New techniques in the repair of anal sphincter between success and failure

Background Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. It is defined as the uncontrolled passage of faeces or gas over at least 1 month’s duration, in an individual of at least 4 years of age, who had previously achieved control. Aim of Work to evaluate the outcome of overlap anal sphincter repair as regard the anal continence and postoperative complications. Patients and Methods this is a prospective clinical trial was conducted on thirty (30) patients presented to Ain-Shams University hospitals with anal sphincter injury that were operated upon by a modified overlap repair done by the same surgical team. Endoanal ultrasonography was done and Wexner continence score was estimated for all cases preoperatively and postoperatively. All patients sharing in the study were fully informed about the procedure they had with a written informed consent. Results In this study the mean preoperative Wexner score was 12.9 and the mean postoperative Wexner was 4.8; this reduction was found to be significant (p value=0.001). Also endoanal ultrasound showed that tear size significantly reduced among the studied cases(p value=0.001). Conclusion from this study that overlapping sphincter repair is an effective method in the treatment of faecal incontinence in patients with repairable sphincter defects. However, long term follow up is required to confirm its efficacy.

End-to-end anal Sphincter Repair in Treatment of Post-traumatic Fecal Incontinence

The present report describes the end-to-end technique of anal sphincter repair in a 36-year-old female patient with post-vaginal delivery fecal incontinence (FI). The patient had a history of two vaginal deliveries and the symptoms of FI were observed after the second delivery. On assessment of the severity of FI using the Wexner incontinence score, the patient had a score of 12. Endoanal ultrasonography revealed an anterior defect of the external anal sphincter extending from 11 to 3 o'clock. The patient had no previous anal surgery and did not have any medical comorbidities.The operation time was 45 minutes. No intraoperative complications were recorded. At 12 months of follow-up, the patient showed significant improvement in the continence state, with her Wexner score dropping to 4. No postoperative complications were recorded. We can conclude that end-to-end anal sphincter repair is a technically feasible operation that confers satisfactory improvement in the continence state without imposing much tension on the site of sphincter repair.

Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization

Background Arterial hyperflow to haemorrhoids has been implicated as a possible pathophysiological co-factor in haemorrhoidal disease. The purpose of this study was to investigate how transanal haemorrhoidal dearterialization (THD) can influence haemodynamic parameters at the level of the haemorrhoidal piles. Methods Patients with grade III haemorrhoids selected for THD between July and December 2018 were evaluated using endoanal ultrasonography and colour Doppler imaging at the level of internal haemorrhoids before and 1 year after the surgical procedure. Peak systolic velocity, pulsatility index, resistivity index, acceleration time, and end-diastolic velocity were measured, and preoperative and postoperative values compared. Symptom severity was measured using a symptom-based questionnaire (score range 0–20). Results Of 21 patients treated, 17 completed the study. Compared with preoperative values, postoperative peak systolic velocity (mean(s.d.) 18.7(1.1) versus 10.3(0.4) cm/s; P < 0.05), pulsatility index (5.5(0.3) versus 2.8(0.4); P < 0.050), and resistivity index (1.0(0.2) versus 0.8(0.5); P < 0.050) decreased significantly, whereas acceleration time increased significantly (65.6(3.6) versus 83.3(4.7) cm/s2; P < 0.050); end-diastolic velocity did not change (1.9(0.2) versus 2.0(0.4); P = 0.753). Symptoms disappeared or had improved significantly in all patients by 1 year after surgery. The mean(s.d.) total symptom severity score decreased from 15.8(1.1) to 1.2(1.6) (P < 0.001). Conclusion THD affects the main haemodynamic parameters at the level of internal haemorrhoids and is associated with a decrease in arterial hyperflow.

Goodsall’s rule– its predictive accuracy in tracing the tract of fistula in ano

Background: Despite being one of the oldest reported medical conditions, the management and treatment of fistula in ano are still in the evolving phase. The management of fistula-in-ano requires confirmation of the diagnosis, identifying the fistulous tract and inner opening. In majority of patients a single primary fistula tract exists and the anatomy can be determined by examination under anaesthesia adhering to the principles described by Goodsall. A thorough clinical examination of the patient is essential in the assessment of fistula-in-ano, sometimes helped by imaging such as magnetic resonance imaging and endoanal ultrasonography. Although Goodsall’s rule was accepted in the past, as a method to determine the course of the fistula, recent studies showed poor conflicting results. Thus, this study attempts to scrutinize the predictive accuracy of Goodsall’s rule. Methods: After approval from ethical committee and obtaining informed consent from each patient, prospective analysis of 188 patients who has fistula-in-ano were included in the study. They were grouped according to Goodsall’s rule and its predictive accuracy was checked with intraoperative findings. Data was entered in excel sheet and analysed by SPSS version 20.0. For all statistical interpretations, p<0.05 was considered the threshold for statistical significance.Results: Predictive accuracy of Goodsall’s rule found to be 84.6% in case of fistula with an anterior external opening. While in case of fistula with posterior external opening this found to be 69.1%. Overall predictive accuracy of Goodsall’s rule is 77%. Conclusions: Goodsall’s rule can be used as guide in predicting the tract.

Perineal Endometriosis: What to Do in These Cases - Analysis of 13 Patients

Objective: To analyse the clinical features of perineal endometriosis (PEM), its treatment and outcome. Methods: Prospective, single-centre study with 13 patients with PEM who were treated between 2011-2018 at Domingo Luciani Hospital and mean followed up for 58.4 months. Results: Mean age was 32,2 years. All cases had a history of vaginal delivery with an episiotomy. All complained of perineal pain related to the menstrual cycle; the perineal mass progressively increased in size and was tender during menstrual periods. Mean VAS was 7. 69,2% with rectal bleeding. The mean size of the lesion was 3.42 cm. CA125 levels were measured in all patients, 3 (23,1%) with abnormal range; all patients were subjected to transvaginal, endoanal ultrasonography (EUS) and FNAB before surgery. Anal sphincter (AS) involvement was demonstrated by EUS in 46.2% (6). Mean EUS pre-treatment volume 18.98 ml. First, these 6 patients received hormonal therapy based on GnRH and evaluated response. Mean EUS post-treatment volume 10.21 ml p < 0.05. Complete local excision was performed on all cases. Mean CCFIS preoperative was 2.46 and postoperative 3.01 p=0.01. No major complications or recurrences were noted. Conclusion: PEM presents with typical clinical features when it involves the AS, it could benefit from first a hormonal therapy before surgery. EUS is a useful preoperative tool to decide what we should do. The main idea at the time of surgery is performed a complete local excision with non-touch AS, and in cases where these aren’t possible, a sphincteroplasty is mandatory with good continence results, minor complications and no recurrences.

Effects of extracorporeal magnetic stimulation in fecal incontinence

BackgroundFecal incontinence (FI) is a common condition that has devastating consequences for patients’ QOL. In some patients, the conventional functional pelvic floor electrical stimulation has been effective but is an invasive and embarrassing treatment. The object of the study was to evaluate the feasibility of functional extracorporeal magnetic stimulation (FMS) in strengthening the pelvic floor muscles without an anal plug and the embarrassment of undressing.Materials and MethodsThirty patients (26 female and 4 males) with FI were enrolled. All patients were assessed during a specialized coloproctology evaluation followed by endoanal ultrasonography and anorectal manometry. All patients underwent an FMS treatment once weekly for 8 weeks. Patients’ outcome was assessed by the Cleveland Clinic Fecal Incontinence Score (CCFIS) and by the fecal incontinence QOL questionnaire (FIQL).ResultsAfter 8 weeks, the number of solid and liquid stool leakage per week was significantly reduced (p<0.05) with a significant improvement of the CCFIS and of the FIQL (p<0.05). Moreover, the authors recorded a missed recruitment of the agonist and antagonists’ defecation muscles.ConclusionFMS is a safe, non-invasive and painless treatment for FI. It could be recommended for selected patients with non-surgical FI to ensure a rapid clinical improvement.