Evaluation of anorectal function using real-time tissue elastography before and after preoperative chemoradiotherapy.

PURPOSE: This study aimed to clarify the relationship between changes in elasticity and anorectal function before and after chemoradiotherapy. METHODS: This is a single-center prospective cohort study (Department of Surgical Oncology, The University of Tokyo). We established a technique to quantify internal anal sphincter hardness as elasticity using transanal ultrasonography with real-time tissue elastography. Twenty-seven patients with post-chemoradiotherapy rectal cancer during 2019-2022 were included. Real-time tissue elastography with transanal ultrasonography was performed before and after chemoradiotherapy to measure internal anal sphincter hardness as "elasticity" (hardest (0) to softest (255); decreased elasticity indicated sclerotic changes). The relationship between the increase or decrease in elasticity pre- and post-chemoradiotherapy and the maximum resting pressure, maximum squeeze pressure, and Wexner score were the outcome measures. RESULTS: A decrease in elasticity was observed in 16/27 (59.3%) patients after chemoradiotherapy. Patients with and without elasticity decrease after chemoradiotherapy comprised the internal anal sphincter sclerosis and non-sclerosis groups, respectively. The maximum resting pressure post-chemoradiotherapy was significantly high in the internal anal sphincter sclerosis group (63.0 mmHg vs. 47.0 mmHg), and a majority had a worsening Wexner score (60.0% vs. 18.2%) compared with that of the non-sclerosis group. Decreasing elasticity (internal anal sphincter sclerosis) correlated with a higher maximum resting pressure (r = 0.36); no correlation was observed between the degree of elasticity change and maximum squeeze pressure. CONCLUSION: Internal anal sphincter sclerosis due to chemoradiotherapy may correlate to anorectal dysfunction.

Correlation between congenital pelvic floor muscle development assessed by magnetic resonance imaging and postoperative defecation.

OBJECTIVE: Children with congenital anorectal malformation (CAM) experience challenges with defecation. This study aims to assess defecation in preschool-age children with CAM and to evaluate the correlation between pelvic floor muscle developed assessed by magnetic resonance imaging (MRI) and postoperative defecation. METHODS: We collected clinical data and MRI results from 89 male children with CAM. The bowel function scores for children with Perineal (cutaneous) fistula, Rectourethral fistula(Prostatic or Bulbar), and Rectovesical fistula were computed. MRI scans were subjected to image analysis of the striated muscle complex (SMC). The association between pelvic floor muscle score and bowel function score was examined using the Cochran-Armitage Trend Test. RESULTS: We observed that 77.4% of the SMC scores by MRI for Perineal fistula were good. The Rectourethral fistula SMC score was 40.6% for moderate and 59.4% for poor. The SMC score for Rectovesical fistula was 100% for moderate. Furthermore, 77.4% of patients with Perineal fistula had bowel function scores (BFS) ≥ 17 points. Among those with Rectourethral fistula and Rectovesical fistula, 12.5% and 0 had BFS ≥ 17 points, respectively. An analysis of muscle development and bowel function in patients with Rectovesical fistula, Rectourethral fistula, and Perineal fistula revealed a correlation between SMC development and BFS. Subgroup analysis showed that the Perineal fistula had statistical significance; however, the Rectourethral fistula and Rectovesical fistula were not statistically significant. CONCLUSION: A correlation exists between pelvic floor muscle development and postoperative defecation in children with Perineal fistula.

Deep Learning in High-Resolution Anoscopy: Assessing the Impact of Staining and Therapeutic Manipulation on Automated Detection of Anal Cancer Precursors.

INTRODUCTION: High-resolution anoscopy (HRA) is the gold standard for detecting anal squamous cell carcinoma (ASCC) precursors. Preliminary studies on the application of artificial intelligence (AI) models to this modality have revealed promising results. However, the impact of staining techniques and anal manipulation on the effectiveness of these algorithms has not been evaluated. We aimed to develop a deep learning system for automatic differentiation of high-grade squamous intraepithelial lesion vs low-grade squamous intraepithelial lesion in HRA images in different subsets of patients (nonstained, acetic acid, lugol, and after manipulation). METHODS: A convolutional neural network was developed to detect and differentiate high-grade and low-grade anal squamous intraepithelial lesions based on 27,770 images from 103 HRA examinations performed in 88 patients. Subanalyses were performed to evaluate the algorithm's performance in subsets of images without staining, acetic acid, lugol, and after manipulation of the anal canal. The sensitivity, specificity, accuracy, positive and negative predictive values, and area under the curve were calculated. RESULTS: The convolutional neural network achieved an overall accuracy of 98.3%. The algorithm had a sensitivity and specificity of 97.4% and 99.2%, respectively. The accuracy of the algorithm for differentiating high-grade squamous intraepithelial lesion vs low-grade squamous intraepithelial lesion varied between 91.5% (postmanipulation) and 100% (lugol) for the categories at subanalysis. The area under the curve ranged between 0.95 and 1.00. DISCUSSION: The introduction of AI to HRA may provide an accurate detection and differentiation of ASCC precursors. Our algorithm showed excellent performance at different staining settings. This is extremely important because real-time AI models during HRA examinations can help guide local treatment or detect relapsing disease.

A step-by-step guide to ileoanal J-pouch MRI interpretation.

BACKGROUND: Multidisciplinary management of patients with an ileoanal pouch requires dedicated imaging to identify structural problems of the pouch associated with dysfunction. The purpose of this study is to provide a framework for interpretation of magnetic resonance imaging (MRI) scan of the ileoanal pouch to enable surgeons and radiologists to work cohesively, optimise diagnosis and ultimately improve patient care. METHODS: We propose a protocol for structured MRI assessment of the ileal pouch, aiming to provide surgeons a systematic report of the anatomy, its variations and pouch complications. This guide consists of studying the characteristics of the bowel, mesentery and anal canal. RESULTS: The presented checklist is designed to systematically interpret and identify abnormalities of the ileoanal pouch on MRI. It focuses on the characteristics of the bowel (encompassing pre-pouch ileum, pouch and rectal cuff), mesentery and anal canal. The different elements of the checklist are presented in the associated supplementary video. CONCLUSIONS: A combination of clinical assessment, endoscopic evaluations and imaging is fundamental to achieving accurate diagnosis of ileoanal pouch surgery complications and pouch dysfunction.

Obstetric anal sphincter injury (OASI) in the presence of an intact perineum.

Obstetric anal sphincter injury (OASI) in the absence of concurrent injury to the perineal skin is not a common diagnosis. A primiparous woman delivered a healthy male infant by spontaneous vertex delivery. At time of delivery, a compound presentation of the fetal hand with the head was noted. Initial examination revealed a presumed second-degree tear; however, a small laceration above the anal verge was noted, which on exploration revealed a perineal injury through the anal sphincter complex. In the operating theatre, the perineal skin was incised to reveal a 3c OASI, which was repaired appropriately. While atypical OASI has been reported previously, this specific injury has never been described in detail in the literature. Awareness of atypical perineal injuries is needed and while careful perineal examination is required in all cases, this is especially important where the perineal skin appears intact to ensure appropriate diagnosis of any concurrent OASI.

Low Rectal Cancers at Initial Staging MRI.

Low rectal cancers, which are associated with increased risk of local recurrent disease and poorer prognosis, have unique anatomic considerations and issues for staging and treatment that do not apply to mid and high rectal cancers. Although tumor histology help drive the staging and treatment of all rectal cancers, it is of particular importance in low rectal cancers, which may involve the anal canal, to help establish whether a low rectal mass should be staged and treated as a rectal cancer (ie, adenocarcinoma) or an anal cancer (ie, squamous cell carcinoma). Optimal staging and treatment of rectal cancer are contingent on tumor location and local extent, which help guide management decisions including neoadjuvant therapy and curative surgical treatment strategies. Tumor location in the low rectum and local involvement of the anal canal, sphincter, and pelvic floor help determine whether a patient can undergo sphincter-preserving resection such as a low anterior resection versus abdominoperineal resection to achieve negative surgical margins. Issues exist related to the anatomy and patterns of disease spread that are unique to the low rectum and include how to determine and stage anal sphincter involvement, mesorectal fascia status at the pelvic floor, and nodal status of extramesorectal nodes such as the external iliac and inguinal lymph nodes. For these reasons, it is imperative that radiologists who interpret rectal cancer staging MRI examinations feel comfortable with the unique anatomy of the low rectum and anal canal, nuances of low rectal cancer local disease spread, and treatment paradigms for low rectal cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Gollub in this issue.

Impact of Preoperative Three-Dimensional Endoanal Ultrasound on the Surgical Outcome of Primary Fistula in Ano. A Multi-Center Observational Study of 253 Patients.

PURPOSE: To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery. METHODS: The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings. RESULTS: A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference (P < .0001; Fisher's exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate. CONCLUSION: The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.

Impact of Internal Anal Sphincter Division on Continence Disturbance in Female Patients.

BACKGROUND: Few studies measured the pre- and postoperative anatomic and functional anal canal using 3-dimensional endoanal ultrasound and anal manometry and correlated sphincter division with fecal incontinence, severity, and function. OBJECTIVE: To assess the incidence of fecal incontinence in patients who underwent internal anal sphincter division for anal fissure or intersphincteric anal fistula and correlate severity of symptoms with percentage of divided muscle, anatomical measurements, and anal pressures. DESIGN: Prospective cohort study. SETTINGS: Colorectal surgery unit, tertiary referral center. PATIENTS: Patients underwent clinical assessment using the Cleveland Clinic Florida Fecal Incontinence score for severity of symptoms, manometry, and ultrasound. MAIN OUTCOMES MEASURES: Ultrasound measurements of length, percentage, and angle of divided internal anal sphincter, anterior external anal sphincter, posterior external anal sphincter plus puborectalis, and gap lengths. RESULTS: Sixty-three women (mean age, 44 years) were divided into 2 groups: 30 (48%) underwent fistulotomy for intersphincteric anal fistula and 33 (52%) underwent sphincterotomy for chronic anal fissure with high anal resting pressure. Forty-six percent experienced some measure of fecal incontinence after internal anal sphincter division. Incidence of fecal incontinence, severity of symptoms, and angle of the divided internal anal sphincter were similar between the groups. Length and percentage of the divided internal anal sphincter were significantly higher in the intersphincteric anal fistula. External anal sphincter and external anal sphincter plus puborectalis lengths were similar in both groups. Gap length was significantly longer in chronic anal fissures with high anal resting pressure. LIMITATIONS: Single-institution, exclusion of males. CONCLUSIONS: Fecal incontinence was reported in half of the patients who underwent internal anal sphincter division. Despite the greater length and percentage of internal anal sphincter division in patients who underwent fistulotomy, incidence and severity of fecal incontinence were similar in both groups. Three-dimensional endoanal ultrasound showed greater gap length in the sphincterotomy group, which may be functionally significant after the division of the shorter internal anal sphincter but with a similar impact on fecal incontinence in both groups. IMPACTO DE LA DIVISIN DEL ESFNTER ANAL INTERNO EN LA ALTERACIN DE LA CONTINENCIA EN PACIENTES DE SEXO FEMENINO: ANTECEDENTES:Pocos estudios han medido el canal anal anatómico y funcional antes y después de la cirugía mediante ecografía endoanal tridimensional y manometría anal, y correlacionado la división del esfínter con la incontinencia fecal, la gravedad y la función.OBJETIVO:Evaluar la incidencia de incontinencia fecal en pacientes sometidos a división del esfínter anal interno por fisura anal o fístula anal interesfinteriana, y correlacionar la gravedad de los síntomas con el porcentaje de músculo dividido, las medidas anatómicas y las presiones anales.DISEÑO:Estudio de cohorte prospectivo.AJUSTE:Unidad de cirugía colorrectal, centro de referencia de tercer nivel.PACIENTES:Pacientes sometidos a una evaluación clínica utilizando la puntuación de incontinencia fecal de Cleveland Clinic Florida para la gravedad de los síntomas, la manometría y la ecografía.PRINCIPALES MEDIDAS DE RESULTADO:Mediciones por ultrasonido de la longitud, el porcentaje y el ángulo del esfínter anal interno dividido y el esfínter anal externo anterior, el esfínter anal externo posterior más el puborrectal y las longitudes del espacio.RESULTADOS:Sesenta y tres mujeres (edad media, 44 años) se dividieron en 2 grupos: 30 (48%) sometidos a fistulotomía por fístula anal interesfinteriana y 33 (52%) sometidos a esfinterotomía por fisura anal crónica con alta presión anal en reposo. El 46% experimentó algún grado de incontinencia fecal después de la división del esfínter anal interno. La incidencia de incontinencia fecal, la gravedad de los síntomas y el ángulo del esfínter anal interno dividido fueron similares entre los grupos. La longitud y el porcentaje del esfínter anal interno dividido fueron significativamente mayores en la fístula anal interesfinteriana. Las longitudes del esfínter anal externo y del esfínter anal externo más el puborrectal fueron similares en ambos grupos. La longitud del espacio fue significativamente mayor en la fisura anal crónica con alta presión anal en reposo.LIMITACIONES:Institución única, exclusión de varones.CONCLUSIÓN:La incontinencia fecal se reportó en la mitad de los pacientes sometidos a división del esfínter anal interno. A pesar de la mayor longitud y porcentaje de división del esfínter anal interno en los pacientes sometidos a fistulotomía, la incidencia y gravedad de la incontinencia fecal fue similar en ambos grupos. La ecografía endoanal tridimensional mostró una mayor longitud del espacio en el grupo de esfinterotomía, lo que puede ser funcionalmente significativo después de la división del esfínter anal interno más corto, pero con un impacto similar en la incontinencia fecal en ambos grupos. (Traducción-Dr. Fidel Ruiz Healy ).

Postoperative three-dimensional endoanal ultrasound findings and relation to anal fistula plug failure.

OBJECTIVES: To explore the utilization of three-dimensional (3D) endoanal ultrasound (EAUS) for the follow-up of the anal fistula plug (AFP), describe morphological findings in postoperative 3D EAUS, and evaluate if postoperative 3D EAUS combined with clinical symptoms can predict AFP failure. MATERIALS AND METHODS: A retrospective analysis of 3D EAUS examinations performed during a single-centre study of prospectively included consecutive patients treated with the AFP between May 2006 and October 2009. Postoperative assessment by clinical examination and 3D EAUS was performed at 2 weeks, 3 months and 6-12 months ("late control"). Long-term follow-up was carried out in 2017. The 3D EAUS examinations were blinded and analysed by two observers using a protocol with defined relevant findings for different follow-up time points. RESULTS: A total of 95 patients with a total of 151 AFP procedures were included. Long-term follow-up was completed in 90 (95%) patients. Inflammation at 3 months, gas in fistula and visible fistula at 3 months and at late control, were statistically significant 3D EAUS findings for AFP failure. The combination of gas in fistula and clinical finding of fluid discharge through the external fistula opening 3 months postoperatively was statistically significant (p < 0.001) for AFP failure with 91% sensitivity and 79% specificity. The positive predictive value was 91%, while the negative predictive value was 79%. CONCLUSIONS: 3D EAUS may be utilized for the follow-up of AFP treatment. Postoperative 3D EAUS at 3 months or later, especially if combined with clinical symptoms, can be used to predict long-term AFP failure.ClinicalTrials.gov identifier NCT03961984.

Description of a new ultrasound sign to distinguish Crohn's anal fistula from cryptoglandular fistula: The rosary sign.

AIM: Endoanal and endorectal ultrasound are essential diagnostic tools for perianal fistula. Recent studies have examined ultrasound signs that help differentiate cryptoglandular anal fistula from perianal fistulizing Crohn's disease. The main aim of this work was to describe a new ultrasound sign for perianal fistula and to evaluate its ability to differentiate Crohn's disease from cryptoglandular anal fistula. METHOD: This study included 363 patients (113 women; mean age 46.5 ± 14.3 years). Overall, 287 (79.1%) patients had a cryptoglandular perianal fistula and 76 (20.9%) had fistulizing Crohn's disease. All patients underwent three-dimensional anal endosonography for perianal fistula. The reading was carried out by two observers. RESULTS: Observer 1, who was an experienced sonographer and colorectal surgeon, observed the ultrasound sign in 120 patients (33.1%), while observer 2, who was inexperienced, observed it in 129 patients (35.5%). The overall interobserver agreement was 67.22%. The Kappa coefficient measuring interobserver agreement was 0.273 (0.17-0.38). Among those patients with Crohn's disease, 48.68% had the sign and 16% did not (p = 0.001). A logistic regression study showed that the sign was a predictor of Crohn's disease (p = 0.001), with an odds ratio of 2.33 (1.39-3.91). Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 38.68%, 71.08%, 30.83%, 83.95% and 66.39%, respectively. CONCLUSION: This study provides a new ultrasound sign for perianal fistula (the rosary sign) in patients with Crohn's disease. The sign can be used to differentiate Crohn's disease from other types of fistula. This is useful in the management of patients with anal fistula.

Three-dimensional pelvic ultrasound is a practical tool for the assessment of anal fistula.

OBJECTIVE: This study aims to investigate the diagnostic value of three-dimensional pelvic ultrasound in the preoperative assessment of anal fistula compared with findings of MRI and surgery. METHODS: A total of 67 patients (62 males) with suspected anal fistula were analyzed retrospectively. Preoperative three-dimensional pelvic ultrasound and magnetic resonance imaging were performed in all patients. The number of internal openings and the type of fistula were recorded. The accuracy of three-dimensional pelvic ultrasound was determined by comparing these parameters with surgical outcomes. RESULTS: At surgery, 5 (6%) were extrasphincteric, 10 (12%) were suprasphincteric, 11 (14%) were intersphincteric, and 55 (68%) were transsphincteric. There was no significant difference in the accuracy of pelvic 3D US and MRI, based on internal openings (97.92%, 94.79%), anal fistulas (97.01%, 94.03%), and those under Parks classification (97.53%, 93.83%). CONCLUSION: Three-dimensional pelvic ultrasound is a reproducible and accurate method for determining the type of fistula and detecting internal openings and anal fistulas.

Comparison of MRI and Endoanal Ultrasound in Assessing Intersphincteric, Transsphincteric, and Suprasphincteric Perianal Fistula.

OBJECTIVES: Perianal fistula is a common disorder characterized by an anomalous perianal track connecting two epithelialized surfaces, most commonly the anal canal and the perianal skin. Although each has its limitations, magnetic resonance imaging (MRI) and endoanal ultrasound are currently two acceptable modalities for assessing perianal fistula. This study aimed to evaluate the accuracy of MRI and endoanal ultrasonography in diagosing perianal fistula, considering the surgical results as the references. METHODS: This prospective cohort study was performed on patients with symptomatic perianal fistulas. MRI results of patients reported by the radiologist were collected along with the findings of endoanal ultrasonography performed by a gastroenterologist. These results were compared with surgical findings as the reference standard. RESULTS: The study enrolled 126 patients. Exactly 222 definitive fistulas were identified during surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound for perianal fistula were 87.38, 38.46, 92.38, 26.31, and 82.25% respectively; and for MRI were 76.12, 57.69, 93.88, 22.05, and 74.19% respectively. The accuracy of endoanal ultrasound for detecting transsphincteric and intersphincteric fistulas was higher than MRI. In contrast, the diagnostic value of MRI for detecting suprasphincteric fistulas was higher than endoanal ultrasound. CONCLUSIONS: Using endoanal ultrasonography to diagnose perianal fistulas is a relatively accurate method. This method may be more sensitive than MRI in detecting patients with perianal fistulas and abscesses.

The Functional Luminal Imaging Probe (FLIP): A Good Tool for Adjustment of anal Canal Dimensions During Operative Management of Fecal Incontinence.

PURPOSE: Fecal incontinence is a troublesome problem in the field of colorectal surgery. The main aim of this study was to adjust the anal canal resistance during operative management of anal incontinence using Endo-FLIP. METHODS: This was a prospective cohort study held at Cairo university hospital. Hundred forty-eight incontinent patients treated by different surgical procedures were included. During the procedure the Endo-FLIP was applied to adjust the anal canal dimensions (ACL and ACD) so the ACR could be adjusted based on the flow equation. These were also assessed pre-operatively with Endo-FLIP system and the flow equation calculator. The clinical severity of the disease and outcome after surgical procedures were assessed and correlated to the physiologic parameters. RESULTS: ACL, ACD and ACR had had significant correlations to the degree of incontinence (P < .001). ACL, ACD and ACR showed statistically significant change with primary repair and gluteus maximus transposition operations. After treatment of fecal incontinence, in good responders' group, the mean resting anal canal resistance increased significantly to 4649.05 ± 1161.49 (postoperative) while in poor responders' group it was 1919.9 ± 1077.73. CONCLUSIONS: The Endo-flip can be used to measure the anal canal geometric parameters (ACL and ACD) and then anal canal resistance could be calculated by the flow equation - pre-and post-operatively- which help the adjustment of the surgical repair of sphincter injury in fecal incontinence patients which may improve the surgical outcome.

The Importance of Screening for Additional Anomalies in Patients with Anorectal Malformations: A Retrospective Cohort Study.

BACKGROUND: In children with anorectal malformations (ARM), additional anomalies can occur within the VACTERL-association. Routine screening is of great importance for early identification and potential treatment. However, uniformity in screening protocols is lacking and only small cohorts have been described in literature. The aim of this study was to assess and describe a unique large cohort of ARM patients who underwent VACTERL screening in the neonatal period. METHODS: A retrospective mono-center cohort study was performed. Included were all neonates born between January 2000 and December 2020 who were diagnosed with ARM and screened for additional anomalies. Full screening consisted of x-ray and ultrasound of the spine, cardiac and renal ultrasound, and physical examination for limb deformities, esophageal atresia, and ARM. Criteria for VACTERL-classification were predefined according to the EUROCAT-definitions. RESULTS: In total, 216 patients were included, of whom 167 (77.3%) underwent full VACTERL-screening (66% in 2000-2006 vs. 82% in 2007-2013 vs. 86% in 2014-2020). Median age at follow-up was 7.0 years (IQR 3.0-12.8). In 103/167 patients (61.7%), additional anomalies were identified. Some 35/216 patients (16.2%) fulfilled the criteria of a form of VACTERL-association. In 37/216 patients (17.1%), a genetic cause or syndrome was found. CONCLUSIONS: The majority of ARM patients underwent full screening to detect additional anomalies (77%), which improved over time to 86%. Yet, approximately a quarter of patients was not screened, with the potential of missing important additional anomalies that might have severe consequences in the future. Forms of VACTERL-association or genetic causes were found in 16% and 17% respectively. This study emphasizes the importance of routine screening. LEVEL OF EVIDENCE: III.

Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer.

INTRODUCTION: Distance from anal verge of rectal tumours and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumours and if the pelvic MRI can substitute the classical instrumental methods. METHODS: Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. RESULTS: 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC = 103.5 mm, was significantly greater than others, which had similar values: pRR = 81.1; MRI = 77.4; iRR = 82.9 mm (P < .001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. CONCLUSIONS: There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumours of any location in the rectum.

Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process.

PURPOSE: The aim of this study was to examine whether OASIS, and its extent, can be confirmed or excluded using transperineal ultrasound (TPUS). A further objective of this study was to monitor the healing process over a period of 6 months and to establish a connection between the sonographic appearance of obstetric anal sphincter injury (OASIS) and anal incontinence. MATERIALS AND METHODS: In this retrospective clinical study, women with OASIS who gave birth between March 2014 and August 2019 were enrolled. All the patients underwent TPUS 3 days and 6 months after delivery. A GE E8 Voluson ultrasound system with a 3.5-5 MHz ultrasound probe was used. The ultrasound images showed a third-degree injury, with the measurement of the width of the tear and its extent (superficial, partial, complete, EAS and IAS involvement). A positive contraction effect, a sign of sufficient contraction, was documented. Six months after delivery, a sonographic assessment of the healing (healed, scar or still fully present) was performed. A Wexner score was obtained from each patient. The patients' medical histories, including age, parity, episiotomy and child's weight, were added. RESULTS: Thirty-one of the 55 recruited patients were included in the statistical evaluation. Three patients were excluded from the statistical evaluation because OASIS was excluded on TPUS 3 days after delivery. One patient underwent revision surgery for anal incontinence and an inadequately repaired anal sphincter injury, as shown sonographic assessment, 9 days after delivery. Twenty patients were excluded for other reasons. The results suggest that a tear that appears smaller (in mm) after 3 days implies better healing after 6 months. This effect was statistically significant, with a significance level of alpha = 5% (p = 0.0328). Regarding anal incontinence, women who received an episiotomy had fewer anal incontinence symptoms after 6 months. The effect of episiotomy was statistically significant, with a significance level of alpha = 5% (p = 0.0367). CONCLUSION: TPUS is an accessible, non-invasive method for detecting, quantifying, following-up and monitoring OASIS in patients with third-degree perineal tears. The width, as obtained by sonography, is important with regard to the healing of OASIS. A mediolateral episiotomy seems to prevent anal incontinence after 6 months.

Evaluation of Nursing Effects of Pelvic Floor Muscle Rehabilitation Exercise on Gastrointestinal Tract Rectal Cancer Patients Receiving Anus-preserving Operation by Intelligent Algorithm-based Magnetic Resonance Imaging.

Based on magnetic resonance imaging (MRI) technology under artificial intelligence algorithm, the postoperative nursing effects of pelvic floor muscle rehabilitation exercise on gastrointestinal tract rectal cancer (RC) patients were investigated. A total of 88 patients receiving RC anus-preserving surgery in hospital were selected. The included patients were divided randomly into the experimental group (44 cases) and the control group (44 cases). Patients in the control group engaged in Kegel motion, while patients in the experimental group underwent self-designed comprehensive pelvic floor training. Anorectum function rating scale and quality of life questionnaire for colorectal cancer (EORTC QLQ-CR29) were utilized to compare and analyze anus functions and living quality of patients in the two groups. Besides, all patients in two groups received MRI examinations, and images were processed by a convolutional neural network (CNN) algorithm. The results showed that in MRI images, there were significant signal differences between lesion tissues and normal tissues. After being processed by an artificial intelligence algorithm, the definition of MRI images was remarkably enhanced with clearer lesion edges. The quality of images was also significantly improved. Besides, the comparison of anus functions of patients in two groups showed that the differences demonstrated statistical meaning after the intervention (P < 0.05). In conclusion, artificial intelligence algorithm-based MRI and comprehensive pelvic floor muscle exercise showed significant application prospects and values in the recovery of patients' intestinal functions after RC anus-preserving surgery.

Fecobionics characterization of female patients with fecal incontinence.

Defecatory disorders including fecal incontinence (FI) are diagnosed on the symptom pattern supplemented by anorectal manometry (ARM), the balloon expulsion test (BET), and endo-anal ultrasonography. In this study, we used a simulated stool named Fecobionics to study distinct defecation patterns in FI patients using preload-afterload diagrams and to provide comparative data on defecation indices (DIs) between passive and urge incontinent patients. All subjects had Fecobionics, endo-anal ultrasonography and ARM-BET done. The Fecobionics bag was distended in rectum until urge in 37 female patients (64.1 ± 1.5 yrs) and a group of normal subjects (NS, 12F, age 64.8 ± 2.8 yrs). Rear-front pressure (preload-afterload) diagrams and DIs were compared between groups. The FISI score in the patients was 8.6 ± 0.6. The NS did not report FI-related symptoms. All patients and NS defecated Fecobionics and ARM-BET within 2 min. The urge volume was 46.1 ± 3.6 and 35.3 ± 5.9 mL in the FI and normal groups (P > 0.1). The expulsion duration was 14.8 ± 2.4 and 19.8 ± 5.1 s for the two groups (P > 0.1). The preload-afterload diagrams demonstrated clockwise loops that clearly differed between the FI subtypes and NS. The DIs showed profound difference between patients and NS. Fecobionics data showed higher correlation with symptoms in FI patients than ARM-BET. Fecobionics obtained novel pressure signatures in subtypes of FI patients and NS. Fecobionics provides DI data that cannot be obtained with ARM-BET.

Impact of near-infrared fluorescence imaging with indocyanine green on structural sequelae of anastomotic leakage after laparoscopic intersphincteric resection of malignant rectal tumors.

BACKGROUND: Recent studies have indicated the potential benefit of intraoperative near-infrared fluorescence imaging (NIR-FI) with indocyanine green in reducing early anastomotic leakage in colorectal surgery. Nonetheless, whether NIR-FI is effective in reducing structural sequelae of anastomotic leakage (SSAL) remains unclear. The aim of the present study was to investigate the impact of NIR-FI on SSAL after laparoscopic intersphincteric resection (ISR) of malignant rectal tumors. METHODS: This study was a retrospective single-center cohort study. A total of 293 consecutive patients who underwent elective laparoscopic ISR from May 2010 to August 2017 were included. Patients were divided into 2 groups; those who underwent elective laparoscopic ISR with lymphadenectomy for malignant rectal tumors using NIR-F (NIR-FI group) and those who underwent elective laparoscopic ISR with lymphadenectomy for malignant rectal tumors without using NIR-FI (control group). Thirty were excluded from the analyses (13 died, 7 had pelvic recurrence, and 10 were lost to follow-up). The primary endpoint was the rate of SSAL within 2 years after the primary resection, whereas the secondary endpoint was the rate of natural defecation via the anus at 2 years after the primary resection. Using various statistical analyses, such as propensity score matching, the rate of SSAL was compared between groups. RESULTS: A total of 263 patients were analyzed [177 males and 86 females, median age 61 (27-84) years]. Prior to propensity score matching (n = 263), NIR-FI was performed in 70 patients (26.6%) The rates of SSAL were 1.4% (1/70) in the NIR-FI group and 10.4% (20/193) in the control group (p = 0.02). After propensity score matching (n = 163), the rates of SSAL were 1.5% (1/66) in the NIR-FI group and 11.7% (12/103) in the control group (p = 0.02). Propensity score analyses, as well as simple regression analyses, revealed that NIR-FI was associated with a significantly lower risk of SSAL (OR 0.10-0.13; p = 0.03-0.05). CONCLUSIONS: NIR-FI is useful in reducing the rate of SSAL after laparoscopic ISR.