AnÃlise das caracterÃsicas anatÃmias relacionadas à fÃstula perianal utilizando ultrassom anorretal 3D

Surgery for anal fistula is often associated with continence disorders due to the transection of sphincter muscles. Extensive knowledge of anal canal anatomy and anal fistula can help prevent this outcome. Objective:Correlate the anatomical conformation of the anal canal, fistula track and the internal opening according to gender and hemicircumference (anterior vs. posterior) using 3-D ultrasonography. Methods:165 patients with fistula were evaluated with 3-D ultrasound and grouped according to gender, fistula type, internal opening and track position. Fistulae were transsphincteric in 128 and intersphincteric in 37 subjects. The study measured the external and internal anal sphincter, the puborectalis, the distance from the internal opening to the distal edge of the external and internal sphincter, the length of the internal and external sphincter compromised by the track and the percentage of compromised muscle. Results:Muscles were longer in males. The distance from the internal opening to the internal sphincter was greater for the posterior hemicircumference. The point where the fistulous track crossed the anterior external sphincter was similar for the two genders but the compromised muscle percentage was greater in females. The point where the fistulous track crossed the internal sphincter was similar for the two genders but the percentage of compromised internal sphincter was greater in males for the posterior hemicircumference. The study was limited by the absence of testing for interobserver and intraobserver agreement. Conclusion:The anal canal muscles are longer in males and the pectinate line is asymmetrical. In females, the percentage of compromised external sphincter was greater in the anterior hemicircumference due to the shorter external sphincter, while in males the percentage of compromised internal sphincter was greater in the posterior hemicircumferenceA cirurgia para fÃstula anal à muitas vezes associada a distÃrbios de continÃncia, devido à transecÃÃo do esfÃncter. Amplo conhecimento da anatomia do canal anal e fÃstula anal podem ajudar a evitar esse resultado. O objetivo deste estudo foi correlacionar a conformaÃÃo anatÃmica do canal anal, trajeto fistuloso e o orifÃcio interno de acordo com sexo e hemicircumferÃncia (anterior versus posterior), utilizando ultrassonografia 3D. MÃtodo: 165 pacientes com fÃstula foram avaliados com ultra-som 3-D e agrupados de acordo com gÃnero, tipo de fÃstula, orifÃcio interno e trajeto fistuloso. FÃstulas foram transesfinctÃricas em 128 e interesfinctÃrica em 37 pacientes. O estudo mediu o esfÃncter anal externo e interno, o puborretal, a distÃncia a partir do orifÃcio interno para a borda distal do esfÃncter externo e interno, o comprimento do esfÃncter interno e externo comprometido pelo trajeto e a percentagem de massa muscular comprometida. Resultados: mÃsculos no sexo masculino apresentaram-se mais longos. A distÃncia a partir do orifÃcio interno para o esfÃncter interno foi maior para a hemicircunferÃncia posterior. O ponto onde o trajeto fistuloso cruzou o esfÃncter externo anterior foi semelhante para os dois sexos, mas a porcentagem de mÃsculo comprometido foi maior no sexo feminino. O ponto onde o trajeto fistuloso cruzou o esfÃncter interno foi semelhante para os dois sexos, mas a porcentagem de esfÃncter interno comprometido foi maior no sexo masculino para a hemicircunferÃncia posterior. O estudo foi limitado pela ausÃncia de testes de inter e intra-observador. ConclusÃo: Os mÃsculos do canal anal sÃo mais longos em homens e a linha pectÃnea à assimÃtrica. Nas mulheres, a percentagem de esfÃncter externo comprometida foi maior na hemicircunferÃncia anterior devido ao esfÃncter externo mais curto, no sexo masculino, a percentagem de esfÃncter interno comprometido foi maior na hemicircunferÃncia posterio

Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome

CONTEXT: Management of patients with obstructed defecation syndrome is still controversial. OBJECTIVE: To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. METHODS: The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. RESULTS: Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. CONCLUSIONS: Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts