Effectiveness of a three-dimensional anorectal ultrasound in perianal Crohn's disease: incompatibility with clinical and surgical examinations.

PURPOSE: We have correlated the 3D anorectal ultrasound (3D ARU) findings with clinical examination and the surgical findings and examined its capacity to provide ancillary information, which potentially alters patient management. PATIENTS AND METHODS: This is a prospective analysis conducted at a tertiary academic hospital. A total of 95 patients were included. We screened for sphincter defects and the presence of perianal Crohn's disease (PACD)-related lesions. RESULTS: We performed 150 3D ARUs. Exploratory ultrasound coincided with the rationale for diagnosis in 67.7% of cases, and fistulae were detected in 79% of cases where there was clinical suspicion. Fistulae were associated with abscesses in 29 cases, and isolated abscesses were identified in 19 cases (17.7%), only 12 of which (63.2%) were clinically suspected. Sphincter defects were observed in 15 cases with 7 cases (77.8%) presenting with clinical fecal incontinence. The operative findings coincided with ultrasonographic findings in 81.3% of the analyzed cases. The inter-observer variability of endosonographic classification resulted in a kappa score of 0.86. Ultrasonographic data altered the therapeutic plan of management in 73 cases (48.6%). CONCLUSIONS: Three-dimensional ARU is accurate in the diagnosis of fistula type in PACD and in the delineation of ancillary suspected and unsuspected abscess collections. Its use impacts therapeutic management in about half the cases examined. A new ultrasonographic-based PACD classification system is presented which has high inter-observer agreement but which requires future prospective validation in clinical PACD patients.

Percutaneous neuromodulation of the posterior tibial nerve for the treatment of faecal incontinence - mid-term results: is retreatment required?

AIM: Posterior tibial nerve stimulation (PTNS) has emerged in recent years as a therapy for faecal incontinence. Its long-term effectiveness is yet to be established, along with what the form of retreatment should be in the event of loss of effectiveness. The present study aimed to establish the mid-term results to identify the proportion of patients who may need further treatment, and if so when. METHOD: A prospective study including 30 patients was conducted at an academic hospital. The patients underwent 12 weekly outpatient treatment sessions, each lasting 30 min (first PTNS phase). Neuromodulation was discontinued in those patients who did not have a 40% decrease in their pretreatment Wexner score. Patients having a better than 40% response were offered another 12-week course of complete treatment (second PTNS phase), following which they received no further PTNS treatment (phase without PTNS) but were assessed at 6 months and 2 years. RESULTS: All patients finished the first phase and 22/30 patients continued to the second phase. During this phase 11 patients showed an improved Wexner score (baseline/first phase/second phase: 14.3 ± 4.2 vs 9.9 ± 5.4 vs 6.8 ± 5.4). After a 6-month period without any treatment, the score was still improved in 11/30 patients (9.1 ± 6.2). At 2 years there was improvement in 16/30 patients (8.8 ± 7.1). There was a significant improvement in three variables of the quality of life questionnaire: lifestyle, coping behaviour and embarrassment. CONCLUSION: The response to first and second phase PTNS was maintained for up to 2 years. Retreatment was not required in about half of patients, even when they had finished the treatment 6 months or 2 years previously.

The rabbit as an animal model for proctology research: anatomical and histological description.

PURPOSE: This study was designed to describe the surgical anatomy and histology of the rabbit anorectum comparing it to that of humans, in order to decide whether it can be a good experimental model for research in proctology. MATERIAL AND METHODS: This study of the anorectal region was performed on six female New Zealand white rabbits, weighting between 2.5-2.9 kg. An autopsy was performed immediately after sacrificing the animal and an anatomical and histological description was performed. RESULTS: The mean rectum and anal canal lengths were of 7.2 cm and 0.9 cm, respectively. The macroscopic study showed that the musculature of the anal canal is formed by the coccygeus muscle, which serves as puborectalis in humans. It also defined an external anal sphincter with a deep and superficial portion. The histological evaluation showed similarity to that of humans, with mucosa of simple columnar type, muscularis mucosae, a small submucosa, with a muscular wall divided into internal and external layers, separated by the myenteric plexus. CONCLUSION: The great similarity to both the anatomy and the histology of humans, appropriate size and easy-handling and care, make the rabbit an attractive animal for the use as experimental and research model in proctology.