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The Role of Endoluminal Imaging in Clinical Outcome of Overlapping Anterior Anal Sphincter Repair in Patients with Fecal Incontinence

Annette C. Dobben1, Maaike P. Terra1, Marije Deutekom2, J. Frederik M. Slors3, Lucas W. M. Janssen4, Patrick M. M. Bossuyt2 and Jaap Stoker1

1 Department of Radiology, Academic Medical Center, G1-228, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
2 Department of Clinical Epidemiology & Biostatistics, Academic Medical Center, Amsterdam, The Netherlands.
3 Department of Colorectal Surgery, Academic Medical Center, Amsterdam, The Netherlands.
4 Department of Colorectal Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.


Figure 1
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  		Fig. 1 —Ladder graph presents individual changes in Vaizey incontinence score [22] before and after surgery for 30 patients in study group; mean change is decrease of 5 points. Each patient is represented by different symbol.

 

Figure 2
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  		Fig. 2A —Normal anatomy at mid anal canal of internal anal sphincter (IS) and external anal sphincter (ES). Transverse endoanal sonogram of 65-year-old man shows normal anatomy at mid anal canal of internal anal sphincter and external anal sphincter. Top of figure is anterior. Example of one sphincter measurement performed for our study is shown by area between arrowheads, which shows external anal sphincter thickness measurement.

 

Figure 3
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  		Fig. 2B —Normal anatomy at mid anal canal of internal anal sphincter (IS) and external anal sphincter (ES). Transverse endoanal T2-weighted fast spin-echo MR image (TR/TE, 2,500/70) of 78-year-old man shows normal anatomy at mid anal canal of internal anal sphincter and external anal sphincter. Top of figure is anterior. Example of one of sphincter measurements performed is given by area between arrowheads, which shows external anal sphincter thickness measurement.

 

Figure 4
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  		Fig. 3A —69-year-old woman with complicated vaginal delivery and history of hysterectomy. Transverse endoanal sonogram (A) and transverse endoanal T2-weighted fast spin-echo MR image (B) (TR/TE, 2,500/70) at mid anal canal show residual defect from 11- to 13-o'clock positions (arrowheads). Top of both images is anterior. IS = internal anal sphincter, ES = external anal sphincter.

 

Figure 5
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  		Fig. 3B —69-year-old woman with complicated vaginal delivery and history of hysterectomy. Transverse endoanal sonogram (A) and transverse endoanal T2-weighted fast spin-echo MR image (B) (TR/TE, 2,500/70) at mid anal canal show residual defect from 11- to 13-o'clock positions (arrowheads). Top of both images is anterior. IS = internal anal sphincter, ES = external anal sphincter.

 

Figure 6
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  		Fig. 4A —53-year-old woman after complicated vaginal delivery (rupture). Transverse endoanal sonogram (A) and transverse endoanal T2-weighted fast spin-echo MR image (B) (TR/TE, 2,500/70) at mid distal anal canal show sphincter overlap (thin arrows) of both external anal sphincter ends, left over right, after anterior anal sphincter repair and continuity of sphincter ring has been restored. Although appearances at endoluminal imaging show overlap, surgery failed for this patient because patient was still fecal incontinent. Top of both images is anterior. LIS = lower edge of internal anal sphincter, ES = external anal sphincter.

 

Figure 7
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  		Fig. 4B —53-year-old woman after complicated vaginal delivery (rupture). Transverse endoanal sonogram (A) and transverse endoanal T2-weighted fast spin-echo MR image (B) (TR/TE, 2,500/70) at mid distal anal canal show sphincter overlap (thin arrows) of both external anal sphincter ends, left over right, after anterior anal sphincter repair and continuity of sphincter ring has been restored. Although appearances at endoluminal imaging show overlap, surgery failed for this patient because patient was still fecal incontinent. Top of both images is anterior. LIS = lower edge of internal anal sphincter, ES = external anal sphincter.

 

Figure 8
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  		Fig. 5 —Graph shows correlation between external anal sphincter thickness at baseline and outcome of surgery determined by Vaizey incontinence score [22]. Line shows trend. EAS = external anal sphincter.

 

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