using anal plugs for managing anal fistulae.MethodsA chart review was performed for patients who had undergone plug insertion between January 2008 and December 2015 at Copenhagen University Hospital, Hvidovre. Data were collected through a prospectively collected database. Plugs were inserted according to guidance provided by 2 experienced surgeons. Long-term results were determined by clinical visits 3, 6, and 12 months after surgery and once yearly thereafter.ResultsFrom 2008 to 2015, 36 fistula plugs were inserted. During the follow-up period with a median duration of 18 months (range, 7–60 months), the fistulae of 52.8% of the patients healed. The plug failure rate was 44.4%, and the fistula recurrence rate was 26.3%. The median time to recurrence was 12 months. The overall success rate for plug treatment in our department was 39% when adjusted for recurrence.ConclusionThe use of bioprosthetic plugs to treat patients with complex anal fistulae seems to be a safe, viable option for complex fistula repair when other surgical attempts have failed. However, it should not be the treatment of choice. Further prospective randomized studies with a sufficient sample-size and standardized measurements are necessary to evaluate the efficacy of fistula plugs fully.

Quality of life and 3D-EUS assessment for anal incontinence after childbirth.

the incidence of obstetric sphincter tears has risen to 15-30% and the prevalence of anal incontinence (AI) symptoms after childbirth may be as high as 40%. The present study evaluates the correlation between obstetric injuries detected by endoanal ultrasound (3D-EUS) and AI symptoms, as well as their impact on the quality of life (QOL) of women after childbirth. a prospective observational study was performed of pregnant women evaluated before (baseline) and three months after childbirth to ensure the integrity of the anal sphincters and to evaluate possible injuries. The Fecal Incontinence Quality of Life (FIQL) questionnaire and the Cleveland Clinic Score of Incontinence (Wexner) were completed before and after childbirth. The questionnaire results were correlated with an assessment of sphincter defects performed by 3D-EUS. a total of 56 females were included in the study. Overall, 48% developed symptoms of AI after childbirth, with a significant decrease in their FIQL compared to the initial evaluation, 3.9 (0.05) vs 3.4 (0.8), respectively (p = 0.000). In addition, 42% of the cohort presented with some kind of obstetric sphincter defect on the 3D-EUS. Instrumental assisted delivery and the sphincter defects were the only two significant factors identified via multivariate analysis that were associated with a decrease in QOL (0.4, 95% CI, 0.07-0.8). AI after childbirth was associated with a huge impact on QOL, especially in patients with sphincter injuries. A complete clinical evaluation, including 3D-EUS, is recommended to prevent, manage or treat AI in primiparous females.

The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury.

Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.