Sthela Maria Murad Regadas

Importância do ultra-som tridimensional na avaliação anorretal

BACKGROUND Anorectal endosonography is actually the main image exam to evaluate some anorectal diseases. AIM To show the three-dimensional endosonography importance in the anal canal anatomic evaluation and the anorectal diseases diagnosis. METHODS Seventy four anorectal ultrasound were performed, 23 normal individuals (13 women) and 51 patients (33 women) with benign and malignant diseases. All the patients were examined with a 3-D equipment with 360 degrees transducer. Normal individuals were evaluated in midline sagittal plane concerning to the length of the anal canal, the internal anal sphincter, the external anal sphincter and the anatomic defect in the anterior quadrant. RESULTS There were no differences in the anal canal and the internal anal sphincter length between men and women. Otherwise, the external anal sphincter length is longer in men and the anatomic defect is longer in women. In those with anorectal diseases, 11 sphincter injuries, 8 anal fistulas, 7 abscess, 1 perirectal endometriosis, 1 pre-sacral cyst, 3 anal canal and 10 rectal malignant neoplasias were diagnosed. The surgical findings confirmed the ultrasound diagnosis in all the patients. CONCLUSION Three-dimensional endosonography demonstrated the anatomic differences between male and female anal canal, justifying the larger incidence of pelvic floor disorders in female patients. It was possible to diagnose the anorectal diseases, in multi-plane, with high spatial resolution, adding also important informations about the therapeutic decision. Such characteristics become it similar to nuclear magnetic resonance with intra-rectal coil, with the advantages to be easier, quicker, low cost and better tolerated.

Imaging atlas of the pelvic floor and anorectal diseases

This chapter should help to clarify the anatomical relationships and complex anorectal topography that can be clearly visualized by modern ultrasound techniques and should be recognized by the pelvic surgeon. The pelvic floor forms the supportive and caudal border of the abdominal cavity. Previous anatomical studies have demonstrated that the pelvic connective tissue can be divided into three compartments: anterior, middle, and posterior. This chapter is dedicated to the posterior compartment and reflects the supportive function of the pelvic floor muscle systems as well as its impact on continence function and defecation.

2- and 3-D Ultrasonography of Endometriosis, Pelvic Cyst, Rectal Solitary Ulcer, Muscle Hypertrophy, Rare Neoplasms

Here we discuss the role of the anorectal two- and three-dimensional ultrasonography in evaluating rarer benign and malignant anorectal and pelvic diseases. This is a useful exam to stage such lesions, identifying their relationship with the rectal wall and sphincter muscles and helping choose the best treatment option.

Two- and Three-dimensional Ultrasonography in Benign and Malignant Rectal Neoplasms

Ultrasound (US) scanning plays an important role in locoregional tumor staging and has been shown to be efficient in detecting parietal invasion and metastasized perirectal lymph nodes. This chapter discusses the role of anorectal US in evaluating the extent of tumor invasion in the rectal wall, sphincter muscles, and perirectal lymph nodes; the extent of tumor invasion following radiotherapy; and detecting early local recurrence in the rectal wall or perirectal lymph nodes. The three-dimensional scanning mode enables the examiner to stage lesions in multiple planes, measure tumor length, and determine the distance between the distal tumor border and the sphincter muscles for comparison with measurements taken after radiotherapy. This is an important aspect to consider when planning surgical resection with or without sphincter saving. In addition, the three-dimensional scanning mode is safer, as it makes it possible to review the images posteriorly, in real time, as required by some lesions.

Two- and Three-dimensional Ultrasonography in Abscess and Anal Fistula

Three-dimensional anorectal ultrasound presents an important role in the evaluation of cryptoglandular disease of the anal canal. It clearly shows the location, extent of the abscess cavity, and relation to the sphincter muscles and rectal wall, making classification possible, which is particularly important for the complex abscess. It is also particularly useful for evaluating anorectal fistulas, as it identifies primary and secondary tracts, internal opening, and adjacent cavities. This information facilitates surgical planning, consequently preventing recurrence and fecal incontinence.

Two- and Three-dimensional Ultrasonography of Anatomic Defects in Fecal Incontinence

Here we discuss the role of endoanal ultrasound (US) scanning in fecal incontinence. Two-dimensional (2-D) US demonstrates precisely the type and extent of muscle injuries in relation to the anal circumference, whereas 3-D scanning shows it in relation to anal canal length. Interpretation of 3-D imaging is simpler, as muscle length can also be measured longitudinally. The exact identification of the injured muscles is important in deciding upon the best therapeutic option. Anal US can also be useful in evaluating the results of surgical repair, identifying adjacent or overlapping muscles, and documenting persisting muscle injury.

Dynamic Two- and Three-dimensional Ultrasonography: Echodefecography

Here we describe a novel dynamic ultrasonography technique — echodefecography — using a 360° two-and three- dimensional transducer with automatic scanning to assess patients with obstructed defecation. The technique is useful to evaluate evacuation disturbances affecting the posterior compartment (anorectocele, intussusception, prolapse, and anismus) and the middle compartment (enterocele). Echodefecography may be used as an alternative method to assess patients with obstructive defecation syndrome, as it has been shown to detect the same anorectal dysfunctions identified by defecography.

Staging and Follow-up of Anal Canal Neoplasms with 2- and 3-D Ultrasonography

Here we discuss the importance of the three-dimensional ultrasonography in evaluating malignant tumor of the anal canal as it allows quantifying the extent of tumor invasion into the sphincter muscles, adjacent tissues, and rectum, identifying lymph nodes as well. This modality is very useful in evaluating chemoradiotherapy response and selecting safe biopsy sites in case of suspicion of early recurrence.

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.

Utilização do método videolaparoscopico na reconstituição do trânsito intestinal após a operação de Hartmann

O objetivo e apresentar a padronizacao da tecnica operatoria e os resultados obtidos com a utilizacao do acesso videolaparoscopico na reconstituicao do trânsito intestinal em pacientes previamente submetidos a operacao de Hartmann por causas diversas. Foram analisados prospectivamente 32 pacientes, no periodo de dezembro de 1991 a junho de 1997, com distribuicao semelhante com relacao ao sexo e com idade media de 42,4 anos. Todos os pacientes foram submetidos ao mesmo preparo pre-operatorio e a mesma tecnica cirurgica. Ocorreram tres (9,3%) complicacoes transoperatorias. Uma (3,1 %) anastomose mecânica incompleta, necessitando de endossutura manual, uma (3,1 %) laceracao do reto com o grampeador mecânico e uma (3,1 %) lesao da arteria epigastrica direita. Ocorreram ainda tres (9,3%) conversoes, sendo uma (3,1 %) devido a laceracao do reto com o grampeador mecânico, outra (3.1 %) pela invasao tumoral na pelve e outra (3,1 %) pela presenca de excessivas aderencias intraperitoneais. O tempo operatorio variou de 30 a 240 minutos, na media de 126,2 minutos (2,1 horas). A evolucao clinica pos-operatoria foi satisfatoria. Nove (31,0%) pacientes nao referiram dor, enquanto 13 (44,8%) a referiram em pequena intensidade, e apenas sete (24,0%) queixaram-se de dor com maior intensidade. A dieta liquida via oral foi instituida no periodo medio de 1,6 dias, e a primeira evacuacao ocorreu na media de 3,2 dias de pos-operatorio. O periodo medio de hospitalizacao foi de 4,7 dias. Ocorreram complicacoes pos-operatorias em oito (27,5%) pacientes. Duas (6,8%) infeccoes da ferida do estoma, dois pacientes (6,8%) com dor no ombro direito, uma (3,4%) deiscencia de anastomose, um (3,4%) caso de peritonite por provavel contaminacao do material cirurgico, uma colecao liquida pelvica e uma hernia incisional. Em conclusao, a reconstituicao do trânsito intestinal por videolaparoscopia apresentou-se segura e eficaz, podendo constituir-se no metodo cirurgico de escolha, pois foi utilizada com sucesso em 90,6% dos pacientes.