• Nenhum resultado encontrado

anorectal ultrasonography canal and rectal wall vascularity with colorDoppler Establishing the normal ranges of female and maleanal Coloproctology Journal of

N/A
N/A
Protected

Academic year: 2022

Share "anorectal ultrasonography canal and rectal wall vascularity with colorDoppler Establishing the normal ranges of female and maleanal Coloproctology Journal of"

Copied!
7
0
0

Texto

(1)

w w w . j c o l . o r g . b r

Journal of

Coloproctology

Original Article

Establishing the normal ranges of female and male anal canal and rectal wall vascularity with color Doppler anorectal ultrasonography

Sthela M. Murad-Regadas

a,b,c,∗

, Francisco Sergio Pinheiro Regadas

a

, Iris Daiana Dealcanfreitas

a

, Francisco Sergio Pinheiro Regadas Filho

a,c

, Graziela Olivia da S. Fernandes

a

, Matheus Couto Furtado Albuquerque

a

, Carolina Murad Regadas

c

, Marina Murad Regadas

c

aUniversidadeFederaldoCeará(UFC),FaculdadedeMedicina,DepartamentodeCirurgia,Fortaleza,CE,Brazil

bUniversidadeFederaldoCeará(UFC),HospitaldasClínicas,UnidadedeFisiologiaAnorretaleAssoalhoPélvico,Fortaleza,CE,Brazil

cHospitalSãoCarlos,DepartamentodeCirurgiaColorretal,UnidadedeFisiologiaAnorretaleAssoalhoPélvico,Fortaleza,CE,Brazil

a r t i c l e i n f o

Articlehistory:

Received1March2018 Accepted26March2018 Availableonline30April2018

Keywords:

Analcanalvascularization Rectumvascularization Color-doppler

Endoanalultrasound Endorectalultrasound

a bs t r a c t

Studyobjectives:Toevaluatebloodsupplyintheanalcanal,rectalwallandmesorectalfat ofmenandwomen,usingcolorDopplerendorectalsonographytoestablishnormalranges forvascularparameters.

Methods:Aprospectivecross-sectionalstudyconductedatatertiary-carehospitalrecruited asymptomaticvolunteers(≤50years).Vascularitypercentageandindexwerecalculatedfor definedregions.

Results:Vascularitypercentageandindexweresignificantlyhigherinthepuborectalis,mid- level externalandupperinternalanalsphincter comparedtothelowanalcanal;these parameterswerehigherinmenthaninwomenatupperandmiddlelevelsoftheinner analcanalstructures.Atmid-level,vascularitywasgreaterintheexternalcomparedto theinternalanalsphincterinbothsexes;however,attheupperlevelitwasgreaterinthe puborectaliscomparedtotheinternalanalsphincterinwomen.Vascularitywasgreater intherectalwallcomparedtothemesorectalfat,withnodifferencebetweenmiddleand lowerlevels.

Correspondingauthor.

E-mail:smregadas@hospitalsaocarlos.com.br(S.M.Murad-Regadas).

https://doi.org/10.1016/j.jcol.2018.03.005

2237-9363/©2018SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

(2)

Conclusions: Bloodsupplyishighestatupperlevelsoftheanalcanal;however,innerstruc- tures arebetterirrigatedin men.Moreover,the rectalwallis betterirrigatedthanthe mesorectalfat.Establishingnormalrangesmaypermitfuturecomparisonsofthestudied structuresindiseasestatesaswellasthehormonalandagerelatedchanges.

©2018SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Estabelecendopadrõesnormaisdavascularizac¸ãodocanalanaleda parederetalemindivíduosdosexomasculinoefemininocomultrassom anorretalcomDopplercolorido

Palavras-chave:

Vascularizac¸ãodocanalanal Vascularizac¸ãodoreto Dopplercolorido Ultrassomendoanal Ultrassomendorretal

r e s u m o

Objetivo:Avaliarvascularizac¸ãodocanalanal,parederetalegorduramesorretalemhomens e mulheres, usando ultrassonografiaendorretal comDoppler coloridoparaestabelecer parâmetrosvascularesdenormalidade.

Métodos: Estudoprospectivotransversalincluindovoluntáriosassintomáticoscomaté50 anos.Medidososvaloresdaporcentagemedoíndicedevascularizac¸ãoforamcalculados pararegiõesescolhidas.

Resultados: Valoresdaporcentagemedoíndiceforamsignificativamentemaioresnopub- orretal,esfíncter externo(canal analmédio)e oesfíncterinterno (canalanal superior) comparadoaocanalanalinferior;essesparâmetrosforammaioresemhomensqueem mulheresnocanalanalmédioealto.Nomédio,avascularizac¸ãofoimaiornoesfíncter externocomparadoaointernoemambosossexos;contudo,nocanalanalsuperior,foi maiornopuborretalcomparadoaoesfíncteranalinternoemmulheres.Avascularizac¸ão foimaiornaparederetalcomparadaàgorduramesorretal,semdiferenc¸asentreosníveis.

Conclusões: Osuprimentosanguíneoémaiornosníveisaltosdocanalanal.Asestruturas internassãomaisirrigadas noshomens.Aparederetalé maisirrigadaqueagordura mesorretal.Os parâmetrosvascularesestabelecidospermitiráfuturascomparac¸ões das estruturasestudadasnoscasosdedoenc¸as,assimcomo,alterac¸õesqueocorremcoma idadeemudanc¸ashormonais.

©2018SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Ultrasonographyenablesvisualizationoftheanatomicaland functional aspects of the anal canal and rectum and is a well-establishedtoolforevaluating benign, malignant,and functionaldisorders.Numerousstudieshaveshowngoodcor- relationbetweenultrasoundimagingandsurgicalfindings.1–8 Ultrasoundcanalsobeusedtoassessvascularity,andseveral studieshaveevaluatedtheefficacyofintrarectalultrasound withcolorDopplerandDopplerflowanalysisindetectingpos- sibledifferencesinbloodflowpatternsbetweenmalignant9–11 andbenign12–14analcanalandrectaldiseases.Althoughcolor Dopplerultrasoundhasbeenusedtoevaluatetissuechanges, toourknowledge nodata are availableconcerningnormal vascularizationintheanalcanalandrectalwall.

Itisknownthattheanalcanalandrectalwalldifferfrom eachotherinanatomicstructuresandinbloodvesselsupply anddistribution.Thepurposeofthisstudywastouse360 colorDopplerendorectalultrasonographytodeterminenor- malrangesforvascularparametersatdifferentlevelsofthe femaleandmaleanalcanal,rectalwall,andmesorectalfat

inordertoprovidereferencevaluesthatcanfacilitatefuture comparisonsofanalcanalstructuresindiseasestates.

Subjects and methods

Subjects

Consecutiveasymptomaticvolunteers(aged≤50years)were recruitedamongemployeesattwoacademichospitalsinFor- taleza(ClinicalHospitaloftheFederalUniversityofCearáand SãoCarlosHospital).Theclinicalprotocolwasapprovedbythe ResearchEthicsCommitteeoftheWalterCantídioUniversity Hospital,andallsubjectsgavewritteninformedconsent.

Prospectivesubjectswereevaluatedclinicallyandunder- went aphysicalexaminationwhichincludeddigitalexami- nation and assessmentforpelvic organprolapse according to thePelvic OrganProlapse Quantificationsystem (POP-Q) inwomen.11 Menandnulliparous womenwereincluded if theyhadnoanalcanal,rectal,orurinarydisorders.Women were included if their POP-Q status was stage 0. Subjects with fecal incontinence, constipation, urinary symptoms,

(3)

inflammatoryboweldisease,HumanImmunodeficiencyVirus (HIV),analsphincterinjury,ahistoryofcolorectalorprocto- logicalsurgery,orvaginaldeliverywereexcluded.

Endorectalultrasonography

Allsubjectsunderwent360 colorDopplerendorectal ultra- sonography(5–7MHz).ADoppler360radial-arrayendorectal ultrasoundtransducer(Hitachi-AlokaEUP-R54AW-33,Hitachi MedicalSystems, Tokyo, Japan)was used witha Hi Vision AviusUltrasoundSystem(Hitachi).

Subjectswere examinedintheleft lateral positionafter administrationofarectalenema(completed2hbeforescan- ning). After digital rectal examination, the endoprobewas introducedintotheanalcanalandtherectum.Thevascular patternsoftheanalcanalandrectumwereacquiredincolor Dopplermode.

Assessments

Todefinevascularparametersandassesspotentialdifferences amongvariouslevelsandstructures,theanalcanalandrec- tumweredividedintodifferentmanuallydelineatedregions ofinterest.Theanal canalregionwasdivided into3levels (upper,middle, andlow anal canal)at2depths (outerand innerstructures).Theouterstructuresincludedthepuborec- talispluslongitudinalmuscleattheupperlevel,theExternal Anal Sphincter (EAS) plus longitudinalmuscle atthe mid- dlelevel,andtheEASatthelowerlevel.Theinner(deeper) structures included the Internal Anal Sphincter (IAS) plus thesubepithelialtissuesatboththeupperandmiddlelevels (Figs.1–3).

Theregionsofinterestfortherectumincludedtherectal wallandmesorectalfatat2positions:5–6cm(low)and8–9cm (middle)fromtheanalverge(Fig.4).

Thesystemautomaticallycalculatedthevascularityper- centageandvascularityindexwithineachregionofinterest.

Vascularitypercentagewasdefinedasthepercentageofpix- elswithintheregionofinterestthatshowedacolorDoppler signalofanyintensity(indicatingthepresenceofbloodflow).

Vascularityindexwasdefinedasthemeanpowerofeachpixel withintheregionofinterest.

Thesystem also automaticallycalibrated distancesand colorhuesasflowvelocitiesandcalculatedthecolorpixelarea andflowvelocity–encodedbyeachpixel–insideeachregion ofinterest.ThesamesetupofcolorDopplermodewasused for all participants (Pulse Repetition Frequency [PRF=0.5];

gain=50%;velocity=3.3cm/s).

Thestructures were traced manually at each level and thedeviceautomaticallymeasuredthevascularparameters twice,calculatedthemean,andmadecomparisonsbylevel, structure,andsex.

Statisticalanalysis

Theanatomic structureswerecomparedaccordingtolevel, depth,andsexandwithregardtovascularitypercentageand index.Differencesbetweengroupswereassessedbymeansof theStudentttestforcontinuousdata.Thelevelofstatistical significancewassetatp<0.05.

DatawereanalyzedusingSPSSsoftware(version14.0for Windows;IBM-SPSS,Chicago,IL).

Results

Subjectcharacteristics

BetweenAugust2012andFebruary2013,atotalof31volunteer subjectsconsentedtoparticipateinthis study.Ofthese,31 subjectsmetinclusioncriteriaandwereenrolledinthestudy.

Thestudypopulationincluded15women,withameanageof 31(SD=6.4;range23–47years),and16men,withameanage of38(SD=7.4;range27–48years).

Analcanal

Table1presentsthe vascularparametersfortheouter and innerstructuresoftheanalcanalat3levels(upper,middle, andlow)inwomenandmen.

Women

Evaluationoftheouterstructuresoftheanalcanalinwomen showed significantly highermean vascular percentage and vascularindexvaluesinthepuborectalis(upperlevel)andin themid-levelEASthanintheEASatthelowerlevel,butthere wasnodifferencebetweenthepuborectalisandtheEASatthe middlelevel.Evaluationoftheinnerstructuresattheupper andmiddlelevelsshowedthatthevascularpercentageand indexfortheIASweresignificantlyhigherattheupperlevel thanatthemiddlelevel.Comparisonoftheouterandinner structuresshowedthatbothvascularpercentageandindex weresignificantlyhigherinthepuborectalisthanintheupper IASandalsosignificantlyhigherinthemid-levelEASthanin themid-levelIAS.

Men

Asinwomen,assessmentoftheouterstructuresoftheanal canalinmenshowedthatthevascularpercentageandindex werebothsignificantlyhigherinthepuborectalisandinthe mid-level EAS than in the low EAS, but no difference was observedbetweenthepuborectalisandthemid-levelEAS.Of theinnerstructuresinmen,theIAShadsignificantlyhigher meanvascularity percentageandindexvaluesattheupper level than atthe middle level. Incontrast to women,men showednodifferenceinvascularitypercentagebetweenthe puborectalisandtheupperIAS.However,asinwomen,the vascularityindexinmenwassignificantlyhigherinthepub- orectalisthanintheupperIAS.Bothvascularitypercentage andindexweresignificantlyhigherinthemid-levelEASthan inthemid-levelIAS.

Comparisonsbetweenmenandwomen

No significant differences were found between men and women regardingeithervascularity percentageor indexin any of the outer anal canal structures. However,men had higher values for both vascularity percentage and index at the upper and middle levels of the inner anal canal structures.

(4)

Fig.1–Femaleanalcanal–upperanalcanal–regionsofinterest.PR,puborectal;LM,longitudinalmuscle;IAS,internalanal sphincter;ST,subepithelialtissues.(A)Outerstructures;(B)Innerstructures.

Fig.2–Femaleanalcanal–middleanalcanal–regionsofinterest.EAS,externalanalsphincter;LM,longitudinalmuscle;

IAS,internalanalsphincter;ST,subepithelialtissues.(A)Outerstructures;(B)Innerstructures.

Fig.3–Femaleanalcanal–lowanalcanal–regionof interest–outerstructures.

Rectumandmesorectalfat

Table2presentsthevascularparametersfortherectumand themesorectumatthemiddleandlowlevels.

Women

Themeanvascularitypercentageandindexweresignificantly higherintherectalwallthaninthemesorectalfatatboththe middleandlowlevels.However,nodifferencesinvascularity percentageorindexwereobservedbetweenmiddleandlow levelsofeithertherectalwallorthemesorectalfat.

Men

Asinwomen,themeanvascularitypercentageandindexin menwerebothsignificantlyhigherintherectalwallthanin themesorectalfatatlowandmiddlepositions,andnosignif- icantdifferenceswereseeninvascularitypercentageorindex incomparisonsofmiddlevslowlevelsoftherectalwallorof mesorectalfat.

Comparisonsbetweenmenandwomen

No significant differences were found between men and womenregardingvascularityoftherectalwallormesorectal fatateithermiddleorlowlevels.

Discussion

Treatment ofanorectaldisorders requiresextensiveknowl- edge of anatomy. Detailed evaluation of vascularity may be important for understanding the physiopathology of

(5)

Fig.4–Maleanalcanal–middleposition–regionsofinterest.(A)Rectalwall;(B)Mesorectalfat.

Table1–Vascularitypercentageandvascularityindexfortheouterandinnerstructuresoftheanalcanalat3levels (upper,middle,andlow)inwomenandmen.

Vascularity% Vascularityindex

Women(n=14) Men(n=16) Women(n=14) Men(n=16) Outerstructures,mean±SD(range)

Upper-levelPR+LM 6.0±2.2a(3.1–10.7) 6.4±2.6a(2.6–10.3) 0.29±0.19(0.12–0.71)a 0.25±0.17(0.05–0.61)a Mid-levelEAS+LM 5.0±2.4a(1.8–8.9) 6.0±1.6a(3.3–7.7) 0.27±0.18(0.12–0.71)a 0.28±0.14(0.07–0.53)a Lower-levelEAS 2.4±1.2a(0.7–4.7) 3.2±1.9a(0.6–6.1) 0.06±0.03(0.01–0.13)a 0.09±0.07(0.01–0.26)a Comparisonbylevel(p)

Upper-levelPRvs.mid-levelEAS 0.29 0.66 0.10 0.72

Upper-levelPRvs.lower-levelEAS 0.0001 0.007 0.0009 0.01

Mid-levelEASvs.lower-levelEAS 0.005 0.002 0.0009 0.002

Innerstructures,mean±SD(range)

Upper-levelIAS+SE 3.7±2.7b(0.8–8.1) 6.6±2.9b(1.5–10.9) 0.30±0.30(0.02–0.79)b 0.76±0.52(0.09–1.80)b Mid-levelIAS+SE 0.6±0.4c(0.1–1.1) 2.0±1.7c(0.2–4.8) 0.03±0.04(0.0–0.11)d 0.14±0.17(0.0–0.49)d Comparisonbylevel(p)

UpperIASvs.midIAS 0.001 0.001 0.01 0.01

Outervs.innerstructures(p)

Upper-levelPRvs.upper-levelIAS 0.04 0.84 0.01 0.01

Mid-levelEASvs.mid-levelIAS 0.0001 0.0001 0.0003 0.03

PR,Puborectalis;LM,LongitudinalMuscle;EAS,ExternalAnalSphincter;IAS,InternalAnalSphincter;SE,SubepithelialTissues.

a Nosignificantdifferencebetweenmenandwomen:p>0.05.

Significantlyhigherinmenthaninwomen:

b p=0.02.

c p=0.01.

d p=0.048.

such disorders in order to choose the best methods of treatment. Various Doppler techniques have been used to understanddistributionofvascularityinbenignand malig- nant disorders.9–15 Thisis the first report using 360 color Doppleranorectalultrasonographytoassessthevascularity ofstructures at different levels of the anal canal, rectum, andmesorectalfat.Theadvantageofthistechniqueisthat itmakesitpossibletomeasurevascularitycircumferentially instead of by quadrant. The 360 endoluminal approach clearly identified and enabled quantitative assessment of vascularparametersforinnerandouteranatomicstructures atupper,mid,andlowlevelsoftheanalcanal,andatmiddle andlowlevelsoftherectalwallandmesorectalfat.

Becausethe participants were asymptomatic volunteers agedupto50years,thestudyprovidesreferencevaluesfor these areas. There was a very large variation in the nor- malrangesforallmeasurements.Inbothsexes,thegreatest degreeofvascularitywasfoundattheupperlevelsoftheanal canalandleastinthelowanalcanal.Comparedwiththeupper levels,thelowanalcanalrequiresonlyamodestbloodsupply andmanyofitsbloodvesselsaresmallindiameter.Wealso analyzedtheanalcanalaccordingtothefunctionsofthemus- clesintheouterstructures,includingthelongitudinalmuscle, puborectalis, and EAS (voluntary muscles), as well as the innerstructures,includingsubepithelialtissuesandtheIAS(a smoothmuscleinastateofcontinuousmaximalcontraction,

(6)

Table2–Vascularitypercentageandvascularityindexmeasuredintherectalwallandmesorectalfatat2levels(middle andlower)inwomenandmen.

Vascularity% Vascularityindex

Women(n=14) Men(n=16) Women(n=14) Men(n=16)

Middlelevel,mean±SD(range)

Rectalwall 10.9±8.3a(4.0–29.7) 12.2±7.0a(1.9–24.0) 1.59±1.37a(0.39–5.46) 1.74±0.98a(0.14–3.27) Mesorectalfat 4.1±3.2a(0.4–9.6) 4.6±2.6a(1.1–9.6) 0.37±0.27a(0.03–0.73) 0.59±0.34a(0.20–1.30)

Rectalwallvs.mesorectalfat 0.01 0.0008 0.006 0.0003

Lower-level,mean±SD(range)

Rectalwall 12.8±7.0a(2.2–22.3) 11.4±7.2a(1.1–23.5) 1.52±1.27a(0.28–4.21) 1.72±1.23a(0.09–3.60) Mesorectalfat 5.9±4.1a(0.5–12.6) 4.0±3.3a(0.2–10.5) 0.52±0.57a(0.04–2.11) 0.51±0.58a(0.01–2.20)

Rectalwallvs.mesorectalfat 0.01 0.002 0.02 0.003

Comparisonbylevel(p)

Midvs.lowerrectalwall 0.7 0.78 0.9 0.96

Midvs.lowermesorectalfat 0.25 0.62 0.45 0.68

a Nosignificantdifferencebetweenmenandwomen:p>0.05.

representinganaturalbarriertotheinvoluntarylossofstool andgas).Inbothsexes,greatervascularitywasfoundinthe outerstructuresoftheupperandmid-levelanalcanalthanin theinnerstructures,reflectingrequirementsforalargesupply ofbloodintheouterstructures,possiblybecausetheycontain striatedmuscles,whicharethickerthansmoothmuscles.

Previousstudieshaveshownthatanalcanalmuscles(both striated and smooth muscles) are longer in men than in women.Wefoundgreatervascularityattheupperandmid- dlelevelsoftheinneranalcanalstructuresinmencompared withwomen.Howevernodifferenceswerefoundbetweenthe sexesregardingvascularityofthemiddleorlowrectalwallor mesorectalfat.Vascularitywasgreaterintherectalwallthan inthemesorectalfatatbothlevelsandinbothsexes.Despite itsthinnerrectallayer,therectalwallrequiresalargeblood supplyandhasmanyhigh-diameterbloodvessels.

Onelimitationofthismethod isthenecessityforman- ualdelineationoftheregionofinterest.However,theimage hashighresolutionandisthereforeabletoeasilyidentifythe anatomic structuresand muscles inordertoassess vascu- larity.Futuredevelopmentofthemethodmayenable3D/4D analysisofthe vasculardistribution andquantitativevolu- metricassessmentofthevesselnetwork.Inthemeantime, becausetheDoppler360endorectalultrasoundisarelatively newtechnique,furtherstudies shouldcompareit withthe useofdifferentultrasoundmethods,suchastransperinealor transvaginaltechniques.

Applicationof360colorDopplerendorectalultrasonogra- phycanbeusefulinmanydifferentsituations.Forexample, patientswithhemorrhoidsshouldbeinvestigatedwiththis method.Changesinthevascularityofinnerandouterstruc- tures may correlate with the resultsof treatment, making it possibletodemonstratethe efficacy ofdifferent surgical techniques.14,15 In another application, Drudi et al.10 com- pared the ability of gray-scale transrectal ultrasound with thatofcolorDopplerimagingtodifferentiatebetweenpost- radiationfibrosis andresidualtumororlocalrelapse.Color Dopplerincreasedthespecificityoftransrectalultrasoundin differentiatingtumorrelapsefromfibrosis,demonstratingits valueintheevaluationofcarcinomaoftheanalcanal,bothin thepre-therapeuticstageandduringfollow-up,whencolor

Doppler-guided biopsy should be preferred to ultrasound- guidedbiopsy.

New researchshould evaluatesome ofthe factors that could affect the Doppler flow spectrum in the anal canal andrectum,forexample,previousstudieshavedemonstrated the influence offactors suchassex hormones,aging, par- ity, bodymassindex,andmenopause onthevascularityof various structures.16 Oliveira etal.12 evaluated theDoppler velocimetric parameters of the levator ani muscle vessels in premenopausalwomenwithand without urinary stress incontinenceandfoundthatDopplervelocimetricdifferences inthelevatoranimusclevesselsmightbeduetohormonalsta- tus.Jármy-DiBellaetal.17usedDopplervelocimetricanalysis toinvestigatetheeffectofhormonetherapyinperiurethral vessels and demonstrated that hormonal therapy ofshort duration had a positive effect on the urethral continence mechanism,increasingthenumberofperiurethralvessels.

Afurtherstudyinpatientswithsymptomsoffecalincon- tinenceand/orobstructeddefecationsyndromewithperineal descentshouldbeconductedtoinvestigatevascularparam- eters insuchpatients and toidentifyany riskfactors that couldnegativelyaffecttreatmentoutcome.Apreviousstudy18 demonstratedthatpregnancyandlabormayleadtoperineal trauma,deteriorationofvascularsupply,andnervefunction inthepelvicfloorarea,therebyimpairingurinarycontinence, butnocorrelationwithfecalincontinencewasfound.

Itwouldalsobeinterestingtostudy agroupofpatients withinflammatorydisease,becauseapreviousinvestigation19 usingpowerDopplerabdomensonographyhasshownacor- relationbetweenbowelwallvascularityanddiseaseactivity inpatientswithconfirmedCrohn’sdisease.Theauthorssug- gestedthatpowerDopplerabdomenultrasoundmaybeable tomonitoractivitychangesofthebowelwallcausedbyphar- maceuticaltreatment.Afurtherstudyshouldbeconducted toinvestigatetherelationshipbetweenanalcanalvascularity anddiseaseactivityinpatientswithperianalCrohn’sdisease.

TheusefulnessofendorectalDopplersonographicanalysis of rectal tumor vascularization before and after preopera- tiveradiotherapy hasalso beendescribed in theliterature.

Barbaro etal.20 usedcolorDopplerultrasoundtostudy the relationship between the vasculature supplying blood flow

(7)

torectalcancerand responsetoaneoadjuvantregimenin patients with rectal cancer. Homogeneous vascularity and low pulsatility index values from arterial signals sampled from the peripheralportion ofrectalmasses were positive indicatorsoftherapyoutcome.Oguraetal.9suggestedthatthe intratumoralvascularpoint indexasassessedbytransanal color Doppler ultrasonography is better than conventional immunohistochemicalanalysisasapreoperativeindicatorof angiogenesisandmayalsobeapredictorforhematogenous metastasisinrectalcarcinoma.

Inconclusion,thedegreeofvascularityvariesamongthe differentlevelsandstructuresoftheanalcanal.Bloodsup- plyishighestatupperlevelsofouterandinnerstructuresof theanalcanalinbothmenandwomen,butinnerstructures arebettersuppliedinmenthaninwomen.Inbothsexes,the rectalwallisbettersuppliedthaninmesorectalfat.Consid- eringthesevariations,thenormalrangesdeterminedinthis study using360 colorDopplerultrasonography may facili- tatefuturecomparisonsofanalcanaland rectalstructures indiseasestates,aswell as,the hormonalandagerelated changes.

Compliance with ethical standards

TheInstitutionalReviewBoardoftheWalterCantídioUniver- sityHospitalapprovedthestudyprotocolandallsubjectsgave theirwritteninformedconsent.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

references

1. NielsenMB,HaugeC,PedersenJF,ChristiansenJ.

Endosonographicevaluationofpatientswithanal incontinence:findingsandinfluenceonsurgical management.AmJRoentgenol.1993;160:771–5.

2. WestRL,DwarkasingS,Felt-BersmaRJ,SchoutenWR,Hop WC,HussainSM,etal.Hydrogenperoxide-enhanced three-dimensionalendoanalultrasonographyandendoanal magneticresonanceimaginginevaluatingperianalfistulas:

agreementandpatientpreference.EurJGastroenterol Hepatol.2004;16:1319–24.

3. ChristensenAF,NielsenMB,EngelholmSA,RoedH,Svendsen LB,ChristensenH.Three-dimensionalanalendosonography mayimprovestagingofanalcancercomparedwith two-dimensionalendosonography.DisColonRectum.

2004;47:341–5.

4. Murad-RegadasSM,RegadasFS,RodriguesLV,BarretoRG, MonteiroFC,LandimBB,etal.Roleofthree-dimensional anorectalultrasonographyintheassessmentofrectalcancer afterneoadjuvantradiochemotherapy:preliminaryresults.

SurgEndosc.2009;23:1286–91.

5. RegadasFS,Murad-RegadasSM,LimaDM,SilvaFR,Barreto RG,SouzaMH,etal.Analcanalanatomyshowedby

3-dimensionalanorectalultrasonography.SurgEndosc.

2007;21:2207–11.

6.RegadasFS,HaasEM,AbbasMA,MarcioJorgeJ,Habr-GamaA, SandsD,etal.Prospectivemulticentertrialcomparing echodefecographywithdefecographyintheassessmentof anorectaldysfunctioninpatientswithobstructeddefecation.

DisColonRectum.2011;54:686–92.

7.Murad-RegadasSM,RegadasFS,RodriguesLV,HolandaEC, BarretoRG,OliveiraL.Theroleof3-dimensionalanorectal ultrasonographyintheassessmentofanterior

transsphinctericfistula.DisColonRectum.2010;53:1035–40.

8.VittonV,VignallyP,BarthetM,CohenV,DurieuxO,Bouvier M,etal.DynamicanalendosonographyandMRI

defecographyindiagnosisofpelvicfloordisorders:

comparisonwithconventionaldefecography.DisColon Rectum.2011;54:1398–404.

9.OguraO,TakebayashiY,SameshimaT,MaedaS,YamadaK, HataK,etal.Preoperativeassessmentofvascularitybycolor Dopplerultrasonographyinhumanrectalcarcinoma.Dis ColonRectum.2001;44:538–46.

10.DrudiFM,GiovagnorioF,RaffettoN,RicciP,CasconeF, SantarelliM,etal.TransrectalultrasoundcolorDopplerinthe evaluationofrecurrenceofanalcanalcancer.EurJRadiol.

2003;47:142–8.

11.TankovaLT,PenchevPI,KovatchkiD,StoilovG,HadjievaT.

Endosonographicassessmentofrectalcancerafter neoadjuvantradiotherapy.MedUltrason.2012;14:19–23.

12.OliveiraE,CastroRA,TakanoCC,BezerraLR,SartoriMG,Lima GR,etal.UltrasonographicandDopplervelocimetric evaluationofthelevatoranimuscleinpremenopausal womenwithandwithouturinarystressincontinence.EurJ ObstetGynecolReprodBiol.2007;133:213–7.

13.KobataSA,GirãoMJ,BaracatEC,KajikawaM,DiBellaVJr, SartoriMG,etal.Estrogentherapyinfluenceonperiurethral vesselsinpostmenopausalincontinentwomenusing Dopplervelocimetryanalysis.Maturitas.2008;61:

243–7.

14.MiyamotoH,AsanomaM,MiyamotoH,TakasuC,Masamune K,ShimadaM.Visualizationandhypervascularizationofthe haemorrhoidalplexusinvivousingpowerDopplerimaging transanalultrasonographyand3-dimensionalpowerDoppler angiography.ColorectalDis.2013;15:e686–91.

15.MiyamotoH,AsanomaM,MiyamotoH,TakasuC,ShimadaM.

Three-dimensionalpowerDopplertransanalultrasonography, tomonitorhaemorrhoidalbloodflowafterDoppler-guided ALTAsclerosingtherapy.ColorectalDis.2013;15:e84–8.

16.MiodragA,CastledenCM,VallanceTR.Sexhormonesandthe femaleurinarytract.Drugs.1988;36:491–504.

17.Jármy-DiBellaZI,GirãoMJ,DiBellaV,SartoriMG,SzejnfeldJ, BaracatEC,etal.Hormonalinfluenceonperiurethralvessels inpostmenopausalincontinentwomenusingDoppler velocimetryanalysis.Maturitas.2007;56:297–302.

18.LienKC,MooneyB,DeLanceyJO,Ashton-MillerJA.Levatorani musclestretchinducedbysimulatedvaginalbirth.Obstet Gynecol.2004;103:31–40.

19.DrewsBH,BarthTF,HänleMM,AkinliAS,MasonRA,Muche R,etal.Comparisonofsonographicallymeasuredbowelwall vascularity,histology,anddiseaseactivityinCrohn’sdisease.

EurRadiol.2009;19:1379–86.

20.BarbaroB,ValentiniV,CocoC,ManciniAP,GambacortaMA, VecchioFM,etal.Tumorvascularityevaluatedbytransrectal colorDopplerUSinpredictingtherapyoutcomeforlow-lying rectalcancer.IntJRadiatOncolBiolPhys.2005;63:1304–8.

Referências

Documentos relacionados

The probability of attending school four our group of interest in this region increased by 6.5 percentage points after the expansion of the Bolsa Família program in 2007 and

The mean rest pressures of the anal canal were analyzed, as well as the gauge length of the sphincter. The mean pressure and the differentials obtained in the contention

Firstly, we checked if the participants that chose Habit Validation interventions reported different levels of emotional arousal, difficulty to attend to everything the

Neste trabalho o objetivo central foi a ampliação e adequação do procedimento e programa computacional baseado no programa comercial MSC.PATRAN, para a geração automática de modelos

FIGURA 5 - FLUTUAÇÃO POPULACIONAL DE Hypothenemus eruditus, Sampsonius dampfi e Xyleborus affinis (SCOLYTINAE, CURCULIONIDAE) COLETADOS COM ARMADILHAS ETANÓLICAS (25%)

Em sua pesquisa sobre a história da imprensa social no Brasil, por exemplo, apesar de deixar claro que “sua investigação está distante de ser um trabalho completo”, ele

É nesta mudança, abruptamente solicitada e muitas das vezes legislada, que nos vão impondo, neste contexto de sociedades sem emprego; a ordem para a flexibilização como

Este artigo discute o filme Voar é com os pássaros (1971) do diretor norte-americano Robert Altman fazendo uma reflexão sobre as confluências entre as inovações da geração de