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International Urogynecology Journal Jul 2021The management of isolated rectal buttonhole tears is not standardised and can be challenging in an acute obstetric setting. Our aim was to review the published... (Review)
Review
INTRODUCTION AND HYPOTHESIS
The management of isolated rectal buttonhole tears is not standardised and can be challenging in an acute obstetric setting. Our aim was to review the published literature and describe management and repair techniques in a case series.
METHODS
A literature search was carried out. All results were screened and reviewed. Rectal buttonhole tears following vaginal delivery between April 2012 and January 2020 in our institution were identified. Repair technique and post-operative management were recorded.
RESULTS
There were nine published case reports (four instrumental deliveries, two vaginal breech and three normal vaginal deliveries). Four case reports described a two-layer closure and five described a three-layer closure. Two cases were repaired in collaboration with colorectal surgeons. All nine cases made an uneventful recovery. We identified three patients with buttonhole tears all of whom had instrumental deliveries. A colorectal surgeon repaired the tear in two layers in one case, and an obstetrician performed the repair in the other two cases, one in three layers and the other in two layers. One patient had a de-functioning stoma at a later date due to a second breakdown of the recto-vaginal fistula repair.
CONCLUSION
Buttonhole tears are rare but techniques of repair vary. Most cases reviewed had an uneventful recovery after repair. We provide standardised steps for repair and management of isolated rectal buttonhole tears along with a video demonstrating the repair technique in an animal tissue (pig) model.
Topics: Anal Canal; Animals; Delivery, Obstetric; Female; Humans; Lacerations; Obstetric Labor Complications; Obstetrics; Pregnancy; Rectal Diseases; Swine
PubMed: 32930849
DOI: 10.1007/s00192-020-04502-2 -
Journal of Visceral Surgery Feb 2020
Topics: Anal Canal; Electric Stimulation Therapy; Electrodes, Implanted; Fecal Incontinence; Humans; Patient Selection; Sacrum; Sphincterotomy
PubMed: 31837943
DOI: 10.1016/j.jviscsurg.2019.12.005 -
World Journal of Gastroenterology Apr 2022Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas... (Review)
Review
Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas.
Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.
Topics: Anal Canal; Guidelines as Topic; Humans; Pelvic Floor; Prognosis; Rectal Fistula; Rectum
PubMed: 35581966
DOI: 10.3748/wjg.v28.i16.1608 -
International Urogynecology Journal Jun 2016The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.
DATA SOURCES
A review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.
METHODS OF STUDY SELECTION
Observational studies (cohort/case-control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.
TABULATION, INTEGRATION AND RESULTS
From the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42-4.01) or ventouse (OR 2.44, 95 % CI 1.83-3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24-2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06-2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1-1.35).
CONCLUSION
The overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.
Topics: Anal Canal; Anus Diseases; Delivery, Obstetric; Female; Humans; Pregnancy; Recurrence; Risk Factors
PubMed: 26676912
DOI: 10.1007/s00192-015-2893-4 -
Clinical Gastroenterology and... May 2019The neuropathophysiology of fecal incontinence (FI) is incompletely understood. We examined the efferent brain-anorectal and spino-anorectal motor-evoked potentials...
BACKGROUND & AIMS
The neuropathophysiology of fecal incontinence (FI) is incompletely understood. We examined the efferent brain-anorectal and spino-anorectal motor-evoked potentials (MEP) to characterize the locus of neuronal injury in patients with FI.
METHODS
We performed bilateral transcranial, translumbar, and transsacral magnetic stimulations in 27 patients with FI (19 female) and 31 healthy individuals (controls, 20 female) from 2015 through 2017. MEPs were recorded simultaneously from the rectum and anus using 4 ring electrodes. The difference in MEP latencies between the transcranial (TMS) and translumbar transsacral magnetic stimulations was calculated as cortico-spinal conduction time. MEP data were compared between patients with FI and controls. Patients filled out questionnaires that assessed the severity and effects of FI.
RESULTS
The MEP latencies with TMS were significantly longer in patients with FI than controls at most sites, and on both sides (P < .05). Almost all translumbar and transsacral MEP latencies were significantly prolonged in patients with FI vs controls (P < .01). The cortico-spinal conduction time were similar, on both sides, between patients with FI and controls. Ninety-three percent of patients had 1 or more abnormal translumbar and transsacral latencies, but neuropathy was patchy and variable, and not associated with sex or anal sphincter function or defects.
CONCLUSIONS
Patients with FI have significant neuropathy that affects the cortico-anorectal and spino-anorectal efferent pathways. The primary loci are the lumbo-rectal, lumbo-anal, sacro-rectal, and sacro-anal nerves; the cortico-spinal segment appears intact. Peripheral spino-anal and spino-rectal neuropathy might therefore contribute to the pathogenesis of FI.
Topics: Adult; Anal Canal; Cerebral Cortex; Evoked Potentials, Motor; Fecal Incontinence; Female; Follow-Up Studies; Humans; Magnetic Field Therapy; Male; Manometry; Middle Aged; Neural Conduction; Retrospective Studies; Sensory Thresholds; Treatment Outcome
PubMed: 30213585
DOI: 10.1016/j.cgh.2018.09.007 -
Expert Review of Gastroenterology &... Jun 2008Neurophysiological tests of anorectal function can provide useful information regarding the integrity of neuronal innervation, as well as neuromuscular function. This... (Review)
Review
Neurophysiological tests of anorectal function can provide useful information regarding the integrity of neuronal innervation, as well as neuromuscular function. This information can give insights regarding the pathophysiological mechanisms that lead to several disorders of anorectal function, particularly fecal incontinence, pelvic floor disorders and dyssynergic defecation. Currently, several tests are available for the neurophysiological evaluation of anorectal function. These tests are mostly performed on patients referred to tertiary care centers, either following negative evaluations or when there is lack of response to conventional therapy. Judicious use of these tests can reveal significant and new understanding of the underlying mechanism(s) that could pave the way for better management of these disorders. In addition, these techniques are complementary to other modalities of investigation, such as pelvic floor imaging. The most commonly performed neurophysiological tests, along with their indications and clinical utility are discussed. Several novel techniques are evolving that may reveal new information on brain-gut interactions.
Topics: Anal Canal; Diagnostic Techniques, Neurological; Electrodiagnosis; Humans; Manometry; Rectal Diseases; Rectum
PubMed: 19072383
DOI: 10.1586/17474124.2.3.323 -
American Journal of Veterinary Research Dec 2021To compare 3 anal purse-string suture techniques for resistance to leakage and to identify the suture technique requiring the fewest tissue bites to create a consistent...
OBJECTIVE
To compare 3 anal purse-string suture techniques for resistance to leakage and to identify the suture technique requiring the fewest tissue bites to create a consistent leak-proof orifice closure.
ANIMALS
18 large-breed canine cadavers.
PROCEDURES
3 purse-string suture techniques (3 bites with 0.5 cm between bites [technique A], 5 bites with 0.5 cm between bites [technique B], and 3 bites with 1.0 cm between bites [technique C]) were evaluated. Each technique involved 2-0 monofilament nylon suture that was placed in the cutaneous tissue around the anus and knotted with 6 square throws. Standardized 2.0-cm-diameter circular templates with the designated bite number and spacing indicated were used for suture placement. Leak-pressure testing was performed, and the pressure at which saline was first observed leaking from the anus was recorded. The median and interquartile (25th to 75th percentile) range (IQR) were compared among 3 techniques.
RESULTS
Median leak pressure for technique A (101 mm Hg; IQR, 35 to 131.3 mm Hg) was significantly greater than that for technique C (19 mm Hg; IQR, 14.3 to 25.3 mm Hg). Median pressure did not differ between techniques A and B (50 mm Hg; IQR, 32.5 to 65 mm Hg) or between techniques B and C.
CLINICAL RELEVANCE
Placement of an anal purse-string suture prevented leakage at physiologic colonic and rectal pressures, regardless of technique. Placement of 3 bites 0.5 cm apart (technique A) is recommended because it used the fewest number of bites and had the highest resistance to leakage.
Topics: Anal Canal; Animals; Dogs; Skin; Suture Techniques; Sutures
PubMed: 34941565
DOI: 10.2460/ajvr.21.03.0050 -
Developmental Biology Jan 2016The developmental process through which the cloaca transforms from one hollow structure to two separated urinary and digestive outlets remains controversial and...
The developmental process through which the cloaca transforms from one hollow structure to two separated urinary and digestive outlets remains controversial and speculative. Here, we use high-resolution episcopic microscopy to examine a comprehensive series of normal and mutant mouse cloaca in which the detailed 3-dimensional (3-D) morphological features are illuminated throughout the development. We provide evidence that the dorsal peri-cloacal mesenchyme (dPCM) remains stationary while other surrounding tissues grow towards it. This causes dramatic changes of spatial relationship among caudal structures and morphological transformation of the cloaca. The 3-D characterizations of Dkk1 mutants reveal a hyperplastic defect of dPCM, which leads to a significant anterior shift of the caudal boundary of the cloaca, premature occlusion of the cloaca and, imperforate anus phenotype. Conversely, Shh knockout causes a severe hypoplastic defect of cloaca mesenchyme including dPCM and persistent cloaca. Collectively, these findings suggest that formation of the dPCM is critical for cloacal morphogenesis and furthermore, growth and movement of the mesenchymal tissues towards the dPCM lead to the cloaca occlusion and separation of the urinary and digestive outlets.
Topics: Anal Canal; Animals; Anorectal Malformations; Anus, Imperforate; Cloaca; Imaging, Three-Dimensional; Mammals; Mesoderm; Mice, Inbred C57BL; Microscopy; Morphogenesis; Rectum; Urogenital Abnormalities
PubMed: 26485363
DOI: 10.1016/j.ydbio.2015.10.018 -
BMC Pediatrics Jan 2022The prenatal diagnosis of foetal imperforate anus is difficult. Most previous studies have been case reports. To provide useful information for diagnosing foetal...
BACKGROUND
The prenatal diagnosis of foetal imperforate anus is difficult. Most previous studies have been case reports. To provide useful information for diagnosing foetal imperforate anus, a retrospective review of diagnostic approaches was conducted. Ultrasonography was performed in 19 cases of foetal imperforate anus from 2016 to 2019 at our prenatal diagnostic centre. The prenatal sonographic features and outcomes of each case were collected and evaluated.
RESULT
The anal sphincter of a normal foetus shows the 'target sign' on cross-sectional observation. Of the 19 cases of imperforate anus, 16 cases were diagnosed by the ultrasound image feature called the 'line sign'. 1 case with tail degeneration was low type imperforate anus with the irregular 'target sign' not a real 'target sign'. There was two false-negative case, in which the 'target sign' was found, but irregular.
CONCLUSION
In this study, we find that the anus of a foetus with imperforate anus presents a 'line sign' on sonographic observation. The absence of the 'target sign' and then the presence of the 'line sign' can assist in the diagnosis of imperforate anus. The 'line sign' can be used as a secondary assessment to determine the type of the malformation following non visualization of the 'target sign'. The higher the position of the imperforate anus is, the more obvious the 'line sign'. It is worth noting that the finding of the short 'line sign' and irregularr 'target sign' can not ignore the low type imperforate anus.
Topics: Anal Canal; Anus, Imperforate; Cross-Sectional Studies; Female; Humans; Pregnancy; Ultrasonography; Ultrasonography, Prenatal
PubMed: 34980064
DOI: 10.1186/s12887-021-03084-2 -
Neurogastroenterology and Motility Mar 2011Brain-gut dysfunction has been implicated in gastrointestinal disorders but a comprehensive test of brain-gut axis is lacking. We developed and tested a novel method for...
BACKGROUND
Brain-gut dysfunction has been implicated in gastrointestinal disorders but a comprehensive test of brain-gut axis is lacking. We developed and tested a novel method for assessing both afferent anorectal-brain function using cortical evoked potentials (CEP), and efferent brain-anorectal function using motor evoked potentials (MEP).
METHODS
Cortical evoked potentials was assessed following electrical stimulations of anus and rectum with bipolar electrodes in 26 healthy subjects. Anorectal MEPs were recorded following transcranial magnetic stimulation (TMS) over paramedian motor cortices bilaterally. Anal and rectal latencies/amplitudes for CEP and MEP responses and thresholds for first sensation and pain (mA) were analyzed and compared. Reproducibility and interobserver agreement of responses were examined.
KEY RESULTS
Reproducible polyphasic rectal and anal CEPs were recorded in all subjects, without gender differences, and with negative correlation between BMI and CEP amplitude (r -0.66, P=0.001). Transcranial magnetic stimulation evoked triphasic rectal and anal MEPs, without gender differences. Reproducibility for CEP and MEP was excellent (CV <10%). The inter-rater CV for anal and rectal MEPs was excellent (ICC 97-99), although there was inter-subject variation.
CONCLUSIONS & INFERENCES
Combined CEP and MEP studies offer a simple, inexpensive and valid method of examining bidirectional brain-anorectal axes. This comprehensive method could provide mechanistic insights into lower gut disorders.
Topics: Adult; Anal Canal; Cerebral Cortex; Electric Stimulation; Evoked Potentials; Female; Gastrointestinal Diseases; Humans; Male; Middle Aged; Rectum; Reproducibility of Results; Sensory Thresholds; Transcranial Magnetic Stimulation; Young Adult
PubMed: 20964791
DOI: 10.1111/j.1365-2982.2010.01619.x