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Nakajima Y, Muro S, Nasu H, Harada M, Yamaguchi K, Akita K. Morphology of the region anterior to the anal canal in males: visualization of the anterior bundle of the longitudinal muscle by transanal ultrasonography. Surg Radiol Anat 2017; 39:967-973. [DOI: 10.1007/s00276-017-1832-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/12/2017] [Indexed: 11/28/2022]
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Abstract
Endoanal ultrasound is a technique that provides imaging of the anal sphincters and its surrounding structures as well as the pelvic floor. However, endoanal magnetic resonance imaging (MRI) is preferred by most physicians, although costs are higher and demand easily outgrows availability. Endoanal ultrasound is an accurate imaging modality delineating anatomy of both cryptoglandular as well as Crohn perianal fistula and abscess. Endoanal ultrasound is comparable with examination under anesthesia and equally sensitive as endoanal MRI in fistula detection. When fistula tracts or abscesses are located above the puborectal muscle, an additional endoanal MRI should be performed. Preoperative imaging is advocated in recurrent cryptoglandular fistula because a more complex pattern can be expected. Endoanal ultrasound can help avoid missing tracts during surgery, lowering the chance for the fistula to persist or recur. It can easily be performed in an outpatient setting and endosonographic skills are quickly incremented. Costs are low and endoanal ultrasound has the potential to improve outcome of patients with both cryptoglandular and fistulizing Crohn disease; therefore, it values more attention.
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Affiliation(s)
- Arjan Paul Visscher
- From the Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
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Stensrud KJ, Emblem R, Bjørnland K. Anal endosonography and bowel function in patients undergoing different types of endorectal pull-through procedures for Hirschsprung disease. J Pediatr Surg 2015; 50:1341-6. [PMID: 25783406 DOI: 10.1016/j.jpedsurg.2014.12.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/10/2014] [Accepted: 12/27/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The reasons for fecal incontinence after surgery for Hirschsprung disease (HD) remain unclear. The aim of this study was to examine the anal sphincters by anal endosonography and manometry after transanal endorectal pull-through, with or without laparotomy or laparoscopy, in HD patients. Furthermore, we aimed to correlate these findings to bowel function. PATIENTS AND METHODS Fifty-two HD patients were followed after endorectal pull-through. Anal endosonography and manometry were performed without sedation at the age of 3 to 16 years. RESULTS Endosonographic internal anal sphincter (IAS) defects were found in 24/50 patients, more frequently after transanal than transabdominal procedures (69 vs. 19%, p=0.001). In a multiple variable logistic regression model, operative approach was the only significant predictor for IAS defects. Anal resting pressure (median 40mm Hg, range 15-120) was not correlated to presence of IAS defects. Daily fecal incontinence occurred more often in patients with IAS defects (54 vs. 25%, p=0.03). CONCLUSIONS Postoperative IAS defects were frequently detected and were associated with daily fecal incontinence. IAS defects occurred more often after solely transanal procedures. We propose that these surgical approaches are compared in a randomized controlled trial before solely transanal endorectal pull-through is performed as a routine procedure.
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Affiliation(s)
- Kjetil J Stensrud
- Oslo University Hospital, Department of Pediatric surgery, P.O. Box 4950 Nydalen, 0424 Oslo, Norway.
| | - Ragnhild Emblem
- Oslo University Hospital, Department of Pediatric surgery, P.O. Box 4950 Nydalen, 0424 Oslo, Norway; University of Oslo, Faculty of Medicine, P.O. Box 1078 Blidern, 0316 Oslo, Norway
| | - Kristin Bjørnland
- Oslo University Hospital, Department of Pediatric surgery, P.O. Box 4950 Nydalen, 0424 Oslo, Norway; University of Oslo, Faculty of Medicine, P.O. Box 1078 Blidern, 0316 Oslo, Norway
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Rehman Y, Stensrud KJ, Mørkrid L, Bjørnland K, Emblem R. Endosonographic evaluation of anal sphincters in healthy children. J Pediatr Surg 2011; 46:1587-92. [PMID: 21843728 DOI: 10.1016/j.jpedsurg.2011.03.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 02/24/2011] [Accepted: 03/25/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE To describe the endosonographic anatomy of anal sphincters in healthy children and to evaluate the reproducibility of sphincter thickness measurements. METHODS Forty-five healthy children with median age of 3.6 years (range, 1.0-14.5 years) were studied while under general anesthesia for minor surgery. Anal endosonography was performed with a 7- to 10-MHz rotating transducer with a diameter of 19 mm. The internal anal sphincter (IAS) and the external anal sphincter (EAS) were assessed by 2 independent observers. RESULTS IAS and EAS were identified in all children. The mean thickness of IAS and EAS were 1.3 mm and 5.3 mm, respectively. Identification of the inner and outer border of IAS was difficult, especially in children younger than 3 years. The thickness of EAS was easier to assess, and the interrater reliability for EAS thickness measurements was excellent. EAS thickness was positively correlated with the children's age. Reflectivity varied within the EAS with frequent hyporeflective areas. CONCLUSIONS Anal endosonography provided visualization of the IAS and EAS in children. Assessment of exact IAS thickness was difficult, especially in the youngest children. Mean EAS thickness was 5.3 mm, increasing with age. Hyporeflective areas of the intact EAS should not be misinterpreted as sphincter defects.
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Affiliation(s)
- Yasser Rehman
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Al-Ali S, Blyth P, Beatty S, Duang A, Parry B, Bissett IP. Correlation between gross anatomical topography, sectional sheet plastination, microscopic anatomy and endoanal sonography of the anal sphincter complex in human males. J Anat 2009; 215:212-20. [PMID: 19486204 DOI: 10.1111/j.1469-7580.2009.01091.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This study elucidates the structure of the anal sphincter complex (ASC) and correlates the individual layers, namely the external anal sphincter (EAS), conjoint longitudinal muscle (CLM) and internal anal sphincter (IAS), with their ultrasonographic images. Eighteen male cadavers, with an average age of 72 years (range 62-82 years), were used in this study. Multiple methods were used including gross dissection, coronal and axial sheet plastination, different histological staining techniques and endoanal sonography. The EAS was a continuous layer but with different relations, an upper part (corresponding to the deep and superficial parts in the traditional description) and a lower (subcutaneous) part that was located distal to the IAS, and was the only muscle encircling the anal orifice below the IAS. The CLM was a fibro-fatty-muscular layer occupying the intersphincteric space and was continuous superiorly with the longitudinal muscle layer of the rectum. In its middle and lower parts it consisted of collagen and elastic fibres with fatty tissue filling the spaces between the fibrous septa. The IAS was a markedly thickened extension of the terminal circular smooth muscle layer of the rectum and it terminated proximal to the lower part of the EAS. On endoanal sonography, the EAS appeared as an irregular hyperechoic band; CLM was poorly represented by a thin irregular hyperechoic line and IAS was represented by a hypoechoic band. Data on the measurements of the thickness of the ASC layers are presented and vary between dissection and sonographic imaging. The layers of the ASC were precisely identified in situ, in sections, in isolated dissected specimens and the same structures were correlated with their sonographic appearance. The results of the measurements of ASC components in this study on male cadavers were variable, suggesting that these should be used with caution in diagnostic and management settings.
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Affiliation(s)
- S Al-Ali
- Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Knowles AM, Knowles CH, Scott SM, Lunniss PJ. Effects of age and gender on three-dimensional endoanal ultrasonography measurements: development of normal ranges. Tech Coloproctol 2008; 12:323-9. [PMID: 19018467 DOI: 10.1007/s10151-008-0443-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 09/08/2008] [Indexed: 12/26/2022]
Abstract
BACKGROUND Faecal incontinence is a common and morbid disorder that is often related to anal sphincter dysfunction. High-frequency, three-dimensional (3-D) endoanal ultrasonography (EAUS) allows greater spatial resolution and longitudinal appreciation of the anal canal than conventional 2-D assessment. A robust normal range of values allowing for age and sex is required for subsequent disease comparison. METHODS A group of 30 healthy male (n=12) and female (n=18) volunteers (median age, 49 years; range, 31-63 years) underwent 3-D EAUS using a high-frequency 10-MHz transducer. A reconstructed data cube was interrogated to measure anal canal structures in 2-D at high, middle and low levels, and in 3-D for longitudinal measurements. RESULTS Men had a significantly longer 3-D external anal sphincter (EAS) and internal anal sphincter (IAS) than women, especially the anterior EAS (mean in men 2.5 cm, mean in women 1.6 cm, p<0.0001). There were no significant differences between the sexes for anal canal length or by 2-D scanning for the thickness of the EAS and IAS. No significant differences were observed between parous and nulliparous women. Age had no significant effect on 3-D length measurements, but 2-D EAUS measurements of the thickness of both the IAS and EAS increased with age significantly (mid canal, p=0.004). On these bases, normal ranges were generated. CONCLUSIONS Sphincter measurements, enabled by 3-D reconstruction, vary with age and sex. A normal range incorporating these variations has been produced for future data comparison in disease states.
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Affiliation(s)
- A M Knowles
- Centre for Academic Surgery Institute of Cellular and Molecular Science Barts and the London, Queen Mary's School of Medicine and Dentistry Whitechapel, London, UK
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Felt-Bersma RJF. Endoanal ultrasound in benign anorectal disorders: clinical relevance and possibilities. Expert Rev Gastroenterol Hepatol 2008; 2:587-606. [PMID: 19072406 DOI: 10.1586/17474124.2.4.587] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Endoanal ultrasound is a well-established technique used to evaluate benign anorectal disorders. The technique is easy to perform, has a short learning curve and causes very little discomfort. Reconstruction of 3D images is possible. The clinical indications for endoanal ultrasound in benign anorectal diseases are fecal incontinence and peri-anal fistula. Sphincter defects can be depicted with precision and correlate perfectly with surgical findings. Furthermore, an impression of sphincter atrophy can be established. With perianal fistula the tracts can be visualized. Introducing hydrogen peroxide via the external fistula opening improves imaging. Endoanal ultrasound and MRI have comparable results in diagnosing anorectal disorders.
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Affiliation(s)
- Richelle J F Felt-Bersma
- VU University Medical Center, Department of Gastroenterology and Hepatology, De Boelelaan 1117, 1081 HV, PO Box 7057, Amsterdam, The Netherlands.
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Fowler GE, Adams EJ, Bolderson J, Hosker G, Lowe D, Richmond DH, Alfirevic Z. Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound. BJOG 2008; 115:767-72. [PMID: 18355367 DOI: 10.1111/j.1471-0528.2008.01680.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter. DESIGN A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed. METHODS To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans. MAIN OUTCOME MEASURES Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A-E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations. CONCLUSIONS LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.
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Affiliation(s)
- G E Fowler
- Department of Urodynamics, Liverpool Women's Hospital, Liverpool, UK.
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Valsky DV, Yagel S. Three-dimensional transperineal ultrasonography of the pelvic floor: improving visualization for new clinical applications and better functional assessment. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:1373-87. [PMID: 17901141 DOI: 10.7863/jum.2007.26.10.1373] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE With increasing awareness of the scope of pelvic floor disorders has come development and introduction into clinical practice of new imaging techniques, with increasing importance of ultrasonography. Complex pelvic floor anatomy, the conceptual difficulty in the basics of some pelvic floor disorders, and the uneven standardization of ultrasonographic techniques were the impetuses of this review. The purpose of this study was to review the basic anatomy of the pelvic floor and the transperineal ultrasonographic evaluation technique and to provide an overview of the current clinical use of 3-dimensional transperineal ultrasonography in the evaluation of the anterior and posterior pelvic floor compartments. METHODS A literature review illustrated with index cases from our center was conducted. RESULTS Ultrasonography has been widely applied to evaluation of the anterior and posterior compartments of the pelvic floor. Three-dimensional ultrasonography has a role in improving pelvic floor assessment. CONCLUSIONS Three-dimensional transperineal ultrasonography has been applied to evaluation of normal and pathologic pelvic floor anatomy. Practical application, through well-designed and sufficiently powered clinical studies, will establish the association between the clinical presentations of dysfunction with ultrasonographic findings.
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Affiliation(s)
- Dan V Valsky
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, PO Box 24035, Mt Scopus, 91240 Jerusalem, Israel
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Gregory WT, Boyles SH, Simmons K, Corcoran A, Clark AL. External anal sphincter volume measurements using 3-dimensional endoanal ultrasound. Am J Obstet Gynecol 2006; 194:1243-8. [PMID: 16647906 DOI: 10.1016/j.ajog.2005.10.822] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 09/28/2005] [Accepted: 10/21/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Significant nerve injury to a muscle can be associated with muscle atrophy and volume loss. Three-dimensional (3D) ultrasound can measure muscle volume, but the reproducibility of the technique has not been established for the anal sphincter. STUDY DESIGN Using a 10 MHz 360-degree rotating endoanal probe, we performed 3D endoanal ultrasounds on 9 nulliparous and 23 asymptomatic primiparous subjects at 12 weeks' postpartum. Two blinded examiners measured the length of the external anal sphincter (EAS) from a midsagittal image, and the width of the EAS and internal anal sphincter (IAS) from axial images at mid anal canal. The EAS volume was calculated by repetitively outlining only the EAS in each sequential axial view. Both examiners measured the EAS volumes twice, blinded to previous calculations. RESULTS The intrarater reliability for EAS volume was 0.79 to 0.89 (intraclass coefficient). The mean difference of the EAS volume between the 2 examiners was 0.5 mL (P = .3, t test). Correlation between the 2 examiners for measuring EAS volume was r = 0.77 (P < .001, Pearson's). The "limits of agreement" (between 2 examiners) varied by as much as 40% of the mean volume. CONCLUSION Quantitative 3D ultrasound of the anal sphincter is moderately reproducible.
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Affiliation(s)
- W Thomas Gregory
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
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Abstract
Accurate staging of rectal and anal carcinoma is crucial for planning surgery and indicating adjuvant therapy. Although, computed tomography and magnetic resonance imaging are very sensitive in detecting metastatic disease, the local staging of rectal cancer with these techniques has been disappointing. Endorectal ultrasound (ERUS) and anal endosonography (AE) remain the most accurate methods for staging rectal and anal cancer. Anal endosonography is also of value in evaluating perianal sepsis: it can assist the surgeon in planning the surgical strategy by delineating the anatomy of fistula tracts, and can aid in puncturing abscesses in the operating room. Continued research and development has made the instrumentation for ERUS and AE more accurate and user-friendly. New techniques that have contributed significantly to the evolution of ERUS include three-dimensional ERUS, high-frequency miniprobes, transrectal ultrasound-guided biopsy techniques and hydrogen peroxide-enhanced endosonography. Further improvements can be expected from contrast enhancement with microbubbles and colour Doppler imaging. In this new millennium, new developments in ERUS and anal endosonography, such as tri-dimensional ERUS and anal endosonography and radial electronic probing, widen the role of ERUS in the staging of rectal and anal carcinoma, as well as for perianal inflammatory conditions.
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Affiliation(s)
- M Giovannini
- Paoli-Calmettes Institute, 232 Boulevard St-Marguerite, 13273 Marseille-Cedex 9, France
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Felt-Bersma RJF, Cazemier M. Endosonography in anorectal disease: an overview. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 2006:165-74. [PMID: 16782637 DOI: 10.1080/00365520600664292] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Anorectal endosonography (AE), which was introduced 20 years ago, derives from the study of urology. It was first used to evaluate rectal tumours and later also to investigate benign disorders of the anal sphincters and pelvic floor. The technique is easy to perform, it has a short learning curve and causes no more discomfort than a routine digital examination. A rotating probe with a 360 degrees radius and a frequency between 5 and 16 MHz is introduced to the rectum and then slowly withdrawn so that the pelvic floor and subsequently the sphincter complex are seen. Recently, it has become possible to reconstruct three-dimensional images. AE has been used for almost every possible disorder in the anal region and has increased our insight into anal pathology. The clinical indications for AE are: 1. Faecal incontinence in patients when surgery is an option. AE can show sphincter defects with excellent precision. There is a perfect correlation with surgical findings. Studies comparing AE with endoanal magnetic resonance imaging (MRI) have shown that both methods are equally good for demonstrating defects in the external anal sphincter; the internal anal sphincter is better visualized with AE. After sphincter repair, the effect is directly related to the decrease in the sphincter defect. 2. Perianal fistulae. AE has been shown to be accurate in staging perianal cryptoglandular fistulae and fistulae in Crohn's disease. When there is an external fistula opening, H2O2 can be introduced with a plastic infusion catheter. The tract then becomes visible as a hyperechoic lesion ("white"). It has been shown that this corresponds well with surgical findings. It is equally sensitive as endoanal MRI. Since recurrent cryptoglandular fistulae are complex in 50% and Crohn's fistula in 75%, it is mandatory to perform AE preoperatively in these patients to avoid missed tracts during surgery and subsequent recurrences. 3. Rectal tumors. In low tubulovillous adenomas or malignant polyps considered removable locally, confirming the local resectability (T0 or T1) is mandatory. Although larger rectal and more advanced tumours can be evaluated with AE, MRI is more sensitive in staging nodal involvement. 4. Anal carcinoma for staging. AE has been shown to stage better than the classical TNM classification for both local extension and prognosis. In conclusion, AE images the internal and external anal sphincter with high accuracy. It is easy to perform and is of particular value in the diagnosis of anal incontinence and perianal fistulae. It is excellent in staging anal carcinoma and can also be used in staging rectal carcinoma, especially very low large malignant polyps.
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Affiliation(s)
- R J F Felt-Bersma
- Department of Gastroenterology and Hepatology, VU University Hospital Amsterdam, The Netherlands.
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Starck M, Bohe M, Fortling B, Valentin L. Endosonography of the anal sphincter in women of different ages and parity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 25:169-176. [PMID: 15685668 DOI: 10.1002/uog.1818] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To obtain reference data representative of normal findings at anal endosonography in pregnant and non-pregnant women. To determine intraobserver and interobserver agreement in the detection of endosonographic anal sphincter defects in asymptomatic women. METHODS Twenty-five non-pregnant nulliparous women and 25 non-pregnant parous women (age range, 20-67 years) and 47 pregnant women (age range, 21-39 years) underwent anal manometry and anal endosonography. The endosonographic internal and external sphincter thickness and sphincter length were measured online. Endosonographic sphincter defects were measured and classified offline from videotapes by two independent examiners using an endosonographic defect score ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extension of the defect. RESULTS Endosonographic sphincter thickness and length did not differ between non-pregnant nulliparous and parous women and did not change substantially with age. The anal sphincter was thicker and the anal resting pressure area and manometric sphincter length were greater in pregnant than in non-pregnant women of the same age (20-39 years). There was good intra- and interobserver agreement with regard to detection of endosonographic anal sphincter defects (kappa > or = 0.70). Eighteen (19%) women had endosonographic sphincter defects but in only four (4%; 4/97) cases were they moderate or large (defect score, 7-10). Ten (20%) of the non-pregnant women reported minor gas incontinence and one reported minor incontinence for both gas and liquid stool. The frequency of incontinence did not differ between women with and without sphincter defects. CONCLUSIONS Reference data representative of normal findings at anal endosonography have been established for non-pregnant women and for nulliparous women in the third trimester of pregnancy. Small endosonographic sphincter defects and minor gas incontinence are common in women without known sphincter trauma. They seem to be unrelated to each other and may be regarded as normal variants.
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Affiliation(s)
- M Starck
- Department of Surgery, Malmö University Hospital, Malmö, Sweden.
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Etienney I, De Parades V, Atienza P. Apports de l’échographie endoanale dans l’exploration de l’incontinence anale. ACTA ACUST UNITED AC 2003. [DOI: 10.1007/bf03023676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
A working knowledge of anorectal and pelvic anatomy is crucial for the understanding of normal function, pathogenesis and surgical treatment of anorectal diseases. In a field of unlimited details and varying definitions, our goal is to provide an overview of anatomic concepts relevant for the practical management of patients.
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Affiliation(s)
- Andreas M Kaiser
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 450 San Paulo Street, Suite 5400, Los Angeles, CA 90033, USA.
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Abstract
Anal endosonography became a valuable imaging method for diagnosis of anal diseases because of its accessibility, relative simplicity of performance, and low cost. It is used most often to detect anal sphincter defects, to classify anal fistulas and perianal abscesses, and to stage anal tumors. This review presents a normal anatomy of the anal canal, examination technique, and normal endosonographic anatomy of anal sphincters. The endosonographic findings of anal sepsis, malignancy, trauma, abnormalities in Crohn disease, and ulcerative colitis, as well as the role for anal endosonography among other imaging modalities, are discussed.
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Williams AB, Bartram CI, Halligan S, Marshall MM, Nicholls RJ, Kmiot WA. Multiplanar anal endosonography--normal anal canal anatomy. Colorectal Dis 2001; 3:169-74. [PMID: 12790984 DOI: 10.1046/j.1463-1318.2001.00226.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Volume acquisition during anal ultrasound enables multiplanar imaging of the anal canal. The normal ultrasonic multiplanar appearance of the anal canal is described and gender differences in canal anatomy are highlighted. METHODS Ten male and 12 female normal volunteers (mean ages 31.5 years (s.d. 5.9) and 31.2 (s.d. 6.7)) had three-dimensional anal endosonography (3-D AES). Each volume dataset was seeded in the axial plane facilitating multiplanar identification of known anatomical structures. RESULTS The anterior external anal sphincter (EAS) was significantly longer in men than women 30.1 mm (3.9) vs 16.9 mm (7.4) (P < 0.001). There was no difference in the length of the puborectalis 24.7 mm (6.4) vs 24 mm (5) (P=0.78) in men compared with women. The cranial extent of the anterior EAS was tilted forward in both sexes. The angle formed by the anterior EAS and the longitudinal axis of the anal canal was more acute in men than in women (11.1 degrees vs 18.6 degrees; P=0.007). Dataset volume seeding of familiar structures in the axial plane allowed the multiplanar endosonographic anatomy to be described. CONCLUSIONS Multiplanar AES has enabled detailed longitudinal measurement of the components of the anal canal and has revealed important gender differences. The multiplanar ultrasonic appearance of the normal anal canal has been described for the first time.
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Affiliation(s)
- A B Williams
- Department of Intestinal Imaging, St. Mark's Hospital, Northwick Park, Harrow, UK
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Williams AB, Cheetham MJ, Bartram CI, Halligan S, Kamm MA, Nicholls RJ, Kmiot WA. Gender differences in the longitudinal pressure profile of the anal canal related to anatomical structure as demonstrated on three-dimensional anal endosonography. Br J Surg 2000; 87:1674-9. [PMID: 11122183 DOI: 10.1046/j.1365-2168.2000.01581.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Anal canal squeeze pressure is assumed to be due to external sphincter contraction, but the contribution of other muscles has not been explored. METHODS Ten male and ten nulliparous female asymptomatic subjects had three-dimensional anal endosonography and manometry. Incremental squeeze pressures at 0. 5-cm intervals, expressed as a percentage of the maximum pressure recorded anywhere in the canal, were related to the following anatomical levels: puborectalis, overlap between external anal sphincter (EAS) and puborectalis, external and internal anal sphincters, and external anal sphincter only. Levels were determined by coronal and sagittal endosonographic reconstructions. RESULTS Puborectalis was the same length in men and women (median 23.9 versus 27.1 mm) but represented a greater proportion of the anal canal in women (45 versus 61 per cent; P = 0.02). At the level of puborectalis alone, the pressure generated as a proportion of maximum anal canal pressure was 71 (range 32-100) per cent in men and 62 (range 32-100) per cent in women. At the level of the EAS alone, the pressure was 60 (4-98) per cent in men and 82 (41-100) per cent in women; where the external sphincter was overlapped by puborectalis, the pressure was 98 (60-100) per cent in men and 75 (47-100) per cent in women. CONCLUSION Maximal anal canal squeeze pressure is found where the puborectalis overlaps the EAS. This segment represents a significant proportion of anal canal length in women.
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Affiliation(s)
- A B Williams
- Department of Intestinal Imaging, Physiology Unit and Department of Surgery, St Mark's Hospital, Harrow and Department of Surgery, St Thomas' Hospital, London, UK
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Poen AC, Felt-Bersma RJ. Endosonography in benign anorectal disease: an overview. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1999; 230:40-8. [PMID: 10499461 DOI: 10.1080/003655299750025534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Endosonography may be used for diagnosing various anorectal disorders. This review addresses its technique and clinical use in benign anorectal disease. METHODS The English literature available on anal endosonography was reviewed. The different modalities, the endosonography technique itself and its value in benign anorectal disease were described. RESULTS Anal endosonography is easy to perform, has a short learning curve and causes less discomfort than routine digital examination. Anal sphincters can be clearly visualized and distinction is possible between the internal (hypoechoic) and external (hyperechoic) anal sphincters. Other pelvic floor structures, like the puborectalis muscle, can also be visualized. Endosonography is mostly used in the assessment of faecal incontinence; it has brought new insight into the pathophysiological mechanisms of this disorder and can select patients with traumatic incontinence for sphincter repair. It has replaced electromyographical sphincter mapping, which is a painful and time-consuming procedure. In perianal sepsis, endosonography assists in defining fistula tract anatomy. The use of contrast agents has significantly increased the accuracy of endosonography in the assessment of perianal fistulae. In addition, endosonography is an excellent alternative to expensive MRI. Besides its use in incontinence and perianal sepsis, with anal endosonography surgical possibilities can be evaluated in individual patients, for example, to decide whether a sphincter repair or a lateral sphincterectomy is preferable. Finally, endosonography may occasionally identify internal sphincter myopathy in patients with intractable constipation or proctalgia. CONCLUSION Anal endosonography images the internal and external sphincters with high accuracy. It is easy to perform and is especially valuable in the diagnosis of anal incontinence and perianal sepsis.
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Affiliation(s)
- A C Poen
- Dept of Surgery, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
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Abstract
BACKGROUND The aim of this study was to determine intraobserver and interobserver agreement for sonographic measurements of anal canal structures using anal endosonography (AES), and to determine interobserver agreement for the diagnosis of anal sphincter disruption. METHODS Fifty-one consecutive patients referred for AES for the investigation of possible sphincter abnormality were examined. Studies were reviewed by two observers who measured anal canal structures at defined levels and locations, and recorded an opinion on sphincter integrity. Repeated measurements made by each observer were compared to determine intraobserver agreement, and measurements and diagnoses were compared between observers to determine interobserver agreement. RESULTS Intraobserver agreement was better than interobserver agreement for measurements of anal canal structures. Interobserver limits of agreement for external sphincter measurements spanned 5 mm, whereas those for the internal sphincter spanned 1.5 mm. Interobserver agreement for diagnosis of sphincter disruption and internal sphincter echogenicity was very good (kappa = 0.80 and 0.74 respectively). CONCLUSION The limits of agreement for intraobserver and interobserver measurements of anal canal structures on AES have been defined. Interobserver assessment of sphincter disruption is very good.
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Affiliation(s)
- D M Gold
- Intestinal Imaging Centre, St Mark's Hospital, Harrow, UK
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