Prospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 14, 2015; 21(46): 13160-13165
Published online Dec 14, 2015. doi: 10.3748/wjg.v21.i46.13160
Sphincter lesions observed on ultrasound after transanal endoscopic surgery
Laura Mora López, Xavier Serra-Aracil, Salvador Navarro Soto
Laura Mora López, Xavier Serra-Aracil, Salvador Navarro Soto, General and Digestive Surgery Service, Parc Tauli University Hospital, Universidad Autonoma Barcelona, 08208 - Sabadell - Barcelona, Spain
Author contributions: Mora López L and Serra-Aracil X contributed equally to this work; Mora López L and Serra-Aracil X designed and performed the research, analyzed the data, wrote and corrected the paper; and Navarro Soto S contributed to the correction of the paper.
Institutional review board statement: This paper was approved by the ethical committee of our hospital.
Informed consent statement: Informed consent was not necessary as the study was a part of our normal clinical practice.
Conflict-of-interest statement: There were no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Xavier Serra-Aracil, MD, Coloproctology Unit, General and Digestive Surgery Service, Parc Tauli University Hospital, Universidad Autonoma Barcelona, C/Parc Tauli, 2, 08208 - Sabadell - Barcelona, Spain. jserraa@tauli.cat
Telephone: +34-937-231010-21460
Received: March 30, 2015
Peer-review started: March 31, 2015
First decision: May 18, 2015
Revised: May 29, 2015
Accepted: August 30, 2015
Article in press: August 31, 2015
Published online: December 14, 2015
Processing time: 253 Days and 19.2 Hours
Abstract

AIM: To assess the morphological impact of transanal endoscopic surgery on the sphincter apparatus using the modified Starck classification.

METHODS: A prospective, observational study of 118 consecutive patients undergoing Transanal Endoscopic Operation/Transanal Endoscopic Microsurgery (TEO/TEM) from March 2013 to May 2014 was performed. All the patients underwent an endoanal ultrasound prior to surgery and one and four months postoperatively in order to measure sphincter width, identify sphincter defects and to quantify them in terms of the level, depth and size of the affected anal canal. To assess the lesions, we used the “modified” Starck classification, which incorporates the variable “sphincter fragmentation”. The results were correlated with the Wexner incontinence questionnaire.

RESULTS: Of the 118 patients, twelve (sphincter lesions) were excluded. The results of the 106 patients were as follows after one month: 31 (29.2%) lesions found on ultrasound after one month, median overall Starck score of 4 (range 3-6); 10 (9.4%) defects in the internal anal sphincter (IAS) and 3 (2.8%) in the external anal sphincter (EAS); 17 patients (16%) had fragmentation of the sphincter apparatus with both sphincters affected in one case. At four months: 7 (6.6%) defects, all in the IAS, overall median Starck score of 4 (range 3-6). Mean IAS widths were 3.5 mm (SD 1.14) preoperatively, 4.38 mm (SD 2.1) one month postoperatively and 4.03 mm (SD 1.46) four months postoperatively. The only statistically significant difference in sphincter width in the IAS measurements was between preoperatively and one month postoperatively. No incontinence was reported, even in cases of ultrasound abnormalities.

CONCLUSION: TEO/TEM may produce ultrasound abnormalities but this is not accompanied by clinical changes in continence. The modified Starck classification is useful for describing and managing these disorders.

Keywords: Transanal endoscopic surgery; Endoscopic ultrasound; Anal continence; Starck classification; Sphincteric lesions

Core tip: This prospective study shows that transanal endoscopic surgery does not produce lesions in the sphincter apparatus. Alterations are described after using a 4 cm diameter rectoscope, with no alterations in continence.