Endorectal Ultrasound and Real-Time Elastography in Patients with fecal Incontinence Following Anorectal Surgery: A Prospective Comparison Evaluating Short- and Long-Term Outcomes in Irradiated and Non-Irradiated Patients

Abstract

Background and Aims: Transanal real-time elastography (RTE) was demonstrated to yield valuable information regarding elastic properties of the anal sphincter in patients with fecal incontinence. We studied the role of RTE findings as a risk factor for the outcome of patients with fecal incontinence following anorectal surgery in irradiated and non-irradiated individuals and compared these observations with conventional B-mode/color Doppler EUS. 

Patients and Methods: 90 patients with postsurgical fecal incontinence were included in this prospective monocentric study. Baseline and follow-up (after 3 weeks and 1 year) assessment included an incontinence severity score questionnaire, rectal manometry, B-mode/color Doppler EUS and RTE with quantitation of the sphincter elastograms.

Results: 81 patients could be finally assessed, in 24 patients (29.6 %) a pathological elastogram with predominantly hard elements was found; logistic regression analysis revealed no significant association with the short- and long-term clinical outcome nor were any differences seen between irradiated and non-irradiated patients. Defined sphincter defects as seen with conventional EUS were significanntly associated with a worse short- and long-term outcome: odds ratio OR_short-term: 1.414 (1.107 − 1.807, p = 0.0101); OR_long-term: 1.675 (95 % CI: 1.133 − 2.477; p = 0.0294). Submucosal thickening and hypervascularization were found more frequently in the irradiated group (p < 0.01).

Conclusion: RTE with quantitation of sphincter elastic properties yields no further diagnostic and prognostic information compared to conventional EUS in irradiated and non-irradiated patients and, therefore, cannot be regarded as a new tool in the assessment of those patients. Our data further confirm the view that defined sphincter defects may be a major risk factor for an unfavorable outcome.

Zusammenfassung

Hintergrund: Die endorektale Ultraschalluntersuchung (ERUS) kombiniert mit der Real-Time-Elastografie (RTE) hat sich bei der Abklärung der analen Inkontinenz als hilfreich erwiesen. Prospektiv wurden konventionelle ERUS-Techniken mit ERUS-RTE verglichen, um prognostische Aussagen bei Patienten mit Inkontinenz nach anorektalen Operationen (mit oder ohne Bestrahlung) zu ermöglichen.

Patienten und Methoden: Prospektive monozentrische Studie, 90 Patienten mit postoperativer Stuhlinkontinenz. Zum Zeitpunkt 0, nach 3 Wochen und nach einem Jahr wurde der „Incontinence Severity Score Questionnaire“ erfragt und die rektale Manometrie, ERUS sowie quantifizierte ERUS-RTE durchgeführt.

Ergebnisse: 81 Patienten konnten zu allen Zeitpunkten adäquat beurteilt werden. Bei 24/81 (30 %) Patienten fand sich ein pathologisches Elastogramm mit vorwiegend härteren Gewebeeigenschaften. Mittels logistischer Regressionsanalyse zeigten sich keine signifikante Assoziation mit den kurz- und langfristigen Verläufen der Inkontinenz sowie keine eindeutigen Unterschiede zwischen bestrahlten und nicht bestrahlten Patienten. Konventionell endosonografisch nachweisbare Sphinkter-Defekte waren mit einer schlechteren kurz- und langfristigen Prognose assoziiert: Odds Ratio (OR)_short term: 1,414 (1,107 − 1,807, p = 0,0101), OR_long term: 1,675 (95 %-KI: 1,133 − 2,477; p = 0,0294). Submukosale Verdickungen und Hypervaskularisation waren signifikant häufiger in der bestrahlten Gruppe (p < 0,01).

Diskussion: Konventionelle ERUS-Techniken erlauben prognostisch relevante Sphinkter-Defekte zu erkennen. ERUS-RTE erlaubt keine darüber hinausgehenden diagnostischen und prognostischen Aussagen.

Key words

real-time elastography - B-mode/color Doppler EUS - fecal incontinence - anorectal surgery - short-/long-term outcome - irradiation

Schlüsselwörter

Real-Time-Elastografie - endorektaler Ultraschall (ERUS) - Inkontinenz - anorektale Operation - kurz- und langfristige Prognose - Bestrahlung

• References

• 1 Frey H, Dietrich CF. Sonoelastography: a new ultrasound modality for assessing tissue elasticity. In: Dietrich CF, (ed) Endoscopic Ultrasound. Stuttgart, Germany: Thieme Verlag; 2008: 56-69
• 2 Micames CG, Gress FG. EUS elastography: a step ahead?. Gastrointest Endosc 2007; 65: 979-981
• 3 Moon WK, Choi JW Cho N et al. Computer-aided analysis of ultrasound elasticity images for classification of benign and malignant breast masses. Am J Roentgenol 2010; 195: 1460-1465
• 4 Bojunga J, Herrmann E, Meyer G et al. Real-time elastography for the differentiation of benign and malignant thyroid nodules. A meta-analysis. Thyroid 2010; 20: 1145-1150
• 5 Itoi T, Sofuni A, Itokawa F et al. Current status of diagnostic endoscopic ultrasonography in the evaluation of pancreatic mass lesions. Digestive Endoscopy 2011; 23 (Suppl. 01) 17-21
• 6 Aigner F, Mitterberger M, Rehder P et al. Status of transrectal ultrasound imaging of the prostate. J Endourol 2010; 24: 685-691
• 7 Thomas A, Kummel S, Gemeinhardt O et al. Real-time sonoelastography of the cervix: tissue elasticity of the normal and abnormal cervix. Acad Radiol 2007; 14: 193-200
• 8 Waage JE, Havre RF, Odegaard S et al. Endorectal elastography in evaluation of rectal tumours. Colorectal Disease 2010; 13 (Suppl. 10) 1130-1137
• 9 Janssen J, Dietrich CF, Will U et al. Endosonographic elastography in the diagnosis of mediastinal lymph nodes. Endoscopy 2007; 39: 952-957
• 10 Alam F, Naito K, Horiguchi J et al. Accuracy of sonographic elastography in the differential diagnosis of enlarged cervical lymph nodes: comparison with conventional B-mode sonography. Am J Roentgenol 2008; 191: 604-610
• 11 Allgayer H, Ignee A, Dietrich CF. Endosonographic elastography of the anal sphincter in patients with fecal incontinence. Scand J Gastroenterol 2010; 45: 30-38
• 12 Vaizey CJ, Carapeti F, Cahill JA et al. Prospective comparison of fecal incontinence grading systems. Gut 1999; 44: 77-80
• 13 Allgayer H, Dietrich CF, Rohde W et al. Prospective comparison of short- and long-term effects of pelvic floor/biofeedback training in patients with fecal incontinence after surgery plus irradiation versus surgery alone for colorectal cancer: clinical, functional and endoscopic/endosonographic findings. Scand J Gastroenterol 2005; 40: 1168-1175
• 14 Sailer M, Allgayer H, Dietrich CF. Endoanal and endorectal sonography. In: Dietrich CF, (ed) Endoscopic Ultrasound. Stuttgart, Germany: Thieme Verlag; 2011: 431-454
• 15 Gottlieb K. Doppler-endosonography with the GF-UE 160 electronic radial echoendoscope-current use and future potential. J Gastroeintestinal Liver Dis: JGLD 2007; 16: 455-461
• 16 Tankova L, Hadjieva T, Kovatchki D et al. Endosonographic assessment of the response of rectal cancer to preoperative radiotherapy. Hepatogastroenterology 2009; 56: 1645-1650
• 17 Norderval S, Markskog A, Rossaak K et al. Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects. Ultrasound in Obstetrics & Gynecology 2008; 31: 78-84
• 18 Bordeianou L, Lee KY, Rockwood T et al. Anal resting pressures at manometry correlate with Fecal Incontinence Severity Index and with presence of sphincter defects on ultrasound. Dis Colon Rectum 2008; 51: 1010-1014
• 19 Bharucha AE. Management of fecal incontinence. Gastroenterol Hepatol 2008; 4: 807-817
• 20 Reddymasu SC, Singh S, Waheed S et al. Comparison of anorectal ultrasound in the evaluation of fecal incontinence. Am J Med Sci 2009; 337: 336-339
• 21 Laine K, Skjeldestad FE, Sanda B et al. Prevalence and risk factors for anal incontinence after obstetric anal sphincter rupture. Acta Obstetr Gynaecol Scand 2011; 90: 319-234
• 22 Maeda Y, Norton C, Lundby L et al. Predictors of the outcome of percutaneous nerve evaluation for fecal incontinence. Brit J Surg 2010; 97: 1096-1102
• 23 Hill K, Fanning S, Fennerty MB et al. Endoanal ultrasound compared to manometry for the evaluation of fecal incontinence: a study of the effect these tests have on clinical outcome. Dig Dis Sci 2006; 51: 235-240
• 24 Saftoiu A, Vilman P. Endoscopic ultrasound elastography – a new imaging technique for the visualization of tissue elasticity distribution. J Gastrointestin Liver Dis 2006; 15: 161-165
• 25 Devi CU, Vasu RM, Sood AK. Design, fabrication, and characterization of a tissue-equivalent phantom for optical elastography. J Biomed Opt 2005; 10: 44020
• 26 Monti P, Wysocki J, van der Meeren A et al. The contribution of radiation-induced injury to the gastrointestinal tract in the development of multi-organ dysfunction syndrome or failure. BJR supplement 2005; 27: 89-94
• 27 Okunieff P, Cornelison T, Mester M et al. Mechanism and modification of gastrointestinal soft tissue response to radiation: role of growth factors. Int J Radiation Oncol Biol Physics 2005; 6: 273-278
• 28 Francois S, Bensidhoum M, Mouiseddine M et al. Local irradiation not only induces homing of human mesenchymal stem cells at exposed sites but promotes their widespread engraftment to multiple organs: a study of their quantitative distribution after irradiation damage. Stem Cells 2006; 24: 1020-1029
• 29 Van Leeuwen-Segarceanu EM, Dorresteijn LD, Pillen S et al. Progressive muscle atrophy and weakness after treatment by mantle field radiotherapy in Hodgkin lymphoma survivors. Int J Radiation Oncol Biol Physics 2011; 82 (Suppl. 02) 612-618
• 30 Bensamoun SF, Ringleb SI, Chen Q et al. Thigh muscle stiffness assessed with magnetic resonance elastography in hyperthyroid patients before and after medical treatment. J Magn Reson Imag 2007; 26: 708-713
• 31 Allgayer H, Dietrich CF. A 64-year-old woman with rectal bleeding, chronic diarrhea and severe fecal incontinence. Z Gastroenterol 2009; 47: 361-364