Value of three-dimensional endoanal ultrasound scan (3D-EAUS) in preoperative assessment of fistula-in-ano.

OBJECTIVE: The aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound scan (3D-EAUS) in the pre-operative assessment of fistula-in-ano in identifying the fistula tract and comparing with findings at surgery in a South Asian cohort. A retrospective analysis of 87 patients with suspected fistula-in-ano who underwent pre-operative 3D-EAUS between January 2009 and January 2016 was carried out. All patients subsequently had surgical exploration under anaesthesia (EUA), irrespective of 3D-EAUS findings. The 3D-EAUS results were compared with the surgical findings to determine the accuracy of 3D-EAUS. RESULTS: A total of 86 (98.9%) patients (male = 75) were subsequently shown to have a fistula at surgical exploration and of them, 3D-EAUS detected a fistula in 79 (92%) patients. In this cohort, 3D-EAUS correctly predicted the surgical findings in (n = 61, 70.9%) patients with the highest accuracy being for transphincteric fistulae (87.1%). However, the overall concordance in our study was low with a kappa coefficient of 0.318. Additional findings such as sphincter defects were detected by the 3D-EAUS in 37 patients (internal sphincter defects-21, external sphincter defects-7, both-9) which were not evident at EUA. Therefore, 3D-EAUS had a good accuracy in selected types of fistulae and particularly useful in identifying sphincter defects before surgery.

Duration taken for the anal sphincter pressures to stabilize prior to anorectal manometry.

OBJECTIVES: Anorectal manometry (ARM) is an integral part of evaluating the anal sphincter function. The current recommendation of waiting for 5 min (lead-in-time) prior to beginning the recording has no evidence. A prolonged procedure may reduce patient compliance. RESULTS: We analyzed data from 100 consecutive patients who underwent 3-dimensional ARM at a single center. Their pressure studies were analyzed in consecutive 10-s segments, beginning from the time of insertion of the probe into the anal canal. We defined stabilization of the pressure as the absence of a pressure difference among two consecutive 10-s segments. The study population had 31 males. Their mean age was 33.0 years (SD-14.4). The mean time for the pressure to stabilize was 84.2 s (SD-29.5), range 17.2-203.7 s, 95th percentile 136.2 s. Eleven and one participant(s) took longer than 120 and 150 s for the pressure to stabilize, respectively. There was no correlation of sex (Mann-Whitney U test, p = 0.89) and the time to pressure stabilization. Age and the time to stabilize (Spearman rho - 0.246, p = 0.017) showed a weak negative correlation. A lead-in-time of 5 min, as recommended by present guidelines may be unnecessary. Waiting for 150 s/2½ min may be sufficient and will minimize the procedure duration.

Three-Dimensional Endoanal Ultrasound Features of the Anal Sphincter in Asian Primigravidae.

OBJECTIVES: The normal parameters of 3-dimensional endoanal ultrasound (3DEAUS) of the anal sphincter have not been reported for primigravidae or pregnant women at present. 3DEAUS parameters in Asian primigravidae were assessed in this study. METHODS: We analyzed 3DEAUS data of 101 consecutives Asian primigravidae, assessed in the early third trimester. The assessment was performed with a rigid ultrasonic probe (Olympus® RU 12M-R1 probe and EU-ME1 ultrasound system (Olympus Corp., Shinjuku, Japan). The Wilcoxon signed-rank test was used to detect the differences in pressure in different quadrants. RESULTS: The participants had a mean age of 24.7 (standard deviation [SD], 5.1) years. The Cleveland Clinic Incontinence Score was normal in all participants. The anal sphincter complex had 3 characteristic segments that were identifiable: upper, middle and lower. The puborectalis muscle was identified as a striated "V"-shaped sling, and its mean thickness was 7.44 (SD, 1.41) mm. The mean thickness of internal (IAS) and external (EAS) sphincters at the mid-sphincter level were 1.78 (SD, 0.59) and 5.49 (SD, 1.21) mm, respectively. The EAS measured 6.02 (SD, 1.07) mm at the lower sphincter level. The statistically significant differences seen in the in quadrants were: the IAS was thicker anteriorly (Z = -2.642; P = .008), the EAS at both midsphincter level (Z = -3.70; P < .001) and lower sphincter level (Z = -7.712; P < .001) was thicker posteriorly, and the IAS was thicker at the 9 o'clock position (Z = -2.081; P = .037). Good symmetry at all 3 levels was seen in the EAS (including the puborectalis muscle). CONCLUSIONS: Normal values of 3DEAUS for primigravidae have been identified and may serve as reference values for other laboratories.

Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study.

BACKGROUND: Anal incontinence is a known complication following operative treatment of fistula-in-ano which can significantly impact the quality of life. This study was aimed to objectively assess the impact of operative treatment of simple fistula-in-ano on quality of life related to anal incontinence. Therefore, a prospective study was conducted in 34 patients who underwent surgery for fistula-in-ano over a period of 24 months. Quality of life and incontinence were assessed using fecal incontinence quality of life (FIQL) scale and Cleveland clinic incontinence score (CCIS) preoperatively and after a minimum of 12 months follow up (mean-27 months, range 12-40 months). The difference in FIQL and CCIS was analysed using Wilcoxon Rank test and Mann-Whitney U test. RESULTS: The median age of the participants was 42.5 years (range 22-63, males = 30). The majority had a trans-sphincteric tract (n = 22, 65%). Superficial tracts and inter-sphincteric tracts were found in 8 (24%) and 4 patients (12%). The overall preoperative and postoperative rates of incontinence were 18 and 38% respectively, but the severity was low. The mean overall FIQL was 16.0 (SD ± 0.4) preoperatively and 16.1 (SD ± 0.4) postoperatively. Considerable difference was seen in the scale measuring "depression/self-perception" (p = 0.012). Only 1 patient (3%) had reduction in scale "lifestyle" which measures the impact of incontinence on day-to-day activities. CONCLUSIONS: Analysis of a cohort of simple cryptoglandular fistula-in-ano with low pre-operative incontinence showed no worsening in the FIQL following successful treatment despite minor worsening of incontinence. Since greater improvement was noted in scale measuring depression/self-perception, psychological interventions may be helpful before surgery to improve quality of life.

Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

INTRODUCTION AND HYPOTHESIS: The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. METHODS: One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. RESULTS: Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. CONCLUSIONS: Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.

Correlation of three dimensional anorectal manometry and three dimensional endoanal ultrasound findings in primi gravida: a cross sectional study.

BACKGROUND: 3-dimensional anorectal manometry (3DARM) and 3-dimensional endoanal ultrasound (3DEAUS) have not been used to assess the anal sphincter complex (ASC) in primi gravida. This study was conducted to identify any correlation that may exist between 3DARM and 3DEAUS. METHODS: We analyzed 3DARM and 3DEAUS data of 101 consecutive primi mothers assessed in the late second trimester or early 3rd trimester. 3DARM was performed using the Given Imaging(®) Manoscan system and 3DEAUS was performed with the Olympus(®) RU 12M-R1 probe and EU-ME1 ultrasound system. RESULTS: The mean age was 24.7 (SD-5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD-18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD-52.96) mmHg. The mean length of the high pressure zone was 3.67 (SD-0.52) cm. On 3DEAUS, there were three characteristic segments of the ASC that were identified; upper, middle and lower. Mean thicknesses for both internal anal sphincter (IAS) and external anal sphincter (EAS) were identified for primi gravida. IAS was thicker anteriorly and at 9 o' clock positions and EAS was thicker posteriorly. There was good correlation in the length of the ASC at each quadrant between 3DARM and 3DEAUS. There was no correlation between either RP or SP thickness of IAS or EAS at each level and quadrant. CONCLUSION: Correlation is seen only in the length of ASC at each quadrant. No correlation exist between RP or SP and thickness of IAS and EAS.

Types and patterns of colonic polyps encountered at a tertiary care center in a developing country in South Asia.

PURPOSE: To identify the prevalence, types, and patterns of colonic polyps in a cohort of patients presenting to a tertiary care referral center in Sri Lanka. METHODS: Endoscopy and pathology reports of a single unit from 2006 to 2013 were analyzed retrospectively. Spearman's correlation coefficient and chi-square test were used to identify correlations. RESULTS: There were a total of 158 patients (M : F, 10 : 57) who had polyps encountered on colonoscopy (n = 1408) and flexible sigmoidoscopy (n = 2402) with an incidence of 4.1%. Mean age was 56.5 years (SD 16.4) and the incidence of polyps increased with age. The majority (81.6%) had one polyp. A total of 188 polyps were assessed and most were seen in the rectum (33.5%) followed by sigmoid colon (22.9%). The commonest histological type was tubulovillous adenoma (33.5%) followed by tubular adenoma (24.5%). Most polyps were benign (91.5%). There was no statistically significant correlation with age or gender with malignancy, site, or histology. DISCUSSION AND CONCLUSION: The incidence of colorectal polyps was lower than the values reported in the west. More polyps were identified in males. There was no statistically significant association between age, gender, or multiplicity and malignant change in the polyps.

Patterns and trends of medical student research.

BACKGROUND: Our study describes the change in the research output, trends and content of published research involving medical students over the last century. METHODS: Pubmed® and Scopus® were searched for keywords 'Medical Student' in the affiliation field. The search results were combined in Endnote® and duplicate entries removed and the multiple variables described below were assessed. RESULTS: The combined searches after excluding duplicates yielded 416 results and 66 articles were excluded. There was an exponential increase in medical student research from 1980-2010. Medical student was the first author in 170 (48.6%) studies and 55 studies were authored by a single medical student. The 3 most common areas of research in descending order were Psychiatry (n = 26, 7.4%), General Medicine (n = 24, 6.9%) and Medical Education (n = 21, 6%). The commonest type of articles, in descending order were review articles (n = 48, 13.7%), Cross sectional studies (n = 47, 13.4%) and Case reports (n = 43, 12.3. The majority of these articles (n = 207, 59.1%) have never been cited subsequently. The trend of increasing number of articles was seen equally among all article types, fields and countries. CONCLUSIONS: There is an exponential increase in articles by medical students but the majority of articles have not been cited. The numbers of medical student authors per publication have remained static while the total numbers of authors have increased. The proportions in the type of articles, fields of study and country of origin have largely remained static. Publishers and authors should strive to enhance the quality and quantity of data available in indexing services.