Evaluation of diagnostic accuracy of 3-D endoanal ultrasound in perianal fistula in comparison with intraoperative findings / Avaliação da precisão diagnóstica da USE 3D endoanal em casos de fistula perianal, em comparação com os achados cirúrgicos

ABSTRACT Objective: Perianal fistula is a common and debilitating disease. The definite treatment is surgery, identifying of primary and secondary tract, internal opening of fistula has important role in planning of surgical techniques. This study's goal was to determine the diagnostic accuracy of 3-D ultrasound in perianal fistula in comparison with intraoperative findings. Materials and methods: This study is a cross-sectional study. Adult patients (18-85 years old) with anal fistula have been selected. 3-D EUS was done for all patients by gastroenterologist. Then surgery was done. Check lists filled by endoscopist and surgeon was studied and data analysis was done. Results: The study examined 76 patients, in according to results for kappa coefficient there was a perfect agreement between 3-D ultrasound results and surgery in internal opening that was 96% (p < 0.001) and concordance was 0.974. In extension tract the agreement was 0.973 and concordance was 0.987 (p < 0.001). Conclusion: There was perfect agreement between 3-D ultrasound and surgical findings in internal opening, primary tract and trunk expansion. 3-D ultrasound shows a high diagnostic accuracy when compared with surgery to assessment of perianal fistula before surgery.

RESUMO Objetivo: A fistula perianal é doença comum e debilitante. O tratamento definitivo é cirúrgico. A identificação dos tratos primário e secundário e de abertura interna da fístula desempenha papel importante no planejamento das técnicas cirúrgicas. O objetivo do presente estudo foi determinar a precisão diagnóstica da USE 3D em casos de fístula perianal, em comparação com os achados cirúrgicos. Materiais e métodos: Este é um estudo transversal. Foram selecionados pacientes adultos (18-85 anos) com fístula anal. Todos os pacientes foram examinados por USE 3D realizada por um gastroenterologista. Em seguida, procedeu-se à cirurgia. O endoscopista e o cirurgião estudaram as listas de verificação, com análise dos dados. Resultados: Nesse estudo foram examinados 76 pacientes. De acordo com os resultados para o coeficiente kappa, foi observada perfeita concordância entre os resultados da USE 3D e cirurgia para IO, de 96% (p < 0,001), com concordância de 0,974. Na extensão do trato a concordância foi 0,973 e concordância de 0,987 (p < 0,001). Conclusão: Foi observada concordância perfeita entre USE 3D e os achados cirúrgicos em abertura interna, trato primário e expansão do tronco. USE 3D demonstra elevada precisão diagnóstica, quando comparada com a cirurgia, para avaliação da fístula perianal antes da operação.

Therapeutic Decision-Making Using Endoscopic Ultrasonography in Endoscopic Treatment of Early Gastric Cancer

BACKGROUND/AIMS: We evaluated the effectiveness of an endoscopic ultrasonography (EUS)-based treatment plan compared to an endoscopy-based treatment plan in selecting candidates with early gastric cancer (EGC) for endoscopic submucosal dissection based on the prediction of invasion depth. METHODS: We reviewed 393 EGCs with differentiated histology from 380 patients who underwent EUS from July 2007 to April 2010. The effectiveness of the EUS-based and endoscopy-based plans was evaluated using a simplified hypothetical treatment algorithm. RESULTS: The numbers of endoscopically determined mucosal, indeterminate, and submucosal cancers were 253 (64.4%), 56 (14.2%), and 84 (21.4%), respectively. Overall, the appropriate treatment selection rates were 75.3% (296/393) in the endoscopy-based plan and 71.5% (281/393) in the EUS-based plan (p=0.184). For endoscopic mucosal cancers, the appropriate treatment selection rates in the endoscopy-based plan were 88.1% (223/253), while the use of an EUS-based plan significantly decreased this rate to 81.4% (206/253) (p=0.036). For endoscopic submucosal cancers, the appropriate selection rates did not differ between the endoscopy-based plan (46.4%, 39/84) and the EUS-based plan (53.6%, 45/84) (p=0.070). CONCLUSIONS: EUS did not increase the likelihood of selecting the appropriate treatment in differentiated-type EGC. Therefore, EUS may not be necessary before treating differentiated-type EGC, especially in endoscopically presumed mucosal cancers.

Endoanal ultrasound assessment of sphincter defects and thinning – Correlation with anal manometry

This study aims to determine if anal sphincter defects/thinning observed at endoanal ultrasound correlates with anal pressures recorded at anal manometry. A total of 30 consecutive patients with history suggestive of anal sphincter pathology underwent anal endosonography with documentation of internal and external sphincter defects/ thinning. The same patients underwent anal manometry with documentation of maximum resting and maximum squeeze pressures. Patients with a sphincter defect [SD] were compared to patients without a sphincter defect [NSD] and both groups were compared with respect to findings in manometry. The Mann-Whitney U test was used for statistical analysis. This study was approved by the Institutional Ethics Committee. A statistically significant correlation was found between decreased maximal resting pressure and decreased internal anal sphincter [IAS] thickness or an IAS defect. The correlation between MSP and external sphincter pathology was significantly less consistent in our study. Our study showed a statistically significant correlation between maximum resting pressure and observation of internal sphincter defects at endoanal ultrasound. The patients with documented internal sphincter defects have significantly reduced maximum resting pressures. There was however, no correlation between external sphincter defects and decrease in maximum squeeze pressure as has been observed in other studies. Until a manometry cut-off can be set to discriminate between the absence and presence of defects, both manometry and ultrasound should be offered to patients with history suggesting anal sphincter pathology

Indicaciones y resultados de la endosonografía ano-rectal: Análisis de las primeras 1000 endosonografías / Indications and results of the Endoluminal Ultrasonography

Introducción: La endosonografía anorrectal (EAR) es una alternativa diagnóstica en las patologías anorrectales. Objetivo: Analizar las principales indicaciones y resultados de la EAR. Material y método: Estudio prospectivo, descriptivo desarrollado entre Noviembre 1999 hasta Septiembre 2004. Se correlacionó el informe de la EAR con los hallazgos quirúrgicos y resultados de biopsias. Análisis mediante concordancia. Resultados: En el período mencionado se realizaron 1000 EAR, (62 por ciento mujeres, edad promedio 55 años). Las indicaciones fueron etapificación y seguimiento de cáncer rectal (CR) en 279 pacientes, otros tumores 119, incontinencia fecal (IF) en 336, fístulas perianales en 137, dolor anal (DA) en 73, y otras indicaciones en 56 pacientes. En la etapificación del CR la concordancia general para la profundidad tumoral y compromiso linfonodal fue 81,6 por ciento y 67,8 por ciento, respectivamente. En el estudio de IF, la EAR resultó normal en el 17 por ciento, se informó interrupción de ambos esfínteres en 16 por ciento de los pacientes, interrupción del esfínter anal externo en el 65 por ciento y del esfínter anal interno aislado en el 2 por ciento. En 30 pacientes operados por IF en nuestra institución, hubo 100 por ciento de concordancia entre hallazgos endosonográficos e intraoperatorios. En el estudio por fístulas perianales, 10,2 por ciento normales, 64,2 por ciento confirmaron la fístula, 13,1 por ciento evidenció una colección y en el 12,5 por ciento otros diagnósticos. En el estudio por DA, 36 EAR fueron normales y en 37 se evidenció alguna alteración (50,7 por ciento). Conclusión: Las indicaciones más frecuentes fueron el estudio de pacientes con incontinencia fecal y etapificación del cáncer de recto. Existe adecuada concordancia entre hallazgos endosonográficos y quirúrgicos.

Introduction: The endoluminal ultrasonography (EU) is a diagnostic alternative in the anorectal pathologies. Aim: To analyze the indications and results of the EU. Material and Method: Prospective, descriptive study, between November 1999 and September 2004. The results obtained with the EU were compared with surgical findings and biopsies results. Accuracy analysis was developed. Results: During this period 1000 patients underwent EU, (62 percent females, 55 years average). Indications were staging and follow up of rectal cancer (RC) in 279 patients, other tumors 119, fecal incontinence (FI) in 336, anal fistulae in 137, anal pain (AP) in 73 and other indications in 56 patients. In the assessment of RC the overall accuracy in staging depth of infiltration and lymph nodal involvement was 81.6 percent and 67.8 percent respectively. In the assessment of FI, the EU was normal in 17 percent, evidence abnormalities of both sphincters in 16 percent, only disrupt of external anal sphincter in 65 percent and isolated defect of internal anal sphincter in 2 percent. Thirty patients were operated in our institution, in them the accuracy between the EU results and the surgical find were 100 percent. In the assessment of anal fistulae, 10,2 percent EU results normal, 64,2 percent confirm the fistula, 13,1 percent evidence a collection and 12,5 percent other diagnosis. In the anal pain assessment, 36 (49.4 percent) EU was normal and 37 (50.7 percent) evidence alterations. Conclusion: The most frequent indications were the assessment of patients with fecal incontinence and the staging of rectal cancer. There are an adequate accuracy between the EU results and surgical findings.