Rachel L. West

Prospective comparison of hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas.

AbstractPURPOSE: This study was conducted to determine agreement between hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in the preoperative assessment of perianal fistulas and to compare these results with the surgical findings. METHODS: Twenty-one patients (aged 26–71 years) with clinical symptoms of a cryptoglandular perianal fistula and a visible external opening underwent preoperative hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography, endoanal magnetic resonance imaging, and surgical exploration. The results were assessed separately by experienced observers blinded as to each other’s findings. Each fistula was described with notice of the following characteristics: classification of the primary fistula tract according to Parks (intersphincteric, transsphincteric, extrasphincteric, or suprasphincteric), horseshoe, or not classified; presence of secondary tracts (circular or linear); and location of an internal opening. RESULTS: The median time between hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging was 66 (interquartile range, 21–160) days; the median time between the last study (hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography or endoanal magnetic resonance imaging) and surgery was 154 (interquartile range, 95–189) days. Agreement for the classification of the primary fistula tract was 81 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 90 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. For secondary tracts, agreement was 67 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 57 percent for endoanal magnetic resonance imaging and surgery, and 71 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in case of circular tracts and 76 percent, 81 percent, and 71 percent, respectively, in case of linear tracts. Agreement for the location of an internal opening was 86 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 86 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. CONCLUSIONS: For evaluation of perianal fistulas, hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging have good agreement, especially for classification of the primary fistula tract and the location of an internal opening. These results also show good agreement compared with surgical findings. Therefore, hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging can both be used as reliable methods for preoperative evaluation of perianal fistulas.

Hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in evaluating perianal fistulas: Agreement and patient preference

Objectives To determine agreement between hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography (3D HPUS) and endoanal magnetic resonance imaging (MRI) in preoperative assessment of perianal fistulas, and to assess patient preference with regard to these techniques. Methods Forty patients (31 males, aged 21–70 years) with symptoms of a perianal fistula and a visible external opening underwent preoperative 3D HPUS and endoanal MRI. The results were assessed separately by experienced observers. Fistulas were described according to the following characteristics: classification of the primary fistula tract according to Parks, location of the internal opening, presence of secondary tracts and fluid collections. Patients were asked to score the amount of discomfort experienced during both procedures and express their preference for either method. Results The median time interval between 3D HPUS and endoanal MRI was 14 days (range, 0–91 days). The methods agreed in 88% (35/40, κ = 0.45) for the primary fistula tract, in 90% (36/40, κ = 0.83) for the location of the internal opening, in 78% (31/40, κ = 0.62) for secondary tracts, and in 88% (35/40, κ = 0.63) for fluid collections. Both methods were associated with similar discomfort, and there was no patient preference for one procedure over the other. Conclusions 3D HPUS and endoanal MRI are equally adequate for the evaluation of perianal fistulas. Both methods are associated with similar discomfort and patients have no preference for either procedure.

Volume Measurements of the Anal Sphincter Complex in Healthy Controls and Fecal-Incontinent Patients With a Three-Dimensional Reconstruction of Endoanal Ultrasonography Images

OBJECTIVESThe aim of this study was to determine sphincter volume, length, and external anal sphincter thickness in healthy controls and fecal incontinent patients by use of a three-dimensional reconstruction of endoanal ultrasonography images.METHODSForty-four controls (15 males, 15 females, and 14 parous females) and 28 incontinent parous females (with and without a sphincter defect) were studied. Internal anal sphincter, external anal sphincter and puborectalis volume, sphincter length, and external anal sphincter thickness were measured. Intraobserver and interobserver variability were assessed. Anal pressure profile was also determined.RESULTSInternal anal sphincter and external anal sphincter volumes were larger in males than in females (P = 0.001 and P = 0.04), and external anal sphincter volume was smaller in parous females but this was not significant (P = 0.084). Anterior sphincter length was longer in males (P = 0.004) and shorter in parous females (P = 0.06). Males had a larger anterior external anal sphincter thickness (P = 0.018); parity made no difference. Sphincter volumes were not smaller in incontinent females. Incontinent females with a sphincter defect had a shorter anterior sphincter length than that of continent (P = 0.001) and incontinent females without a sphincter defect (P < 0.001). Anterior external anal sphincter thickness was smaller in incontinent females with a sphincter defect (P = 0.006), and posterior and right external anal sphincter thickness was smaller in incontinent females without a sphincter defect (P = 0.02 and P = 0.03). Intraobserver variability was seen for internal anal sphincter volume and sphincter length, but there was no interobserver variability. Correlation between anal pressures and endoanal ultrasonography measurements was poor.CONCLUSIONSDifferences in anal sphincter volumes are seen for gender but not for parity. Fecal incontinence is not associated with loss of sphincter volume. However, anterior sphincter length and external anal sphincter thickness are smaller.

Impact of double-balloon enteroscopy findings on the management of Crohn's disease

Abstract Objective. It is estimated that 10%–30% of Crohns disease (CD) patients have small-bowel lesions, but the exact frequency and clinical relevance of these findings are unknown. Double-balloon enteroscopy (DBE) enables endoscopic visualization of the small bowel. The aim of this study was to evaluate the use of DBE for detecting small-bowel lesions in CD patients suspected of having small-bowel involvement. Furthermore, the clinical impact of adjusting treatment in these patients was assessed. Material and methods. A prospective study was performed in a tertiary referral center. CD patients suspected of small-bowel involvement and in whom distal activity had previously been excluded were included. All patients underwent DBE, followed by step-up therapy in patients with small-bowel lesions. The presence of small-bowel lesions during DBE was noted and clinical outcome was assessed after adjusting therapy. Results. Thirty-five patients (70%) showed small-bowel lesions; these lesions could not be assessed by conventional endoscopy in 23 (46%). At 1-year follow-up, step-up therapy in 26 patients (74%) led to clinical remission in 23 (88%). This was confirmed by a significant decrease in Crohns disease activity index and mucosal repair on second DBE. Conclusions. DBE showed a high frequency of small-bowel lesions in known CD patients with clinically suspected small-bowel activity. Most of these lesions were not accessible for conventional endoscopy. Adjusting treatment in patients with small-bowel CD involvement led to clinical remission and mucosal repair in the majority of cases.

Detection of anal sphincter defects in female patients with fecal incontinence: a comparison of 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound.

BACKGROUND: 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. OBJECTIVE: 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. DESIGN: This study was designed as a prospective observational study. SETTINGS: The study took place in a university hospital. PATIENTS: 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. MAIN OUTCOME MEASURES: The main outcome measures are the presence of external and internal anal sphincter defects. RESULTS: 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 &kgr; coefficient for the detection of external (&kgr; = 0.63) and internal (&kgr; = 0.78) anal sphincter defects was good. LIMITATIONS: This study’s limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. CONCLUSION: 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.

Integrity of the Anal Sphincters After Pouch-Anal Anastomosis: Evaluation With Three-Dimensional Endoanal Ultrasonography

PURPOSEThe aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography.METHODSPatients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI).RESULTSFifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores.CONCLUSIONHandsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.

Stimulation of defecation: Effects of coffee use and nicotine on rectal tone and visceral sensitivity

Objective Coffee and cigarette use is believed to induce bowel movements, although the literature is controversial and precise measurements of rectal tone and sensitivity with a barostat have never been performed. The aim of this study was to assess the effects of coffee and nicotine on rectal tone, compliance and sensitivity. Material and methods Sixteen healthy volunteers were recruited for the coffee (n=8) and nicotine (n=8) experiments. The experiments were randomly performed in a placebo-controlled crossover design on separate days. In the coffee experiment, 280 ml strong coffee or warm water was drunk and in the nicotine experiment, nicotine (2 mg) or placebo was given sublingually. A rectal barostat procedure was carried out. A flaccid bag, mounted on a catheter, was inserted in the rectum. Continuous pressure distension was exerted to register basal visceral sensitivity and compliance. After rectal adaptation, the stimulus was given. Rectal tone was measured for 1 h, after which continuous pressure distension was repeated. Results Rectal tone increased by 45% 30 min after coffee intake (p=0.031) and by 30% after water intake (p=0.032), but the effects of coffee and water were not significantly different. Rectal tone did not change significantly after administration of nicotine (7%) or placebo (10%). There was no difference in compliance and visceral sensitivity between coffee and water or nicotine and placebo. Conclusions Both coffee and warm water have an effect on defecation by increasing rectal tone, but nicotine (2 mg) did not affect rectal tone. Coffee and nicotine did not influence sensitivity or compliance.