Anal endosonographic assessment of the accuracy of clinical diagnosis of obstetric anal sphincter injury

Introduction and hypothesis Obstetric anal sphincter injuries (OASIS) are a common cause of maternal morbidity with an overall incidence in the UK of 2.9% (range 0–8%). They can cause a range of physical symptoms and psychological distress. This study aims to assess the accuracy of clinical diagnosis of OASIS using endoanal ultrasound (EAUS) and the correlation between confirmed injury and change to anorectal physiology squeeze pressure and the incidence of bowel symptoms. Methods and materials Retrospective study of prospectively collected data from 1135 women who attended the Third- and Fourth-Degree Tears Clinic at our institution, 12 weeks post-delivery, between June 2008 and October 2019. Results OASIS was confirmed in 876 (78.8%) women and 236 (21.3%) had no injury. Of the women who underwent anorectal physiology, 45.6% had a mean maximal resting pressure below the normal range and 68.8% had a mean incremental squeeze pressure below normal. Women with confirmed OASIS had significantly lower pressures (p < 0.001) than those without a confirmed sphincter injury. Three hundred ninety-three (34.8%) women reported bowel symptoms, with those with endosonographic evidence of injury more likely to develop flatus incontinence. Conclusion Of the women in this study with a suspected OASIS, 21.2% could be reassured that they did not have an injury. This information is useful for women considering future mode of delivery. Those with confirmed injury are more likely to complain of flatus incontinence and have reduced anal sphincter pressures.

Outcome of treatment of high fistula in ANO, with fistulectomy plus seton placement.

Objective: To determine post procedure recurrence and incontinence rate for high fistula-in-ano cases, who underwent procedure of fistulectomy and Seton placement. Study Design: Descriptive study. Setting: Department of General Surgery, Khyber Teaching Hospital Peshawar. Period: January to December, 2018. Material & Methods: This study was conducted over 50 patients with diagnosis of high fistula-in-ano, treated with combined procedure of fistulectomy and Seton placement. Patients follow up was done for one year for recurrence and incontinence. Results: Out of 50 patients, 28(56%) were male and 22(44%) were female. Overall male to female ratio was 1.27:1. Average age of patient was 36.88 years+6.63 SD. Flatus Incontinence was observed in single case (2%), no patient reported stool Incontinence. Recurrence of disease was found in 2 patients (4%). All patients were followed for one year. Conclusion: This technique for treating high Fistula-in-ano showed overall low recurrence and incontinence rates during follow up, thus reducing morbidity and costs associated with recurrent surgery for Fistula-in-ano.

A Comparative Study Of Lateral Anal Sphincterotomy Versus Transfissure Sphincterotomy In Cases Of Fissure In Ano

OBJECTIVE The present study is designed to compare the effect of two most commonly used surgical procedure for anal fissure: Lateral Anal Sphincterotomy and Trans fissure Sphincterotomy with regards to fissure healing time, pain reduction, cessation of bleeding per rectum post operatively as well as the complications like flatus and feces incontinence post operatively in both surgical procedures. METHODOLOGY This hospital based prospective cohort study was undertaken at GCS hospital Ahmedabad (tertiary care hospital) from March 2019 to December 2019. 50 patients were enrolled in the study from which 25 patients were randomly assigned to lateral anal sphincterotomy group and 25 were assigned to trans fissure sphincterotomy group. RESULTS Our study establishes that although there is no statistically significant difference in pain alleviation and relief from bleeding per rectum post operatively in anal fissure between the Lateral Anal Sphincterotomy and Trans fissure Sphincterotomy, yet the fissure healing is earlier in Lateral Anal Sphincterotomy than in Trans fissure Sphincterotomy. There is also slight predominance of flatus incontinence rate in Trans fissure Sphincterotomy group as compared to Lateral Anal Sphincterotomy. CONCLUSION Thus, we can conclude from over all study that the lateral anal sphincterotomy is far better than the trans fissure sphincterotomy for the treatment of the fissure in ano by looking at various perspectives in areas of postoperative outcome.

A comparative study of the results of the lateral internal anal sphincterotomy vs manual dilatation of anus for chronic anal fissure.

Objectives: To compare the results of surgical treatment of chronic anal fissure after lateral internal sphincterotomy with manual dilatation of anus. Study Design: Randomized Controlled Prospective study. Setting: Department of Surgery District Teaching Hospital Sargodha, Pakistan. Period: April 2018 to Feb 2019. Material & Methods: Patients were divided into two groups by lottery method. The procedures were performed using standard protocols after obtaining written informed consent. 50 patients underwent lateral internal anal sphincterotomy (Group 1) and 50 patients manual dilatation of anus (Group 2). Patients having atypical anal fissures associated with other diseases were excluded from this study. We assessed both groups for persistence of symptoms, complications and better satisfaction in terms of surgical techniques. Results: All patients became symptoms free within 07-14 days of surgery. Urinary retention was noted in 2(4%) patients in lateral internal sphincterotomy and 2(4%) in manual dilatation of anus. Temporary flatus Incontinence was noted in 2(4%) patient of lateral internal sphincterotomy and 2(4%) in manual dilatation of anus. Faecal soiling was observed in 1(2%) patient of lateral internal sphincterotomy. No recurrence, anal stenosis, hemorrhage, infection of wound, pain and bleeding associated with defecation was seen in both groups. Conclusion: Both lateral internal sphincterotomy and manual dilatation of anus techniques are effective.

Spinal cord infarction in children: Can gymnastics be a cause?

INTRODUCTION: Spinal cord infarction (SCI) in children is rare and difficult to diagnose. Fibrocartilaginous embolism (FCE) is probably the underlying cause for some unexplained cases of spinal cord infarcts. Abrupt back pain followed by a progressive syndrome of myelopathy appears to be the typical presentation, with a close temporal relationship between the onset of symptoms and preceding minor trauma. Supportive care and rehabilitation are essential in the treatment of children with SCI. CASE REPORT: A previously healthy 12-year-old girl who practiced acrobatic gymnastics was admitted to a rehabilitation centre 14 days after being diagnosed with an acute anterior SCI with no identified cause. Sensory modality of pin prick and light touch were impaired, with the former more significantly affected. She was not able to run and had difficulty on monopodal standing and performing motor sequencing. Additionally, she mentioned ineffective cough along with flatus incontinence and normal bladder function. After a 4-week multidisciplinary rehabilitation program her neurologic deficits improved. DISCUSSION: Given the patient’s age and clinical presentation, a literature review led to the consideration of FCE as the most likely definitive diagnosis. It should be recognized as a cause of SCI especially in those involved in sport activities, even if previous trauma is denied.

Single centre randomized comparative trial of lateral internal sphincterotomy versus 2% diltiazem in chronic anal fissure

Background: Anal fissures are often encountered in surgical practice with surgery the gold standard management for chronic anal fissures. Recently the widespread use of pharmacologic agents for chronic fissures has increased. In our study we compare topical 2% diltiazem with lateral sphincterotomy with respect to symptoms such as relief of pain, ulcer healing, and side effects of treatments.Methods: A prospective comparative study, a total of 80 patients were randomized into 2 groups 40 each. Group A patients were subjected to open internal lateral sphincterotomy and group B to 2% topical diltiazem. The patients in both groups were followed up at 1st, 4th, 14th weeks and 6 months in OPD and were assessed for pain, sphincter tone and complications.Results: In group A (lateral anal sphincterotomy), patients achieved a good pain relief with a mean pain score of 1.98 by one week post procedure whereas group B (2% diltiazem) had taken 14 weeks to achieve similar pain relief (pain score of 1.5). At the end of 6 months, healing of fissure was noted in 100% of group A and in 90% of group B. 4 patients (10%) had recurrences in group B. Flatus incontinence was reported in 2 patients (5%) in group A although transient.Conclusions: Lateral anal sphincterotomy is superior to 2% diltiazem especially in healing of fissure, pain relief, quality of life and recurrence. Pharmacologic agents should be reserved for patients who are unfit or unwilling for surgery or can be used as a bridge therapy till sphincterotomy can be planned.

Quality of Life in Women with Defecatory Dysfunctions: Systematic Review of Questionnaires Validated in the Portuguese Language

Objective To identify the quality of life (QoL) assessment instruments related to the health of women with fecal incontinence (FI) or anal incontinence (AI). Data Sources Systematic review conducted in the Virtual Health Library (VHL), PubMed and Cochrane Library databases. The descriptors used were: Questionnaire, Questionnaires, Quality of life, validation, validation Studies, anal incontinence, fecal incontinence and constipation. The search was performed between December 26, 2017 and the beginning of January 2018. The limits used were female gender. Selection of Studies Initially, 5,143 articles were obtained in the search. The articles of validation for Portuguese of questionnaires for the evaluation of the impact of FI/AI on the QoL of women were considered eligible. Data Collection The article search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Data Synthesis Of the 5,143 articles, only 2 fulfilled the inclusion and exclusion criteria: Fecal Incontinence Quality of Life (FIQL) and the Wexner scale (WS). The FIQL evaluates the QoL related to FI, not covering flatus incontinence. The WS assesses flatus incontinence and the severity of the AI. The WS obtained an interclass correlation coefficient (ICC) of 0.932 and a Cronbach α coefficient > 0.90. The FIQL obtained intraexaminer and interexaminer reproducibility ranging from 0.929 to 0.957 and from 0.944 to 0.969, respectively. Conclusions The WS and the FIQL have satisfactory reliability and validity for use during gynecological consultations.

Efficacy of chemical sphincterotomy with 2% diltiazem cream vs. surgical sphincterotomy in the management of chronic fissure in ano: a clinical study

Background: Surgical intervention like lateral internal sphincterotomy is very effective and in a time of few weeks, healing can occur but there is danger of the anal incontinence. Hence alternative methods were sought like 2% diltiazem and other agents and they have been shown to lead to proper healing without anal incontinence. The objective was to study efficacy of chemical sphincterotomy with 2% diltiazem cream vs. surgical sphincterotomy in the management of chronic fissure in ano.Methods: A hospital based follow up study was carried out among 60 patients with chronic fissure in ano. They were randomly assigned in two groups. Group I consisted 30 patients who were treated with 2% diltiazem cream on outpatient basis. Group II patients i.e. 30 patients were operated for sphincterotomy. Both the group patients were followed for six weeks at two weeks interval. Outcome like complete healing, fecal incontinence, flatus incontinence was seen at follow up. Chi square test and t test were used to determine the significant difference between the groups.Results: Both the groups were comparable to each other in terms of age, sex, presenting symptoms, mean duration of symptoms and internal findings. Diltiazem group patients had significantly much better healing rate i.e. 96.7% compared to only 80% from patients with surgery group. Incidence of complications like fecal/flatus incontinence was zero in diltiazem group compared to 13.3%/20% in surgery group.Conclusions: Authors conclude that diltiazem 2% topical application is better than surgical sphincterotomy and should be used instead of surgery.