Predictors of long-term healing for endorectal advancement flap for anorectal fistulas

Introduction: Anorectal fistulas are some of the commonest surgical proctologic disorders treated by surgeons. Despite the recent introduction of various sphincter preserving techniques, the search for the optimal operation continues. The purpose of this study was to determine the predictors of long-term healing for the endorectal advancement flap. Methods: A retrospective review of a single surgeon experience with the endorectal advancement flap for anorectal fistulas over an 18-year period. The impact of various patient and fistula related factors were analyzed for their impact on the primary endpoint of long-term fistula healing. Results: 87 patients underwent endorectal advancement flap (Male/Female 42.5/57.5%). Median age was 41 years. Sixty-nine patients (79.3%) had anal fistula while 18 patients had rectal fistula (20.7%). An anterior based fistula was noted in 45 patients (51.7%). The most common etiology was cryptoglandular disease (87.4%). The median operative time was 75minutes (range 36-250). Postoperative septic complications were noted in 4 patients (4.6%). Fistula healing was documented in 80 patients (93%). During a median follow-up of 4 months (range 1-38, 1 patient lost to follow-up), recurrence was noted in 8 patients (9.3%), yielding an overall long-term success rate of 83.7%. The long-term healing rate was higher in patients with fistulas from cryptoglandular etiology (86.6%) compared to fistulas from other etiologies (63.6%) [p = 0.027]. Conclusions: The endorectal advancement is associated with a high healing rate, a low postoperative septic complication rate, and infrequent risk for recurrence. Long-term healing without recurrence is achieved more frequently in patients with cryptoglandular etiology of the fistula compared to patients with non-cryptoglandular etiology. (AU)

Value of endorectal ultrasonography in the assessment of invasion staging of low rectal cancer with local progression after neoadjuvant radiochemotherapy / Valor de la ultrasonografía endorectal en la evaluación de la estadificación de la invasión del cáncer rectal bajo con progresión local, después de administrar radioquimioterapia neoadyuvante

Abstract Although stages T3 and T4 rectal cancer can be reduced to T1 or T2 after neoadjuvant radiochemotherapy, the accuracy of the endorectal ultrasonography (ERUS) for the post-radiochemotherapy evaluation of low rectal cancer has seldom been reported. We aimed to investigate the value of ERUS in the assessment of invasion staging in low rectal cancer with local progression, and the factors affecting its accuracy, after neoadjuvant radiochemotherapy. A total of 114 patients administered with neoadjuvant radiochemotherapy for stages II and III low rectal cancer (local stage T3/T4) from February 2018 to December 2020 were enrolled in the study. The changes in local lesions were evaluated using ERUS before and after radiochemotherapy, and compared with the pathological T staging. The accuracy of post-neoadjuvant radiochemotherapy re-staging examined with ERUS was evaluated, and univariate analysis was used to identify the factors affecting the accuracy. After neoadjuvant radiochemotherapy, the blood flow distribution within the lesion significantly declined (P<0.05), the max length and max thickness of the longitudinal axis of the lesion were reduced (P<0.05), and the uT staging was decreased (P<0.05), when compared with lesions before the treatment. Compared with postoperative pathological T staging, the accuracies of ERUS in T1, T2, T3 and T4 stages were 11.11%, 28.57%, 27.27% and 100%, respectively. Univariate analysis indicated that review time of ERUS, post-operative T staging and Wheeler rectal regression stage were factors affecting the accuracy of ERUS re-staging. ERUS is more accurate for T4 re-staging, follow-up reviewed six weeks after neoadjuvant radiochemotherapy and low regression tumors, with a high application value for the assessment of the efficacy of neoadjuvant radiochemotherapy for low rectal cancer.

Resumen Aunque el cáncer de recto en estadios T3 y T4 se puede reducir a T1 o T2 después de la radioquimioterapia neoadyuvante, rara vez se ha informado la precisión de la ecografía endorrectal (ERUS) para la evaluación posterior a la radioquimioterapia del cáncer de recto inferior. Nuestro objetivo fue investigar el valor de ERUS en la evaluación de la estadificación de la invasión en el cáncer de recto inferior con progresión local, después de la radioquimioterapia neoadyuvante y los factores que afectan su precisión. Se incluyeron en el estudio un total de 114 pacientes a los que se les administró radioquimioterapia neoadyuvante para el cáncer de recto inferior en estadios II y III (estadio local T3/T4), desde febrero de 2018 hasta diciembre de 2020. Los cambios en las lesiones locales se evaluaron mediante ERUS antes y después de la radioquimioterapia y se compararon con la estadificación patológica T. Se evaluó la precisión de la re-estadificación examinada con ERUS, después de la radioquimioterapia neoadyuvante y se utilizó un análisis univariado para identificar los factores que afectan su precisión. Después de la radioquimioterapia neoadyuvante, la distribución del flujo sanguíneo dentro de la lesión disminuyó significativamente (P<0,05), la longitud máxima y el espesor máximo del eje longitudinal de la lesión se redujeron (P<0,05) y la estadificación uT disminuyó (P<0,05), en comparación con las lesiones antes del tratamiento. En comparación con la estadificación T patológica posoperatoria, las precisiones de ERUS en las etapas T1, T2, T3 y T4 fueron del 11,11%, 28,57%, 27,27% y 100%, respectivamente. El análisis univariable indicó que el tiempo de revisión de ERUS, la estadificación T postoperatoria y la etapa de regresión rectal de Wheeler fueron factores que afectaron la precisión de la re-estadificación con ERUS. ERUS es más preciso para la re-estadificación de T4, el seguimiento seis semanas después de la radioquimioterapia neoadyuvante y en tumores de baja regresión, con un alto valor de aplicación para la evaluación de la eficacia de la radioquimioterapia neoadyuvante para el cáncer rectal bajo.

Value of endorectal ultrasonography and MRI examination in the preoperative evaluation of T staging and circumferential resection margin of rectal cancer / 中华消化外科杂志

Objective To investigate the value of endorectal ultrasonography (ERUS) and MRI examination in the preoperative evaluation of T staging and circumferential resection margin (CRM) of rectal cancer.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 193 patients [122 males and 71 females,age (60± 12)years with the range of 26-90 years] who underwent radical resection of rectal cancer at the First Hospital of Jilin University from May 2016 to January 2018 were collected.All patients underwent ERUS and MRI examination before surgery,total mesorectal excision during surgery and postoperative pathological examination.Postoperative pathological results as the gold standard,the sensitivity,specificity in T staging and the CRM diagnostic coincidence rate of rectal carcinoma by ERUS and MRI examination are evaluated.Observation indicators:(1) evaluation of T staging of rectal cancer by ERUS and MRI examination;(2) evaluation of CRM in rectal cancer by ERUS and MRI examination.Measurement data with normal distribution were represented as Mean±SD.Sensitivity,specificity and coincidence rate were calculated by chi-square test of paired fourfold table.McNemar test was used to compare the coincidence rate of T staging between ERUS and MRI examination.Consistency between CRM measurement by ERUS examination and pathological examination of rectal cancer was conducted by Kappa analysis.Fisher exact probability test was used to compare the coincidence rate of positive CRM between ERUS and MRI examination.Results (1) Evaluation of T staging of rectal cancer by ERUS and MRI examination.The overall coincidence rate of T staging of rectal cancer and coincidence rates of T1,T2,T3,T4 staging by ERUS examination were 74.61％ (144/193),93.78％ (181/193),80.83％ (156/193),79.79％ (154/193) and 94.82％ (183/193),respectively.The sensitivity ofT1,T2,T3 and T4 staging was 55.56％ (10/18),77.50％ (31/40),78.46％ (102/130),20.00％ (1/5),and the specificity was 97.71％ (171/175),81.70％ (125/153),82.54％ (52/63),96.81％ (182/188),respectively.The overall coincidence rate of T staging of rectal cancer and coincidence rates of T1,T2,T3,T4 staging by MRI examination were 50.78％ (98/193),90.67％ (175/193),74.09％ (143/193),58.55％ (113/193) and 78.24％ (151/193),respectively.The sensitivity of T1,T2,T3 and T4 staging was 0 (0/18),17.50％ (7/40),68.46％ (89/130),40.00％ (2/5),and the specificity was 100.00％ (175/175),88.89％ (136/153),38.10％ (24/63),79.26％ (149/188),respectively.There was statistically significant difference between the overall coincidence rate of ERUS and MRI examination for T staging of rectal cancer (x2 =8.631,P＜0.05).(2) Evaluation of CRM in rectal cancer by ERUS and MRI examination.The sensitivity and specificity of positive CRM evaluation of rectal cancer by ERUS examination were 100.00％ (5/5) and 97.34％ (183/188) respectively,and the coincidence rate with results of pathological examination was 97.41％ (188/193),showing a high consistency between positive CRM evaluation of rectal cancer by ERUS examination and pathological examination (Kappa value =0.655,P ＜ 0.05).The sensitivity and specificity of positive CRM evaluation of rectal cancer by MRI examination were 40.00％ (2/5) and 92.02％ (173/188),and the coincidence rate with pathological examination was 90.67％ (175/193),respectively,showing a high consistency between positive CRM evaluation of rectal cancer by MRI and pathological examination (Kappa value =0.206,P＜0.05).There were statistically significant differences in the diagnostic coincidence rate and specificity of CRM positive evaluation for rectal cancer between ERUS and MRI examination (x2 =5.896,P＜0.05).Conclusion ERUS examination has a high coincidence rate in the preoperative T staging of rectal cancer and a high consistency between positive CRM evaluation of rectal cancer with pathological examination,which are superior to MRI examination in the two aspects.

Establishing the normal ranges of female and male anal canal and rectal wall vascularity with color Doppler anorectal ultrasonography / Estabelecendo padrões normais da vascularização do canal anal e da parede retal em indivíduos do sexo masculino e feminino com ultrassom anorretal com Doppler colorido

ABSTRACT Study objectives: To evaluate blood supply in the anal canal, rectal wall and mesorectal fat of men and women, using color Doppler endorectal sonography to establish normal ranges for vascular parameters. Methods: A prospective cross-sectional study conducted at a tertiary-care hospital recruited asymptomatic volunteers (≤50 years). Vascularity percentage and index were calculated for defined regions. Results: Vascularity percentage and index were significantly higher in the puborectalis, mid-level external and upper internal anal sphincter compared to the low anal canal; these parameters were higher in men than in women at upper and middle levels of the inner anal canal structures. At mid-level, vascularity was greater in the external compared to the internal anal sphincter in both sexes; however, at the upper level it was greater in the puborectalis compared to the internal anal sphincter in women. Vascularity was greater in the rectal wall compared to the mesorectal fat, with no difference between middle and lower levels. Conclusions: Blood supply is highest at upper levels of the anal canal; however, inner structures are better irrigated in men. Moreover, the rectal wall is better irrigated than the mesorectal fat. Establishing normal ranges may permit future comparisons of the studied structures in disease states as well as the hormonal and age related changes.

RESUMO Objetivo: Avaliar vascularização do canal anal, parede retal e gordura mesorretal em homens e mulheres, usando ultrassonografia endorretal com Doppler colorido para estabelecer parâmetros vasculares de normalidade. Métodos: Estudo prospectivo transversal incluindo voluntários assintomáticos com até 50 anos. Medidos os valores da porcentagem e do índice de vascularização foram calculados para regiões escolhidas. Resultados: Valores da porcentagem e do índice foram significativamente maiores no puborretal, esfíncter externo (canal anal médio) e o esfíncter interno (canal anal superior) comparado ao canal anal inferior; esses parâmetros foram maiores em homens que em mulheres no canal anal médio e alto. No médio, a vascularização foi maior no esfíncter externo comparado ao interno em ambos os sexos; contudo, no canal anal superior, foi maior no puborretal comparado ao esfíncter anal interno em mulheres. A vascularização foi maior na parede retal comparada à gordura mesorretal, sem diferenças entre os níveis. Conclusões: O suprimento sanguíneo é maior nos níveis altos do canal anal. As estruturas internas são mais irrigadas nos homens. A parede retal é mais irrigada que a gordura mesorretal. Os parâmetros vasculares estabelecidos permitirá futuras comparações das estruturas estudadas nos casos de doenças, assim como, alterações que ocorrem com a idade e mudanças hormonais.

Functional outcome of Hirchsprung's disease, post-surgical trans-anal endorectal pull-through at National Children's Hospital

BACKGROUND@#Hirschprung's Disease, is a congenital illness secondary to lack of ganglion cells in the intestinal tract leading to mechanical obstruction. In the Philippines, Hirschsprung's Disease ranks 9th over the top 10 cases causing morbidity to Filipino children and the mortality rate can reach up to 50%. The treatment is still surgery, such as Soave procedure.@*DESIGN@#Descriptive cross sectional study.@*SUBJECTS@#The participants of the study were follow up patients at the Surgery Out Patient Department from March 2016 to August 2017, ages 0-7 years old, diagnosed with Hirschsprung's Disease, post Trans-anal endorectal pull-through.@*METHODOLOGY@#Purposive sampling was used to select participants. Sample size was 40 based on the proportion of good functional outcome among patients who underwent trans-anal endorectal pull-through.@*STATISTICAL ANALYSIS@#Descriptive Analysis using proportion and percentages were used to present the results in all the variables.@*RESULTS@#Out of the 40, 82 % were diagnosed with the disease as early as the newborn period and 55% of the patients were operated at an age from 1 to 3 years old and about 80% were males. It also showed that post operatively, 60% had normal z scores and 65% of the population still had an abnormal stool. Moreover, the study showed that 95% of the subjects returned to schooling or playing post surgery.@*SUMMARY/CONCLUSION@#Comparing it to the 96% result of Dela Merced 2003, this study had 95% of patients who were able to achieve good functional outcome, 4-6 weeks post-surgery.

Endorectal ultrasound in evaluation on mesorectal fascia invasion in preoperative rectal cancer / 中国医学影像技术

Objective To evaluate the value of endorectal ultrasonography (ERUS) in assessment of mesorectal fascia (MRF) invasion in rectal cancer.Methods Data of 44 patients who accepted preoperative ERUS and total mesorectal excision surgery within a week were retrospective analyzed.There were 18 patients who accepted preoperative neoadjuvant chemotherapy and 26 patients didn't acceped.Taking the pathological diagnosis of circumferential resection margin (CRM) as the gold standard,the diagnostic efficiency of ERUS for the MRF invasion in rectal cancer was evaluated.Results The final pathological T staging was T1 in 2 cases,T2 in 17 cases and T3 in 25 cases.There were 2 cases of CRM positive results,and 42 cases of CRM negative results.With regard to the location of tumor,there were 16 cases located in low,and 28 cases in mid rectum.There were 26 cases located in anterior or antero-lateral wall of rectum,13 cases in posterior or postero-lateral wall,and 5 cases with a circle of rectum.The diagnostic accuracy were 83.33 ％ (15/18) and 92.31％ (24/26) for cases of accepting and not accepting the preoperative neoadjuvant chemotherapy;80.77％ (21/26) for cases located in anterior or antero-lateral wall,and 100％ (13/13) for cases located in posterior or postero-lateral wall;75.00％ (12/16)and 96.43 ％ (27/28) for low position and mid position tumors.The total diagnostic accuracy was 88.64％ (39/44).Conclusion ERUS can be an effective method in preoperative assessment of the MRF invasion in rectal cancer.

Application of the three-dimensional endorectal ultrasonography in the rectal tumor staging before transanal endoscopic microsurgery / 中华消化外科杂志

Objective To investigate the value of the three-dimensional endorectal ultrasonography (3D-ERUS) in the tumor staging before transanal endoscopic microsurgery (TEM).Methods The clinical data of 30 patients with rectal cancer who underwent 3D-ERUS before TEM at the Nanjing Hospital of Traditional Chinese Medicine from April 2012 to December 2013 were retrospectively analyzed.The accuracy,sensitivity and specificity of the 3D-ERUS were evaluated according to the results of the postoperative pathological examination.The consistency of the results of the 3D-ERUS and postoperative pathological examination were compared by Kappa consistency test.Results Of 30 patients,25 patients in stage T0,3 in stage T1 and 2 in stage T2 were diagnosed by preoperative 3D-ERUS.There were 2 patients (stage pT0) with inflammatory polyp by postoperative pathological diagnosis,6 patients (stage pT0) with tubular adenoma,16 patients (stage pT0) with villioustublar adenoma,2 patients (stage pTis) with carcinoma in situ,2 patients (stage pT1) with tectal adenoma and 2 patients (stage pT2) with rectal adenoma.There were 2 patients with excessive tumor staging by 3D-ERUS,1 patient in stage pT0 was misdiagnosed in stage T1,1 in stage pT1 was misdiagnosed in stage T2 and 1 in stage pT2 was misdiagnosed in stage T1 with insufficient tumor staging.The accuracy of 3D-ERUS in the preoperative tumors staging of TEM was 90.0％ compared with the resuls of postoperative pathological examination.The accuracy,sensitivity and specificity of 3D-ERUS in stage pT0,pTl,and pT2 of TEM were 96.7％,90.0％,93.3％ and 96.2％,50.0％,50.0％ and 100.0％,92.8％,96.4％,respectively.There was a significant difference in the consistency between preoperative 3D-ERUS and postoperative pathological examination (κ =0.685,P ＜ 0.05).Conclusion 3D-ERUS is an accurate clinical method in the preoperative tumors staging of TEM,and can be used as the preoperative assessment for TEM.

Primary Laparoscopic-Assisted Endorectal Pull-Through for Hirschsprung's Disease

The application of laparoscopic techniques for the surgical management of Hirschsprung's disease is the recent trend. We described the surgical technique and postoperative long-term outcomes of the one-stage, laparoscopic-assiseted endorectal pull-through operation for Hirschsprung's disease. The technique uses three to four small abdominal ports. Laparoscopic mobilization of the sigmoid colon and rectum is performed and marginal artery-preserving colon pedicle is prepared. The rectal mobilization is performed using a transanal endorectal sleeve technique. The anastomosis is performed 0.5~1 cm above the dentate line. The age at surgery ranged from 6 days to 4 years. The average operative time was 144 minutes. Almost all of the patients passed stool and flatus within 36 hours of surgery. The average hospital stay after surgery was 6.5 days. Among 42 patients, 32 patients older than 3 years old were evaluated for function on defecation. All 32 patients have been continent, of those who needed laxatives were 11 (34.3%) due to constipation and overflow incontinence. Four children (12.5%) have remained dependent on laxatives. Laparoscopic-assisted endorectal pull-through operation for Hirschsprung's disease appears to be safe, provides the less pain, shorter time to full feeding, shorter hospital stay, and excellent cosmetic outcomes. Helping patients and parents ensure the quality of life, they should be provided with counseling, education, and longer-term follow-up care.

Evolución clínica de los pacientes operados de enfermedad de Hirschsprung por técnicas transanales / Clinical evolution of patients with Hirschsprung's disease operated on by transanal techniques

Introducción: el tratamiento quirúrgico de la enfermedad de Hirschsprung ha evolucionado positivamente desde que, en 1998, De la Torre Mondragón describiera su técnica de descenso endorrectal totalmente transanal. No obstante, estas variantes técnicas son relativamente nuevas y poco se ha escrito en cuanto a su evolución posoperatoria y estado de la continencia de los pacientes operados. Métodos: se realizó un estudio observacional y descriptivo de 43 pacientes operados de enfermedad de Hirschsprung por medio de técnicas transanales, en un solo tiempo quirúrgico, entre 2004 y 2011, en el Hospital Pediátrico Universitario de Centro Habana. Se aplicó un cuestionario a todos los pacientes en relación con el estado de la función intestinal y urinaria en diferentes momentos de la evolución, luego de los 6 meses de operados, y se relacionaron los resultados con aspectos como la edad y la longitud del segmento resecado. Se utilizó el test de Fisher para el análisis estadístico, considerando significativos los valores de p< 0,05. Resultados: la media de la edad de la intervención fue de 3 años (rango 1-15 años), y predominó el sexo masculino. La variedad rectosigmoidea fue la más frecuente, que se demostró por medio del enema de bario. Todos los casos fueron operados en un solo tiempo quirúrgico, 38 pacientes tienen una evaluación de excelente en relación con la continencia, y solo 2 casos presentaron estreñimiento. Se encontró una relación significativa entre una mayor longitud de segmento resecado, con la presencia de alteraciones del patrón defecatorio. Conclusiones: la función intestinal es satisfactoria en la mayoría de los pacientes intervenidos por medio de técnicas de descenso transanal en un tiempo quirúrgico para el tratamiento de la enfermedad de Hirschsprung.

Introduction: the surgical treatment of Hirschsprung's disease has positively evolved since 1998 when De la Torre Mondragón described his totally transanal endorectal pull through technique. Nevertheless, these technical variants are relatively new and little has been said about the postoperative evolution and the continence status of the surgical patients. Methods: an observational descriptive study of 43 surgical patients, who suffered Hirschsprung's disease and were operated on by transanal one-stage techniques from 2004 to 2011 at university pediatric hospital of Centro Havana, was carried out. All the patients were given a questionnaire to find out the condition of the intestinal and urinary functions at different times, six months after surgery. The results were correlated with age and length of the resected segment. Fisher's test was used for the statistical analysis, being p< 0,05. Results: the average age at the time of operation was 3 years (range, 1 to 15 years) and males prevailed. The rectosigmoid variant was the most common, which was evidenced by the barium enema. All these cases underwent one-stage surgery; 38 patients were satisfactorily evaluated in terms of continence and just two cases presented with constipation. A significant association between longer resected segment and the presence of altered defecation pattern was found. Conclusions: the intestinal function is satisfactory in most of patients operated on by transanal one-stage pull-through techniques for treating Hirschsprung's disease.

Significance of Contrast Enema in One-stage Transanal Endorectal Pull-through Operation for Hirschsprung Disease

In one-stage transanal endorectal pull-through operation (TERPT) for Hirschsprung disease, preoperative evaluation by contrast enema (CE) is important tool in aspect of planning of surgical procedure as well as diagnosis. This study was to evaluate the significance of CE for identifying the extent of aganglionic bowel. A retrospective analysis was performed in 40 patients who underwent TERPT between 2003 and 2011. The authors reviewed the CE studies and their correlation with pathologic extent of aganglionosis. Total 66 contrast enemas were performed in 40 patients. Twenty patients underwent single CE, but 20 patients required multiple CEs. In single CE group, 17 had clear radiographic transition zone, but 3 had less definite transition zone. In multiple CE group, 17 patients who had equivocal finding in first or second CE had definite radiographic transition zone, but 3 patients of this group had less definite radiographic transition zones. Overall, 34 patients (85%) had clear radiographic transition zone by single or repeated CE. One (2.9%) out of 34 patients with clear radiographic transition zone had discordance between radiographic and pathologic transition zone. In contrast 4 (66.7%) out of 6 patients with equivocal radiographic transition zone had discordance between radiographic and pathologic transition zone. Observation of clear radiographic transition zone is important in preparation of TERPT, and repeated CE is helpful to reduce the discordance between radiographic and pathologic transition zone. Awareness of the possibility of discordance is also important if radiographic transitional zone is not clear.

Sensibilidade da ecografia endorectal no estadiamento do cancro do recto: correlação com o estadiamento patológico / Sensitivity of endorectal ecography in the staging of rectal chancre: correlation with pathological staging

OBJECTIVO: Avaliar a sensibilidade da ecografia endorectal, em nossa experiência, no estadiamento do cancro do recto comparando com o resultado anatomopatológico. MATERIAL E MÉTODOS: Estudo retrospectivo, realizado entre Janeiro de 2005 e Agosto de 2009. Calculou-se a sensibilidade, a especificidade, o valor preditivo positivo e negativo para cada estadio T e N. Por meio da elaoração de curvas ROC avaliou-se a precisão do estadiamento ecoendoscópico e por meio do teste de McNemar comparou-se com o resultado anatomopatológico. RESULTADOS: Dos 112 doentes, 76 cumpriram os critérios de inclusão. Obtivemos uma eficácia de 75 a 97 por cento para uT e de 75 por cento para uN. Verificou-se sensibilidade, especificidade, valor preditivo positivo e negativo, respectivamente, de 63;98;92 e 89 por cento para uT1; 71;76;54 e 88 por cento para uT2; 67;81;73 e 76 por cento para uT3; 100;97;60 e 100 por cento para uT4; e 39;91;62 e 78 por cento para uN. As curvas ROC indicaram que a ecografia endorectal é um bom teste para o estadiamento do T e razoável para o N. O teste de McNemar revelou que não há diferenças significativas entre o estadiamento ecoendoscópico e anatomopatológico (p>0,05). CONCLUSÕES: Conclui-se que a ecografia endorectal é uma importante ferramenta no estadiamento do cancro do recto, apresentando boa correlação com o resultado anatomopatológico.

OBJECTIVE: This study aimed to evaluate endorectal ultrasound sensibility, in our experience, in rectal cancer staging comparing with pathologic result. METHODS: A retrospective study between January 2005 and August 2009. We calculated sensibility, specificity, positive and negative predictive value for T and N. Through ROC curves we evaluated endoscopic ultrasound accuracy and through McNemar test we compared it with the anatomopathological result. RESULTS: Of 112 patients, 76 met the inclusion criteria. We obtained an efficiency of 75 to 97 percent for uT and 75 percent in uN. There was a sensibility, specificity, positive and negative predictive value, respectively of 63, 98, 92 and 89 percent for uT1, 71 percent and 76, 54 and 88 for uT2, 67, 81; 73 and 76 percent for uT3, 100, 97, 60 and 100 percent uT4, and 39, 91, 62 and 78 percent for uN. The ROC curves indicated that endorectal ultrasound is a good test for T staging and reasonable for N staging. The McNemar test revealed no significant differences between endoscopic ultrasound and histological staging (p>0.05). CONCLUSIONS: We concluded that endorectal ultrasound is an important tool in rectal cancer staging, showing a good correlation with histopathological results.

PTV Margins for Prostate Treatments with an Endorectal Balloon / 대한방사선종양학회지

PURPOSE: To determine the appropriate prostate planning target volume (PTV) margins for 3-dimensitional (3D) conformal radiotherapy (CRT) and intensity-modulated radiation therapy (IMRT) patients treated with an endorectal balloon (ERB) under our institutional treatment condition. MATERIALS AND METHODS: Patients were treated in the supine position. An ERB was inserted into the rectum with 70 cc air prior to planning a CT scan and then each treatment fraction. Electronic portal images (EPIs) and digital reconstructed radiographs (DRR) of planning CT images were used to evaluate inter-fractional patient's setup and ERB errors. To register both image sets, we developed an in-house program written in visual C++. A new method to determine prostate PTV margins with an ERB was developed by using the common method. RESULTS: The mean value of patient setup errors was within 1 mm in all directions. The ERB inter-fractional errors in the superior-inferior (SI) and anterior-posterior (AP) directions were larger than in the left-right (LR) direction. The calculated 1D symmetric PTV margins were 3.0 mm, 8.2 mm, and 8.5 mm for 3D CRT and 4.1 mm, 7.9 mm, and 10.3 mm for IMRT in LR, SI, and AP, respectively according to the new method including ERB random errors. CONCLUSION: The ERB random error contributes to the deformation of the prostate, which affects the original treatment planning. Thus, a new PTV margin method includes dose blurring effects of ERB. The correction of ERB systematic error is a prerequisite since the new method only accounts for ERB random error.

Imaging Diagnosis of Colorectal Cancer

Recently, treatment strategy of rectal cancer has undergone a dramatic change. Application of total mesorectal excision and preoperative chemoradiation therapy (PCRT) has become standard procedure for locoregional and locally advanced rectal cancer, respectively. Functional and morphological radiologic evaluation as well as multidisciplinary approach is both essential for planning patient-specific therapy. In other words, the needs for more accurate T-and N-staging and assessment of circumferential resection margin, both before and after PCRT, are increasing rapidly. Although there is no consensus on the role of diagnostic imaging such as endorectal ultrasonography, computed tomography and magnetic resonance imaging (MRI), in evaluation of rectal cancer patient so far, MRI is emerging as an essential imaging modality with superior trssue contrast and multiplanar approach.

Ultrassom anorretal tri-dimensional pode selecionar pacientes com tumor no reto após neoadjuvância para cirurgia de preservação esfincteriana? / Can three-dimensional anorectal ultrasound select patients with rectal tumor for sphincter-saving resection after post-chemoradiotherapy

OBJETIVO: Avaliar a resposta pós-quimioradioterapia-QT no tratamento do tumor no reto utilizando ultrassom anorretal tridimensional(US-3-D) visando definir a estratégia cirúrgica adequada. MÉTODO: Avaliou-se prospectivamente 32 pacientes com adenocarcinoma no reto médio e inferior. Realizou-se US-3-D para estadiamento e avaliação quanto à invasão no canal anal ou distância(cm) entre tumor e esfíncter anal interno-EAI: GrupoI-invasão no canal anal; GrupoII-distância menor-ou-igual 2cm, GrupoIII-distância maior 2. Foram encaminhados neoadjuvância e realizado US-3D após 50-55 dias. A escolha da estratégia cirúrgica baseou-se na resposta pós-QT e achados do US-3-D/pós-QT e comparado com histopatológico. RESULTADOS: O US-3-D/pós-QT coincidiu com histopatológico em 31/32, eficácia de 97 por cento. Evidenciou-se 26/27 casos com lesão residual, sensibilidade de 96 por cento, sendo 19(59 por cento) resposta parcial e 07 (22 por cento) sem resposta. Em 5/5 o US-3-D/pós-QT demonstrou resposta completa, especificidade e valor preditivo positivo 100 por cento. Valor preditivo negativo 83 por cento pois um(3 por cento) caso inconclusivo. Realizou-se cirurgia de preservação esfincteriana em 16 pacientes (05 com resposta completa, 10 com resposta parcial e um inconclusivo) com margem maior que 2cm. Confirmados ao histopatológico com margem livre. O índice Kappa na avaliação de linfonodos demonstrou concordância substancial(87,5 por cento). Conclui-se que o US-3D pode ser útil na escolha de pacientes que irão beneficiar-se com a cirurgia de preservação esfincteriana.

PROPOSAL: Evaluate the post-chemoradiotherapy response for treatment of rectal tumor using three-dimensional anorectal ultrasound-3D-US to determine the best surgical approach METHODS: 32 patients with lower and middle rectal cancer were prospectively staged using 3D-US to identify anal canal invasion and the distance(cm) between tumor and the internal anal sphincter-IAS, Group l:with anal canal invasion; Group II-with distance =2cm; Group III-with distance >2. They were submitted to neoadjuvant chemoradiation-CRT and the 3-D US was repeated 50-55 days later. The choice of the surgical approach was based on the post-chemoradiation response identified by the 3D-US comparing with pathologic findings. RESULTS: The post-chemoradiation/3D-US findings were concordant with pathologic results in 31/32(97 percent). It was identified residual tumors in 26/27(96 percent sensibility), 19(59 percent) with partial response and 7(22 percent) without response. Complete response was demonstrated in 5/5 by 3D-US, with specificity and predictive valor in 100 percent. Negative predictive valor in 83 percent since one(3 percent) case was inconclusive. Sphincter-saving resection was performed in 16 patients, 5 with complete response, 10 with partial response and one inconclusive, with distal margin >2cm. The pathologic findings confirmed distal margins without tumor. It was demonstrated high concordance(87.5 percent) concerning the lymph nodes evaluation(Kappa test). CONCLUSION: 3D-US can be useful to determine the patients who should be submitted to sphincter-saving resections.

Fístula rectovaginal posobstétrica: tratamiento quirúrgico mediante avance de colgajo endorrectal / Postobstetric rectovaginal fistula: surgical treatment using endorectal advancement flap

Introducción: Las fístulas rectovaginales ocurren con una frecuencia menor a 5 % respecto a otros tipos de fístulas de la región anorrectal; el trauma obstétrico es la causa más común de este tipo de fístulas. Existen diversos procedimientos quirúrgicos para la reparación de las mismas. Material y métodos: Se realizó un estudio de 16 pacientes con diagnóstico de fístula rectovaginal posobtétrica, atendidas en el Hospital Juárez de México entre enero de 1992 y diciembre de 2006. Se analizó edad de las pacientes, tipo de trauma obstétrico, tiempo de inicio de la sintomatología después del parto, localización y tamaño de la fístula, índice de éxito y recidivas mediante el tratamiento con avance de colgajo endorrectal, y necesidad de esfinteroplastia complementaria. Resultados: La edad promedio fue de 25.6 años. En todas las pacientes, la sintomatología inició después de un parto vaginal durante el cual se realizó episiotomía o hubo desgarro perineal. Todas las fístulas fueron menores de 2.5 cm de diámetro y de localización baja. Con el colon preparado, en todas las pacientes se reparó la fístula rectovaginal mediante avance de colgajo endorrectal. En dos pacientes se llevó acabo, además, esfinteroplastia del esfínter anal. Los resultados fueron satisfactorios en 15 pacientes (93.7 %); no hubo mortalidad operatoria y no fueron utilizados estomas de protección. Conclusiones: El colgajo endorrectal es un procedimiento seguro para la reparación de fístulas rectovaginales de origen posobstétrico, algunos casos pueden requerir esfinteroplastia del esfínter anal.

BACKGROUND: Rectovaginal fistulas account for <5% of all rectal fistulas. Obstetrical injuries are the most common cause of these types of fistulas. There have been a multitude of surgical approaches developed for operative repair. METHODS: Between January 1992 and December 2006, 16 patients with postobstetric rectovaginal fistula were treated at the Hospital Juárez of México. Age, type of obstetric trauma, time elapsed between delivery and beginning of symptoms, location, and size of the fistulas, rate of success and recurrence with the use of endorectal flap, and need for complementary sphincteroplasty were all evaluated. RESULTS: Median age of the patients was 25.6 years. All women reported that their symptoms began after a vaginal delivery that included an episiotomy or 4th degree laceration. All fistulas were low and small (<2.5 cm in diameter). Patients received bowel preparation and underwent rectovaginal repair using endorectal advancement flap. In two cases, additional overlap repair of the anal sphincter was performed. Result of repair was good to excellent in 15 patients (93.7%). There were no operative mortalities, and no covering stomas were used. CONCLUSIONS: Endorectal flap repair provides successful postobstetric rectovaginal fistula closure. Concomitant sphincteroplasty may be necessary in some cases.

Utilidad del ultrasonido transrectal sin balón en la estadificación preoperatoria del cáncer rectal / Usefulness of the endorectal ultrasound without ballon in preoperative staging of rectal cancer

Objective: To determine the usefulness of Endorectal Ultrasound (ERUS) without balloon in preo-perative staging of malignant rectal tumors. Method: From July 2003 to July 2007 a study was performed in 57 patients diagnosed with cancer of the rectum, who underwent preoperative staging by transrectal ultrasonography to be subsequently compared with an anatomopathologic analysis of the surgical sample. Results: US staging according to degrees of invasion (T-stage) was coincident in 87,7 percent with the anatomopathologic staging. Sensitivity and specificity values were 0,80 and 0,92 percent respectively for UT2,while 0,94 and 0,81 percent, respectively, for UT3. According to regional lymph nodes spread (N-stage), it exhibited a coincidence of 78,9 percent; sensitivity was 0,82 percent and specificity was 0,74 per cent for UNO; while sensitivity and specificity reached values of 0,74 and 0,82 percent, respectively, for UN1. Conclusion: Endorectal US without balloon has proved to be useful in the preoperative staging of malignant rectal tumors.

Objetivos: Determinar la utilidad del ultrasonido transrectal sin balón (USTRsb) en la estadificación preoperatoria del cáncer rectal. Método: Estudiamos 57 pacientes con diagnóstico de cáncer rectal desde julio 2003 a Julio 2007, a los que se les realizó estadificación preoperatoria por ultrasonido transrectal y anatomopatológico por medio del examen de la pieza quirúrgica. Resultados: La estadificación ultrasonográfica según grado de invasión tumoral coincidió con la anatomopatológica en el 87,7 por ciento ; la sensibilidad y especificidad fue 0,80 y 0,92 para los UT2 y 0,94 y 0,81 para los UT3. Según la invasión de ganglios linfáticos regionales, la coincidencia fue 78,9 por ciento ; la sensibilidad y especificidad fue 0,82 y 0,74 para los UNO y 0,74 y 0,82para los UN1. Conclusión: El USTRsb fue útil en la estadificación preoperatoria del cáncer rectal.

Design of MRI interventional RF coil / 医疗卫生装备

Objective To design a new type of RF endorectal coil so as to increase signal to noise ratio(SNR) and improve the efficiency of MRI diagnosis.Methods Through circuit and construction optimization,a MRI model of coil in vivo was designed.Results The images and spectroscopy of a special phantom were acquired and the results were compared to those of the commercial TORSO coil.Conclusion This coil gives a significantly higher SNR at the region of interest(ROI).The achieved high local SNR and resulting high spatial resolution can add more anatomic and biochemical information to the diagnosis of prostate diseases.

The Usefulness of Endo-rectal Coil MRI in the Staging of Clinically Localized Prostate Cancer / 대한비뇨기과학회지

PURPOSE: We evaluated the ability of endo-rectal coil MRI (ER-MRI) to predict the local pathological stage of prostate cancer prior to radical prostatectomy and compared the results with those of transrectal ultrasonography (TRUS). MATERIALS AND METHODS: ER-MRI using high field magnets (1.5 Tesla) were performed in 22 patients (mean age 62.8 years, range 51-73) with clinically localized prostate cancer before radical prostatectomy. Of the 22 patients, 17 patients were also assessed by TRUS. The results of the imaging techniques were compared with the post-operative histopathological findings. As one patient with pelvic lymph node metastasis, which was detected on frozen-section examination during surgery, was spared radical prostatectomy, the final evaluation included 21 patients. RESULTS: DSeven of the 21 patients (33%) were found to have extraprostatic extension (EPE), and 5 had seminal vesicle invasion (SVI). The sensitivity and specificity for diagnosing EPE using ER-MRI were 62.5% and 84.6%, respectively, and 16.7% and 100% with TRUS. The sensitivity and specificity for diagnosing SVI were 80.0% and 93.8%, respectively with ER-MRI, and 0% and 92.3% with TRUS. The accuracy of predicting SVI was 90.5% with ER-MRI compared to 70.6% with TRUS. CONCLUSIONS: ER-MRI was significantly better than TRUS for determining the local extent of prostatic cancer and for prediction of SVI in the preoperative staging of clinically localized prostate cancer.

The Comparative Assessment of Endorectal Coil and Body Coil in MR Imaging of Prostate Disease / 实用放射学杂志

Objective To evaluate the value of endorectal coil(E-coil) in the diagnosis of prostate diseases.Methods The comparative study was done with E-coil and body coil in 15 patients including 9 cases of prostate carcinoma,4 cases of benign prostatic hyperplasia and 2 normal individuals.The conventional spin-echo sequence(SE T 1WI,FSE T 2WI)were done in all cases.The axial images obtained with two types were compared according to the subjective viewing and scoring.Results Overall imaging quality on E-coil was significantly superior to that on body coil.The average scores were 2.97?0.61 points with body coil vs 3.4?0.60 points with E-coil on T 2WI (?

The Efficacy of Transanal Ultrasonography in Fistula In Ano

BACKGROUND: Successful treatment of a fistula in ano (FIA) depends on identifying track of the fistula and the internal opening at the time of surgery as well as on eradicating them by appropriate surgery. Transanal ultrasonography (TUS) has been known to be an useful tool for the evaluation of anorectal inflammatory lesion, such as perianal abscess and FIA. Preoperative TUS was performed to determine the accuracy in respect to detection the of fistula track and the internal opening. METHODS: One hundred nineteen patients were examined by preoperative TUS among 176 patients with FIA treated from January 1996 to December 1997. TUS findings were compared with operative findings in respect to location of track, types and primary opening of the fistula. TUS was performed by using the Scanner type 2001 with an attached endoprobe. RESULTS: The track of fistula on preoperative TUS was identified in 119 cases, and TUS findings were not identical with operative findings in 14 cases. The accuracy of determining the fistula track was 88.2%. The most common type of fistula and the location of primary opening were intersphincteric type (53.0%) and posterior aspect (52.7%) respectively. The accuracies were 95% in intersphincteric type, 90.5% in transsphincteric type, 90% in suprasphincteric type and 62.5% in extrasphincteric type. Accurate identification of the internal opening was possible in 91 of the 119 cases. External sphincter damage was identified in 3 cases, and all of them were treated by sphincteroplasty at the time of surgery. CONCLUSIONS: TUS is an accurate and minimally invasive method to identify the fistula track in relation to the anal sphincters and internal opening.