Richelle J. F. Felt-Bersma

Unsuspected sphincter defects shown by anal endosonography after anorectal surgery: A prospective study

PURPOSE: Anorectal surgery can lead to fecal soiling and incontinence. Whether surgery changes the anatomy and causes symptoms is unknown. Anatomic changes can be visualized by anal endosonography. METHODS: We studied 50 patients after hemorrhoidectomy (24), fistulectomy (18), and internal sphincterotomy (8). Symptoms were assessed, and anal endosonography, anal manometry, mucosal electrosensitivity, and neurophysiologic tests were performed. RESULTS: In 23 (46 percent) patients, a defect of the anal sphincter was found (13 patients had an internal sphincter defect, 1 had an external sphincter defect, and 9 had a combined sphincter defect), 3 after hemorrhoidectomy, 13 after fistulectomy, and 7 after internal sphincterotomy. Seven patients had symptoms, and they all had a sphincter defect. In the other 16 of 23 patients (70 percent), the sphincter defect did not produce symptoms. An internal sphincter defect lowered maximum basal pressure and shortened sphincter length. CONCLUSION: Anal endosonography can reveal sphincter defects after anorectal surgery. Seventy percent of the patients in this group had no complaints; therefore, defects were unsuspected. This has clinical implications in the evaluation of patients with fecal incontinence.

Hydrogen peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano

Appropriate classification of the fistulous tracts in patients with fistula-in-ano may be of value for the planning of proper surgery. Conventional transanal ultrasound has limited value in the visualization of fistulous tracts and their internal openings. Hydrogen peroxide can be used as a contrast medium for ultrasound to improve visualization of fistulas. PURPOSE: This prospective study evaluates hydrogen peroxide-enhanced ultrasound in comparison with physical examination, standard ultrasound, and surgery in the assessment of fistula-in-ano. METHODS: Twenty-one consecutive patients (4 women; mean age, 42 years) with fistula-in-ano were evaluated by local physical examination (inspection, probing, and digital examination), conventional ultrasound, and hydrogen peroxide-enhanced ultrasound before surgery. Ultrasound was performed using a B&K Diagnostic Ultrasound System™ with a 7-MHz rotating endoprobe. Hydrogen peroxide (3%) was infusedvia a small catheter into the fistula. The results of physical examination, ultrasound, and hydrogen peroxide-enhanced ultrasound were compared with surgical data as the criterion standard. The additive value of standard ultrasound and hydrogen peroxide-enhanced ultrasound compared with physical examination was also determined. RESULTS: At surgery, 8 intersphincteric and 11 transsphincteric fistulas and 2 sinus tracts (without an internal opening) were found. During physical examination, probing was incomplete in 13 patients, the diagnosis being correct in the other 8 patients (38%) as a low (intersphincteric or transsphincteric) fistula. With conventional ultrasound, the assessment of fistula-in-ano was correct in 13 patients (62%); defects in one or both sphincters could also be found (n=8). With hydrogen peroxide-enhanced ultrasound, the fistulous tract was classified correctly in 20 patients, the overall concordance with surgery being 95%. The internal opening was found at physical examination in 15 patients (71%), with hydrogen peroxide-enhanced ultrasound in 10 patients (48%), and during surgery in 19 patients (90%). Secondary extensions, confirmed during surgery, were found in five cases. In two patients, a secondary extension with hydrogen peroxide-enhanced ultrasound was not confirmed during surgery. Both patients developed a recurrent fistula. CONCLUSION: Hydrogen peroxide-enhanced ultrasound is superior to physical examination and standard ultrasound in delineating the anatomic course of perianal fistulas. It makes accurate preoperative assessment of the fistula possible and may be of value for the surgeon in planning therapeutic strategy.

Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy

Objective To determine risk factors for third degree obstetric perineal tears and to give recommendations for prevention.

Endosonographic Evidence of Persistence of Crohn’s Disease-Associated Fistulas After Infliximab Treatment, Irrespective of Clinical Response

PURPOSE: Infliximab has been reported to improve fistulizing Crohn’s disease. Moreover, prompt healing of mucosal ulcers has been described. Whether fistulas disappear or remainders of fistulas persist is unknown. This study documents fistulous tracts before and after infliximab therapy by means of hydrogen peroxide-enhanced endosonography METHODS: Eight patients with perianal, vaginal, or perineal fistulas were treated with a triplet of infliximab 5 mg/kg infusions. At baseline, and at Week 4 after the last infusion, fistulas were documented by local inspection, digital examination, and hydrogen peroxide-enhanced anal or vaginal endosonography. RESULTS: Patients with vaginal or perineal fistulas did not respond clinically to therapy, whereas patients with perianal fistulas improved considerably. However, in all patents remainders of fistulous tracts were demonstrated by endosonographic techniques. CONCLUSIONS: Short-term treatment of Crohn’s disease-associated fistulas with infliximab does not induce disappearance of fistulous tracts, irrespective of therapeutic response.

Anal sphincter repair improves anorectal function and endosonographic image: A prospective clinical study

PURPOSE: This study investigated the effect of anal sphincter repair on fecal continence in relation to anal endosonography and anal manometry. METHODS: Eighteen patients (7 male, 11 female) with anal sphincter defects and complaints of fecal incontinence (5), soiling (= liquid discharge; 3), or both (10) were studied before and after sphincter repair with endosonography and anal manometry. Complaints were the result of obstetric trauma (7), surgical trauma (7), both (3), and other trauma (1). Five patients had previous surgery. Preoperative endosonography showed a defect of both sphincters in nine patients, a defect of the external anal sphincter in five patients, and a defect of the internal anal sphincter in four patients. An overlapping sphincter repair was performed. RESULTS: Postoperatively and subjectively (S; patients view), 13 (72 percent) patients became continent or improved; in 5 (28 percent) patients the complaints were unaltered. Objectively (O) (incontinence or soiling frequency), these figures were 12 (67 percent) and 6 (33 percent). Postoperative endosonographic images improved in 14 (78 percent) patients; defects of the sphincters (almost) disappeared (4) or were smaller (10). In the other four patients, images were unchanged. In two patients, overlapping of the muscle was clearly visible with anal endosonography. Clinical result (subjective (S) and objective (O)) of sphincter repair correlated with changes in anal endosonography (S,r=0.64,P<0.004; O,r=0.51,P=0.03) and anal manometry (S,r=0.54,P=0.038; O,r=0.44,P=0.09 (not significant)) and not with pudendal nerve latency. CONCLUSION: In 78 percent of our patients, endosonographic sphincter defect had diminished or disappeared after sphincter repair. There was a good correlation between clinical effect of sphincter repair and changes with anal endosonography and anal manometry. Postoperative persistent incontinence is attributable to remaining sphincter defects. Anal endosonography should be performed as a routine procedure in patients with fecal incontinence or soiling, also after failed surgery.

RECTAL PROLAPSE, RECTAL INTUSSUSCEPTION, RECTOCELE, AND SOLITARY RECTAL ULCER SYNDROME

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis

Background: The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed. Methods: A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities. Results: The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy. Conclusion: Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeons personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.

Anal endosonography: Relationship with anal manometry and neurophysiologic tests

Thirty-seven patients were referred for evaluation of anal function; their clinical diagnoses were traumatic fecal incontinence (13), idiopathic (pudendal neuropathy) fecal incontinence (7), fecal soiling (9), and other (8). In all patients, anal endosonography (sphincter defects and internal sphincter thickness [IST]) and anal manometry (maximal basal pressure [MBP] and maximal squeeze pressure [MSP]) were performed. In 18 patients, neurophysiologic tests (EMG-maximal contraction pattern [MCP], single-fiber EMG [fiber density; FD], and pudendal nerve terminal motor latency [PNTML]) were also performed. Endosonography demonstrated in seven patients both an internal and external sphincter defect (Group 1), in seven patients an internal sphincter defect and in one patient an external sphincter defect (Group 2), and in 22 patients no sphincter defect (Group 3). There was a significant difference among these three groups for MBP and MCP, the lowest being in Group 1. Between the patients with traumatic fecal incontinence and idiopathic fecal incontinence, no differences in IST, MBP, MSP, MCP, FD, and PNTML were found. In two patients with a suspected obstetric trauma, there was an unexpected additional severe pudendal neuropathy. In one patient with a suspected obstetric trauma, no damage of the anal sphincters could be demonstrated. In one patient with suspected idiopathic fecal incontinence, there was an additional, unsuspected defect of the internal sphincter. There was concordance between endosonography and EMG in the mapping of the external sphincter. Clinical diagnoses can be misleading in differentiating between traumatic and idiopathic fecal incontinence; anal endosonography provides unsuspected and additional information about the sphincters; PNTML can reveal unsuspected neuropathy in traumatic fecal incontinence. Therefore, the combination of endosonography and PNTML is promising in selecting patients for surgery.

Effects of prucalopride on colonic transit, anorectal function and bowel habits in patients with chronic constipation

There is a need for better tolerated drugs to normalize bowel function in chronic constipation. Prucalopride is a highly selective, specific, serotonin4 receptor agonist with enterokinetic properties.

Defecography in patients with anorectal disorders

To evaluate the results and clinical impact of defecography in patients with anorectal disorders, 100 results of defecographic examinations from 92 patients were reviewed. The defecographic results were screened for the anorectal angle, defined both at rest and during straining, perineal descent, and abnormalities of the rectal configuration during straining. Anal manometry, saline infusion test, rectal capacity measurement, and anal electromyography (EMG) were also performed. There was a significant difference (P<0.001) both at rest (22°) and during straining (12°) between the two anorectal angle measurements. Incontinent patients had a larger anorectal angle, both at rest and during straining, than continent patients (P<0.04), but with a large overlap. The anorectal angle was not influenced by gender or age. An abnormal rectal configuration was found in 62 defecographic examinations. From the 8 patients with rectopexy performed for a large rectocele or intussusception, incontinent patients with an intussusception had the best results. In four patients, anal EMG showed an increased activity of the external sphincter during straining. Two of these four patients had abnormal defecograhic results. No correlations were found between anorectal angle and the other function tests. In conclusion, the anorectal angle lacks clinical relevance. In patients with defecation problems, defecography may be indicated whenever other investigations (physical examination, anal manometry, anal EMG) have excluded local pathology or a spastic pelvic floor syndrome. In these situations, defecography could detect an intussusception, which could easily be treated with rectopexy.