Integrity of the anal sphincters after pouch-anal anastomosis: evaluation with three-dimensional endoanal ultrasonography.
OBJECTIVE
The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography.


METHODS
Patients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI).


RESULTS
Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores.


CONCLUSIONS
Handsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.
Gosselink
Martijn P
MP
Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
West
Rachel L
RL
Kuipers
Ernst J
EJ
Hansen
Bettina E
BE
Schouten
W Rudolph
WR
D011125:Adenomatous Polyposis Coli / Q000601:surgery*; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000000981:diagnostic imaging*; D000714:Anastomosis, Surgical / Q000379:methods*; D003093:Colitis, Ulcerative / Q000601:surgery*; D039021:Colonic Pouches; D019160:Endosonography; D005242:Fecal Incontinence / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008365:Manometry; D008875:Middle Aged; D016737:Proctocolectomy, Restorative; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D013536:Suture Techniques