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.
Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
Martijn P
MP
Gosselink
Rachel L
RL
West
Ernst J
EJ
Kuipers
Bettina E
BE
Hansen
W Rudolph
WR
Schouten
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