Erico de Carvalho Holanda

The role of 3-dimensional anorectal ultrasonography in the assessment of anterior transsphincteric fistula.

PURPOSE: The aim of this study was to evaluate the role of 3-dimensional anorectal ultrasonography in the choice of surgical technique according to the position of the fistulous tract in patients with anterior transsphincteric anal fistula. METHODS: A total of 33 patients (18 male) with anterior transsphincteric fistulas were evaluated by ultrasonography. The length of the external and internal anal sphincters, the position of the internal opening, the length of the compromised sphincter, and the percentage of sphincter muscle to be transected during surgery were measured, compared between sexes, and used in planning the surgery. Postoperative incontinence symptoms were quantified with a Wexner score. RESULTS: The external and internal sphincters were longer and the position of the internal opening was higher in males. The position where the tract crossed the external sphincter was in both sexes, but the percentage of compromised muscle was higher in females because of the smaller length of the external sphincter. Seton placement followed by fistulotomy or advanced flap repair were indicated in 11 of 18 males and 13 of 15 females as the tract crossed the external sphincter above 50.0%. The mean postoperative follow-up was 12 months. Overall, minor fecal incontinence symptoms were identified in 16 (48.0%) patients. Of these, 11 (73.0%) females and 5 (28.0%) males had a mean incontinence score of 2.9 and 3.0, respectively. CONCLUSIONS: Three-dimensional ultrasonography was shown to be useful in the preoperative assessment of anterior transsphincteric fistulas by quantifying the length of muscle to be transected, contributing to the choice of a safe treatment approach and to the reduction of the rate of postoperative continence disorders.

Anatomic characteristics of anal fistula on three-dimensional anorectal ultrasonography.

BACKGROUND: Surgery for anal fistula is often associated with continence disorders due to the transection of sphincter muscles. Extensive knowledge of anal canal anatomy and anal fistula can help prevent this outcome. OBJECTIVE: This study aimed to correlate the anatomical conformation of the anal canal, the fistula track, and the internal opening according to sex and hemicircumference (anterior vs posterior) by use of 3-dimensional ultrasonography. METHODS: One hundred sixty-five patients with fistula were evaluated with 3-dimensional ultrasound and grouped according to sex, fistula type, internal opening, and track position. Fistulas were transsphincteric in 128 subjects and intersphincteric in 37 subjects. The study measured the external and internal anal sphincter, the puborectalis, the distance from the internal opening to the distal edge of the external and internal sphincter, the length of the internal and external sphincter compromised by the track, and the percentage of compromised muscle. RESULTS: The anal canal muscles were longer in males. The distance from the internal opening to the internal sphincter was greater for the posterior hemicircumference. The point where the fistulous track crossed the anterior external sphincter was similar for the 2 sexes, but the percentage of compromised muscle was greater in females. The point where the fistulous track crossed the internal sphincter was similar for the 2 sexes, but the percentage of compromised internal sphincter was greater in males for the posterior hemicircumference. The study was limited by the absence of testing for interobserver and intraobserver agreement. CONCLUSION: The anal canal muscles are longer in males and the pectinate line is asymmetrical. In females, the percentage of compromised external sphincter was greater in the anterior hemicircumference because of the shorter external sphincter, whereas in males the percentage of compromised internal sphincter was greater in the posterior hemicircumference.

AVALIAÇÃO DA EXPERIÊNCIA INICIAL DOS 15 PRIMEIROS CASOS DE DESARTERIALIZAÇÃO HEMORROIDAL TRANSANAL (THD) NO NOSSO SERVIÇO

rial, na qual estão associados fatores de risco, genéticos e imunológicos. Objetivo: Apresentar uma revisão sistemática sobre o perfil epidemiológico, socioeconômico, nutricional e clínico dos portadores da DC. Metodologia: Revisão de artigos indexados em três bases de dados: Biblioteca Virtual em Saúde, Pubmed e Scielo. Com uso dos seguintes descritores: doença de Crohn, epidemiologia, etiologia e perfil socioeconômico. Os critérios de inclusão foram: artigos científicos publicados em periódicos da área da saúde, nacionais completos publicados em português ou inglês, com resumos disponíveis nas bases de dados selecionadas. Resultados: Com base nos estudos analisados, nos pacientes com DC predominam o sexo feminino, a etnia branca e faixa entre 20-40 anos, porém pode acometer desde a população pediátrica até idosos. A maioria dos portadores dessa doença apresenta nível de escolaridade até ensino fundamental e baixa renda per capita. Uma porcentagem considerável de pacientes encontrava-se desnutrida ao diagnóstico. Observou-se também relação do hábito de fumar com a presença e o curso da alteração patológica. Nota-se que alguns pacientes apresentaram quadro de gastroenterite antes da manifestação da DC. Conclusão: A DC tem relevante taxa de morbimortalidade, pode desenvolver muitas complicações e debilitar seus portadores. Para formular um projeto terapêutico adequado que altere o curso natural da doença e evite suas complicações, é importante ter o conhecimento prévio dos fatores epidemiológicos desses doentes. A partir da revisão, observa-se a presente impossibilidade de determinar um único perfil de pacientes que manifestam a DC, além de haver estudos divergentes aos resultados encontrados.

Ultrassom anorretal tri-dimensional pode selecionar pacientes com tumor no reto após neoadjuvância para cirurgia de preservação esfincteriana?

ABSTRACT: Proposal:Evaluate the post-chemoradiotherapy response for treatment of rectal tumor using three-dimensionalanorectal ultrasound-3D-US to determine the best surgical approach Methods:32 patients with lower and middle rectal cancerwere prospectively staged using 3D-US to identify anal canal invasion and the distance(cm) between tumor and the internal analsphincter-IAS, Group l:with anal canal invasion; Group II-with distance =2cm; Group III-with distance >2. They were submittedto neoadjuvant chemoradiation-CR T and the 3-D US was r epeated 50-55 days later . The choice of the surgical appr oach was basedon the post-chemoradiation response identified by the 3D-US comparing with pathologic findings. Results:The post-chemoradiation/3D-US findings were concordant with pathologic results in 31/32(97%). It was identified residual tumors in 26/27(96% sensibility), 19(59%) with partial response and 7(22%) without response. Complete response was demonstrated in 5/5 by3D-US, with specificity and predictive valor in 100%. Negative predictive valor in 83% since one(3%) case was inconclusive.Sphincter-saving resection was performed in 16 patients, 5 with complete response, 10 with partial response and one inconclusive,with distal margin >2cm. The pathologic findings confirmed distal margins without tumor. It was demonstrated highconcordance(87.5%) concerning the lymph nodes evaluation(Kappa test). Conclusion: 3D-US can be useful to determine thepatients who should be submitted to sphincter-saving resections.Key words: Rectal Cancer; Endorectal Ultrasonography; Radiotherapy; Surgery Treatment.