Incidence of obstetric anal sphincter injuries according to the type of forceps used in the Mexican population.

OBJECTIVE: This study describes the frequency of obstetric anal sphincter injuries (OASIS) in patients after instrumental delivery according to the type of forceps used. METHODS: A retrospective comparative cohort study was conducted on patients who underwent instrumental delivery from January 2017 to April 2022. The primary outcome was the presence of OASIS following delivery. Patients were categorized into Cohort A if only rotation forceps were used, Cohort B for only traction forceps, and Cohort C if both types were used sequentially. Statistical analysis was performed with SPSS (IBM, New York, NY) with χ2, Fisher's exact, and analysis of variance testing. A P-value <0.05 was considered significant. RESULTS: OASIS occurred in 45 of 328 instrumental deliveries. OASIS after rotation forceps occurred in 12.9% (n = 8) of cases, after traction forceps in 13.2% (n = 34), and after sequential use of rotation and traction forceps in 37.5% (n = 3) of cases (p = 0.141). An odds ratio (OR) of 0.91 (95% confidence interval [CI] 0.40-2.08) for OASIS was obtained with the use of rotation forceps, 0.81 (95% CI 0.38-1.70) for traction forceps, and 3.97 (95% CI 0.91-17.2) for the sequential use of rotation and traction forceps. CONCLUSION: There were no significant differences in the presence of OASIS comparing traction and rotation forceps. A non-significant trend of higher OASIS following the sequential use of traction and rotation forceps was observed.

Histiocitosis de células de Langerhans en un paciente con lesión perianal. Caso clínico / Langerhans cell histiocytosis in a patient with perianal lesion. A case report

La histiocitosis de células de Langerhans es una expresión de células dendríticas mieloides, asociada a un componente inflamatorio significativo y compromiso sistémico variado. La edad más frecuente de presentación es entre 1 y 4 años, y predomina en el sexo masculino. Se comunica el caso de un niño de 5 años de edad cuya forma de presentación fue una lesión granulomatosa con fístula perianal, afectación pulmonar y de oído externo. El abordaje interdisciplinario permitió llegar al diagnóstico, realizar las intervenciones necesarias e iniciar el tratamiento adecuado.

Langerhans cell histiocytosis is an expression of myeloid dendritic cells, associated with a significant inflammatory component and varied systemic involvement. The most common age at presentation is between 1 and 4 years, and it prevails among male subjects. Here we describe the case of a 5-year-old boy who presented with a granulomatous lesion with perianal fistula and lung and external ear involvement. An interdisciplinary approach helped to make a diagnosis, provide the necessary interventions, and start an adequate treatment.

Traumatismo anorrectal contuso. Reporte de un caso y revisión bibliográfica / Blunt anorectal trauma. Case reportand literature review

Introducción: El traumatismo anorrectal es una causa poco frecuente de consulta al servicio de emergencias, con una incidencia del 1 al 3%. A menudo está asociado a lesiones potencialmente mortales, por esta razón, es fundamental conocer los principios de diagnóstico y tratamiento, así como los protocolos de atención inicial de los pacientes politraumatizados. Método: Reportamos el caso de un paciente masculino de 47 años con trauma anorrectal contuso con compromiso del esfínter anal interno y externo, tratado con reparación primaria del complejo esfinteriano con técnica de overlapping, rafia de la mucosa, submucosa y muscular del recto. A los 12 meses presenta buena evolución sin incontinencia anal. Conclusión: El tratamiento del trauma rectal, basado en el dogma de las 4 D (desbridamiento, derivación fecal, drenaje presacro, lavado distal) fue exitoso. La técnica de overlapping para la lesión esfinteriana fue simple y efectiva para la reconstrucción anatómica y funcional. (AU)

Introduction: Anorectal trauma is a rare cause of consultation to the Emergency Department, with an incidence of 1 to 3%. It is often associated with life-threatening injuries, so it is essential to know the principles of diagnosis and treatment, as well as the initial care protocols for the polytrau-matized patient. Methods: We present the case of a 47-year-old man with a blunt anorectal trauma involving the internal and external anal sphincter, treated with primary overlapping repair of the sphincter complex and suturing of the rectal wall. At 12 months the patient presents good outcome, without anal incontinence. Conclusion: The treatment of rectal trauma, based on the 4 D ́s dogma (debridement, fecal diversion, presacral drainage, distal rectal washout lavage) was successful. Repair of the overlapping sphincter injury was simple and effective for anatomical and functional reconstruction. (AU)

Langerhans cell histiocytosis in a patient with perianal lesion. A case report. / Histiocitosis de células de Langerhans en un paciente con lesión perianal. Caso clínico.

Langerhans cell histiocytosis is an expression of myeloid dendritic cells, associated with a significant inflammatory component and varied systemic involvement. The most common age at presentation is between 1 and 4 years, and it prevails among male subjects. Here we describe the case of a 5-year-old boy who presented with a granulomatous lesion with perianal fistula and lung and external ear involvement. An interdisciplinary approach helped to make a diagnosis, provide the necessary interventions, and start an adequate treatment.

La histiocitosis de células de Langerhans es una expresión de células dendríticas mieloides, asociada a un componente inflamatorio significativo y compromiso sistémico variado. La edad más frecuente de presentación es entre 1 y 4 años, y predomina en el sexo masculino. Se comunica el caso de un niño de 5 años de edad cuya forma de presentación fue una lesión granulomatosa con fístula perianal, afectación pulmonar y de oído externo. El abordaje interdisciplinario permitió llegar al diagnóstico, realizar las intervenciones necesarias e iniciar el tratamiento adecuado.

Medical illustration: a pictorial essay visual illustration of obstetric anal sphincter injuries (OASIS) degrees of severity, a picture is worth a thousand words

Obstetric anal sphincter injury affects about 5.7% of primiparous women who deliver vaginally. Perineal injury during childbirth is a common event with important morbidity associated with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries -OASIS). As there was a lack of consistency in the classification of a partial anal sphincter injury, with up to 33% of consultant obstetricians classifying a complete or partial tear of the EAS as a second-degree tear. We have proposed simple, digital diagrammatic drawings to visually represent all degrees (grades) of OASIS based on the WHO OASIS classification. (AU)

Papel de la reparación muscular en el tratamiento de la incontinencia anal

La incontinencia anal (IA) tiene una alta prevalencia en la sociedad, aumenta con la edad, presenta elevados costes económicos y tiene un importante impacto negativo en la calidad de vida de los pacientes que la padecen. El tratamiento quirúrgico se reserva para aquellos pacientes que no responden a medidas conservadoras. Clásicamente, las técnicas de reparación muscular han jugado un papel principal en el tratamiento de la IA, sobre todo en aquellos casos en los que había un defecto del complejo esfinteriano, siendo la más extendida la esfinteroplastía solapante y reservando técnicas más complejas como la graciloplastía para casos con lesiones esfinterianas catastróficas. Otras técnicas como la reparación total del suelo pélvico se encuentran en desuso por sus pobres resultados.

Anal Incontinence (AI) is a prevalent disease, increases with aging, has high economic costs and a deep impact in the quality of life of the patients who suffer it. Surgical treatment is proposed in patients with no-response to medical therapy. Muscle repair techniques have been the main approach in AI, specially when there is a sphincteric damage. Overlapping sphincteroplasty is the most common technique and graciloplasty is used when there is a wide damage in sphinteric complex. Some other techniques such as postanal or total pelvic floor repair are not used any more because of their poor results.

Cutting of sphincter in fistulectomy with primary closure in complex fistula-in-ano: is it feasible?

Introduction: Treatment of complex fistulas such as inter- or transsphincteric, recurrent, and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistulas. Material and Methods: There were 60 patients with complex fistulae involving the sphincter, with 56 male and 4 female, mean age 40.6 years, operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence, and incontinence. Results: The majority of patients (50, 83.3%) had complete wound healing in 2 weeks, while 4 (6.6%) patients had hematoma and superficial wound dehiscence, which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively, except for mild fecal incontinence (FI, score 3), seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks. Conclusions: Primary reconstruction of anal sphincter with fistulectomy is a safe option for complex fistula-in-ano. (AU)

Revisión de la fisiología anorrectal y posibles compuestos bioactivos para la erocosmética / Anorectal physiology and possible bioactive compounds for erocosmetics: A review / Fisiologia anorretal e possíveis compostos bioativos para erocosméticos: uma revisão

RESUMEN Objetivo: realizar una revisión bibliográfica sobre la fisiología ano-rectal, el proceso de relajación y contracción del músculo liso del tracto digestivo y posibles materias primas y formulaciones que podrían incorporarse a formulaciones erocosméticas de uso tópico en la región ano-rectal. Métodos: la revisión bibliográfica se realizó utilizando diferentes descriptores y mediante la consulta en las bases de datos ScienceDirect, PubMed, Clinical Key, Google Scholar y Google Patents. Resultados: inicialmente la revisión de la literatura permite comprender la anatomía y fisiología ano-rectal y los mecanismos que modulan la continencia anal, el tono basal del esfínter anal interno y el reflejo inhibitorio rectoanal (RAIR). Posteriormente, se obtuvo información sobre ejemplos de afrodisíacos naturales y se analizaron formulaciones cosméticas utilizadas como lubricantes anales con el fin de estudiar a profundidad los ingredientes de origen natural e identificar su utilidad, mecanismos de acción tópicos y su función dentro de la formulación. Conclusiones: el entendimiento de la fisiología ano-rectal permite el estudio y desarrollo de formulaciones cosméticas con propiedades analgésicas, anestésicas y relajantes, como los lubricantes anales. Productos naturales como la manzanilla, árnica, Aloe vera y mentol han sido estudiados para su uso cosmético y tópico como analgésicos, anestésicos o relajantes, por lo que su utilidad comprobada los hace útiles en el desarrollo de productos erocosméticos destinados para ser utilizados en la región anogenital.

SUMMARY Aim: To review the anorectal physiology, the process of relaxation and contraction of the smooth muscle of the digestive tract, and possible raw materials and formulations that could be incorporated into erocosmetic formulations for topical use in the anorectal region. Methods: The bibliographic review was carried out using different descriptors and by consulting the databases ScienceDirect, PubMed, Clinical Key, Google Scholar and, Google Patents. Results: Initially, a literature review was carried out to understand anorectal anatomy and physiology and the mechanisms that modulate anal continence, the internal anal sphincter basal tone, and the recto-anal inhibitory reflex (RAIR). Subsequently, information related to natural aphrodisiacs examples was obtained, and cosmetic formulations used as anal lubricants were analyzed to study the natural ingredients and identify their usefulness, mechanisms of action, and function in the formulation. Conclusion: Understanding anorectal physiology allows the study and development of cosmetic formulations with analgesic, anesthetic, and relaxing properties, such as anal lubricants. Natural products such as chamomile, arnica, Aloe vera, and menthol have been studied for cosmetic and topical use as analgesics, anesthetics, and relaxants, so the evidence makes them helpful in developing erocosmetic products intended to be used in the anogenital region.

RESUMO Objetivo: revisar a fisiologia anorretal, o processo de relaxamento e contração da musculatura lisa do trato digestivo e possíveis matérias-primas e formulações que possam ser incorporadas em formulações erocosméticas de uso tópico na região anorretal. Métodos: a revisão bibliográfica foi realizada utilizando diferentes descritores e consultando as bases de dados ScienceDirect, PubMed, Clinical Key, Google Scholar e, Google Patents. Resultados: inicialmente, foi realizada uma revisão da literatura para entender a anatomia e fisiologia anorretal e os mecanismos que modulam a continência anal, o tônus basal do esfíncter anal interno e o reflexo inibitório retoanal (RAIR). Posteriormente, foram obtidas informações relacionadas aos exemplos de afrodisíacos naturais e analisadas formulações cosméticas usadas como lubrificantes anais para estudar os ingredientes naturais e identificar sua utilidade, mecanismos de ação e função na formulação. Conclusão: a compreensão da fisiologia anorretal permite o estudo e o desenvolvimento de formulações cosméticas com propriedades analgésicas, anestésicas e relaxantes, como os lubrificantes anais. Produtos naturais como camomila, arnica, Aloe vera e mentol foram estudados para uso cosmético e tópico como analgésicos, anestésicos e relaxantes, de modo que as evidências os tornam úteis no desenvolvimento de produtos erocosméticos destinados ao uso na região anogenital.

End-to-end anal sphincter repair in treatment of post-traumatic fecal incontinence

The present report describes the end-to-end technique of anal sphincter repair in a 36-year-old female patient with post-vaginal delivery fecal incontinence (FI). The patient had a history of two vaginal deliveries and the symptoms of FI were observed after the second delivery. On assessment of the severity of FI using the Wexner incontinence score, the patient had a score of 12. Endoanal ultrasonography revealed an anterior defect of the external anal sphincter extending from 11 to 3 o'clock. The patient had no previous anal surgery and did not have any medical comorbidities. The operation time was 45minutes. No intraoperative complications were recorded. At 12 months of follow-up, the patient showed significant improvement in the continence state, with her Wexner score dropping to 4. No postoperative complications were recorded. We can conclude that end-to-end anal sphincter repair is a technically feasible operation that confers satisfactory improvement in the continence state without imposing much tension on the site of sphincter repair. (AU)

Short- and Long-Term Outcomes of Overlap Anal Sphincter Repair for Fecal Incontinence Following Sphincter Injury / Resultados em curto e longo prazos do reparo por sobreposição do esfíncter anal para incontinência fecal após lesão esfincteriana

Abstract Objective Several techniques are used to repair the anal sphincter following injury. The aim of the present study is to comprehensively analyze the short- and long-term outcomes of overlap repair following anal sphincter injury. Methods A search was conducted in the PubMed, Medline, Embase, Scopus and Google Scholar databases between January 2000 and January 2020. Studies that described the outcomes that are specific to overlap sphincter repair for fecal incontinence with a minimum follow-up period of one year were selected. Results A total of 22 studies described the outcomes of overlap sphincter repair. However, 14 studies included other surgical techniques in addition to overlap repair, and were excluded from the analysis. Finally, data from 8 studies including 429 repairs were analyzed. All studies used at least one objective instrument; however, there was significant heterogeneity among them. Most patients were female (n=407; 94.87%) and the mean age of the included individuals was 44.6 years. The majority of the procedures were performed due to obstetric injuries (n=384; 89.51%). The eight included studies described long-term outcomes, and seven of them demonstrated statistically significant improvements regarding the continence; one study described poor outcomes in terms of overall continence. The long-term scores were significantly better compared with the preoperative scores. However, compared with the shortterm scores, a statistically significant deterioration was noted in the long-term. Conclusion The majority of the studies described good long-term outcomes in terms of anal continence after overlap sphincter repair. However, further studies are needed

Resumo Objetivo Diversas técnicas são usadas no reparo do esfíncter anal após lesões. O objetivo deste estudo é fazer uma análise completa dos desfechos nos curto e longo prazos do reparo por sobreposição após lesão do esfíncter anal. Métodos Realizou-se uma busca nas bases de dados PubMed, Medline, Embase, Scopus e Google Scholar entre janeiro de 2000 e janeiro de 2020. Estudos que descreviam desfechos específicos do reparo de esfíncter por sobreposição para incontinência fecal, com um mínimo de 1 ano de seguimento, foram selecionados. Resultados No total, 22 estudos descreviam os desfechos do reparo de esfíncter por sobreposição. No entanto, 14 estudos incluíam outras técnicas cirúrgicas além do reparo por sobreposição, e foram excluídos da análise. Por fim, dados de 8 estudos que incluíam 429 reparos foram analisados. Todos os estudos usaram pelo menos um instrumento objetivo, mas havia uma heterogeneidade significativa entre eles. A maioria dos pacientes era do sexo feminino (n=407; 94,87%), e a idade média dos indivíduos incluídos foi de 44,6 anos. A maioria das cirurgias foi realizada devido a lesões obstétricas (n=384; 89,51%). Os oito estudos incluídos descreveram os desfechos no longo prazo, e sete deles demonstraram melhoras estatisticamente significativas com relação à continência; um estudo descreveu resultados ruins em termos gerais com relação à continência. As pontuações no longo prazo foram significativamente melhores em comparação com as pontuações no pré-operatório. No entanto, em comparação com as pontuações no curto prazo, percebeu-se uma piora estatisticamente significativa no longo prazo. Conclusão A maioria dos estudos descrevia bons resultados no longo prazo em termos de continência anal depois do reparo do esfíncter por sobreposição. Entretanto mais estudos são necessários para que se identifiquem os fatores associados aos desfechos ruins para auxiliar na seleção de pacientes para o reparo por sobreposição.

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study

ABSTRACT BACKGROUND: The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial. OBJECTIVE: To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury. DESIGN AND SETTING: Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail. METHODS: The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes. RESULTS: The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001). CONCLUSION: Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

Leuprolide Acetate, a GnRH Agonist, Improves the Neurogenic Bowel in Ovariectomized Rats with Spinal Cord Injury.

BACKGROUND: Electromyographic studies have shown that external anal sphincter activity is modified in response to distension in animals with spinal cord injury. Gonadotropin-releasing hormone and its agonist leuprolide acetate have neurotrophic properties in animals with spinal cord injury. AIM: This study was to determine the effects of leuprolide acetate treatment on electromyographic activity of the external anal sphincter and anorectal manometry in ovariectomized rats with spinal cord injury. METHODS: Adult ovariectomized rats were divided in three groups: (a) sham of spinal cord injury, (b) spinal cord injury treated with saline solution, and (c) spinal cord injury treated with leuprolide acetate. The spinal cord injury was induced by clamping at level T9. Leuprolide acetate dosage of 10 µg/kg was proctored intramuscular for 5 weeks, commencing the day after the lesion. Electromyography of the external anal sphincter, anorectal manometry, and volume of the cecum were evaluated in all groups. RESULTS: The electromyographic study of the external anal sphincter activity showed a significant improvement in injured rats treated with leuprolide acetate. Manometric analysis and cecum volume data obtained in animals with leuprolide acetate were very similar to those found in the sham group. CONCLUSIONS: These results demonstrate that leuprolide acetate treatment improves the neurogenic colon in ovariectomized rats with spinal cord injury.

Long-term outcomes of radiofrequency treatment for fecal incontinence: are the results maintainable?

PURPOSE: Temperature-controlled radiofrequency (RF) energy delivery to the sphincter complex has been proposed as an option for those patients not susceptible to a major surgical procedure for fecal incontinence (FI). The aim of the study was to evaluate the long-term (15 years) functional outcomes obtained after RF procedure for FI. METHODS: This was a retrospective analysis of our prospectively collected database of patients that underwent RF procedure for FI. Primary outcomes measured were the Cleveland Clinic Florida Fecal Incontinence scale (CCF-FI), Fecal Incontinence-related Quality of Life Score (FIQLS), the 36-Item Short Form survey (SF-36), endoanal ultrasound, and anorectal manometry. Evaluations were compared at baseline and at 15 years of follow-up. RESULTS: Ten patients were followed up 15 years after RF procedure. There was no significant improvement in the CCF-FI score (13.8 vs. 12.4, p = 0.24). No significant changes in the FIQLS were observed including lifestyle (2.39 vs. 2.13, p = 0.23), coping (1.91 vs. 1.92, p = 0.96), and embarrassment (1.66 vs. 1.86; p = 0.43). However, significant worsening was found in the depression category (2.47 vs. 1.60, p = 0.001). The SF-36 showed significant worsening in the mental (36.7 vs. 25.8, p < 0.001), physical (53.1 vs. 41.4, p = 0.01), and social functions (50.9 vs. 31.25, p = 0.001). Anorectal manometry and endoanal ultrasound showed no significant changes. No complications were found in the long-term follow-up. CONCLUSIONS: Radiofrequency procedure for fecal incontinence did not maintain its efficacy during long-term follow-up.

Factores de riesgo asociados con lesión obstétrica del esfínter anal: cohorte retrospectiva / Risk factors associated with obstetric anal sphincter injury: A retrospective cohort

Resumen OBJETIVO: Analizar los factores de riesgo asociados con lesión obstétrica del esfínter anal en una población donde la aplicación de fórceps es bien aceptada. MATERIALES Y MÉTODOS: Estudio de cohorte simple, retrospectivo, al que que se incluyeron pacientes que finalizaron el embarazo por parto, entre enero de 2013 y diciembre de 2017, en el Instituto Nacional de Perinatología Isidro Espinosa de los Reyes. Criterios de inclusión: embarazo mayor de 35 semanas, con feto único y en presentación cefálica. La variable dependiente de lesión obstétrica del esfínter anal se clasificó en tercer y cuarto grado. Para el análisis estadístico se utilizó el programa SPSS Statistics 23; la prueba de χ2 y t de Student para la comparación entre grupos, y razón de momios con intervalo de confianza de 95%. RESULTADOS: Se incluyeron 6199 pacientes. La edad promedio fue de 26.5 años; el peso al nacimiento de 2745 g y se colocaron fórceps en 6.9% (n = 428) casos. La frecuencia de lesión obstétrica del esfínter anal fue de 1.03% (n = 65). Entre los factores de riesgo asociados con lesión del esfínter anal se encontraron: aplicación de fórceps (RM 22.4; IC95% 13.3-36.7, p < 0.001) y primiparidad (RM 2.8; IC95% 1.68-4.93, p < 0.001). CONCLUSIONES: La edad materna de 20 a 30 años, el peso fetal mayor de 3500 g, el parto con fórceps y la primiparidad son factores de riesgo asociados con lesión obstétrica del esfínter anal.

Abstract OBJECTIVE: To analyze the associated risk factors of obstetric anal sphincter injury in a population in which the use of forceps is well accepted. MATERIALS AND METHODS: A simple retrospective cohort was performed where all women with vaginal delivery were identified in a period of 5 years (January 2013 to December 2017). Pregnancies older than 35 weeks were included, unique and in cephalic presentation. The dependent variable of obstetric lesion of the anal sphincter was classified in 3rd and 4th grade. The SPSS 23 program was used for the statistical analysis. χ2 test and Student's t test were used to compare the groups, as well as Odds radio (OR) with a 95% confidence interval (95%CI). RESULTS: A total of 6199 women were included. The average age was 26.5 years, birth weight of 2745 grams on average, forceps were placed in 6.9% (n = 428). The frequency of obstetric lesion of the anal sphincter was 1.03% (n = 65) in the study period. The following risk factors were found to be associated with anal sphincter injury: use of forceps OR 22.4 (95% CI 13.3-36.7, p <0.001), primiparity OR 2.8 (95% CI 1.68-4.93 p < 0.001. CONCLUSIONS: Maternal age of 20 to 30 years, fetal weight greater than 3500 grams, births with forceps and primiparity are risk factors for obstetric anal sphincter injuries.

Prevalencia de desgarros perineales en pacientes con aplicación de vacuum / Prevalence of perineal tars in patients submitted to the application of vacuum

Resumen OBJETIVO: Estimar la prevalencia de desgarro perineal en pacientes a quienes se aplicó vacuum e identificar los factores de riesgo de lesión del esfínter anal. MATERIALES Y MÉTODOS: Estudio descriptivo, transversal, retrospectivo y observacional. Se seleccionaron todos los partos en los que se aplicó vacuum del total de partos instrumentados en un hospital de segundo nivel de la Ciudad de México. Se incluyeron mujeres con embarazo de término, únicos y de evolución normal. Las lesiones perineales se clasificaron según la OMS. Se calcularon la prevalencia y el intervalo de confianza. Las variables se describen mediante medias y desviaciones estándar o frecuencias absolutas y relativas. Los desgarros se compararon con χ22 y los valores con significación estadística fueron los de p < 0.05. RESULTADOS: Se estudiaron 74 partos instrumentados en 708 partos totales, de los que 70 de 74 fueron con vacuum. En relación solo con estos últimos, los desgarros más prevalentes fueron de primer y segundo grado con valores de 40.0% (IC95%: 29-51) y 38.6% (IC95%: 27-50), respectivamente. No se identificaron factores de riesgo asociados con desgarros perineales severos. CONCLUSIONES: La prevalencia en la población estudiada fue similar a la de países industrializados y los desgarros moderados fueron los de mayor prevalencia.

Abstract OBJECTIVES: To estimate the prevalence of perineal tears in patients which delivery was instrumented by vacuum and to identify the risk factors that lead to a tear in the anal sphincter. MATERIAL AND METHOD: Descriptive, cross-sectional, retrospective and observational study. All vacuum deliveries were selected among the instrumental deliveries of the population in a secondary care hospital in Mexico City. The inclusion criteria were women who delivered vaginally at term with sole and normoevolutive pregnancies. The perineal tears were classified according to WHO. The statistical analysis included the estimation of prevalences with their corresponding confidence intervals. Variables were described by means and standard deviations or absolute and relative frequencies. Tears were compared using χ2 tests considering a statistical significance of p < 0.05. RESULTS: The number of instrumented deliveries was 74 out of 708 cases of total deliveries, those with vacuum were 70 out of 74. Considering the instrumented deliveries with vacuum, the most prevalent tears were those of first and second degree with values of 40.0% (CI 29-51) and 38.6% (CI 27-50) respectively. There were not associated risk factors to severe perineal tears. CONCLUSIONS: Prevalence in the studied population was similar to developed countries and moderate tears are the most prevalent.

A simple, reproducible and low-cost simulator for teaching surgical techniques to repair obstetric anal sphincter injuries / Um Simulador simples, reproduzível e de baixo custo para o ensino de técnicas cirúrgicas para reparar lesões obstétricas do esfíncter anal

Abstract Objective To describe and evaluate the use of a simple, low-cost, and reproducible simulator for teaching the repair of obstetric anal sphincter injuries (OASIS). Methods Twenty resident doctors in obstetrics and gynecology and four obstetricians participated in the simulation. A fourth-degree tear model was created using lowcost materials (condom simulating the rectal mucosa, cotton tissue simulating the internal anal sphincter, and bovine meat simulating the external anal sphincter). The simulator was initially assembled with the aid of anatomical photos to study the anatomy and meaning of each component of the model. The laceration was created and repaired, using end-to-end or overlapping application techniques. Results The model cost less than R$ 10.00 and was assembled without difficulty, which improved the knowledge of the participants of anatomy and physiology. The sutures of the layers (rectal mucosa, internal sphincter, and external sphincter) were performed in keeping with the surgical technique. All participants were satisfied with the simulation and felt it improved their knowledge and skills. Between 3 and 6 months after the training, 7 participants witnessed severe lacerations in their practice and reported that the simulation was useful for surgical correction. Conclusion The use of a simulator for repair training in OASIS is affordable (low-cost and easy to perform). The simulation seems to improve the knowledge and surgical skills necessary to repair severe lacerations. Further systematized studies should be performed for evaluation.

Resumo Objetivo Descrever e avaliar a utilização de um simulador simples, de baixo custo e reprodutível para o ensino de sutura de lacerações perineais de 4° grau. Métodos Participaram da simulação 20 residentes de ginecologia e obstetrícia e quatro profissionais especialistas. Um modelo de laceração de 4° grau foi criado com materiais de baixo custo (preservativo simulando a mucosa retal, tecido de algodão simulando o esfíncter anal interno e carne bovina simulando o esfíncter anal externo). O simulador foi inicialmente montado com ajuda de fotos anatômicas, para estudar a anatomia e o significado de cada componente do modelo. A laceração foi criada e suturada, utilizando técnicas de borda a borda e de sobreposição do esfíncter anal. Resultados O modelo custou menos de R$ 10,00 e foi montado sem dificuldade, aprimorando os conhecimentos dos participantes sobre anatomia e fisiologia. As suturas das camadas (mucosa retal, esfíncter interno e esfíncter externo) foram realizadas seguindo a técnica cirúrgica. Todos os participantes ficaram satisfeitos coma simulação e consideraram que estamelhorou seus conhecimentos e habilidades. Entre 3 a 6 meses após o treinamento, 7 participantes presenciaram em sua prática lacerações graves e relataram que a simulação foi útil para a correção cirúrgica. Conclusão A utilização de um simulador para treinamento de sutura de lacerações obstétricas graves é acessível (baixo custo e fácil execução). A simulação parece aprimorar conhecimentos e habilidades cirúrgicas para sutura de lacerações graves. Mais estudos sistematizados devem ser realizados para avaliação.

Perineal trauma in a low-risk maternity with high prevalence of upright position during the second stage of labor / Trauma perineal em uma maternidade de baixo risco com alta prevalência de parto vertical durante o período expulsivo

Abstract Objective Perineal trauma is a negative outcome during labor, and until now it is unclear if the maternal position during the second stage of labormay influence the risk of acquiring severe perineal trauma. We have aimed to determine the prevalence of perineal trauma and its risk factors in a low-risk maternity with a high incidence of upright position during the second stage of labor. Methods A retrospective cohort study of 264 singleton pregnancies during labor was performed at a low-risk pregnancymaternity during a 6-month period. Perineal trauma was classified according to the Royal College of Obstetricians and Gynecologists (RCOG), and perineal integrity was divided into three categories: no tears; first/ second-degree tears + episiotomy; and third and fourth-degree tears. A multinomial analysis was performed to search for associated factors of perineal trauma. Results From a total of 264 women, there were 2 cases (0.75%) of severe perineal trauma, which occurred in nulliparous women younger than 25 years old. Approximately 46% (121) of the women had no tears, and 7.95% (21) performed mediolateral episiotomies. Perineal trauma was not associated with maternal position (p = 0.285), health professional (obstetricians or midwives; p = 0.231), newborns with 4 kilos or more (p = 0.672), and labor analgesia (p = 0.319). The multinomial analysis showed that white and nulliparous presented, respectively, 3.90 and 2.90 times more risk of presenting perineal tears. Conclusion The incidence of severe perineal trauma was low. The prevalence of upright position during the second stage of labor was 42%. White and nulliparous women were more prone to develop perineal tears.

Resumo Objetivo O trauma perineal é um desfecho negativo durante o parto, e é incerto, até omomento, se a posiçãomaternal durante o período expulsivo pode influenciar o risco de evoluir com trauma perineal severo. Nós objetivamos determinar a prevalência de trauma perineal e seus fatores de risco em uma maternidade de baixo risco com alta prevalência de posição vertical durante o período expulsivo. Métodos Um estudo de coorte retrospectivo de 264 gestações únicas durante o trabalho de parto foi realizado durante 6 meses consecutivos. O trauma perineal foi classificado de acordo com o Royal College of Obstetricianns and Gynecologists (RCOG). A integridade perineal foi dividida em três categorias: períneo íntegro; trauma perineal leve (primeiro e segundo graus + episiotomia); e trauma perineal severo (terceiro e quarto graus). Uma análise multinomial foi realizada para buscar variáveis associadas ao trauma perineal. Resultados De um total de 264 mulheres, houve 2 casos (0,75%)de trauma perineal severo m nulíparas com menos de 25 anos. Aproximadamente 46% (121) das mulheres não tiveram trauma perineal e 7,95% (21) realizaram episiotomias mediolaterais. Não houve correlação do trauma perineal com a posição de parto (p = 0,285), tipo de profissional que realizou o parto (p = 0,231), recém-nascidos com 4.000 gramas ou mais (p = 0,672), e presença de analgesia de parto (p = 0,319). Uma análise multinomial evidenciou que mulheres brancas e nulíparas apresentaram, respectivamente, um risco 3,90 e 2,90 vezes maior de apresentar trauma perineal. Conclusão A incidência de trauma perineal severo foi baixa. A prevalência de parto vertical durante o período expulsivo foi de 42%. Mulheres brancas e nulíparas foram mais suscetíveis a apresentar trauma perineal.

Diagnostic Role of Anal Sphincter Relaxation Integral in High-Resolution Anorectal Manometry for Hirschsprung Disease in Infants.

OBJECTIVE: To investigate the possible diagnostic role of anal sphincter relaxation integral (ASRI) in high-resolution anorectal manometry (HRAM) for Hirschsprung disease. STUDY DESIGN: We performed conventional anorectal manometry (ARM) in 24 infants (8 with Hirschsprung disease and 16 without Hirschsprung disease) and HRAM in another 21 infants (9 with Hirschsprung disease and 12 without Hirschsprung disease) before and after October 2014. All infants underwent rectal suction biopsy for confirmation of Hirschsprung disease. We quantified rectoanal inhibitory reflex (RAIR) adequacy by calculating the ASRI in HRAM study at pressure cutoffs of less than 10, 15, and 20 mm Hg (ASRI10, ASRI15, and ASRI20, respectively) and investigated the diagnostic utility. RESULTS: Patients with Hirschsprung disease who underwent HRAM had significantly lower ASRI10, ASRI15, and ASRI20 values than did infants without Hirschsprung disease (P = .0002, .0002, and .0003, respectively), indicating significant difference in internal anal sphincter relaxation during RAIR test between these 2 groups. ASRI10 exhibited a greater diagnostic accuracy, area under the curve, sensitivity, and specificity than did ASRI15 and ASRI20 for Hirschsprung disease. Moreover, the diagnostic accuracy of HRAM for Hirschsprung disease based on ASRI10 <7 mm Hg.s.cm was significantly greater than that of conventional ARM (P = .02). CONCLUSIONS: ASRI10 may be indicative of the adequacy of RAIR by HRAM in infants, thus assisting the diagnosis of Hirschsprung disease. The diagnostic accuracy of HRAM (based on the ASRI10 value) is greater than that of conventional ARM for Hirschsprung disease. ASRI10 may be used in an automatic HRAM analysis system for the diagnosis of anorectal motility disorders.

Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study.

OBJECTIVES: To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. METHODS: This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. RESULTS: Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. CONCLUSIONS: Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Electrical stimulation structurally affects the tissues of the rectum and anus of nulliparous rats.

Considering that the muscles of the anus perform a critical role in maintaining continence, losses in their structure can negatively affect the physiological control of the intestinal contents. Anorectal electro-stimulation (ARES) has been reported to have a positive effect on the functionality of treated patients, but how ARES affects the structural tissues of the anorectal segment remains unknown. Because the study of how ARES structurally affects human tissues is not possible, this study aimed to clarify these effects in a murine model, which has a similar anorectal segment (structure and physiology) to humans. For the descriptive and comparative study, randomly selected nulliparous adult Wistar rats (n = 5) were submitted to 30 anorectal sessions of ARES with a biphasic current (700 µs, 50 Hz from 2 to 4 mA). After treatment, the animals were euthanized, and the anorectal segments were dissected and processed for histopathological analysis. Our results showed that ARES increased the widths of the mucosal, submucosal and muscle layers of the rectum, as well as the number of leukocytes in the mucosa. ARES also caused hyperplasia of the smooth muscle of the internal anal sphincter and hypertrophy of the external anal sphincter muscle. In conclusion, our results showed that ARES had not only a positive effect on the structure (morphology) of all tissues associated with the rectum and anus but, more importantly, on the structural gain of the muscles (hyperplasia and hypertrophy), which could point to a functional gain of the anal sphincter, reinforcing the applicability of ARES as a non-invasive treatment for anal incontinence.