Endorectal/anal ultrasound scanning is an essential component of the service provided by a Specialist Colorectal unit. This technique scans the anal canal and rectum detecting and staging cancers of both, using a rotating head scanner, which provides a 360-degree view of the entire anal canal and rectal wall and the adjacent structures.
Benefits to Patients with Anal and Rectal pathologies:

a) Drastic reduction in waiting time – Patients with Rectal cancers need their tumour to be staged to plan appropriate treatment. Experience in Colorectal units would suggest that Endorectal ultrasound scanning of the rectum is the most accurate of current modalities of investigation and can be undertaken much more quickly than alternative methods of staging investigation. In the East Kent NHS Trust, the accuracy of ERUS is 82% for low rectal cancers as apposed to MRI which is 64%. Two thirds of rectal cancers are below the peritoneal reflection and well within reach of endo-rectal scanner. Many of these would then undergo curative resection of their rectal cancer. In the Pelvic floor clinic, one would expect these patients to have a USS of the liver in the same sitting. This would shorten the staging time significantly.

I currently run outpatient clinics at William Harvey Hospital on Monday afternoons, at Bucklands hospital, Dover on Wednesday mornings alternating with RVH Folkestone. A patient with suspected rectal cancer seen in one of these clinics could be listed urgently for Endorectal and anal scan without special bowel preparation in the Pelvic floor list on Tuesday afternoon. Having staged the tumour, a decision can be made towards using preoperative Radiotherapy or alternatively surgery as the primary modality of treatment. If surgery is decided upon, then the patient can be listed at the earliest available date. With this arrangement, I anticipate that rectal cancers need not wait longer than three weeks for initiation of their treatment after having been seen in the outpatient clinic and they need not wait longer than four to five weeks from seeing their GP. In other words the Endorectal scanner will enable the colorectal unit to practice within the Government guidelines for treatment of cancers within four weeks. This is only for 2/3 rds of rectal cancers.

b) Delineation of anatomy of anal sphincter damage and complex fistulae:
At the moment there are a number of patients with sphincter damage or with
complex fistulae. In the past, these patients have necessarily been referred to
St.Marks, London for evaluation, leading to inevitable delay in treatment.
Provision of local Endoanal ultrasound represents a cost-effective approach to
Patients with damaged sphincters and functional disorders of the anorectum. Here is a picture of an endoanal USS which shows the damaged anal external and internal sphincter. The dark line is the internal spincter and the white line is the external sphincter.

Personnel:

I have the necessary training and experience to establish the scanner service. I have spent two years of my research period with a B-K endorectal/anal scanner at the University of Hull (Professorial colorectal unit) and I have spent a sabbatical at the University of Minnesota in the Pelvic floor laboratory learning about endorectal and anal scanning. This is in addition to attending the course at the University of Minnesota in the art of scanning the anorectum. I will therefore be the primary operator of this and all those who are interested (eg- our Gastroenterological/Gynaecological/Urological colleagues) in learning the technique can use the scanner under my supervision.

Quality control:

a) Initial quality control will be with the help of the B-K ultrasound scanner personnel who will make sure there are no technical problems with the machine.
b) I will interpret the images obtained, during and immediately after the procedure. Doubtful images will be discussed in our Multidisciplinary meetings Final confirmation will be provided by the Histopathologist who will be able to correlate the scanned images with the stage of the tumour under the microscope following resection.

FUTURE

I envisage an excellent ‘state of the art’ service to patients with anorectal disorders in general and anorectal cancers in particular. With the introduction of the scanner into William Harvey Hospital, highest quality East Kent staging service can be offered, which will undoubtedly cut down the waiting times for patients with rectal cancers. This facility will help in providing an ideal rapid access service to our unfortunate patients with rectal malignancies.
I see the scanner as the way forward in gaining vital recognition for what we are trying to do in our Colorectal unit. This will be in the form of Level 3 recognition and a steady input of senior trainees in Coloproctology.

With extra-contractual referrals, the scanner will probably pay for itself and at the same time provide an accurate staging service for rectal malignancies and diagnose sphincter damage and fistulae.

FURTHER DEVELOPMENTS

This scanner can be used in theatre for complex anorectal evaluations and during laparoscopic or open surgery to the liver to identify metastasis. There are also facilities for scanning the pancreas and for the assessment of Portal vein blood flow in patients with Cancer of pancreas. These additional attachments may be obtained in the future if the clinical need arises or perhaps, with the help of a research fund for a specific project in that area.