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With ManoView the radial orientation of the 2D pressure reconstructions was determined by the pressure profile of the PR, shown as a longer pressure area posterior in relation to the shorter anterior pressure map.

The middle of the PR pressure area was figured as the posterior part of the anal canal Fig. The 3D and 2D pressure profile in rest a and during contraction b.

Legend: The puborectal muscle PR muscle is seen in the middle of the 2D profile. The sphincter length was based on the mean length of anterior and posterior pressure.

Areas of low pressure, judged upon the distinction of a different color, that could present a fistula or a preexisting defect pattern were noted.

Normal values of 3D-HRAM have been published in male and female adults by four different authors [ 21 , 22 , 23 , 24 ] and show a large range as well as an effect of gender and ageing.

The dotted line is an automatic generated line of lowest pressure, and in this case that coincides with the groove. The visual concordance of the fistula tract on 3D-EUS and same area the areas of low pressure with 3D-HRAM as mentioned above was scored as scored as good, moderate and poor.

Measurement of difference between pressure in fistula tract area and the surrounding area. Categorical variables were analysed using the Pearson Chi Square test.

Analysis was performed using SPSS, version Previously performed surgical procedures were fistulotomy 11 , LIFT 8 , mucosal advancement plasty 3 and laser therapy 1.

Multiple operations were performed in 8 patients. In addition to their complaints of the perianal fistula, two patients were incontinent for liquid faeces.

One patient was a year old female with an anterior high transsphincteric fistula and a traumatic delivery, and the other patient was a year old male with a high transsphincteric fistula and three previous fistula surgical interventions, including resection of a sinus in the sphincter.

Seven patients had a simple fistula and 33 patients a complex fistula. Side branches were present in 5 patients.

Five were females who all had had traumatic VDs, three had simple fistula and two had complex fistulas. Both men had recurrent suprasphincteric fistulas.

There were no differences in pressures or sphincter length between patients with or without previous treatments or recurrences, but since men were over represented in the recurrent group no conclusion could be made.

The surgical procedures were single or combined procedures: seton 2 , LIFT 2 Permacol 2 abscess drainage with mucosal advancement plasty 2 and fistulotomy 3.

The mean pressures did not change after these procedures. However, in the patient with a previous excision of a sinus, a distinct distal local pressure drop became evident after fistulotomy.

The 3D-EUS showed disappearance of the fistula and healing with a scar. There were 10 patients with a defect on anal ultrasound.

Those with good concordance had a childbirth injury 3 and anorectal surgery hemorrhoidectomy 2, lateral internal sphincterotomy 1 ; all defects throughout the length of the sphincter and had a groove.

These were small areas of lower pressure and there were no grooves. This study has shown that there is a moderate to good visual agreement between the fistula tract on 3D-EUS and a 3D-HRAM pressure drop in the same area in patients with active perianal fistulas.

In the control patients who had a sphincter defect, similar differences in pressure were found. When measuring actual pressures in both areas, it becomes difficult to define a pressure abnormality and translate this into a threshold pressure.

This issue has been addressed by Vitton in patients with sphincter defects [ 16 ]. Automatic analysing software did not improve the detection rate [ 17 ].

This suggests that not all ultrasound abnormalities are functional and low pressures cannot always be seen with 3D-EUS. The results in the control patients with sphincter defects were similar.

Further lowering of the definition of difference could give false positive defects in patients, as physiological differences in pressure would be falsely identified as FTA.

Clearly, 3D-HRAM measures function and the fistula tract only becomes visible if it leads to pressure drops. In some pressure profiles these areas were visible as a groove Fig.

In the control patients grooves were found in those with large defects throughout the sphincter. The groove aspect seems to be related to large complex fistulas or large sphincter defects.

In one male patient with a recurrent fistula the 3D-HRAM showed a drop of the local pressure profile without a change in mean pressure.

The repeated 3D-EUS showed disappearance of the fistula tract and scar tissue. His complaints of faecal incontinence increased.

These are interesting findings, but what do they mean? Most surgeons will consider normal mean anal pressures as a permit to perform a fistulotomy.

Are the patients with normal mean anal pressures but with large local pressure drops prone to develop postoperative faecal incontinence? How low may the local pressure drop be before becoming important as a risk of postoperative faecal incontinence?

Or is it only of importance in women after VD or patients who underwent multiple surgical procedures? This study aimed to evaluate the pressure profiles in relation to the fistula tracts.

There are some limitations to this study. To date, normal values have been reported in 6 studies, four in healthy adults [ 21 , 22 , 23 , 24 , 25 ], one in pregnant women [ 26 ] and one in children [ 27 ].

Reproducibility of 3D-HRAM has been assessed in two studies showing a good to moderate correlation [ 22 , 28 ]. Furthermore, 3D-HRAM has been demonstrated to measure higher pressures than conventional anal manometry [31].

In addition, ageing and female sex are correlated with lower anal pressures and a large overlap between normal controls and patients has been shown in previous studies [ 13 , 16 , 17 , 21 , 22 , 23 , 24 , 28 ].

Other limitations of this study are the relatively small patient groups and the retrospective nature of the study.

In spite of these shortcomings, the results warrant further prospective studies in patients with perianal fistulas before and after surgery to gain more insight with possible clinical consequences.

Considering the costs of 3D-HRAM we cannot recommend this as a routine procedure in patients undergoing fistula surgery use at this point.

Detection by means of a threshold pressure is not feasible. Fistulotomy can cause local pressure drops.

The extent of these pressure drops after surgery may be interesting to evaluate prospectively in patients to determine whether they correlate with functional outcome and it may influence type of fistula surgery if added to 3D-EUS findings.

Predictive factors for recurrence of cryptoglandular fistulae characterised by preoperative 3D-endoanal ultrasound.

Color Dis. Long-term follow-up after surgery for simple and complex cryptoglandular fistulas: fecal incontinence and impact on quality of life.

Dis Colon rectum ;—9. Crypotoglandular fistulae: faecal incontinence and impact on quality of life. J Gastrointest Surg.

Patient satisfaction after surgical treatment for fistula in ano. Dis Colon rectum ;— Endoanal ultrasound in perianal fistulae and abscesses. Ultrasound Q.

Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula.

Tech Coloproctol. Pre-operative assessment of anal fistulas using endoanal ultrasound. Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines.

Colorectal Dis. Dutch Proctology Guidelines. Accessed 4 Jan Systematic review and meta-analysis of surgical interventions for high cryptoglandular perianal fistula.

Int J Color Dis. Minimum standards of anorectal manometry. Neurogastroenterol Motil. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.

Ann Surg. Anorectal function evaluation and predictive factors for faecal incontinence in patients. Water-perfused manometry vs three-dimensional high-resolution manometry: a comparative study on a large patient population with anorectal disorders.

Comparison of three-dimensional high-resolution manometry and enodanal ultrasound in the diagnosis of anal sphincter defects.

Three dimensional high-resolution anorectal manometry: does it allow automated analysis of sphincter defects? Can 3D high resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence?

Three-dimensional anorectal manometry enhances diagnostic gain by detecting sphincter defects and Puborectalis pressure. Dig Dis Sci. Impact of three-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study.

Normal values and pressure morphology for three-dimensional high-resolution anorectal manometry of asymptomatic adults: a study in subjects.

Accuracy and reproducibility of high-definition anorectal manometry and pressure topography analyses in healthy subjects.

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