1. SURGEON-PERFORMED
ULTRASOUND IN
PROCTOLOGICAL PRACTICE
A.P. ZBAR MD MBBS FRCS (Ed) FRCS (Gen) FRACS
Universities of New England and Newcastle
Tamworth Rural Referral Centre
Tamworth NSW
Provincial Surgeons Meeting Wagga Wagga 2008
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2. ENDOLUMINAL ULTRASONOGRAPHY
First introduced by Law and Bartram in 1989
Association with normal anatomy
Constitutive variations with age
Modifications – 3-dimensional, Contrast enhancement
and Transperineal technology
UTILIZATION
Perirectal Sepsis
Faecal Incontinence
Rectal and Anal Cancers
Functional Disorders
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3. PRINCIPLES OF ULTRASOUND
Resolution depends on frequency (MHz)
and pulse repetition frequency
Lateral resolution is controlled by beam width
A standard BK 10 MHz transducer has an
axial resolution < 0.05 mm with a lateral
resolution of 0.5-1 mm and a focal range
of 5-45 mm.
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4. TECHNIQUES - ENDOANAL
LM
IAS
EAS
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5. TECHNIQUES - ENDORECTAL
3-DIMENSIONAL ENDOANAL TRANSPERINEAL
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6. PERIRECTAL SEPSIS
Primary information
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7. 7

8. TRANSPERINEAL SONOGRAPHY
Sensitivity for detection of trans-
sphincteric and extrasphincteric
fistulae = 100%
Sensitivity for internal opening
with TPUS is 90% and 80% for
EAUS
Sensitivity for horseshoeing with
TPUS is 28.6%
Sensitivity for ancillary abscess
and secondary tracks with TPUS
Zbar AP et al. Techniques in Coloproctol 2007
is 63.6%
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9. FAECAL INCONTINENCE
PREOPERATIVE ENDOANAL PREOPERATIVE TRANSPERINEAL
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10. Intraoperative
Endoanal
Postoperative Endoanal
Postoperative
Transperineal
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11. RECTAL AND ANAL TUMOURS
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12. NORMAL ENDOSONOGRAPHIC RECTAL WALL LAYERS
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13. T1
SM
PF
INFILTRATIVE VILLOUS LESION
NOT INVADING SUBMUCOSA (SM)
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14. T2 TUMOUR T3 TUMOUR
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15. T4 TUMOUR – SEMINAL VESICLE INFILTRATION
Accuracy for T stage = 85%
Accuracy for N staging = 50%
SENSITIVITY 75%
PPV 82%
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16. PARARECTAL NODES
Inherent endosonographic problems with nodal detection
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17. WORLDWIDE FIGURES OF ERUS - T AND N STATUS OF RECTAL CANCERS
AUTHOR YEAR NR T ACC OVERSTAGE UNDERSTAGE N ACC
(%) (%)
HILDEBRANDT 1985 25 92
BEYNON 1987 100 93
RIFKIN 1987 102 67 50
GLASER 1990 117 90 80
KATSURA 1992 120 92 8.3 5.3 72.3
HERZOG 1993 152 89 10.2 0.8 80.2
FEDAYEV 1995 132 91 3.7 3.7 54.5
ZRIHEN 1996 62 84 71
GENNA 2000 42 81 71.4
GARCIA- 2002 545 69 18 13 64
AGUILAR
NESBAKKEN 2003 91 74 65
HSIEH 2003 67 88 9 3 73
MACKAY 2003 356 89 66
BALI 2004 33 79 10 10 59
PRESENT 2005 40 85 5 10 50
SERIES
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18. TRANSPERINEAL SONOGRAPHY IN
RECURRENT ANORECTAL TUMOUR
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19. Managing Evacuatory Disorders
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20. DYNAMIC TRANSPERINEAL IMAGING
AXIAL
IAS
SAGITTAL
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21. Rectocele Rectoanal intussusception
RECTOCELE RECTOANAL INTUSSUSCEPTION
PERITONEOCELE
Peritoneocele ENTEROCELE
Enterocele
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22. DYNAMIC TRANSPERINEAL ULTRASONOGRAPHY
AND THE ANTERIOR COMPARTMENT
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23. DYNAMIC TRANSPERINEAL SONOGRAPHY
IN FUNCTIONAL DISORDERS
RECTOCELE CYSTOCELE
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24. Beer-Gabel M, Zbar AP DCR 2002
Zbar AP et al. Dis Colon Rectum 2004
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25. DTP-US VERSUS DEFAECOGRAPHY IN EVACUATORY DYSFUNCTION
PATHOLOGY DTP-US DEFAECOGRAPHY
One 6 (18.2%) 12 (36.4%)
Two 19 (57.6%) 15 (45.4%)
Three 6 (18.2%) 3 (9.1%)
None 2 (6%) 3 (9.1%)
P = 0.3
RECTOCELE 8/17 (47.1%) 4/18 (22.2%)
PLUS Enterocele
P = 0.15
RECTOCELE
Sensitivity 88.9%
Specificity 100%
RECTOANAL INTUSSUSCEPTION
Sensitivity 89.5%
Specificity 100%
Beer-Gabel M, Zbar A et al. Int J Colorect Dis 2005
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26. BLAND-ALTMAN PLOT OF ARA AT REST
70
60
50
40
30
°° °
(Proctography-Ultrasound)Degrees
Difference in Ano-Rectal Angle
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° ° °
° ° °
10 ° ° °
0 ° ° °
° ° °
-10
°
°°° °°
-20 °
° ° °
-30 ° °
-40
°
-50
-60 °
-70 °
50 60 70 80 90 100 110 120 130
Average Change in Ano-Rectal Angle measured by Proctography and Ultrasound (Degrees)
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27. BLAND-ALTMAN PLOT OF ARJ DURING STRAINING
70
60 °
50
° °
Difference in Ano-Rectal Junction Displacement
40
°
30 ° °
20 °°
(Proctography-Ultrasound)Degrees
°
10 ° °
° ° °
0
° ° °° ° ° ° °°
-10 ° ° °
°
-20 ° °
-30 ° ° °
-40
°
-50
-60
-70
70 80 90 100 110 120 130 140 150 160
Average Change in Ano-Rectal junction displacement measured by Proctography and Ultrasound (Degrees)
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28. DYNAMIC TRANSPERINEAL ULTRASONOGRAPHY (DTP-US)
Simple
Non-invasive
Avoids radiation in young patients
Repeatable
Portable
Simultaneously assesses the anterior and posterior perineum & pelvic floor
Avoids the need for multiorgan opacification
Dynamic transperineal ultrasound is accurate in
the diagnosis of specific pelvic floor conditions
It tends to diagnose multiple conditions in
functional disorders
Quantitative assessment of the pelvic floor is
comparable with defaecography for pelvic
floor disorders at rest and during straining
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