Accuracy of hydrogen peroxide-enhanced ultrasound in the identification of internal openings of anal fistulas

Objective This prospective study was designed to assess the accuracy of hydrogen peroxide‐enhanced ultrasound in the identification of internal openings of anal fistulas, with surgical findings as the golden standard. Patients and methods A total of 143 consecutive patients (102 men; mean age, 45 years) with fistula‐in‐ano were assessed by hydrogen peroxide‐enhanced ultrasound before surgery involving one radiologist. Ultrasound was performed using a B & K Diagnostic Ultrasound System^? with a 10‐MHz rotating endoprobe. Hydrogen peroxide (3%) was infused into the fistula. All operations were perfomed by the same surgeon who was unaware of results of anal endosonography. Results In 128 (89.5%) patients, an internal opening was identified at surgery. Correct identification of an internal opening endosonographically was recorded in 80 (62.5%) patients. The internal opening was correctly identified by ultrasound in 32% (8/25) of patients with intersphincteric fistulas, in 77% (70/91) with transsphincteric fistulas, and in 17% (2/12) with suprasphincteric fistulas. Conclusion The accuracy of hydrogen peroxide‐enhanced anal endosonography for the identification of internal openings was still insufficient to justify pre‐operative endosonography as a diagnostic method for routine use in patients with fistula‐in‐ano.     

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目的 了解经肛门超声内镜检查对内口已经愈合的肛瘘病人内口部位的诊断价值。方法 对临床常规手术未能发现肛瘘内口的12例病人进行超声内镜检查,并进行手术治疗。分析经肛门超声内镜检查对内口已经愈合的肛瘘病人内口部位的诊断价值和超声影像学特点,并与其它常规检查方法比较。结果 内镜超声检查在12例病 人均发现已经愈合的内口的准确位置,准确性优于Goodsall规律、肛门直肠肛门指诊、窦道造影或美蓝注射以及窦道探针探查。结论 经肛瘘外口位置注射美蓝,可方便手术医师快速定位内口。经肛门超声内镜检查是定位已经愈合的肛瘘内口的准确、快速、简单、耐受性好的检查手段。在超声内镜发现内口后,经内镜在内口位置注射美蓝,可方便手术医师快速定位内口。     

Anal sphincter defects. Correlation between endoanal ultrasound and surgery.

OBJECTIVE: This study was performed to (1) correlate and sphincter defects, identified by endoanal ultrasound with operative findings, and (2) define the appearance of such sphincter defects as seen at operation. SUMMARY BACKGROUND DATA: Endoanal ultrasonography is a minimally invasive method of imaging the anal sphincter complex and enables identification of anal sphincter defects. Little is known about the accuracy and limitations of endoanal ultrasound in identifying such defects. Furthermore, there are no data about the appearances of these endosonic sphincter defects as seen at operation. METHODS: Forty-four patients (40 women; age range, 26 to 80 years; mean age, 56 years) with fecal incontinence, undergoing pelvic floor repair, were investigated by endoanal ultrasound before operation. Endosonic findings were correlated with the appearances of external anal sphincter, internal anal sphincter, and intersphincteric space, at operation. Diagnosis of the site and type of defect was made by macroscopic appearances. Uncertainty about the type of sphincter defect was resolved by obtaining muscle biopsies for histology. RESULTS: All external sphincter defects seen by endoanal ultrasound (n = 23) were confirmed at operation. Twenty-one of 22 internal sphincter defects identified by endosonography also were confirmed at operation. In ten patients with a neuropathic anal sphincter complex, the morphology was normal on endosonography, and this was confirmed at operation. (Sensitivity and specificity of 100% for external anal sphincter; 100% and 95.5%, respectively, for internal and sphincter) CONCLUSIONS: These data show that endoanal ultrasound is an accurate method of identifying anal sphincter defects.     

Incidence of fistula-in-ano complicating anorectal sepsis: a prospective study

The incidence of fistula-in-ano following anorectal abscesses was studied prospectively in 50 consecutive patients. A total of 13 patients (26 per cent; 95 per cent confidence limits: 14-40) had a fistula diagnosed either in the acute phase or during follow-up within 6 months. Half of the fistulas diagnosed at follow-up were unrecognized by the patients and no fistulas developed in patients where culture from the abscess only revealed skin-derived bacterias. X-ray examination was of no value in the diagnosis of anal fistula.     

Accuracy of endorectal ultrasound after preoperative radiochemotherapy in locally advanced rectal cancer

Objectives: Factors limiting the accuracy of endorectal ultrasound in staging, locally advanced primary rectal cancer after preoperative neoadjuvant radiochemotherapy (RCT) were evaluated. Methods: Patients (n= 84) with initial locally advanced rectal cancer (uT3/uT4) undergoing R0 resection were investigated after preoperative treatment that combined radiotherapy up to 45 Gy with two cycles of chemotherapy (5-FU and leucovorin on d 1–5 and 22–28). At 4 to 6 weeks after completion of RCT and before tumor resection, preoperative endoluminal ultrasound was performed. Results: The accuracy to predict the depth of tumor infiltration (T-category) was found to correlate with downstaging. The T-category was correctly staged before surgery in 15 of the 51 responders (29%) and in 27 of 33 nonresponders (82%), whereas misinterpretation occurred in 36 of the responders (71%) and in 6 of the nonresponders (18%) (p < 0.001). Neither tumor distance from anal verge nor tumor location correlated with the staging accuracy. Lymph node involvement was correctly assessed in 48 patients (57%). Wall invasion was correctly ascertained in 42 patients (50%), with under estimation in 11 patients (13%) and overestimation in 31 patients (37%). Conclusions: After radiochemotherapy, endosonography does not provide a satisfactory accuracy for preoperative staging of rectal cancer. New interpretation and diagnostic criteria are needed for the prediction of treatment response. Received: 28 February 1999/Accepted: 2 April 1999     

Rolle der Bildgebung bei Analinkontinenz

Endoanal sonography is a well established method for the morphological diagnosis of anal sphincter damage. The best images are obtained using a 7-10 MHz rotating rigid endoprobe. The internal anal sphincter and the external anal sphincter, as well as the other pelvic floor structures, can be clearly visualised with this technique. Endosonography has shown physiological differences in sphincter anatomy and brought new insights into the pathogenesis of anorectal disorders. Apart of anal fistulas, faecal incontinence represents the main indication for the use of this method. In addition, rectal evacuation disorders are an indication for which endosonography allows a first step towards a diagnosis. Anal ultrasound is a technique friendly to both the physician and the patient, and belongs in every coloproctological unit for the assessment of faecal incontinence. Accuracy, specificity and sensitivity for the detection of anal sphincter defects range between 83 and 100% in almost all studies. Additional methods are vaginal endosonography, three dimensional endosonography and perineal sonography.     

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??Three-dimensional endoanal ultrasound for the locational diagnosis of anal fistula: a preliminary application study BEI Shao-sheng??DING Ke, WANG Jian-xin, et al??Department of Anorectal Surgy??the Second Hospital of Shandong University??Jinan 250033??China Corresponding author??DING Ke??E-mail??dingke@163.com Abstract Objective To evaluate the effectiveness and applied value of three-dimensional (3D)-Endoanal ultrasound combined with hydrogen peroxide angiography for the locational diagnosis of anal fistula. Methods 3D-endoanal ultrasound examination was performed in 17 patients with clinically suspected anal fistulas between November 2008 and January 2009 at the Second Hospital of Shandong University and results were compared with surgical findings. Results Seventeen patients were confirmed by 3D-endoanal ultrasound examination. Nine patients had simple fistulas. Eight patients had complex fistulas. At the same time 7 patients had low located fistulas, and 10 patients had high located fistulas including 8 patients with trsphincter fistulas, 1 patient with inter sphincter fistula and 1 patient with extra-sphincter fistula. All patients were confirmed by operation. But on surgery’s professional examination 1 case with high located fistulas was remisdiagnosed as low located fistulas.3D-Endoanal ultrasound had a accuracy of 90.9%. The 3D shape and track of fistula could be well shown the site of anal fistula and its relationship with the phincter complex and the levator animuscle. Conclusion 3D-Endoanal ultrasound examination combined with fistulography is a very effective and reliable method for the locational diagnosis of anal fistula.     

Diagnosis of anorectal tuberculosis by polymerase chain reaction,GeneXpert and histopathology in 1336 samples in 776 anal fistula patients

BACKGROUNDThe association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas. AIMTo detect TB in fistula-in-ano patients were analyzed in different methods utilized.METHODSA retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.RESULTSIn 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 vs 3/197 respectively) (P = 0.0012, significant, Fisher’s exact test) and PCR-pus was significantly better than PCR-tissue (77/331 vs 52/703 respectively) (P < 0.00001, significant, Fisher’s exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) vs 278/727 (44.3%) respectively] (P < 0.00001, significant, Fisher’s exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) vs 518/556 (93.2%) respectively] (P = 0.10, not significant, Fisher’s exact test).CONCLUSIONThis is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.     

Endosonographic examination of gastrointestinal anastomoses with suspected locoregional tumor recurrence

Background: Endoscopic ultrasound is considered one of the best tools for the preoperative staging of esophageal, gastric, and rectal carcinoma. Depending on the individual investigator, the sensitivity of preoperative tumor staging by endosonography of the upper gastrointestinal tract (GEUS) is 80–92% for gastric carcinoma and 86–95% for esophageal carcinoma. However, the sensitivity and specificity of endosonography for the staging of lymph node metastases is less accurate. The accuracy of rectal endosonography (REUS) is ∼90% for tumor assessment and ∼80% for the detection of lymph node metastases. In this study, we address the question of whether endosonography enables the surgeon to distinguish scar tissue, which is rather homogeneous and echo-rich, from changes such as an anastomositis or a locoregional tumor recurrence, which are typically noninhomogeneous and echo-poor. Methods: During a 24-months period, we studied patients enrolled in a special tumor follow-up care program by either upper gastrointestinal (GEUS, n= 37 patients) or rectal endosonography (REUS, n= 49 patients) for exclusion of a locoregional tumor recurrence. In each patient, local tumor recurrence was suspected because of either medical history, clinical examination, or other diagnostic procedures. Results: As in previous studies, our retrospective analysis revealed that endosonography has a high sensitivity in the detection of local tumor recurrences (>90%) for both GEUS and REUS. Conclusion: Endosonography is a highly accurate means of detecting local tumor recurrence. Received: 9 March 1998/Accepted: 9 November 1998     

Pre-operative assessment of anal fistulas using endoanal ultrasound

Objective To study the accuracy of endoanal ultrasound in pre‐operative assessment of cryptoglandular anal fistulas, with respect to the site of the internal opening, type and depth of the fistula tract. Patients and methods A consecutive series of 151 patients with anal sepsis underwent pre‐operative endoanal ultrasound assessment of a suspected anal fistula. Hydrogen peroxide was used to define the tract when there was doubt as to the course of the fistula. All patients subsequently had surgical exploration under anaesthesia, irrespective of findings at sonography. The site of the internal opening, depth and type of fistula were recorded at surgery, and concordance with the ultrasound was assessed. Results One hundred and forty‐five patients were subsequently shown to have a fistula at surgical exploration. Type of fistula: Two thirds were transsphincteric (63%) and one third were inter sphincteric (32%), with a few submucosal, and supra sphincteric fistulas. Ultrasound correctly predicted surgical findings in 82% of patients (124/151). Concordance was highest for transsphincteric fistulas (87%). Internal opening: Accuracy of predicting the site of the internal opening was 93% (140/151). The commonest site for the internal opening was the midline posteriorly (49%), followed by the midline anteriorly (25%), the rest lay laterally. Fistula depth: Ultrasound and surgical assessment of the depth of fistulas was concordant in 120 of 145 patients (83%). Conclusions Endoanal ultrasound has a high accuracy of predicting the site of internal opening of an anal fistula. Endoanal ultrasound is able to assess the type and depth of a fistula. This information is useful for pre‐operative planning of fistula treatment.     

The use of intra-operative endo-anal ultrasound in perianal disease

INTRODUCTION: Endoanal ultrasound (EAUS) has demonstrated high sensitivity and specificity for the structural imaging of anorectal pathology. This study prospectively assessed the impact of intra-operative EAUS on the surgical management of perianal disease. METHODS: EAUS was performed prior to and after examination under anaesthesia (EUA) in a consecutive series of patients with perianal disease. The impact of EAUS on the surgery performed was identified. RESULTS: Forty-three procedures have been performed in 38 patients (21 male, 17 female; mean age 42.7 years, range 6-76 years) over a three year period. Pathologies encountered were fistula-in-ano (42%), fissure-in-ano (26%), complicated perianal sepsis (16%) and carcinoma (5%). No specific abnormality was identified in 5 symptomatic patients (12%). Four patients with fissures had undergone previous sphincterotomy. In 22 cases (51.2%) the EAUS findings affected the surgical management (extent of muscle above a fistula 9 cases, extent of sphincterotomy 7 cases, site of sepsis identified 2 cases, exclusion of sepsis 2 cases, assessment of cancer resectability 1 case, biopsy of intersphincteric lesion 1 case). CONCLUSION: Intra-operative EAUS accurately identifies perianal disease and influences the surgical procedure performed. While not essential, it is a useful adjunct especially in recurrent perianal sepsis, undiagnosed anorectal pain and anal fissure.     

How the location of the internal opening of anal fistulas affect the treatment results of primary transsphincteric fistulas

Purpose  

The purpose of this study was to assess the influence of identification of the location of the internal opening of anal fistula on the recurrence rate after surgical treatment in patients with primary transsphincteric anal fistulas. The influence of preoperative rectal ultrasound on the treatment results was studied.     

Procedimiento LIFT en fístulas anales de localización posterior. ¿Son buenos los resultados? Revisión sistemática y metaanálisis de estudios observacionales

IntroductionEfficacy of the ligation of intersphincteric fistula tract (LIFT) procedure for posterior fistula-in-ano remains under debate. However, there is scarcity of quality evidence analysing this issue. Thus, the aim of this study is to evaluate outcomes of LIFT surgery in patients with posterior anal fistula.Material and methodsSystematic review and meta-analysis to evaluate efficacy of LIFT procedure for posterior anal fistula. MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar data sources were searched for key-words (MeSH terms): “LIFT” OR “Ligation of the intersphincteric fistula tract” AND “posterior anal fistula” OR “posterior fistula-in-ano”. Original, observational and experimental, non-language restriction studies published from January 2000 to March 2020 and reporting outcomes on LIFT procedure for posterior anal fistula were reviewed. Quality and potential biases were assessed using Newcastle-Ottawa scale, following AHRQ recommendations. Additional sensitivity analysis and publication bias evaluation (Beg and Egger's tets) were performed.ResultsNo significant differences were found in recurrence rate among patients undergoing LIFT procedure for posterior fistula-in-ano in contrast to other locations (OR 1.36 [IC 95% 0.60-3.07]; p = .46). I² test value was 77%, expressing a fair heterogeneity among included studies. The weighed median for overall recurrence was 37.8% (RI 18.3-47.7%); with a weighed median of 47.1% (RI 30.7 - 63.7%) and 36.3% (RI 15.8-51.3%) (p = .436) respectively for recurrence after LIFT for posterior fistula and fistula in other locations. There was not clear evidence about the sample size (“n”) of included studies nor the disparities in quality assessment of those, could justify the observed heterogeneity. No significant publication bias was found.ConclusionThis systematic review and meta-analysis suggests that there are no clear data in the literature for not performing the LIFT procedure in posteriorly located fistulas.     

术前三维肛管直肠腔内超声检查对肛瘘的应用价值

目的：探讨三维肛管直肠腔内超声（3D-EAUS）检查在肛瘘术前评估中的应用价值。方法前瞻性纳入2012年3月至2013年3月第二炮兵总医院结直肠肛门外科连续收治的诊断明确、拟行手术的100例肛瘘患者,采用计算机产生随机号的方法随机分为超声组和对照组,每组各50例。超声组术前采用3D-EAUS检查,对照组术前常规检查、采用指诊或探针探查,比较两组肛瘘内口定位、肛瘘分型及是否存在分支瘘管的准确率。结果与对照组比较,超声组的内口定位准确率较高,超声组和对照组分别为96．0％（48／50）和82．0％（41／50）（P＝0．02）。超声组与对照组对复杂性肛瘘的诊断分别为96．7％（29／30）比74．1％（20／27）（P＝0．021）;对肛瘘分型的诊断分别为96．0％（48／50）比78％（39／50）（P＝0．01）;对是否存在分支瘘管的诊断分别为94．0％（47／50）比84．0％（42／50）（P＝0．025）。但对于简单性肛瘘,两组内口定位准确率相当[95．0％（19／20）比91．3％（21／23）, P＝1．000]。结论三维肛管直肠腔内超声在内口定位、瘘管分型及分支瘘管的诊断方面具有较高的应用价值,尤其对复杂性肛瘘患者,值得在临床推广。     

Late results of treatment of anal fistulas

OBJECTIVE: The aim of this paper was to analyse the results of treatment of anal fistulas retrospectively. METHODS: Between 1992 and 2004, 407 patients were operated on for perianal fistula. In the follow-up period, 107 patients were lost, so 300 patients were analysed in the study. The mean follow-up time was 4.2 years. Analysed parameters included: types of surgical procedures in different kinds of fistulas and postoperative complications. Various types of surgical procedures and their effectiveness were described. Late results were assessed taking into account healing time, duration of sick leave, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed according to the Cleveland Clinic Incontinence Score. RESULTS: In our study, subcutaneous fistula was diagnosed in 23.3%, inter-sphincteric in 18%, trans-sphincteric in 37.7%, supra-sphincteric in 16% and extra-sphincteric in 5% of patients. Single-tract fistulas were present in 88.7% and multi-tract fistulas were present in 11.3%. Overall, 242 patients had primary fistulas and 58 patients had recurrent fistulas. The most frequently performed procedures were cutting seton (139 patients) and radical fistulectomy (104 patients). Recurrent fistulas developed in 14.3%. Postoperative gas and/or stool incontinence was noticed in 10.7%. The recurrence rate was 5.4% in patients with primary fistula and in 51.7% patients presenting with a recurrent fistula. Gas and stool incontinence developed in 3.7% of patients with primary fistulas and in 39.7% of patients presenting with recurrent fistulas. Recurrence rate was 12% in the patients of single-tract fistulas and 32.4% in the patients of multi-tract fistulas. Postoperative gas and/or stool incontinence occurred in 8.3% of patients of single-tract fistulas and in 29.4% of patients of multi-tract fistulas. CONCLUSIONS: The complication rate was 10-fold higher in patients presenting with a recurrent fistula than in those with primary fistulas and threefold higher in patients with multi-tract fistulas than in those with single-tract fistulas.     

Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn's disease

BACKGROUND: Endosonography and magnetic resonance imaging (MRI) are promising methods for evaluating perineal and anorectal fistulas or abscesses. The aim of this study was to compare the results of anal endosonography (AES), MRI and surgical exploration in the assessment of anorectal fistula or abscess complicating Crohn's disease. METHODS: Twenty-two patients with Crohn's disease, seven men and 15 women of mean age 38 (range 17-67) years, were included in this prospective study. All patients underwent AES (linear probe 7 MHz), MRI and operative assessment. RESULTS: AES and MRI demonstrated 14 and nine abscesses respectively, whereas 11 abscesses were confirmed by surgical exploration in ten patients. The sensitivity of AES and MRI as means of evaluating anorectal abscesses was 100 and 55 per cent respectively. The agreement per patient was 86 per cent (19 of 22) for AES and 59 per cent (14 of 22) for MRI. AES and MRI demonstrated 26 and 14 fistulas respectively, whereas 27 fistulas were confirmed during surgical exploration in 16 patients. The sensitivity of AES and MRI was 89 and 48 per cent respectively. The level of agreement per patient was 82 per cent (18 of 22) for AES and 50 per cent (11 of 22) for MRI. CONCLUSION: AES with a linear probe is more accurate than MRI in detecting anorectal abscesses complicating Crohn's disease, and much more accurate in the evaluation of complex fistulas.     

The anatomical basis of anal endosonography

Purpose: Anal endosonography is an imaging modality new to the diagnostic workup of incontinence. Interpretations even of normal endosonomorphologic findings now vary considerably. The conjoined longitudinal muscle (LM), a widely ignored structure, has until recently not been fully recognized by anal endosonography. The aim of this study, therefore, was to accurately determine the normal anatomy of the anal canal and correlate it with the findings obtained by anal endosonography. Methods: Eight postmortem specimens of the anal canal were examined by endosonography. The findings were correlated with macroscopical dissection and gross sectional histology of the same specimens. Results: The external echogenic ring is composed of two anatomical structures: the LM and the external anal sphincter (EAS). However, during anal endosonography the LM cannot always be differentiated from the EAS. Histologically, the relation of the diameters of the LM and the EAS ranged from 0.45:1 to 1.25:1. The narrow hyperechogenic ring between the inner hypoechoic layer and the external hyperechoic ring is an artificial finding that cannot be related to a distinct anatomical structure and most likely represents a sonographic interface. Conclusions: This study exactly outlines the relation of diameters of the conjoined longitudinal muscle and external anal sphincter for the first time. Until now, the LM has been underestimated in its dimensions. The role of such a thick muscular structure should be included in the conception of anal continence in the future. Especially in view of the fact that anal endosonography is increasingly used in the diagnostic workup of incontinence and fistula in ano, it is essential to understand the anatomical basis of endosonography. This study accurately delineates the sonomorphology of the anal muscles. When viewed in light findings reported here, endosonographic findings in diseases of the anal canal are now based on a correct idea of the correlation between endosonomorphology and anal anatomy. Received: 28 January 1997/Accepted: 28 February 1997     

Three-dimensional endosonography for staging of rectal cancer.

OBJECTIVE: This prospective study was conducted to investigate the value of three-dimensional (3D) endosonography for staging of rectal cancer. SUMMARY BACKGROUND DATA: Transrectal ultrasound is the most sensitive technique for peroperative staging and follow-up of rectal cancer. Major limitations of this technique include the complexity of image interpretation and the inability to examine stenotic tumors or to identify recurrent rectal cancer. METHODS: Three-dimensional endosonography was performed in 100 patients with rectal tumors. Transrectal volume scans were obtained using a 3D multiplane transducer (7.5/10.0 MHz). Stenotic tumors were examined with a 3D frontfire transducer (5.0/7.5 MHz). The volume scans were processed and analyzed on a Combison 530 workstation (Kretztechnik, Zipf, Austria). RESULTS: The 3D endosonography and conventional endosonography were performed in 49 patients with nonstenotic rectal cancer. Display of volume data in three perpendicular planes or as 3D view facilitated the interpretation of ultrasound images and enhanced the diagnostic information of the data. The accuracy of 3D endosonography in the assessment of infiltration depth was 88% compared to 82% with the conventional technique. In the determination of lymph node involvement, 3D and two-dimensional endosonography provided accuracy rates of 79% and 74%, respectively. The 3D scanning allowed the visualization of obstructing tumors using reconstructed planes in front of the transducer. Correct assessment of the infiltration depth was possible in 15 of 21 patients with obstructing tumors (accuracy, 76%). Three-dimensional endosonography displayed suspicious pararectal lesions in 30 patients. Transrectal ultrasound-guided biopsy was extremely precise (accuracy, 98%) and showed malignancy in 10 of 30 patients. Histologic analysis changed the endosonographic diagnosis in 8 (27%) of the patients. CONCLUSIONS: The 3D endosonography permits examination of rectal cancer using previously unattainable planes and 3D views. The 3D imaging and ultrasound-guided biopsy seem capable to improve staging of rectal cancer and should be evaluated in further studies.     

Anal endosonography is useful for postoperative assessment of anorectal malformations

Aim

This study aimed to develop and evaluate a scoring system for anal endosonography to assess anal canal structures after repair of anorectal malformations (ARM).

Methods

Forty patients with ARM aged 16 years (range, 1-22 years) and 20 controls aged 17 years (range, 0.5-20 years) were examined. Anal function was assessed clinically and by anal canal manometry. The anal canal structures were imaged by anal endosonography using a 7.5-MHz transducer. A scoring system was developed to assess the anal sphincters as visualized on the endosonographic images.

Results

Continence was significantly correlated to anal canal pressures. The estimated extent of muscle defect (measured in quadrants) and the number of disruptions in the internal and external anal sphincters correlated significantly to the rest and squeeze pressures, respectively. Thus, patients (>4 years) with squeeze pressure of less than 80 cm H₂O were characterized by more than 1 disruption in the external anal sphincter ring and 2 or more quadrants with scar tissue.

Conclusion

The extent of scar tissue and the number of disruptions in the anal sphincters correlate with anal canal pressures and continence after ARM repair. Anal endosonography may be used to study the results after different surgical techniques and for prognosis on continence in patients with ARM.     

Preoperative Radiochemotherapy and Sphincter-Saving Resection for T3 Carcinomas of the Lower Third of the Rectum

OBJECTIVE: To evaluate the complications and oncologic and functional results of preoperative radiochemotherapy and sphincter-saving resection for T3 cancers of the lower third of the rectum. SUMMARY BACKGROUND DATA: Carcinomas of the lower third of the rectum (i.e., located at or below 6 cm from the anal verge) are usually treated by abdominoperineal resection, especially for T3 lesions. Few data are available evaluating concomitant chemotherapy with preoperative radiotherapy for increasing sphincter-saving resection in low rectal cancer. METHODS: Between 1995 and 1999, 43 patients underwent preoperative radiochemotherapy with conservative surgery for a low rectal tumor located a mean of 4.5 cm from the anal verge (range 2-6); 70% of the lesions were less than 2 cm from the anal sphincter. There were 40 T3 and 3 T4 tumors. Patients received preoperative radiotherapy with a mean dose of 50 Gy (range 40-54) and concomitant chemotherapy with 5-FU in continuous infusion (n = 36) or bolus (n = 7). Sphincter- saving resection was performed 6 weeks after treatment, in 25 patients by using intersphincteric resection. Coloanal anastomoses were associated with a colonic pouch in 86% of the patients, and all patients had a protecting stoma. RESULTS: There were no deaths related to preoperative radiochemotherapy and surgery. Acute toxicity was mainly due to diarrhea, with 54% of grade 1 to 2. Four anastomotic fistulas and two pelvic hematomas occurred; all patients but one had closure of the stoma. Distal and radial surgical margins were respectively 23 +/- 8 mm (range 10-40) and 8 +/- 4 mm (range 1-20) and were negative in 98% of the patients. Downstaging (pT0-2N0) was observed in 42% of the patients (18/43) and was associated with a greater radial margin (10 vs. 6 mm; P =.02). After a median follow-up of 30 months, the rate of local recurrence was 2% (1/43), and four patients had distal metastases. Overall and disease-free survival rates were both 85% at 3 years. Functional results were good (Kirwan continence I, II) in 79% of the available patients (n = 37). They were slightly altered by intersphincteric resection (57 vs. 75% of perfect continence; NS) but were significantly improved by a colonic pouch (74 vs. 16%; P =.01). CONCLUSIONS: These results suggest that preoperative radiochemotherapy allowed sphincter-saving resection to be performed with good local control and good functional results in patients with T3 low rectal cancers that would have required abdominoperineal resection in most instances.