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Biomedical subjects

S Halligan

Publications and source records attributed to S Halligan.

At least 73 records · Page 4Linked to original sources
PubMed1999

Results of repeat anal sphincter repair.

BACKGROUND: Patients with a poor outcome from anterior sphincter repair may be candidates for dynamic graciloplasty, artificial bowel sphincter implantation or a secondary repair. This study examines the outcome of repeat overlap repairs in these patients. METHODS: Twenty-six of 235 patients undergoing a sphincter repair (median age 43 (range 23-63) years) underwent repeat repair from May 1994 to April 1997. Twenty-three patients were available for follow-up. Clinical evaluation included a satisfaction scale from 1 to 10, the patient's assessment of percentage improvement, ability to defer defaecation before and after operation, and Wexner continence scores before and after operation. Manometric studies were performed in 21 patients before and 17 patients after operation, and anal ultrasonography was undertaken in 17 patients before and 14 patients after operation. External sphincter defects were present on all preoperative scans. RESULTS: At a median follow-up of 20 (range 5-42) months, 15 patients felt that they were 50 per cent or more improved after operation. On the satisfaction scale of 1-10 the median score was 7 (range 1-10). There was a significant improvement in the Wexner continence score from 19 (range 17-20) before operation to 12 (range 1-20) after operation (P < 0.001). Ability to defer defaecation improved significantly from less than 5 min in all patients before operation to greater than 15 min in six patients after operation. Ultrasonography showed good overlap of the external sphincter muscle in eight of 14 patients. All patients who failed to improve showed a residual defect on ultrasonography. CONCLUSION: Repeat anterior repair produces a significant improvement in continence score and ability to defer defaecation in patients with obstetric sphincter damage. Clinical improvement correlates closely with an improvement in the appearance on endoanal ultrasonography.

Adult↗
PubMed1999

Intraobserver and interobserver agreement in anal endosonography.

BACKGROUND: The aim of this study was to determine intraobserver and interobserver agreement for sonographic measurements of anal canal structures using anal endosonography (AES), and to determine interobserver agreement for the diagnosis of anal sphincter disruption. METHODS: Fifty-one consecutive patients referred for AES for the investigation of possible sphincter abnormality were examined. Studies were reviewed by two observers who measured anal canal structures at defined levels and locations, and recorded an opinion on sphincter integrity. Repeated measurements made by each observer were compared to determine intraobserver agreement, and measurements and diagnoses were compared between observers to determine interobserver agreement. RESULTS: Intraobserver agreement was better than interobserver agreement for measurements of anal canal structures. Interobserver limits of agreement for external sphincter measurements spanned 5 mm, whereas those for the internal sphincter spanned 1.5 mm. Interobserver agreement for diagnosis of sphincter disruption and internal sphincter echogenicity was very good (kappa = 0.80 and 0.74 respectively). CONCLUSION: The limits of agreement for intraobserver and interobserver measurements of anal canal structures on AES have been defined. Interobserver assessment of sphincter disruption is very good.

Adult↗
PubMed1999

Three-dimensional endoanal sonography in assessing anal canal injury.

BACKGROUND: Instrument design limits endosonography of the anal canal to the axial plane, with no capability for longitudinal imaging or measurement. Using three-dimensional reconstructions, the relationship between the radial and linear extent of an anal sphincter tear has been explored, and sex differences in anal canal and sphincter length have been established. METHODS: Three-dimensional reconstructions were performed in 20 controls and 24 patients with faecal incontinence found to have 25 external and five internal sphincter defects. The radial and linear extent of any sphincter tear was measured. In controls the length of the sphincters was compared with the total anal canal length, and the maximum and mean internal sphincter thickness was compared. RESULTS: The radial angle of an internal or external sphincter defect was significantly related to its length (R2 = 96.8 per cent and R2 = 84.4 per cent respectively; both P < 0.001). The anal canal was longer in men than in women (mean(s.d.) 32.6(5.3) versus 25.1(3.4) mm; P < 0.001). The internal anal sphincter was also longer in men (25.6(6.3) versus 19.8(4.0) mm; P < 0.02), but the mean internal sphincter length as a percentage of total anal canal length did not differ (78.3 versus 78.7 per cent; P not significant). The anterior external anal sphincter was longer in men than in women (32.6(5.3) versus 15.3(2.8) mm; P < 0.001), and formed a greater percentage of total anal canal length (100 versus 62.9 per cent; P < 0.001). CONCLUSION: Multiplanar imaging has revealed a direct relationship between the length of a sphincter tear and its radial extent as shown on axial scanning. Marked sex differences in sphincter configuration have been demonstrated. In women the shorter anterior sphincter length highlights the risk of complete sphincter disruption with extensive tears.

Adult↗
PubMed1999

Changes in anal anatomy following vaginal delivery revealed by anal endosonography.

OBJECTIVE: To investigate changes in anal canal anatomy following vaginal delivery in women without apparent sphincter injury. DESIGN: Prospective controlled observational study. SETTING: District general hospital. POPULATION: Consecutive parous and nulliparous women attending a gynaecology outpatient clinic. METHODS: All women were examined using anal endosonography, and parous subjects without apparent sphincter injury compared with age-matched nulliparous controls to determine any differences in general anal canal morphology. MAIN OUTCOME MEASURES: Individual anal canal components were measured at defined levels and subjects compared with controls. RESULTS: Twenty-one of 54 parous women had no anal sphincter scar. Compared with nulliparous women, they had significant anterior sphincter thinning (mean 3.7 mm vs 4.6 mm, P< 0.01) in association with lateral external sphincter thickening (mean 7.0 mm vs 4.4 mm, P<0.01), and longitudinal muscle thickening (mean 2.8 mm vs 2.1 mm, P< 001). CONCLUSIONS: Specific changes in anal morphology have been demonstrated following vaginal delivery in women without apparent sphincter injury.

Adult↗
PubMed1999

Evacuation proctography: a prospective study of diagnostic and therapeutic effects.

PURPOSE: To determine the diagnostic and therapeutic effects of evacuation proctography. MATERIALS AND METHODS: Forty-seven referring clinicians completed preevacuation proctography questionnaires for 50 patients, detailing diagnoses, confidence in these, intended management, and what they hoped to learn. After evacuation proctography, the radiology report was returned with a second questionnaire asking the diagnosis in the light of evacuation proctographic findings, their confidence, and what they had learned. Clinicians quantified management contribution and indicated how useful they found evacuation proctography in general. Results from pre- and post-evacuation proctography questionnaires were compared to determine the diagnostic and therapeutic effects. RESULTS: Diagnostic confidence rose significantly after evacuation proctography (mean, 7.0 before evacuation proctography vs 8.4 after evacuation proctography; P < .001). Lead diagnosis changed in nine (18%) patients. Intended surgical management became nonsurgical after evacuation proctography in seven (14%) patients, and intended nonsurgical therapy became surgical in two (4%). Surgery remained likely in 15 patients, but its nature changed in five (10%). Five (10%) clinicians stated that evacuation proctographic findings resolved diagnostic conflict, and nine (18%) found that evacuation proctographic findings revealed unsuspected diagnoses. Clinicians found evacuation proctography of major benefit in 20 (40%) cases studied and of moderate benefit in 20 (40%). In general, 20 (43%) clinicians found evacuation proctography very useful and 24 (51%) found it moderately useful. CONCLUSION: Evacuation proctography has a substantial diagnostic and therapeutic effect and is of considerable benefit to referring clinicians.

Defecography↗
PubMed1998

Clinical, physiological, and radiological study of a new purpose-designed artificial bowel sphincter.

BACKGROUND: Studies of the use of artificial urinary sphincters for faecal incontinence have led to refinement and adaptation of such sphincters to the anatomy of the anal region. We aimed to test this new device. METHODS: Six women, median age 53 (range 32-58) years, who were unsuitable for sphincter repair, had an artificial bowel sphincter implanted as a one-stage procedure without colostomy cover. Clinical assessment, physiological testing, and endosonography were done before and after the operation. Plain radiography, three-dimensional endosonography, and magnetic-resonance imaging were done after the operation, to define its anatomical location. RESULTS: Median follow-up was 10 (range 5-13) months and the device was functional in five patients. In one patient, the device was removed after ulceration through the skin. Of the patients with intact devices, Wexner incontinence scores improved from a median of 19 (18-20) of 20 before the operation, to 3 (0-6) of 20 after the operation. Median anal pressure at rest significantly increased from 60 (range 30-80) cm H2O to 110 (100-120) cm H2O. Functional anal-canal length varied after the operation from 3.3 cm to 3.8 cm. There was no significant change in the maximum tolerated volume of the rectum (140 [80-230] vs 100 [75-250] mL), or rectal compliance (2.9 [2.8-6.0] cm H2O/mL vs 3.5 [2.3-7.3] cm H2O/mL). All the imaging techniques accurately located the implant relative to the anal canal and pelvic floor in each patient. INTERPRETATION: The new artificial bowel sphincter provided a good functional result in five of the six patients, the surgical procedure was straightforward, and the maximum resting anal pressure rose without affecting rectal function. The ease of visualisation of such implants in situ should aid simple management of complications, should they arise.

Adult↗
PubMed1998

Magnetic resonance imaging of fistula-in-ano: STIR or SPIR?

Patients with clinically suspected anorectal sepsis were studied using MRI in order to determine if T2 weighted sequences with fat suppression conveyed any additional benefit over conventional short tau inversion recovery (STIR) sequences. 23 consecutive patients (16 male) undergoing MRI for suspected perianal sepsis were studied prospectively using a 1.0 T whole body system and body coil. Axial and coronal T1 weighted turbo spin echo sequences were obtained, followed by STIR and T2 weighted spectral fat saturation inversion recovery (SPIR) sequences. Images were assessed for the presence of sepsis or fistula, and information provided by the sequences compared. Active disease was diagnosed in 17 patients, 14 of whom had fistula-in-ano; one intersphincteric, 10 transsphincteric and three extrasphincteric. Internal openings were identified in all of these 14 patients; anal in 10, rectal in two, and both in two. Diagnosis and fistula classification was possible in all of these 14 subjects on the basis of STIR sequences alone. The anal sphincters and pelvic floor musculature were better resolved by STIR than SPIR, leading to easier and more confident determination of fistula anatomy in eight of the 14 (57%). In no case did STIR sequences fail to resolve inflammation seen subsequently on SPIR, despite reduced track intensity. T1 weighted sequences were generally non-contributory. Both STIR and SPIR sequences are adequate to classify fistula-in-ano, but classification was easier with STIR due to superior resolution of pelvic floor structures.

Abscess↗
PubMed1998

MR imaging of fistula in ano: are endoanal coils the gold standard?

OBJECTIVE: It has been suggested that fistula in ano is most accurately assessed using endoanal receiver coils because they provide superior spatial resolution. We aimed to determine their advantage by prospective comparison with conventional body coil imaging. SUBJECTS AND METHODS: Thirty consecutive unselected patients with a diagnosis of anorectal sepsis were examined by MR imaging with an endoanal coil. Imaging with a body coil followed. Imaging was independently evaluated by two radiologists who classified fistulas according to the coil used and then compared their findings, which were validated surgically. RESULTS: Five patients could not tolerate coil insertion. In the remaining 25 patients, endoanal imaging revealed no abnormalities in three patients in whom the body coil image correctly showed Crohn's disease, a sinus, and a transsphincteric fistula. Imaging with both coils revealed sepsis in 16 patients, allowing radiologists to make correct primary track classification in 13 patients on endoanal imaging compared with 15 patients on body coil imaging. Endoanal imaging revealed 10 secondary extensions in eight patients, but further extensions in two of these patients and in a third patient were undetected. All these extensions were seen on body coil imaging. Overall, surgical concordance was 68% for endoanal imaging compared with 96% for conventional body coil imaging. CONCLUSION: Due to field-of-view limitations, endoanal imaging is less accurate than conventional body coil imaging for preoperative assessment of complex anal fistulas.

Adolescent↗
PubMed1997

Patterns of prolapse in women with symptoms of pelvic floor weakness: assessment with MR imaging.

PURPOSE: To show the magnetic resonance (MR) imaging patterns of prolapse and to correlate them with symptoms in patients with constipation or fecal incontinence. MATERIALS AND METHODS: Thirty women underwent MR imaging with fast spoiled gradient-recalled acquisition in the steady state. The women were divided into three groups: 10 were asymptomatic volunteers, 10 had constipation, and 10 had fecal incontinence. Visceral prolapse and the configuration of the pelvic floor muscles were identified at rest and during straining. Visceral descent was compared between the three groups. RESULTS: Visceral prolapse was seen at multiple sites, most frequently in constipated patients. There was significantly greater bladder base descent (P < .01), uterocervical descent (P < .001), and puborectalis muscle ballooning (P < .05) in the group of constipated patients when compared with the group with fecal incontinence or the asymptomatic group. The degree of anorectal junction descent was significantly greater (P < .05) in the group of incontinent patients when compared with the asymptomatic group. CONCLUSION: MR imaging clearly shows pelvic visceral prolapse and pelvic floor configuration on straining. Prolapse frequently involves multiple sites in constipated patients, which is suggestive of global pelvic floor weakness. In contrast, the weakness is frequently posterior in fecally incontinent patients.

Adult↗
PubMed1997

Dynamic MR imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement.

OBJECTIVE: The aim of this study was to determine the agreement between measurements of the anorectal configuration made with dynamic MR imaging and with evacuation proctography. SUBJECTS AND METHODS: Ten women with constipation were examined sequentially using both standard evacuation proctography and dynamic MR imaging. Correlation and agreement between standard measurements of anorectal configuration at rest and during straining or evacuation of the rectum were evaluated. RESULTS: Significant correlation existed for anorectal junction descent (r = .7, p = .023), change in the anorectal angle (r = .78, p = .008), the position of the rectal axis on straining (r = .62, p = .032), and rectocele depth (r = .82, p = .004). The mean of the measurement differences for anorectal junction descent as measured using the two techniques was -0.23 cm (SD, 1.40 cm). The mean of the measurement differences for change of the anorectal angle was +15.3 degrees (SD, 27.92 degrees). CONCLUSION: Standard measurements of anorectal configuration made using evacuation proctography and dynamic MR imaging show significant correlation. However, in our study statistical agreement was poor for measurement of anorectal junction descent and anorectal angle change as seen on imaging obtained with the two techniques.

Adult↗
PubMed1997

Magnetic resonance imaging of the pelvic floor in patients with obstructed defaecation.

BACKGROUND: Evacuation proctography and measurements of anorectal physiology are frequently used to clarify the pathophysiology of obstructed defaecation. In some patients these tests are normal, despite convincing clinical evidence of defaecatory difficulty. The aim of this study was to determine whether magnetic resonance imaging (MRI) could reveal pelvic floor abnormality in patients with obstructed defaecation. METHODS: Eleven women with obstructed defaecation, in whom evacuation proctography and anorectal physiology were normal, were examined by MRI, using a fast gradient echo sequence. Measurements of pelvic visceral and muscular descent were taken at rest and during straining, and compared with those obtained from 13 asymptomatic volunteers. RESULTS: Patients with obstructed defaecation had significantly greater pelvic visceral descent (P < 0.05), levator muscle descent (P = 0.04), levator plate angle change (P = 0.003) and increase in the area of the pelvic floor hiatus (P = 0.0002) than asymptomatic volunteers. CONCLUSION: MRI demonstrated marked pelvic visceral and levator muscle descent in women with obstructed defaecation, despite normal evacuation proctography and anorectal physiology. MRI should be considered if these examinations have been normal.

Adolescent↗
PubMed1996

Is digitation associated with proctographic abnormality?

Constipated patients referred for evacuation proctography were questioned as to the need for digital manoeuvres to assist evacuation, to determine the frequency of digitation, and to investigate whether any proctographic feature was associated with this symptom. Seventy one percent of patients interviewed admitted to digitation. Proctographic findings in 20 constipated patients who digitated per vagina and 20 who digitated per anum were compared to 20 who did not. There was no significant difference between groups with respect to pelvic floor descent, anal canal width or any anrectal angle measurement. Rectocoele depth and area were significantly greater in patients who digitated per vagina, compared to the other two groups. Evacuation time was prolonged and a proctographic diagnosis of anismus more frequent, in patients who digitated per anum. Anal digitation is associated with prolonged evacuation, suggesting a proctographic diagnosis of anismus and vaginal digitation to assist rectal evacuation is significantly associated with large anterior rectocoele.

Constipation↗
PubMed1996

Dynamic cystoproctography and physiological testing in women with urinary stress incontinence and urogenital prolapse.

In order to determine the frequency of posterior compartment pathology in females with anterior and middle compartment pelvic floor weakness, 10 women with urinary stress incontinence and 10 women with uterovaginal prolapse underwent detailed review of their history and clinical findings, and were studied by simultaneous evacuation proctography and cystography. Radiological findings were correlated with anorectal physiological testing. Considerable symptom overlap and occult defaecatory symptoms were revealed. The combined radiological examination visualized cystocoele, enterocoele, rectocoele and rectal intussusception, and diagnosed higher degree prolapse than did clinical examination. There was no significant difference in the frequency of any of these findings with respect to either group, nor was there any significant difference in proctographic measurements. Additionally, there was little significant difference in physiological measurements between the groups, and when cystoproctographic features were compared to the results of anorectal physiological testing, there was little correlation between results obtained from either set of tests. In conclusion, modification of standard proctographic techniques enhances the diagnostic potential of the study, allowing accurate demonstration of the site and degree of pelvic floor weakness in women. Weakness often involves all pelvic compartments, despite differing clinical presentations, suggesting a global pathology. Embarrassing symptoms may not be volunteered, and should be sought so that imaging is appropriate.

Adult↗
PubMed1996

Why is colonoscopy more difficult in women?

BACKGROUND: In our experience colonoscopy in women is more difficult than in men. A retrospective review of 2194 colonoscopies performed by a single experienced endoscopist (CBW) showed that 31% of examinations in women were considered technically difficult compared with 16% in men. METHODS: To investigate a possible anatomic basis for this finding, normal barium enema series from 183 female and 162 male patients were identified. From these barium enemas, measurements of colonic length and mobility were independently taken by two physicians who were unaware of each patient's gender. RESULTS: Total colonic length was greater in women (median, 155 cm) compared to men (median, 145 cm), p = 0.005, despite women's smaller stature (p < 0.0001). Although there were no significant differences in rectum plus sigmoid, descending, or ascending plus cecum segmental lengths, women had longer transverse colons (female median length, 48 cm; male median length, 40 cm), p < 0.0001. There were no differences in mobility of the descending colon and transverse colon between the sexes, but the transverse colon reached the true pelvis more often in women (62%) than in men (26%), p < 0.001. CONCLUSIONS: Colonoscopy appears to be a technically more difficult procedure in women. The reason for this may be due in part to an inherently longer colon.

Adolescent↗