Rosilma Gorete Lima Barreto

Anal canal anatomy showed by three-dimensional anorectal ultrasonography

BackgroundDemonstrate precisely the anatomic configuration of the anal canal and the length and thickness of the anal sphincters using three-dimensional (3-D) anorectal ultra-sonography in both genders.MethodsTwelve normal volunteer males and 14 females, with a mean age of 52.4 and 50.3 years, respectively, were prospectively enrolled in this study. All individuals from both groups were submitted to anorectal ultra-sonography. The anal canal was analyzed, measuring the length and thickness of the external anal sphincter (EAE), internal anal sphincter (IAS), puborectalis muscle (PR) and the gap (distance from the anterior EAS to the anorectal junction) in the midline longitudinal (ML) and transverse (MT) planes, and the results were compared between quadrants and genders.ResultsThe distribution of sphincter muscles is asymmetric in both genders. The anterior upper anal canal is an extension of the rectal wall with all layers clearly identified. The anterior IAS is formed in the distal upper anal canal and is significantly shorter in female than in male in all quadrants. The anterior IAS length is shorter than the posterior and lateral in both genders. The anterior EAS length is significantly shorter (2.2 cm) and the gap is longer (1.2 cm) in female than in male (3.4 cm) (0.7 cm) (p < 0.05), respectively. The posterior and lateral EAS-PR is significant longer in males (3.6 cm) (3.9 cm) than in females (3.2 cm) (3.5 cm) (p < 0.05), respectively. The lateral EAS-PR is significant longer than the posterior part in both genders. The anterior IAS is significantly thicker in males (0.19 cm) than in females (0.12 cm) (p = 0.04).Conclusion3-D anal endosonography enabled measurement of the different anatomical structures of the anal canal and demonstrated its asymmetrical configuration. The shorter anterior EAS and IAS associated with a longer gap could justify the higher incidence of pelvic floor dysfunction in females, especially fecal incontinence and anorectocele with rectal intussusception.

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.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography.

PurposeThis study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD).Materials and methodsThree hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I—105 nulliparous, Group II—165 had at least one vaginal delivery, and Group III—comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions.ResultsNo statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively.ConclusionThe distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

Ecodefecografia tridimensional dinâmica: nova técnica para avaliação da Síndrome da Defecação Obstruída (SDO)

The aim of the present study is to show novel techniques to evaluate the ODS using dynamic three-dimensional endorectal ultrasound and comparing the results with defecography. Twenty-five adult women were included and distributed in two groups. Group I: Fifteen normal women, mean age 52,4 years old (range 23-76) submitted to full proctologic exam and dynamic 3D anorectal ultrasonography to establish the normal patterns of the rectum and anal canal. Group II: Ten female patients complaining of obstructed defecation, mean age 47,8 years old (33 a 65). The main symptoms were incomplete evacuation, disquezia and vaginal or perineal digitation. They were submitted to full proctologic evaluation, followed by defecography and lastly echodefecography by two examiners without knowing the defecography results. The dynamic echodefecography was performed using B-K Medical® equipment, 360o endoprobe, type 2050, with automatic scan during 50 seconds. The mean angle size formed by the PR at rest position (group I) was 87,13o (range 78,9 - 90,8°) (± 1,01) and 99,22o (range 84,9 - 114,5°) (± 1,84) during evacuatory effort.. It was observed that the angle size increased in all normal women, demonstrating PR relaxation during the evacuatory effort. Concerning to anorectocele evaluation, the posterior vagina wall was kept at horizontal position during the evacuatory effort, except in patients with anorectocele. All patients from group II had anorectocele ( grade I = 1, grade II = 5, grade III = 4) demonstrated at clinical and defecography evaluation. All cases were also confirmed by echodefecography. Based on such results, it was established the reference parameters to classify anorectocele according to echodefecography. (grade I - distance of the vaginal wall positions until 5,0mm, grade II from 6,0 to 12,0mm, grade III above 12,0mm). Defecography identified anismus in one patient with anorectocele grade II and in another with grade III and both were confirmed at echodefecography by decreasing the PR angle when compared the resting with straining positions. Defecography showed also four cases of rectal intussusceptions while echodefecography confirmed such findings and identified two other cases. In conclusion, echodefecography can be used as an alternative method to assess patients with ODS because it identifies and quantifies all the anorectal dysfunctions associated with the obstructed defecation, with the advantage to evaluate also the continence disturbances, identifying sphincter injuries. Its minimally invasive, well tolerated, low cost, no radiation exposure and demonstrates precisely all the anatomic structures involved with defecation.

A novel two-dimensional dynamic anal ultrasonography technique to assess anismus comparing with three-dimensional echodefecography

Objective  The aim of this prospective study was to test two‐dimensional dynamic anorectal ultrasonography (2D‐DAUS) in the assessment of anismus and compare it with echodefecography (ECD).

AMPUTAÇÃO ABDOMINOPERINEAL DO RETO E RECONSTRUÇÃO VAGINAL COM RETALHO FASCIOCUTÂNEO GLÚTEO POR RECIDIVA DE CARCINOMA ESPINOCELULAR DE CANAL ANAL ‐ RELATO DE CASO

foram incluídos no estudo todos os pacientes submetidos a cirurgia de APE nesse período, após foi realizado um estudo do perfil epidemiológico desses fazendo revisão do prontuário. Foram analisados a idade, sexo, cor, o tipo histológico e grau de diferenciação celular, realização de tratamento neoadjuvante e o estadiamento clinico. Resultados: Foram incluídos no estudo 21 pacientes, 6 do sexo feminino e 15 do masculino, a média de idade é de 60 anos (27-84). Dois autodeclarados negros. Dois não realizaram neoadjuvância. No estadiamento, 8 pertenciam ao estágio II, 10 ao estágio III e 3 pertenciam ao estágio IV. Quanto ao tipo histológico e grau de diferenciação celular, 15 apresentavam adenocarcinoma moderadamente diferenciado, 2 bem diferenciado, 2 pouco diferenciado e 2 mucinoso. Discussão: Analisando os dados apresentados e comparando com a literatura, podemos observar que em nosso serviço a APE é mais frequente no sexo masculino, 72%, e a média de idade é 60 anos o que é compatível com a literatura. Foi verificado que a maioria dos pacientes realizou tratamento neoadjuvante. Provavelmente devido ao diagnóstico tardio, foi observado a maior prevalência do estágio III, o que evidencia a importância do rastreamento do CCR, no sistema público de saúde. Em relação ao tipo histológico e grau de diferenciação celular o adenocarcinoma moderadamente diferenciado, 72%, tem sido o mais prevalente. Conclusão: Os dados obtidos corroboram a literatura, com predomínio de homens. A média de idade foi de 60 anos, com maior incidência do adenocarcinoma moderadamente diferenciado e com seu diagnóstico tardio, o que reforça a necessidade de diagnóstico precoce.

Managing Adult Anterior Anus and Anovestibular Fistula

This chapter discusses an alternative perspective concerning the management of complex anal fistulae, focusing on anovestibular fistula. There is no single technique for the treatment of all anorectal fistulae. The treatment options must be directed by the surgeon’s experience and judgment. Each of these techniques, including the endorectal advancement flap, formal closure of the internal opening with or without anoplasty, seton deployment and management, ligation of the intersphincteric fistula tract, and the use of fibrin sealants and fistula plugs, should be part of the specialist’s armamentarium.

Three-Dimensional Ultrasonography of Pelvic Floor and Anorectal Anatomy

Here we discuss precisely the anatomic configuration of the anal canal and the length and thickness of the anal sphincters using 3D anorectal ultrasonography in both genders, demonstrating the anal canal’s asymmetrical configuration. The rectum and all adjacent pelvic organs are shown in multiple anatomic planes.