MR-FLIP: A new method that combines FLIP with anatomical information for the spatial compliance assessment of the anal sphincter muscles.

INTRODUCTION Continence results from a complex interplay between anal canal (AC) muscles and sensory-motor feedback mechanisms. The AC's passive ability to withstand opening pressure - its compliance - has recently been shown to correlate with continence. Functional lumen imaging probe (FLIP) is used to assess AC compliance, although it provides no anatomical information. Therefore, compliance assessment of specific anatomical structures has not been possible, and the anatomical position of critical functional zones remains unknown. In addition, FLIP assumes a circular orifice cross-section, which has not been shown for the AC. To address those shortcomings, a technique combining FLIP with a medical imaging modality is needed. METHOD We implemented a new research method (MR-FLIP) that combines FLIP with MR-imaging. Twenty healthy volunteers underwent MR-FLIP and conventional FLIP assessment. MR-FLIP was validated by comparison with FLIP results. Anatomical markers were identified, and the cross-sectional shape of the orifice was investigated. RESULTS MR-FLIP provides compliance measurements identical to those obtained by conventional FLIP. Anatomical analysis revealed that the least compliant AC zone was located at the proximal end of the external anal sphincter. The AC cross-sectional shape was found to deviate only slightly from circularity in healthy volunteers. CONCLUSION The proposed method was equivalent to classical FLIP. It establishes for the first time a direct mapping between local tissue compliance and anatomical structure, which is key for gaining novel insights into (in)continence. In addition, MR-FLIP provides a tool for better understanding conventional FLIP measurements in the AC by quantifying its limitations and assumptions. This article is protected by copyright. All rights reserved

A Rare Case of a Complex System of Fistulas in Crohn’s Disease

Fistulas in Crohn’s disease are a common problem in treatment of the disease. Especially perianal fistulas may cause a loss in patient’s quality of life. They are coincident with an unfavourable development of Crohn’s disease. Because of the frequent young patient's age, they come along with a long life of suffering and high cost for treatment. Therefore a good clinical diagnostic and a balance between drug therapy and surgery is needed. In this report, we present the case of a 28-year old male patient with a complex system of fistula in Crohn’s disease. Based on clinical and radiological findings we performed operative treatment in combination to immunosuppressive therapy as an interdisciplinary collaboratio

Anatomy and mechanical properties of the anal sphincter muscles in healthy senior volunteers.

BACKGROUND A large proportion of age-related fecal incontinence is attributed to weakness or degeneration of the muscles composing the anal continence organ. However, the individual role of these muscles and their functional interplay remain poorly understood. METHODS This study employs a novel technique based on the combination of MR imaging and FLIP measurements (MR-FLIP) to obtain anatomical and mechanical information simultaneously. Unlike previous methods used to assess the mechanics of the continence organ, MR-FLIP allows inter-individual comparisons and statistical analysis of the sphincter morpho-mechanical parameters. The anatomy as well as voluntary and involuntary mechanical properties of the anal continence organ were characterized in 20 healthy senior volunteers. RESULTS Results showed that the external anal sphincter (EAS) forms a funnel-like shape with wall thickness increasing by a factor of 2.5 from distal (6 ± 0 mm) to proximal (15 ± 3 mm). Both voluntary and involuntary mechanical properties in this region correlate strongly with the thickness of the muscle. The positions of least compliance and maximal orifice closing were both located toward the proximal EAS end. In addition, maximal contraction during squeeze maneuvers was reached after 2 s, but high muscle fatigue was measured during a 7 s holding phase, corresponding to about 60% loss of the energy produced by the muscles during the contraction phase. CONCLUSIONS This work reports baseline parameters describing the morpho-mechanical condition of the sphincter muscle of healthy elderly volunteers. New parameters were also proposed to quantify the active properties of the muscles based on the mechanical energy associated with muscle contraction and fatigue. This information could be used to assess patients suffering from AI or for the design of novel implants

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines