The results of sphincterometry in patients after sorgion treatment of extrasphintery anal fistula

More than 30% of patients with chronic paraproctitis have complex forms. They are most often complicated by external sphincter insufficiency due to deformation of the anal canal and scarring of the sphincters. The main principle of substantiation of surgical treatment of extrasphincteric pararectal fistulas is the individual choice of method in each particular patient. It is based on a comprehensive assessment of such factors as the etiology of the fistula, its distance from the edge of the anus, the relationship of the defect or fistula with the sphincter muscles apparatus, the severity of the scarring process, the functional state of the rectum. Aim. Evaluation of the functional state of the sphincter apparatus of the rectum in patients with extrasphincteric pararectal fistulas in the preoperative, early and late postoperative periods. Materials and methods. To determine the average indicators of anal sphincter function, basal tone and maximal compression force were measured using a sphincterometer "Sphinctometer STM-0164-SM" in 114 healthy individuals (68 men and 46 women) of different ages (16 to 80 years) who objectively had no signs of anal incontinence. In all patients, sphincterometry was preceded by a thorough proctological examination, and proctological pathology was excluded. Therefore, hemorrhoids or anal fissures, which lead to increased basal tone at rest, were excluded so as not to lead to falsified values. Results. Indicators of the maximum compression force in the early postoperative period, ie the compression force of the external anal sphincter, in both groups were significantly lower than preoperative and ranged from 55 to 154 mm Hg, respectively. and from 63 to 137 mm Hg. This can be explained by the presence of a granulating wound in the pararectal tissue, edema and partial injury of the external anal sphincter during surgery. In the late postoperative period, 6-12 months after surgery, the indicators of basal tone in both groups approached the preoperative indicators. In the main group, the study was performed in 22 patients. In these 22 patients, the tone of the internal anal sphincter did not differ significantly from the preoperative and ranged from 20 to 37 mm Hg. In the control group, in all 32 patients, the basal tone of the anal sphincter was significantly lower than before surgery - from 17 to 28 mm Hg. There were no clinical manifestations of incontinence at rest in either main or control groups. In the late postoperative period in both groups a decrease in the maximum compression force of the external anal sphincter was revealed. In the main group the maximum compression force of the external anal sphincter varied from 71 to 186 mm Hg, and in the control group from 77 to 135 mm Hg, respectively. Conclusion. Surgical treatment of patients with extrasphincteric pararectal fistulas significantly reduces the contractile function of the external anal sphincter in the postoperative period, regardless of the choice of surgery.

Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence

Background The length of sphincter which can be divided during fistulotomy for perianal fistula is unclear. The aim was to quantify sphincter damage during fistulotomy and determine the relationship between such damage with symptoms and severity of faecal incontinence and long-term quality of life (QOL). Methods A prospective cohort study was performed over a 2-year period. Patients with intersphincteric and mid to low transsphincteric perianal fistulas without risk factors for faecal incontinence were scheduled for fistulotomy. All patients underwent 3D endoanal ultrasound (3D-EAUS) pre-operatively and 8 weeks postoperatively. Measurements were taken of pre- and postoperative anal sphincter involvement and division. Anal continence was assessed using the Jorge-Wexner scale and QOL scores pre, 6 and 12 months postoperatively. Results Forty-nine patients were selected. A strong correlation between pre- and postoperative measurements was found p < 0.001. A median length of 41% of the external anal sphincter and 32% of the internal anal sphincter was divided during fistulotomy. Significant differences in mild symptoms of anal continence were found with increasing length of external anal sphincter division. But there was no significant deterioration in continence, soiling, or quality of life scores at the 1-year follow-up. Division of over two-thirds of the external anal sphincter was associated with the highest incontinence rates. Conclusions 3D-EAUS is a valuable tool for quantifying the extent of sphincter involvement pre- and postoperatively. Post-fistulotomy faecal incontinence is mild and increases with increasing length of sphincter division but does not affect long-term quality of life.

The effect of vaginal delivery and Caesarean section on the anal Sphincter complex of Primipara based on optimized three-dimensional ultrasound image and nuclear regression Reconstruction Algorithm

Objective: The study used the optimized nuclear regression reconstruction algorithm to explore the value of three-dimensional perineal ultrasound evaluation of the effect of caesarean delivery and caesarean section on the anal sphincter complex of primipara. Methods: This study performed three-dimensional perineal ultrasound scanning of the anal sphincter complex of 157 primiparas 42 days after delivery. Among them, 77 were in caesarean delivery (spontaneous delivery group) and 80 were in caesarean section (caesarean delivery group) from September 2018 to December 2020 in our hospital. The thickness of the end plane, the middle plane, the distal plane and the distal plane of the external anal sphincter at 3, 6, 9, 12 o’clock direction, and measure the thickness of the central plane of the pubic rectum muscle at 4, 8 o’clock direction. At the same time, the study used tomography and volume contrast imaging to observe the morphology and integrity of the anal sphincter complex. Results: The thickness of the distal anal sphincter at the 12 o’clock direction, the proximal anal sphincter at 6, 12 o’clock, and the central plane at 9 and 12 o’clock in the obstetric group were smaller than those in the caesarean section group (all P < 0.05). There were no significant differences in the thickness of the remaining anal internal and external anal sphincter and puborectalis muscles between the two groups in different directions (all P>0.05). In the obstetric group, a perineal sphincter defect was found via three-dimensional perineal ultrasound. Conclusion: The delivery method has a certain influence on the shape of the anal sphincter complex. The thickness of the internal and external anal sphincter of the primiparous women in a certain direction is significantly smaller than that of caesarean section. Transperineally three-dimensional ultrasound can clearly show the morphological characteristics and integrity of the anal sphincter complex, and diagnose the defect of the anal sphincter complex. doi: https://doi.org/10.12669/pjms.37.6-WIT.4859 How to cite this:He N, Shi L. The effect of vaginal delivery and Caesarean section on the anal Sphincter complex of Primipara based on optimized three-dimensional ultrasound image and nuclear regression Reconstruction Algorithm. Pak J Med Sci. 2021;37(6):1641-1646. doi: https://doi.org/10.12669/pjms.37.6-WIT.4859 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Obstetric rectal laceration in the absence of an anal sphincter injury

Rectal laceration in the absence of concurrent anal sphincter injury at the time of parturition is not a frequently reported finding. This rarely encountered injury is also referred to as a buttonhole injury. It is a disruption of the vaginal and rectal tissue with resultant disruption of the anal epithelium in the setting of an intact external anal sphincter. A 30-year-old gravida 1 para 0 at 39 weeks presented for induction of labour due to chronic hypertension. During her labour course, she developed with superimposed preeclampsia with severe features and magnesium sulfate was initiated. She underwent a spontaneous vaginal delivery of an infant weighing 3840 g. Following delivery, stool was visualised in the vagina. A rectal examination revealed a rectovaginal defect separate from the second-degree perineal laceration, which extended proximally to the cervix. The anal sphincter was noted to be intact with good tone. Both defects were repaired, and she had an uncomplicated recovery.

O5 Dose mean opening pressure predominantly assess internal anal sphincter function

Introduction We have suggested that mean Opening Pressure (Op) recorded during Anal Acoustic Reflectometry (AAR) predominantly represents IAS function however, the extent remains unknown. The aim was to investigate this by excluding the external anal sphincter during general anaesthetic (GA) with confirmed neuromuscular blockade (NMB). Method Patients undergoing elective abdominal surgery requiring GA+NMB were approached. Patients had pre-operative (awake) and during GA + NMB (asleep) AAR measurements performed. The rectoanal inhibitory reflex (RAIR) was assessed permitting the Op value to also be recorded when the IAS was inhibited. Op was recorded at prerectal distension and then after 100 mls of air was inflated within a balloon in the rectum (post-rectal distension). Result 19 patients were included. The values of Op (cmH20) and the reductions observed during the RAIR when awake/asleep are as follows: Awake Op: prerectal distension (64.94) and post-rectal distension (35.35) therefore mean change 29.59 cmH2O i.e. 44.6% reduction Asleep Op: prerectal distension (37.64) and post-rectal distension (15.55) therefore mean change 22.1 i.e. 55.3% reduction The contribution of the IAS to Op is calculated as follows: (Mean change Op awake x 100)/% reduction in RAIR asleep = IAS contribution awake (29.59cmH20 x 100)/55.3 = 53.51cmH20 Total mean Op awake—IAS contribution awake = EAS contribution awake 64.94cmH20–53.51cmH20 (82.4%) = 11.43cmH20 (17.6%) Conclusion The IAS accounts for 82.4% of Op at rest and it remains our hypothesis that Op primarily represents IAS function. Take-home Message Opening pressure primarily represents internal anal sphincter function.