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Perianal disease
Published in Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan, Take Charge! General Surgery and Urology, 2020
Endoanal ultrasound This is a specialist investigation occasionally performed by a trained surgeon for complex or recurrent cases and may be used in theatre to assist in the identification of fistulae.
Physiology
Published in Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams, Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Anwen Williams, Martyn D. Evans
This technique, along with endoanal ultrasound, forms the mainstay of investigating patients with faecal incontinence. The technique has been described previously. Patients with faecal incontinence may have reduced tone because of weak internal or external sphincter muscles. In addition, weak squeeze pressures may be demonstrated due to a weak external sphincter or puborectalis muscle. Anal manometry studies will therefore provide evidence of impaired muscle function and will also indicate areas of possibly defective muscle which can be represented visually in a 3-dimensional format. Taken together with the information provided by endoanal ultrasound, the tests will indicate whether the patient has neurogenic faecal incontinence or is suitable for repair of a defect in the external anal sphincter. Normal values in men and women for manometry are presented in Tables 2.4a and 2.4b.
Fistula repair
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
In determining the most appropriate management, consideration should be given to the underlying etiology of the intestinovaginal fistula. In patients with obstetric fistula, endoanal ultrasound should be performed to detect anal sphincter damage, as the presence or absence of sphincteric injury may alter the choice of procedure. In patients with radiation rectovaginal fistulae or in those with inflammatory bowel disease, preoperative anorectal manometry is necessary to assess rectal compliance. When rectal reservoir function is poor, there is unlikely to be a good response from local repair. For recurrent fistulas, radiation-induced fistulas, for those associated with active inflammatory bowel disease, or for ileo- or colovaginal fistulas, a preliminary defunctioning colostomy may be appropriate. However, for the majority of rectovaginal fistulas, defunctioning of the bowel is not required. Surgeons vary in the extent to which they prepare the bowel prior to rectovaginal fistula repair. Current evidence suggests that bowel cleansing can be safely omitted prior to colonic surgery without increasing the risk of perioperative complications (Guenaga et al. 2011), and most now would simply administer an enema prior to operation if patients have not moved their bowel within the previous 24 hours.
Anorectal dysfunction after radical cystectomy for bladder cancer
Published in Scandinavian Journal of Urology, 2022
Fredrik Liedberg, Oskar Hagberg, Gediminas Baseckas, Johan Brändstedt, Petter Kollberg, Anna-Karin Lind, Marie-Louise Lydrup, Annica Löfgren, Karin Stenzelius, Anne Sörenby, Marianne Starck
A total of 43 evaluable patients with a median age of 70 (Inter Quartile Range (IQR) 64–76) years were included in the study. Postoperative questionnaires (LARS-score and St Mark’s score) were missing in two individuals who developed metastatic bladder cancer prior to the postoperative assessment and therefore were not offered the postoperative follow-up visit with manovolumetry. One additional individual did not want to attend the postoperative manovolumetry and endoanal ultrasound examination, thus leaving 40 evaluable patients for pre- and postoperative anorectal volume and pressure analyses and ultrasound assessments (Figure 1). A majority of the patients received preoperative chemotherapy (27/43 (63%)), either as neoadjuvant chemotherapy (n = 13) or as induction chemotherapy for node-positive disease (n = 14), and the clinical stage-distribution is given in Table 1. The surgery was performed either as open radical cystectomy (RC) (n = 41) or robotic-assisted RC (n = 2), and the use of nerve-sparing, type of urinary diversion and extent of lymphadenectomy applied are also reported in Table 1. Eleven patients (26%) developed a highest Clavien complication grade 3 (n = 9) or grade 4 (n = 2) within 90 days of surgery (Table 1).
Assessment of anal sphincter distensibility following the STARR procedure: a pilot study
Published in Acta Chirurgica Belgica, 2020
Charlotte Desprez, Chloé Melchior, Guillaume Gourcerol, Jean-Jacques Tuech, Estelle Houivet, Anne-Marie Leroi, Valérie Bridoux
The STARR procedure was performed as described by Pigot [1] For assessing the impact of the STARR procedure on anorectal symptoms, the Cleveland Clinic Severity (CCSC) [4], ODS [5], and Kess scores [6] were determined before and three months post-surgery. An anal distensibility study was performed before and three months post-surgery using a previously described methodology [3]. Briefly, high-resolution impedance planimetry was used to measure the relationship between luminal dimensions and distensive pressure (i.e. distensibility) during controlled volumetric distension [3]. The distensibility index as calculated by the cross-sectional area divided by the intra-balloon pressure at 40 mL of inflation at rest and during voluntary contraction was the primary endpoint of the study [3]. An endoanal ultrasound (7 Mhz, 360°, Two-Dimensional US, Brüel and Kjaer, Naerum, Denmark) was also performed before and three months post-surgery to verify the absence of anal sphincter defects that may have been caused by the STARR procedure. Given the small size of the patient cohort, the results were expressed individually. The normal 40 mL distensibility indexes at rest and during squeeze were defined, respectively, as ≤1mm2.mmHg−1 and ≤0.5 mm2.mmHg−1 based on measurements from a group of healthy volunteers [3].
Faecal incontinence: a narrative review of clinic-based management for the general gynaecologist
Published in Journal of Obstetrics and Gynaecology, 2018
Kathryn S. Williams, Dara F. Shalom, Harvey A. Winkler
Endoanal Ultrasound (EAUS) is the standard diagnostic tool for determining the presence of an anal sphincter injury. It is a simple test that should be utilised in women presenting with FI and a history of prior vaginal delivery or prior anorectal surgery. A recent study of women with known OASIS showed a positive correlation in the number of defecatory symptoms with severity of injury found by endoanal ultrasound (Oude Lohuis and Everhardt 2014). EAUS can easily identify IAS defects. However, identifying defects in the EAS is more difficult as perirectal fat and the EAS are both echogenic (Costilla et al. 2013). This may necessitate the use of newer high-resolution probes. In a comparison of standard ultrasound probes to new high-resolution ultrasound probes, visualisation of EAS and IAS for the standard and the new probes was 83% and 98%, respectively (Rostaminia et al. 2015). Innovative imaging techniques can aid in the optimal management of the anal sphincter defects.