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Background Treatment of complex anal fistula (CAF) can be associated with high rates of recurrence and fecal incontinence (FI). Park suggested drainage of the affected intersphincteric anal gland for treatment of cryptoglandular anal fistula; however, recurrence after this technique was high. We modified the original Park's technique by extending the internal sphincterotomy to ensure adequate drainage of the intersphincteric space. The aim of this study was to evaluate the incidence of recurrence and FI after modified Park's technique in treatment of CAF. Methods Adult patients of both genders with CAF were evaluated before undergoing modified Park's technique with Wexner continence score, clinical examination, and endoanal ultrasonography or MRI. Postoperatively, patients were examined every 2 wk until complete wound healing. The continence state was evaluated with Wexner continence score, and quality of life was assessed before surgery and at 6 mo postoperatively by Short Form–36 questionnaire. Results Thirty-two patients (27 male) of a mean age of 38 y were included. Median follow-up was 12 mo. Two patients (6.25%) experienced recurrence and 5 (15.6%) developed complications. One patient (3.1%) developed new-onset FI postoperatively. Twenty-eight (87.5%) patients were completely satisfied with the procedure. Quality of life showed significant improvement at 6 mo postoperatively. Conclusions The modified Park's technique is a promising procedure for the treatment of CAF with low recurrence and FI rates, and improved quality of life.

The Ligation of Intersphincteric Fistula Tract (LIFT) procedure is a recent sphincter-preserving procedure added to the surgical armamentarium of managing anal fistulas. It has gained popularity for its simple, easy-to-learn technique and success rate reliably exceeding 70%. Studies using validated continence scores have verified its advantage in preserving continence. The procedure is aimed at the cryptoglandular source of infection within the intersphincteric space. This is achieved through a small incision parallel to the intersphincteric groove and corresponding to the internal opening. After excision of the intersphincteric portion of the fistula tract, the openings on the internal and external sphincter are suture-ligated. Wound care is simple with minimal post-operative pain. Pre-operative imaging with endoanal ultrasonography helps to position the incision. Most failures or recurrences occur in the intersphincteric wound. This can be treated successfully with simple fistulotomy. The use of a seton before a LIFT procedure has not been proven beneficial. This technique has also been applied to Crohn׳s disease-related fistulas with similar success. Modifications to the technique using bioprosthetic inserts have also been reported to confer better results albeit at a greater cost.

The aim of this study was to assess the postoperative anorectal anatomy and function in children with congenital anorectal malformations (ARM) using endoanal ultrasonography (EUS) and anorectal manometry.This study included 47 children who had undergone posterior sagittal anorectoplasty (PSARP) or transperineal anorectoplasty for the repair of an ARM. Children were grouped according to symptoms of defecation disorder, including normal defecation, fecal soiling, fecal incontinence, and constipation. Ten children with no history of anal or rectal diseases served as healthy controls. A well-established scoring system was used for the evaluation of anal function and defecation disorder.EUS showed significant differences in the thickness of the interior sphincter between the ARM patients and the healthy controls (P0.05). However, no significant difference was found in the thickness of the interior sphincters between the PSARP group and transperineal anorectoplasty group (P0.05). Anorectal manometry showed that the balloon volumes were significantly different between the surgical group and the control group (P0.01), and between the low defect group and the intermediate-high defect group (P=0.022). Balloon volume was significantly correlated with anal function scores (r=-0.30, P0.05).EUS and anorectal manometry can provide objective assessment of postoperative anorectal anatomy and function in children with ARM.

The Ligation of Intersphincteric Fistula Tract (LIFT) procedure is a recent sphincter-preserving procedure added to the surgical armamentarium of managing anal fistulas. It has gained popularity for its simple, easy-to-learn technique and success rate reliably exceeding 70%. Studies using validated continence scores have verified its advantage in preserving continence. The procedure is aimed at the cryptoglandular source of infection within the intersphincteric space. This is achieved through a small incision parallel to the intersphincteric groove and corresponding to the internal opening. After excision of the intersphincteric portion of the fistula tract, the openings on the internal and external sphincter are suture-ligated. Wound care is simple with minimal post-operative pain. Pre-operative imaging with endoanal ultrasonography helps to position the incision. Most failures or recurrences occur in the intersphincteric wound. This can be treated successfully with simple fistulotomy. The use of a seton before a LIFT procedure has not been proven beneficial. This technique has also been applied to Crohn׳s disease-related fistulas with similar success. Modifications to the technique using bioprosthetic inserts have also been reported to confer better results albeit at a greater cost.

Three-dimensional endoanal ultrasonography (3D-EAUS) provides unequalled quality in terms of the anatomical image of the anal canal and sphincter complex. In less than one minute it produces a three-dimensional "cube" that can be manipulated in all spatial dimensions, then archived. In just a few years it has become a new gold standard exploration in proctology. In addition to image quality, 3D-EAUS has the advantage of being easily and rapidly performed, well-tolerated and moderate in cost. For anal incontinence, 3D-EAUS contributes to the identification of sphincter defects. The anatomy of the sphincters can be evaluated spatially. Simple scoring systems with good reproducibility and readily applicable in routine practice can be used to evaluate the "damaged" sphincter volume. For the management of anoperineal suppurations, 3D-EAUS provides information on the fistulous track(s) and on potential collections. These data are crucial as the choice of treatment and its efficacy depend on accurate topographic assessment of the suppuration and the state of the sphincter apparatus.

Ultrasonography, including 2D, 3D, and 4D and endovaginal, endoanal, and translabial techniques, is relatively easy to perform, cost-effective, and a widely available technique for pelvic floor imaging. In this article, the methodology of the different sonographic modalities and their role in decision making in treating patients with outlet obstruction and pelvic floor disorders of the posterior compartment are presented and critically discussed.

Fecal and urinary incontinence are frequently associated, together with pelvic organ prolapse. The most important risk factors for pelvic floor disorders are vaginal delivery and chronic constipation. Irrespective of the symptom prompting the patient to seek medical attention and the specialist consulted, symptoms in other compartments must be investigated because patients rarely report them spontaneously. Patients with pelvic floor disorders should be evaluated by a multidisciplinary group of specialists. Complete evaluation includes urodynamics, anal manometry, endoanal ultrasonography and neurophysiologic study of the pelvic floor and is recommended in most patients, given that pelvic floor disorders have a complex and multifactorial pathophysiology and that all anatomic and functional abnormalities must be detected to provide the most appropriate treatment. Conservative treatment resolves or improves the problem in a large proportion of patients with mild-to-moderate symptoms. Surgery should be indicated in selected patients with careful evaluation to identify preoperatively all anatomical and functional defects that can be surgically corrected. The identification of risk factors and better knowledge of the prevalence and pathophysiology of this health problem will allow preventive strategies to be established and improve therapeutic outcomes.

Objective The purpose of this study was to determine the rate of new bowel symptoms and anal sphincter defects in primiparous women with and without recognized anal sphincter (AS) injury. Study design One hundred seventeen primiparous women classified with increasing degrees of perineal trauma and 21 controls delivered by cesarean section were enrolled immediately postpartum and demographic and delivery data were collected. At 6 weeks' postpartum, subjects completed a bowel function questionnaire and endoanal ultrasonography was performed. Logistic regression, chi-square, and 2-sample t tests were used for statistical analysis. Results A significant difference in new bowel symptoms was reported in women with (39%) and without (11%) recognized AS injury (P = .002). AS defects were present in 0%, 15%, 23%, 37%, and 67% of women with C/S, first-, second-, third-, and fourth-degree lacerations, respectively. Combined defects of the internal and external AS were associated with the greatest risk of new bowel symptoms (OR 32.1 [95% CI 9.6-107], P Conclusion In women with and without recognized AS trauma, new bowel symptoms were strongly correlated with the presence of anatomic AS defects postpartum.

Resumen Introduccion El aumento de la presion en reposo es uno de los factores implicados en la patogenia de la fisura anal cronica. Se desconoce, sin embargo, si esta anormalidad en la funcion del esfinter anal interno (EAI) se corresponde con alteraciones en su morfologia. Los objetivos son determinar el grosor del EAI en pacientes con fisura anal cronica e investigar la correlacion entre el grosor del EAI y la presion en reposo. Pacientes y metodo Estudio observacional prospective (noviembre de 1999-diciembre de 2002). Se incluyo a pacientes con fisura anal cronica y se excluyo a los que tenian antecedentes de enfermedad inflamatoria, cirugia anal y tratamiento previo con nitroglicerina topica o toxina botulinica. Se practicaron una ecografia endoanal y una manometria. Se considero que el grosor del EAI estaba aumentado cuando era > 2,5 mm en pacientes 3 mm en pacientes ≥ 50 anos. Se considero que la presion en reposo estaba aumentada cuando superaba los 80 mmHg. Resultados Se analizo a 63 pacientes. El EAI estaba aumentado de grosor en 58 (92%) pacientes. El grosor medio del EAI fue de 3,7 ± 0,7 mm. La presion en reposo estaba aumentada en 47 (66%) pacientes. La presion en reposo media fue de 91 ± 28 mmHg. No encontramos ninguna correlacion positiva entre el grosor del EAI y la presion en reposo (r = 0,05; p Conclusiones La mayoria de los pacientes con fisura anal presenta una hipertrofia del EAI. El aumento del grosor del EAI no se correlaciona con un aumento de la presion en reposo.

To understand and adequately manage retrorectal space infections, the surgeon must have an in-depth knowledge of the anorectal and perianal anatomy. Furthermore, because of the oligosymptomatic clinical presentation of supralevator and deep postanal space abscess, complementary tests such as endoanal ultrasonography may be required as part of the preoperative armamentarium. A misdiagnosed or inadequately treated retrorectal space abscess may lead to devastating perineal sepsis, often requiring multiple reoperations. Moreover, iatrogenic injury to the sphincter muscle will culminate in anal incontinence. Surgical drainage is imperative to successfully manage retrorectal space infections. The identification of the fistula tract and internal opening must be preoperatively attempted to minimize postoperative complications. This overview will address the presentation, diagnose, and management of retrorectal space infections.

The purpose of this paper is to describe the current modalities of pelvic floor imaging: pelvic floor and endoanal ultrasonography, cystourethrography, evacuation proctography, dynamic colpocystoproctography, magnetic resonance imaging and endoanal magnetic resonance imaging. As there are no set standards for prescribing imaging tests in pelvic floor disorders, we drew up a table of tests to be performed according to the anatomical abnormality observed on physical examination or functional sign reported by the patient.