Endosonography of the anal canal: findings in children

Role of Autologous Fat Grafting in the Conservative Treatment of Fecal Incontinence in Children

Treatment of organic fecal incontinence in children, typical of anorectal malformations, is most often conservative; however, when necessary, it can be surgical. Autologous fat grafting, or lipofilling, can be used to improve fecal incontinence. We present our experience with the echo-assisted anal-lipofilling and its effects on fecal incontinence in children and on the quality of life of the entire family. Under general anesthesia, fat tissue was harvested according to the traditional technique, and processed in a closed system Lipogems^® set. Injection of the processed adipose tissue was guided by trans-anal ultrasound assistance. Ultrasound and manometry were also used for follow-up. From November 2018, we performed 12 anal-lipofilling procedures in six male patients (mean age 10.7 years). Five children had a stable improvement in bowel function with Krickenbeck's scale scores going from soiling grade 3 pre-treatment in 100% of children to grade 1 post-treatment in 75% of them. No major post-operative complications developed. An increase in thickness of the sphincteric apparatus was shown at ultrasound during follow-up. The quality of life of the entire family, evaluated with a questionnaire, improved after the surgical treatment of the children. Anal-lipofilling is a safe and effective procedure to reduce organic fecal incontinence thereby benefiting both the patients and their families.

Can transcutaneous perianal ultrasonography be the first-line diagnostic instrument for evaluating pediatric perianal fistulas?

BACKGROUND

Pediatric perianal fistula is a common disorder. It is more difficult to detect the fistula tract and internal opening (IO) in children than in adults. This study aimed to evaluate the clinical diagnostic value of transcutaneous perianal ultrasound for children with perianal fistula.

METHODS

A retrospective review was conducted by analysing the preoperative transcutaneous perianal ultrasound and intraoperative exploration results of 203 consecutive patients who were <3 years old and diagnosed with perianal fistula. Analyses were conducted to evaluate the accuracy and consistency of utilizing the transcutaneous perianal ultrasound in the diagnosis of the complexity and location of the IO of perianal fistulas.

RESULTS

Compared with intraoperative exploration, the preoperative transcutaneous perianal ultrasonography has almost perfect agreement (Kappa = 0.881, P < 0.001) in the diagnosis of fistula tract complexity and IO with a sensitivity of 92% and a specificity of 97%. In addition, both intraoperative exploration and transcutaneous perianal ultrasound diagnosis showed high consistency in the identification of the IO of perianal fistulas (Quadrant I Kappa = 0.831, Quadrant II Kappa = 0.773, Quadrant III Kappa = 0.735, Quadrant IV Kappa = 0.802, all P < 0.01). The IOs were mainly distributed in Quadrants IV and II in both simple and complex fistulas.

CONCLUSIONS

Transcutaneous perianal ultrasound, as a non-invasive and simple imaging technique, showed high accuracy in the diagnosis and identification of the fistula classification and IO location. It could be considered a first-line diagnostic instrument for evaluating perianal fistulas among children.

Values From Three-dimensional High-resolution Anorectal Manometry Analysis of Children Without Lower Gastrointestinal Symptoms

BACKGROUND & AIMS

Three-dimensional high-resolution anorectal manometry (3DHRAM) provides a topographic image of pressure along the anal canal. We aimed to determine normal 3DHRAM values in children.

METHODS

We performed a prospective study of 61 children (34 male; mean age, 8.28 years) without any symptoms arising from the lower gastrointestinal tract who were evaluated at the Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland. Manometry procedures were performed by using a rigid probe without medication. Pressure within the anal canal and 3D images of sphincters were measured. If possible, squeeze pressure and thresholds of sensation were evaluated. The population was divided into age groups of <5 years, 5-8 years, 9-12 years, and older than 12 years.

RESULTS

The mean resting and squeeze sphincter pressures were 83 ± 23 mm Hg and 191 ± 64 mm Hg, respectively. The mean length of the anal canal was 2.62 ± 0.68 cm and correlated with age (r = 0.49, P < .0001). The mean rectal balloon volume to elicit rectoanal inhibitory reflex was 15.7 ± 10.9 cm(3). The first sensation, urge, and discomfort were observed at balloon volumes of 24.4 ± 23.98 cm(3), 45.9 ± 34.55 cm(3), and 91.6 ± 50.17 cm(3), respectively. The mean resting pressure of the puborectalis muscle was 69 ± 14 mm Hg, whereas the mean squeeze pressure was 124 ± 33 mm Hg. There was no statistically significant difference in pressure parameters between age groups. We observed a positive correlation between age and balloon volume needed to elicit discomfort (r = 0.49, P < .001).

CONCLUSIONS

In a prospective study, we determined normal values from 3DHRAM analysis of children without symptoms arising from the lower gastrointestinal tract. There were no significant differences in pressure results between children of different sexes or ages. ClinicalTrials.gov number: NCT02236507.

Three-dimensional endoanal ultrasound and anorectal manometry in children with anorectal malformations: new discoveries

BACKGROUND/PURPOSE

Fecal incontinence and constipation are common problems in follow-up of anorectal malformations (ARMs). We evaluated the anal sphincters using the 3-dimensional endoanal ultrasonography (3D-EAUS) and the anorectal manometry after ARMs repair.

METHODS

Seventeen patients, divided into 3 groups according to Wingspread classification, underwent anorectal manometry and 3D-EAUS. Clinical, manometric, and endosonographic scoring systems were used.

RESULTS

The average anal resting pressure (aARP) was significantly higher in low ARMs than in intermediate and high ARMs. The anal squeeze pressure was not statistically different between the 3 groups. Three-dimensional EAUS visualized internal anal sphincter (IAS) disruptions in 7 of 17 patients and absence of IAS in 6 of 17 children with high ARMs. Scars of the external anal sphincter were localized in low ARMs and generalized in the other groups. In the case of IAS disruption with aARP greater than 20 mm Hg, fecal incontinence and constipation improved with biofeedback and/or laxatives, whereas daily enemas were necessary in absence of IAS with aARP less than 20 mm Hg. Statistical correlation was observed between endosonographic and manometric findings and clinical outcomes.

CONCLUSIONS

Lesions of the anal sphincter are common in ARMs. Three-dimensional EAUS and anorectal manometry ensure a complete assessment of the anal sphincter and could provide useful information to define the most appropriate treatments to improve the quality of life.

Three-dimensional anal endosonography in depicting anal-canal anatomy

PURPOSE

This report describes the advantages of 3D anal endosonography in depicting the normal anatomy of the anal canal in relation to sex and age.

MATERIALS AND METHODS

A retrospective study was performed of 85 patients, 33 men and 52 women, previously examined with 3D anal ultrasound (US) for clinically suspected anorectal disease but found to be negative. The examinations were performed with a Bruel and Kjaer US system with a 2050 transducer, scanning from the anorectal junction to the subcutaneous portion of the external anal sphincter (EAS). The 3D reconstructions provided an estimation of sphincter length in the anterior and posterior planes, and axial 2D images enabled calculation of the thickness of the internal anal sphincter (IAS) and EAS in the anterior, posterior and lateral transverse planes.

RESULTS

Distribution of the sphincter complex is asymmetric in both sexes: the EAS and IAS are significantly shorter in females, especially in the anterior longitudinal plane (p=0.005 and p<0.001, respectively). EAS and IAS thickness increases with age, especially the lateral IAS (R(2)=0.37, p<0.001) and the posterior EAS (R(2)=0.29, p=0.01).

CONCLUSIONS

A good knowledge of anal-canal anatomy is essential to detect sphincter abnormalities when assessing pelvic floor dysfunction.

Endosonographic evaluation of anal sphincters in healthy children

PURPOSE

To describe the endosonographic anatomy of anal sphincters in healthy children and to evaluate the reproducibility of sphincter thickness measurements.

METHODS

Forty-five healthy children with median age of 3.6 years (range, 1.0-14.5 years) were studied while under general anesthesia for minor surgery. Anal endosonography was performed with a 7- to 10-MHz rotating transducer with a diameter of 19 mm. The internal anal sphincter (IAS) and the external anal sphincter (EAS) were assessed by 2 independent observers.

RESULTS

IAS and EAS were identified in all children. The mean thickness of IAS and EAS were 1.3 mm and 5.3 mm, respectively. Identification of the inner and outer border of IAS was difficult, especially in children younger than 3 years. The thickness of EAS was easier to assess, and the interrater reliability for EAS thickness measurements was excellent. EAS thickness was positively correlated with the children's age. Reflectivity varied within the EAS with frequent hyporeflective areas.

CONCLUSIONS

Anal endosonography provided visualization of the IAS and EAS in children. Assessment of exact IAS thickness was difficult, especially in the youngest children. Mean EAS thickness was 5.3 mm, increasing with age. Hyporeflective areas of the intact EAS should not be misinterpreted as sphincter defects.