Correlation Between Echodefecography and 3-Dimensional Vaginal Ultrasonography in the Detection of Perineal Descent in Women With Constipation Symptoms.

BACKGROUND: Defecography is an established method of evaluating dynamic anorectal dysfunction, but conventional defecography does not allow for visualization of anatomic structures. OBJECTIVE: The purpose of this study was to describe the use of dynamic 3-dimensional endovaginal ultrasonography for evaluating perineal descent in comparison with echodefecography (3-dimensional anorectal ultrasonography) and to study the relationship between perineal descent and symptoms and anatomic/functional abnormalities of the pelvic floor. DESIGN: This was a prospective study. SETTING: The study was conducted at a large university tertiary care hospital. PATIENTS: Consecutive female patients were eligible if they had pelvic floor dysfunction, obstructed defecation symptoms, and a score >6 on the Cleveland Clinic Florida Constipation Scale. INTERVENTIONS: Each patient underwent both echodefecography and dynamic 3-dimensional endovaginal ultrasonography to evaluate posterior pelvic floor dysfunction. MAIN OUTCOME MEASURES: Normal perineal descent was defined on echodefecography as puborectalis muscle displacement ≤2.5 cm; excessive perineal descent was defined as displacement >2.5 cm. RESULTS: Of 61 women, 29 (48%) had normal perineal descent; 32 (52%) had excessive perineal descent. Endovaginal ultrasonography identified 27 of the 29 patients in the normal group as having anorectal junction displacement ≤1 cm (mean = 0.6 cm; range, 0.1-1.0 cm) and a mean anorectal junction position of 0.6 cm (range, 0-2.3 cm) above the symphysis pubis during the Valsalva maneuver and correctly identified 30 of the 32 patients in the excessive perineal descent group. The κ statistic showed almost perfect agreement (κ = 0.86) between the 2 methods for categorization into the normal and excessive perineal descent groups. Perineal descent was not related to fecal or urinary incontinence or anatomic and functional factors (sphincter defects, pubovisceral muscle defects, levator hiatus area, grade II or III rectocele, intussusception, or anismus). LIMITATIONS: The study did not include a control group without symptoms. CONCLUSIONS: Three-dimensional endovaginal ultrasonography is a reliable technique for assessment of perineal descent. Using this technique, excessive perineal descent can be defined as displacement of the anorectal junction >1 cm and/or its position below the symphysis pubis on Valsalva maneuver.

Anatomical characteristics of anal fistula evaluated by three-dimensional anorectal ultrasonography: is there a correlation with Goodsall's theory? / Características anatômicas da fístula anal avaliadas por Ultrassonografia Anorretal Tridimensional: Há correlação com a teoria de Goodsall?

Purpose: We aimed to correlate the course of the anal fistula tract (T), location of the external opening (EO) and internal opening (IO) in anterior (A) and posterior (P) circumference using 3D-US according to Goodsall's rule. Methods: 151 patients with primary ptoglandular Transsphincteric fistulas were examined with 3D-US and compared with surgical finding. The type of the T (straight or curved), EO and IO were identified and divided into 3 Groups: GI: EO and IO are located in a position; GII: EO and IO are located in P position and GIII: OE and OI are located in the opposite position. The findings were correlated with Goodsall's rule. Results: 74/151(49%) were included in GI, of them, 41 (55%) were male (33/44% had straight tract and 8/11% curved) and 33 (45%) female (15/20%-straight and 18/25%-curved). GII included 68 (45%), of them, 50 (74%) were male (39/57%-straight and 11/15%-curved) and 18 (26%) female (14/20%-straight and 04/8%-curved). GIII = 9 (6%) and all of them had curved tract. The overall concordance between 3D-US and surgical finding was 98% for tract and 96% for IO. Conclusion: The 3D-US findings correlate with the Goodsall's rule in transsphincteric fistulas located in the anterior circumference straight type, in male, while in females the distribution of curved and straight paths is similar. In the posterior circumference no correlation was observed in both the sexes. .

Objetivo: Correlacionar o trajeto (T) da fístula anal, localização do orifício externo (OE) e orifício interno (OI) na hemicircunferência anterior (HCA) e posterior (HCP), utilizando 3D-US, com a lei de Goodsall. Método: 151 pacientes com fístulas transesfinctéricas criptoglangulares foram examinados com US-3D correlacionando com os achados cirúrgicos. Identificou-se o tipo de T (retilíneo ou curvo), OE e OI e distribuiu-se os pacientes em 3 grupos: GI:OE e OI localizados em HCA; GII:OE e OI localizados em HCP e GIII:OE e OI em posiç ões opostas. Os achados foram correlacionados com a lei de Goodsall. Resultados: 74/151(49%) incluídos no GI, destes, 41(55%) homens(33/44% com trajeto retilíneo e 8/11% curvo) e 33(45%) mulheres(15/20%-retilíneo e 18/25%-curvo). No GII incluídos 68(45%), destes, 50(74%) homens(39/57%-retilíneo e 11/15%-curvo) e 18(26%) mulheres(14/20%-retilíneo e 04/8%-curvo). GIII = 9(6%) todos os trajetos curvos. A concordância entre o US-3D e os achados cirúrgicos foi de 98% para trajetos e 96% para o OI. Conclusão: Os achados ultrassonográficos permitiram correlacionar fístulas transesfinctéricas com trajetos retilíneos localizadas na hemicircunferência anterior, em homens, enquanto em mulheres a distribuição dos trajetos em curvo e retilíneo foram similares. Na hemicircunferência posterior não houve correlação em ambos os sexos. .

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.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography.

PURPOSE: This study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD). MATERIALS AND METHODS: Three hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I-105 nulliparous, Group II-165 had at least one vaginal delivery, and Group III-comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions. RESULTS: No statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively. CONCLUSION: The distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

Role of three-dimensional anorectal ultrasonography in the assessment of rectal cancer after neoadjuvant radiochemotherapy: preliminary results.

BACKGROUND: Three-dimensional anorectal ultrasound (3-DAUS) scanning provides accurate information on tumor size and its relation to the anal muscles. The purpose of this study was to evaluate the ability of 3-DAUS to assess response to radiochemotherapy (RCT) for rectal cancer by comparing 3-DAUS images to pathological findings. METHODS: Twenty-five patients (mean age 52.4 years), staged as T2 (n = 3), T3 (n = 16) or T4 (n = 6), with lymph node metastases in 12 cases, were submitted to neoadjuvant RCT, followed by a second 3-DAUS scan 7 weeks later. The patients were grouped according to the distance (cm) between the distal tumor edge and the proximal border of the internal anal sphincter (IAS) (group I, presenting anal canal invasion; group II, < or =2.0 cm; group III, >2.0 cm). All patients were operated on and the pathological findings were compared to post-RCT 3-DAUS scanning results. RESULTS: Four (16%) patients (three in group I, one in group II) experienced complete tumor regression. Fourteen (56%) tumors (six in group I, seven in group II, and one in group III) regressed partially. Distance to the IAS was >2.0 cm in eight patients (seven in group II and one in group III). The remaining six (24%) patients (all group I) experienced no regression. 3-DAUS and pathological findings were concordant in 24 (96%) patients, with only one (4%) nonconclusive post-RCT 3-DAUS result found to be a residual tumor. Tumor regression made sphincter-saving surgery possible in 13 patients (eight in group III, four complete tumor regression, and one nonconclusive on 3-DAUS). Pathological examination revealed free distal margins in all cases. The index of agreement between lymph node metastases on post-RCT 3-DAUS and surgical specimens was moderate (84%). CONCLUSION: 3-DAUS can aid significantly in the choice of surgical approach following RCT. However, a greater sample of patients is required to establish sufficiently accurate post-RCT 3-DAUS parameters.

A novel three-dimensional dynamic anorectal ultrasonography technique (echodefecography) to assess obstructed defecation, a comparison with defecography.

AIM: To test the effectiveness of echodefecography, the dynamic 3D anorectal ultrasonography technique -(EDF). To assess women with obstructed defecation (OD), as compared with conventional defecography (DF). METHODS: A prospective study was carried out with 30 women with OD symptoms, the mean validated Wexner constipation score was 14 (range 7-25) and the mean age 47.7 years. All patients were submitted to DF followed by EDF and the results compared. RESULTS: Six patients were normal at DF and five were normal at EDF. Defecography identified grade I rectocele in five patients (average size: 1.8 cm), grade II in seven (average size: 2.9 cm) and grade III in 12 (average size: 4.6 cm). Different sizes of anorectocele were also observed at EDF and quantified according to DF classification (grade I: 1.3 cm). Significant differences were observed between anorectocele sizes (p < 0.05) and between normal patients and grade I (p < 0.001). The level of agreement between the techniques was high (kappa = 0.902), with only one normal case wrongly identified as anorectocele III at EDF. Rectal intussusception was identified in five patients at DF; EDF confirmed these cases and revealed seven others, demonstrating moderate agreement (kappa = 0.462). Anismus was identified in nine patients in DF and in eight in EDF (kappa = 0.901). CONCLUSION: Echodefecography may be used as an alternative method to assess patients with OD as it has been shown to detect the same anorectal dysfunctions observed in DF. It is minimally invasive, well tolerated, inexpensive, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved with defecation.