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Karmakar R, Gupta D, Mukundan A, Wang HC. Hydrogen peroxide-enhanced magnetic resonance imaging: A novel approach for diagnosing anorectal-fistula. World J Radiol 2025; 17. [DOI: https:/doi.org/10.4329/wjr.v17.i3.105777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2025] Open
Abstract
In this editorial, a commentary on the article by Chang et al has been provided, the course of treatment of anorectal fistulas, especially complex and recurring ones, require accurate diagnostic procedures for determining ideal surgical procedures. Conventional ways of imaging sometimes fall short, offering insufficient insights in aggravated instances. In this editorial, a novel application of hydrogen peroxide-enhanced magnetic resonance imaging (HP-MRI) that promises significant improvements in the imaging of anorectal fistula. Study is based on a retrospective investigation of 60 patients, contrasts the new HP-MRI with conventional diagnostic techniques such as physical examination, trans-perineal ultrasonography and poor spatial resolution MRI. The findings demonstrate HP-MRI's incredible diagnostic performance, with sensitivity and specificity rates of 96.08% and 90.91%, respectively, and unparalleled interobserver agreement (Kappa values ranging from 0.80 to 0.89). It has been a significant advancement for assessment of anorectal fistulas providing a better roadmap for surgical planning, lowering recurrence rates as well as reduced personal and financial burden on patients by reducing the need for repeated treatment and extended hospital stays. The remaining funds can be utilized for treatment of other medical need. Ultimately HP-MRI provides us a healthier & more efficient society by improvising patients well-being & optimized healthcare infrastructure.
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Karmakar R, Gupta D, Mukundan A, Wang HC. Hydrogen peroxide-enhanced magnetic resonance imaging: A novel approach for diagnosing anorectal-fistula. World J Radiol 2025; 17:105777. [PMID: 40176955 PMCID: PMC11959619 DOI: 10.4329/wjr.v17.i3.105777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2025] [Revised: 03/11/2025] [Accepted: 03/17/2025] [Indexed: 03/27/2025] Open
Abstract
In this editorial, a commentary on the article by Chang et al has been provided, the course of treatment of anorectal fistulas, especially complex and recurring ones, require accurate diagnostic procedures for determining ideal surgical procedures. Conventional ways of imaging sometimes fall short, offering insufficient insights in aggravated instances. In this editorial, a novel application of hydrogen peroxide-enhanced magnetic resonance imaging (HP-MRI) that promises significant improvements in the imaging of anorectal fistula. Study is based on a retrospective investigation of 60 patients, contrasts the new HP-MRI with conventional diagnostic techniques such as physical examination, trans-perineal ultrasonography and poor spatial resolution MRI. The findings demonstrate HP-MRI's incredible diagnostic performance, with sensitivity and specificity rates of 96.08% and 90.91%, respectively, and unparalleled interobserver agreement (Kappa values ranging from 0.80 to 0.89). It has been a significant advancement for assessment of anorectal fistulas providing a better roadmap for surgical planning, lowering recurrence rates as well as reduced personal and financial burden on patients by reducing the need for repeated treatment and extended hospital stays. The remaining funds can be utilized for treatment of other medical need. Ultimately HP-MRI provides us a healthier & more efficient society by improvising patients well-being & optimized healthcare infrastructure.
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Affiliation(s)
- Riya Karmakar
- Department of Mechanical Engineering, National Chung Cheng University, Chiayi 62102, Taiwan
| | - Devansh Gupta
- Department of Computer Science & Engineering, Thapar Institute of Engineering & Technology, Patiala 147001, Punjab, India
| | - Arvind Mukundan
- Department of Mechanical Engineering, Center for Innovative Research on Aging Society, National Chung Cheng University, Chiayi 621, Taiwan
| | - Hsiang-Chen Wang
- Department of Mechanical Engineering, National Chung Cheng University, Chiayi 62102, Taiwan
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de la Portilla de Juan F, García-León A, García-Sánchez CJ, Marín G, Reyes-Díaz ML, Vázquez-Monchul J, Padillo Ruiz FJ. Comparative Study of Diluted Hydrogen Peroxide and Sulfur Hexafluoride in the Contrast-Enhanced Ultrasound Assessment of Anal Fistulas. Dis Colon Rectum 2024; 67:1450-1457. [PMID: 39087688 DOI: 10.1097/dcr.0000000000003445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
BACKGROUND Endoanal ultrasound for the diagnosis of anal fistulas requires the injection of hydrogen peroxide, but it is often uncomfortable for the patient and has the potential to cause complications. Novel ultrasound contrast is currently available. OBJECTIVE To assess the efficacy and safety of sulfur hexafluoride as an ultrasound contrast agent for the diagnosis of a perianal fistula by comparing it with those of 50% diluted hydrogen peroxide. DESIGN Double-blinded superiority study with 4 consecutive visits to perform an ultrasound without contrast, a hydrogen peroxide-enhanced ultrasound, a sulfur hexafluoride-enhanced ultrasound, and a rectal exploration in the operating room (the criterion standard). The 3 expert surgeon sonographers independently reviewed the ultrasound images. SETTING This study was conducted at a single university hospital. PATIENTS Data from 176 patients were evaluated. MAIN OUTCOME MEASURES Demographic and exploratory data and the ultrasound findings related to the location of the internal fistula orifice, description of the primary and secondary tracts, and presence of cavities and sphincter defects were analyzed. Complications occurring before and after the contrast agent administration and pain score measured using a visual analog scale were considered. RESULTS Eighty-eight patients were included (men: 71.5%; mean age: 48.3 years), with 62.5% having a complex type fistula and 83.7% having a transsphincteric type fistula. Sulfur hexafluoride-enhanced ultrasounds demonstrated a higher interobserver agreement in determining the secondary tracts (κ = 0.604) and anal fistula height (κ = 0.604) compared with other methods. Both hydrogen peroxide-enhanced ultrasound (90.91%) and sulfur hexafluoride-enhanced ultrasound (89.77%) detected the internal orifice more frequently than ultrasounds without contrast (62.5%; p < 0.001), with no differences between contrast agents ( p = 0.810). Sulfur hexafluoride-enhanced ultrasound was less painful than peroxide-enhanced ultrasound ( p < 0.001). LIMITATIONS Most of the patients had transsphincteric anal fistulas. CONCLUSIONS Sulfur hexafluoride proved comparable to hydrogen peroxide in evaluating fistulous tracts and identifying the internal orifice, and it significantly reduced pain and discomfort. Furthermore, it demonstrated a higher interobserver agreement in determining the secondary tracts and anal fistula height compared with other methods. See Video Abstract . ESTUDIO COMPARATIVO DE PERXIDO DE HIDRGENO DILUIDO Y HEXAFLUORURO DE AZUFRE EN LA EVALUACIN ECOGRFICA CON CONTRASTE DE FSTULAS ANALES ANTECEDENTES:La ecografía endoanal para el diagnóstico de fístulas anales requiere la inyección de peróxido de hidrógeno, pero generalmente resulta incómoda para el paciente y presenta potenciales complicaciones. Actualmente se encuentran disponibles nuevos contrastes ecográficos.OBJETIVO:Evaluar la eficacia y seguridad del hexafluoruro de azufre como agente de contraste ecográfico para el diagnóstico de fístula perianal comparándolo con el peróxido de hidrógeno diluido al 50%.DISEÑO:Estudio de superioridad doble ciego con cuatro visitas consecutivas realizando una ecografía sin contraste, ecografía potenciada con peróxido de hidrógeno, ecografía potenciada con hexafluoruro de azufre y exploración rectal en el quirófano (el estándar de oro). Las imágenes ecográficas fueron revisadas de forma independiente por tres cirujanos ecografistas expertos.AJUSTE:Estudio llevado a cabo en un único hospital universitario.PACIENTES:Se evaluaron datos de 176 pacientes.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los datos demográficos y exploratorios y los hallazgos ecográficos relacionados con la ubicación del orificio interno de la fístula, descripción de los trayectos primario y secundario y la presencia de cavidades y defectos del esfínter. Se consideraron las complicaciones ocurridas antes y después de la administración del agente de contraste y la presencia de dolor medido mediante un puntaje.RESULTADOS:Se incluyeron 88 pacientes (hombres: 71,5%; edad media: 48,3 años). El 62,5% fueron tipo complejo y el 83,7% tipo transesfintérico. Las ecografías mejoradas con hexafluoruro de azufre demostraron mayor concordancia interobservador en la determinación de los trayectos secundarios (κ = 0,604) y la altura de la fístula anal (κ = 0,604) en comparación con otros métodos. Tanto la ecografía con peróxido de hidrógeno (90,91%) como la ecografía con hexafluoruro de azufre (89,77%) detectaron con mayor frecuencia el orificio interno que la ecografía sin contraste (62,5%) (p < 0,001), sin diferencias entre agentes de contraste (p = 0,810). La ecografía potenciada con hexafluoruro de azufre fue menos dolorosa que la ecografía potenciada con peróxido (p < 0,001).LIMITACIONES:La mayoría de los pacientes presentaron fístulas anales transesfintéricas.CONCLUSIONES:El hexafluoruro de azufre demostró ser comparable al peróxido de hidrógeno en la evaluación de los trayectos fistulosos y la identificación del orificio interno y con reducción significativa del dolor y malestar. Además, demostró mayor concordancia interobservador en la determinación de los trayectos secundarios y la altura de la fístula anal en comparación con otros métodos. (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Fernando de la Portilla de Juan
- Colorectal Unit, Department of General and Digestive Surgery, University Hospital Virgen del Rocío, Seville University. Seville, Spain
| | - Anabel García-León
- Department of General and Digestive Surgery, University Hospital Virgen del Rocío, Seville, Spain
| | | | - Gabriel Marín
- Department of General and Digestive Surgery, Colorectal Unit, University Hospital Virgen del Rocío, Seville, Spain
| | - María L Reyes-Díaz
- Department of General and Digestive Surgery, Colorectal Unit, University Hospital Virgen del Rocío, Seville, Spain
| | - Jorge Vázquez-Monchul
- Department of General and Digestive Surgery, Colorectal Unit, University Hospital Virgen del Rocío, Seville, Spain
| | - Francisco J Padillo Ruiz
- Department of General and Digestive Surgery, University Hospital Virgen del Rocío, Seville University. Seville, Spain
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Sudoł-Szopińska I, Garg P, Mellgren A, Spinelli A, Breukink S, Iacobellis F, Kołodziejczak M, Ciesielski P, Jenssen C, SMART Collaborative Group, Santoro GA. Structured magnetic resonance imaging and endoanal ultrasound anal fistulas reporting template (SMART): An interdisciplinary Delphi consensus. World J Gastrointest Surg 2024; 16:3288-3300. [PMID: 39575264 PMCID: PMC11577389 DOI: 10.4240/wjgs.v16.i10.3288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 07/17/2024] [Accepted: 08/23/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND There is still considerable heterogeneity regarding which features of cryptoglandular anal fistula on magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are relevant to surgical decision-making. As a consequence, the quality and completeness of the report are highly dependent on the training and experience of the examiners.
AIM To develop a structured MRI and EAUS template (SMART) reporting the minimum dataset of information for the treatment of anal fistulas.
METHODS This modified Delphi survey based on the RAND-UCLA appropriateness for consensus-building was conducted between May and August 2023. One hundred and fifty-one articles selected from a systematic review of the literature formed the database to generate the evidence-based statements for the Delphi study. Fourteen questions were anonymously voted by an interdisciplinary multidisciplinary group for a maximum of three iterative rounds. The degree of agreement was scored on a numeric 0–10 scale. Group consensus was defined as a score ≥ 8 for ≥ 80% of the panelists.
RESULTS Eleven scientific societies (3 radiological and 8 surgical) endorsed the study. After three rounds of voting, the experts (69 colorectal surgeons, 23 radiologists, 2 anatomists, and 1 gastroenterologist) achieved consensus for 12 of 14 statements (85.7%). Based on the results of the Delphi process, the six following features of anal fistulas were included in the SMART: Primary tract, secondary extension, internal opening, presence of collection, coexisting lesions, and sphincters morphology.
CONCLUSION A structured template, SMART, was developed to standardize imaging reporting of fistula-in-ano in a simple, systematic, time-efficient way, providing the minimum dataset of information and visual diagram useful to referring physicians.
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Affiliation(s)
- Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw 02-637, Poland
| | - Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
| | - Anders Mellgren
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh 11211, Saudi Arabia
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele – Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano – Milan, Italy
| | - Stephanie Breukink
- Department of Surgery, Maastricht and NUTRIM Institute of Nutrition and Translational Research in Metabolism GROW - Research Institute for Oncology and Reproduction, the Netherlands
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, A. Cardarelli Hospital, Naples 80131, Campania, Italy
| | | | | | - Christian Jenssen
- Department of Internal Medicine, Hospital Märkisch Oderland, Strausberg 15344, Brandenburg, Germany and Brandenburg Institute for Clinical Ultrasound, Neuruppin 16186, Brandenburg, Germany
| | | | - Giulio Aniello Santoro
- Third Referral Pelvic Floor Center, Division of Surgery 2, AULSS n.2 Marca Trevigiana, DISCOG University of Padua, Treviso, Italy
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Shehab M, De Marco D, Lakatos PL, Bessissow T. The potential for medical therapies to address fistulizing Crohn's disease: a state-of-the-art review. Expert Opin Biol Ther 2024; 24:733-746. [PMID: 39045643 DOI: 10.1080/14712598.2024.2383882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/25/2024] [Accepted: 07/20/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic, relapsing immune mediated disease, which is one of the two major types of inflammatory bowel disease (IBD). Fistulizing CD poses a significant clinical challenge for physicians. Effective management of CD requires a multidisciplinary approach, involving a gastroenterologist and a GI surgeon while tailoring treatment to each patient's unique risk factors, clinical representations, and preferences. AREAS COVERED This comprehensive review explores the intricacies of fistulizing CD including its manifestations, types, impact on quality of life, management strategies, and novel therapies under investigation. EXPERT OPINION Antibiotics are often used as first-line therapy to treat symptoms. Biologics that selectively target TNF-α, such infliximab (IFX), have shown high efficacy in randomized controlled trials. However, more than 50% of patients lose response to IFX, prompting them to explore alternative strategies. Current options include adalimumab and certolizumab pegol combination therapies, as well as small-molecule drugs targeting Janus kinases such as Upadacitinib. Furthermore, a promising treatment for complex fistulas is mesenchymal stem cells such as Darvadstrocel (Alofisel), an allogeneic stem cell-based therapy. However, surgical interventions are necessary for complex cases or intra-abdominal complications. Setons and LIFT procedures are the most common surgical options.
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Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Al-Kabeer University Hospital, Kuwait University, Kuwait City, Kuwait
| | - Davide De Marco
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
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Verkade C, Brouwers L, Stijns J, van Dal V, Wasowicz DK, de Kiefte M, van Tilborg F, Zimmerman DDE. Validation of a 3D-printed model of cryptoglandular perianal fistulas. Tech Coloproctol 2024; 28:59. [PMID: 38801550 DOI: 10.1007/s10151-024-02925-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/31/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Visualising the course of a complex perianal fistula on imaging can be difficult. It has been postulated that three-dimensional (3D) models of perianal fistulas improve understanding of the perianal pathology, contribute to surgical decision-making and might even improve future outcomes of surgical treatment. The aim of the current study is to investigate the accuracy of 3D-printed models of perianal fistulas compared with magnetic resonance imaging (MRI). METHODS MRI scans of 15 patients with transsphincteric and intersphincteric fistulas were selected and then assessed by an experienced abdominal and colorectal radiologist. A standardised method of creating a 3D-printed anatomical model of cryptoglandular perianal fistula was developed by a technical medical physicist and a surgeon in training with special interest in 3D printing. Manual segmentation of the fistula and external sphincter was performed by a trained technical medical physicist. The anatomical models were 3D printed in a 1:1 ratio and assessed by two colorectal surgeons. The 3D-printed models were then scanned with a 3D scanner. Volume of the 3D-printed model was compared with manual segmentation. Inter-rater reliability statistics were calculated for consistency between the radiologist who assessed the MRI scans and the surgeons who assessed the 3D-printed models. The assessment of the MRI was considered the 'gold standard'. Agreement between the two surgeons who assessed the 3D printed models was also determined. RESULTS Consistency between the radiologist and the surgeons was almost perfect for classification (κ = 0.87, κ = 0.87), substantial for complexity (κ = 0.73, κ = 0.74) and location of the internal orifice (κ = 0.73, κ = 0.73) and moderate for the percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.63, ICC 0.52). Agreement between the two surgeons was substantial for classification (κ = 0.73), complexity (κ = 0.74), location of the internal orifice (κ = 0.75) and percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.77). CONCLUSIONS Our 3D-printed anatomical models of perianal fistulas are an accurate reflection of the MRI. Further research is needed to determine the added value of 3D-printed anatomical models in preoperative planning and education.
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Affiliation(s)
- C Verkade
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - L Brouwers
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - J Stijns
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, University Hospital Brussels, Brussels, Belgium
| | - V van Dal
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - D K Wasowicz
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - M de Kiefte
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- 3D Laboratory, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - F van Tilborg
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- 3D Laboratory, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - D D E Zimmerman
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
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Akhoundi N, Bozchelouei JK, Abrishami A, Frootan M, Siami A, Alimadadi E, Saba GB, Rezazadeh E, Amerifar M, Eghdami E. Comparison of MRI and Endoanal Ultrasound in Assessing Intersphincteric, Transsphincteric, and Suprasphincteric Perianal Fistula. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2057-2064. [PMID: 37040280 DOI: 10.1002/jum.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Perianal fistula is a common disorder characterized by an anomalous perianal track connecting two epithelialized surfaces, most commonly the anal canal and the perianal skin. Although each has its limitations, magnetic resonance imaging (MRI) and endoanal ultrasound are currently two acceptable modalities for assessing perianal fistula. This study aimed to evaluate the accuracy of MRI and endoanal ultrasonography in diagosing perianal fistula, considering the surgical results as the references. METHODS This prospective cohort study was performed on patients with symptomatic perianal fistulas. MRI results of patients reported by the radiologist were collected along with the findings of endoanal ultrasonography performed by a gastroenterologist. These results were compared with surgical findings as the reference standard. RESULTS The study enrolled 126 patients. Exactly 222 definitive fistulas were identified during surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound for perianal fistula were 87.38, 38.46, 92.38, 26.31, and 82.25% respectively; and for MRI were 76.12, 57.69, 93.88, 22.05, and 74.19% respectively. The accuracy of endoanal ultrasound for detecting transsphincteric and intersphincteric fistulas was higher than MRI. In contrast, the diagnostic value of MRI for detecting suprasphincteric fistulas was higher than endoanal ultrasound. CONCLUSIONS Using endoanal ultrasonography to diagnose perianal fistulas is a relatively accurate method. This method may be more sensitive than MRI in detecting patients with perianal fistulas and abscesses.
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Affiliation(s)
- Neda Akhoundi
- Radiology Department, Hillcrest Hospital, University of California San Diego, San Diego, USA
| | - Javad Komijani Bozchelouei
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Abrishami
- Labbafinezhad Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mojgan Frootan
- Gastroenterology Department, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Siami
- Biostatistical Analyzer, Amirkabir University of Technology, Tehran, Iran
| | - Elahe Alimadadi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Gholamreza Bagherzadeh Saba
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Elmira Rezazadeh
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Maryam Amerifar
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Ebrahim Eghdami
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
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Guo M, Zbar AP, Wu Y. Imaging the levator ani and the puborectalis muscle: implications in understanding regional anatomy, physiology and pathology. Scand J Gastroenterol 2023; 58:1295-1308. [PMID: 37309141 DOI: 10.1080/00365521.2023.2220458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 06/14/2023]
Abstract
Purpose:To review the findings of recent dynamic imaging of the levator ani muscle in order to explain its function during defecation. Historical anatomical studies have suggested that the levator ani initiates defecation by lifting the anal canal, with conventional dissections and static radiologic imagery having been equated with manometry and electromyography.Materials and methods:An analysis of the literature was made concerning the chronological development of imaging modalities specifically designed to assess pelvic floor dynamics. Comparisons are made between imaging and electromyographic data at rest and during provocative manoeuvres including squeeze and strain.Results:The puborectalis muscle is shown distinctly separate from the levator ani and the deep external anal sphincter. In contrast to conventional teaching that the levator ani initiates defecation by lifting the anus, dynamic illustration defecography (DID) has confirmed that the abdominal musculature and the diaphragm instigate defecation with the transverse and vertical component portions of the levator ani resulting in descent of the anus. Current imaging has shown a tendinous peripheral structure to the termination of the conjoint longitudinal muscle, clarifying the anatomy of the perianal spaces. Planar oXy defecography has established patterns of movement of the anorectal junction that separate controls from those presenting with descending perineum syndrome or with anismus (paradoxical puborectalis spasm).Conclusions:Dynamic imaging of the pelvic floor (now mostly with MR proctography) has clarified the integral role of the levator ani during defecation. Rather than lifting the rectum, the muscle ensures descent of the anal canal.
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Affiliation(s)
- Maolin Guo
- Department of Radiology, PLA 989 Hospital, Luoyang, P.R. China
| | - Andrew P Zbar
- Department of Neuroscience and Anatomy, University of Melbourne, Melbourne, Australia
| | - Yucen Wu
- Department of Neuroscience and Anatomy, University of Melbourne, Melbourne, Australia
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Okasha HH, Pawlak KM, Abou-elmagd A, El-Meligui A, Atalla H, Othman MO, Elenin SA, Alzamzamy A, Mahdy RE. Practical approach to linear endoscopic ultrasound examination of the rectum and anal canal. Endosc Int Open 2022; 10:E1417-E1426. [PMID: 36262505 PMCID: PMC9576334 DOI: 10.1055/a-1922-6500] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/08/2022] [Indexed: 11/09/2022] Open
Abstract
Standard endosonographic examination of the rectal area is usually performed with radial endoscopic ultrasound (EUS). However, in recent years, widespread availability of linear EUS for assessing various anatomical regions in the gastrointestinal tract has facilitated its use in the assessment of anorectal disorders. Currently, many rectal and anal diseases, including perianal abscesses, fistulae, polyps, and neoplastic lesions, can be well-visualized and evaluated with linear EUS. The aim of this review is to shed light on the anatomy and systematic examination of the anorectal region with linear EUS and clinical implications for different anorectal pathologies.
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Affiliation(s)
- Hussein Hassan Okasha
- Internal Medicine Department, Division of Gastroenterology, Kasr Al-Aini School of Medicine, Cairo University, Cairo, Egypt
| | - Katarzyna M. Pawlak
- Hospital of the Ministry of Interior and Administration, Endoscopy Unit, Department of Gastroenterology, Szczecin, Poland
| | | | - Ahmed El-Meligui
- Internal Medicine Department, Division of Gastroenterology, Kasr Al-Aini School of Medicine, Cairo University, Cairo, Egypt
| | - Hassan Atalla
- Internal Medicine Department, Hepatology and Gastroenterology Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Sameh Abou Elenin
- Department of Gastroenterology and Hepatology, Military Medical Academy, Cairo Egypt
| | - Ahmed Alzamzamy
- Department of Gastroenterology and Hepatology, Military Medical Academy, Cairo Egypt
| | - Reem Ezzat Mahdy
- Internal Medicine, gastroenterology and Hepatology Department, Assiut University, Assiut, Egypt
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Perianal fistulas: A review with emphasis on preoperative imaging. Adv Med Sci 2022; 67:114-122. [PMID: 35134600 DOI: 10.1016/j.advms.2022.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/24/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas. MATERIAL/METHODS Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019. RESULTS In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low. CONCLUSIONS Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.
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11
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Levy AD, Liu PS, Kim DH, Fowler KJ, Bharucha AE, Chang KJ, Cilenti E, Gage KL, Garcia EM, Kambadakone AR, Korngold EK, Marin D, Moreno C, Pietryga JA, Santillan CS, Weinstein S, Wexner SD, Carucci LR. ACR Appropriateness Criteria® Anorectal Disease. J Am Coll Radiol 2021; 18:S268-S282. [PMID: 34794588 DOI: 10.1016/j.jacr.2021.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 01/06/2023]
Abstract
This review summarizes the relevant literature for the selection of the initial imaging in 4 clinical scenarios in patients with suspected inflammatory disease or postoperative complication of the anorectum. These clinical scenarios include suspected perianal fistula or abscess; rectovesicular or rectovaginal fistula; proctitis or pouchitis; and suspected complication following proctectomy, coloproctectomy, or colectomy with a pouch or other anastomosis. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of anorectal disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia.
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California; and Founder, Advisory Board Quantix Bio
| | - Adil E Bharucha
- Chair of the Neurogastroenterology Section, Chair of Research Compliance Subcommittee, and Medical Director, Office of Clinical Trials, Mayo Clinic Rochester, Minnesota; and American Gastroenterological Association
| | - Kevin J Chang
- Boston University Medical Center, Boston, Massachusetts
| | - Elizabeth Cilenti
- Medstar Georgetown University Hospital, Washington, District of Columbia, Primary care physician
| | - Kenneth L Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; SECJNMMI Member-at-Large
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Avinash R Kambadakone
- Massachusetts General Hospital, Boston, Massachusetts; Taubman Museum of Art Board Member; and Past-President VA Rad Society
| | - Elena K Korngold
- Section Chief, Abdominal Imaging, Oregon Health and Science University, Portland, Oregon
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Courtney Moreno
- Emory University, Atlanta, Georgia; Chair ACR CTC Registry Committee; and Executive Council American Roentgen Ray Society
| | - Jason A Pietryga
- University of Alabama at Birmingham, Birmingham, Alabama; Associate Editor Hollow Organ GI
| | - Cynthia S Santillan
- Chief, Body Imaging Division and Vice-Chair, Clinical Operations for Radiology, University of California San Diego, San Diego, California
| | | | - Steven D Wexner
- Cleveland Clinic Florida, Weston, Florida; Editor-in-Chief, Surgery Journal; American College of Surgeons PAC Board; and Managing Member, Unique Surgical Innovations
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia; Director of CT and MRI at VCU, Section Chief, Abdominal Imaging at VCU
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García-Botello S, Garcés-Albir M, Espi-Macías A, Moro-Valdezate D, Pla-Martí V, Martín-Arevalo J, Ortega-Serrano J. Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence. Langenbecks Arch Surg 2021; 406:2497-2505. [PMID: 34468863 PMCID: PMC8578084 DOI: 10.1007/s00423-021-02307-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
Background The length of sphincter which can be divided during fistulotomy for perianal fistula is unclear. The aim was to quantify sphincter damage during fistulotomy and determine the relationship between such damage with symptoms and severity of faecal incontinence and long-term quality of life (QOL). Methods A prospective cohort study was performed over a 2-year period. Patients with intersphincteric and mid to low transsphincteric perianal fistulas without risk factors for faecal incontinence were scheduled for fistulotomy. All patients underwent 3D endoanal ultrasound (3D-EAUS) pre-operatively and 8 weeks postoperatively. Measurements were taken of pre- and postoperative anal sphincter involvement and division. Anal continence was assessed using the Jorge-Wexner scale and QOL scores pre, 6 and 12 months postoperatively. Results Forty-nine patients were selected. A strong correlation between pre- and postoperative measurements was found p < 0.001. A median length of 41% of the external anal sphincter and 32% of the internal anal sphincter was divided during fistulotomy. Significant differences in mild symptoms of anal continence were found with increasing length of external anal sphincter division. But there was no significant deterioration in continence, soiling, or quality of life scores at the 1-year follow-up. Division of over two-thirds of the external anal sphincter was associated with the highest incontinence rates. Conclusions 3D-EAUS is a valuable tool for quantifying the extent of sphincter involvement pre- and postoperatively. Post-fistulotomy faecal incontinence is mild and increases with increasing length of sphincter division but does not affect long-term quality of life.
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Affiliation(s)
- Stephanie García-Botello
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain.
- Department of Surgery, Universidad de Valencia, Valencia, Spain.
| | - Marina Garcés-Albir
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain
| | - Alejandro Espi-Macías
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain
- Department of Surgery, Universidad de Valencia, Valencia, Spain
| | - David Moro-Valdezate
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain
| | - Vicente Pla-Martí
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain
| | - Jose Martín-Arevalo
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain
| | - Joaquín Ortega-Serrano
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Avd. Blasco Ibañez, 17, 46010, Valencia, Spain
- Department of Surgery, Universidad de Valencia, Valencia, Spain
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Mishra D, Jain A. A minimalistic approach to benign anorectal pathologies: Retrospective analysis of 100 patients in armed forces. JOURNAL OF MARINE MEDICAL SOCIETY 2021. [DOI: 10.4103/jmms.jmms_9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Leenders LAM, Stijns J, van Loon YT, Van Tilborg F, Wasowicz DK, Zimmerman DDE. The complexity of cryptoglandular fistula-in-ano can be predicted by the distance of the external opening to the anal verge; implications for preoperative imaging? Tech Coloproctol 2020; 25:109-115. [PMID: 33180233 DOI: 10.1007/s10151-020-02353-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many surgeons believe that the distance from the external opening to the anal verge (DEOAV) predicts the complexity of a cryptoglandular fistulas-in-ano and, therefore, predicts the need for additional imaging. However, there is no evidence to support this. The primary aim of this study was to determine if DEOAV can predict the complexity of a fistula. Secondary aims were clinical outcome and identification of those patients that might not benefit from preoperative imaging. METHODS All patients having surgery for cryptoglandular fistula-in-ano between January 2014 and December 2016 were evaluated. Preoperative imaging was used to classify fistulas as simple or complex. The DEAOV was measured preoperatively and was divided into categories ≤ 1 cm, 1-2 cm, or > 2 cm. The relationship between the DEOAV and complexity of the fistula was investigated. Clinical outcome was recorded and a group of patients that might not benefit from preoperative imaging was identified. RESULTS A total of 103 patients [m:f = 65:38, median age 47 (range 19-79) years] were included. Magnetic resonance imaging identified 39 simple and 64 complex fistulas. The percentage of simple fistula was 88% in fistulas with DEAOV ≤ 1 cm, 48% in DEAOV 1-2 cm and 38% in > 2 cm. There was a significant difference between the complexity of the fistula and the distance to the anal verge (p < 0.001). The overall healing rate was 88%. CONCLUSIONS The complexity of perianal fistula depends on the DEAOV. We propose that preoperative imaging should be performed in fistulas with external opening > 1 cm from the anal verge.
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Affiliation(s)
- L A M Leenders
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - J Stijns
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.,Department of Surgery, UZ Brussel, Brussels, Belgium
| | - Y T van Loon
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - F Van Tilborg
- Department of Radiology, ETZ Tilburg, Tilburg, The Netherlands
| | - D K Wasowicz
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.
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Abstract
BACKGROUND The number of citations a scientific paper has received indicates its impact within any medical field. We performed a bibliometric analysis to highlight the key topics of the most frequently cited 100 articles on perianal fistula to determine the advances in this field. METHODS The Scopus database was searched from 1960 to 2018 using the search terms "perianal fistula" or "anal fistula" or "fistula in ano" or "anal fistulae" or "anorectal fistulae" including full articles. The topic, year of publication, publishing journal, country of origin, institution, and department of the first author were analyzed. RESULTS The median number of citations for the top 100 of 3431 eligible papers, ranked in order of the number of citations, was 100 (range: 65-811), and the number of citations per year was 7.5 (range: 3.8-40.1). The most-cited paper (by Parks et al in 1976; 811citations) focused on the classification of perianal fistula. The institution with the highest number of publications was St Mark's Hospital, London, UK. The most-studied topic was surgical management (n = 47). The country and the decade with the greatest number of publications in this field were the USA (n = 34) and the 2000s (n = 50), respectively. CONCLUSION The 100 most frequently cited manuscripts showed that surgical management had the greatest impact on the study of perianal fistula. This citation analysis provides a reference of what could be considered the most classic papers on perianal fistula, and may serve as a reference for researchers and clinicians as to what constitutes a citable paper in this field.
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [PMID: 31974827 DOI: 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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Affiliation(s)
- A Amato
- Coloproctology Unit, Department of Surgery, Borea Hospital, Sanremo, Italy.
| | - C Bottini
- Unit of Surgery, Hospital S. Antonio Abate, Gallarate, VA, Italy
| | - P De Nardi
- Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - P Giamundo
- Department of Colorectal Surgery, Policlinico di Monza, Monza, Italy
| | - A Lauretta
- Unit of General Oncologic Surgery, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS Aviano, Aviano, Italy
| | - A Realis Luc
- Coloproctology Unit, Hospital S. Rita, Vercelli, Italy
| | - V Piloni
- Diagnostic Imaging Centre "Diagnostica Marche", Osimo Stazione, Ancona, Italy
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17
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [DOI: 14) evaluation and management of perianal abscess and anal fistula: siccr position statement.a.amato, c.bottini, p.de nardi, p.giamundo, a.lauretta, a.realis luc & v.piloni.tech coloproctol 2020 24:127-143 doi 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 09/10/2023]
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Almeida IS, Jayarajah U, Wickramasinghe DP, Samarasekera DN. Value of three-dimensional endoanal ultrasound scan (3D-EAUS) in preoperative assessment of fistula-in-ano. BMC Res Notes 2019; 12:66. [PMID: 30696490 PMCID: PMC6352344 DOI: 10.1186/s13104-019-4098-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/19/2019] [Indexed: 12/13/2022] Open
Abstract
Objective The aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound scan (3D-EAUS) in the pre-operative assessment of fistula-in-ano in identifying the fistula tract and comparing with findings at surgery in a South Asian cohort. A retrospective analysis of 87 patients with suspected fistula-in-ano who underwent pre-operative 3D-EAUS between January 2009 and January 2016 was carried out. All patients subsequently had surgical exploration under anaesthesia (EUA), irrespective of 3D-EAUS findings. The 3D-EAUS results were compared with the surgical findings to determine the accuracy of 3D-EAUS. Results A total of 86 (98.9%) patients (male = 75) were subsequently shown to have a fistula at surgical exploration and of them, 3D-EAUS detected a fistula in 79 (92%) patients. In this cohort, 3D-EAUS correctly predicted the surgical findings in (n = 61, 70.9%) patients with the highest accuracy being for transphincteric fistulae (87.1%). However, the overall concordance in our study was low with a kappa coefficient of 0.318. Additional findings such as sphincter defects were detected by the 3D-EAUS in 37 patients (internal sphincter defects-21, external sphincter defects-7, both-9) which were not evident at EUA. Therefore, 3D-EAUS had a good accuracy in selected types of fistulae and particularly useful in identifying sphincter defects before surgery. Electronic supplementary material The online version of this article (10.1186/s13104-019-4098-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Isuru Sampath Almeida
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Umesh Jayarajah
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Brillantino A, Iacobellis F, Reginelli A, Monaco L, Sodano B, Tufano G, Tufano A, Maglio M, De Palma M, Di Martino N, Renzi A, Grassi R. Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both? Radiol Med 2019; 124:339-349. [PMID: 30607867 DOI: 10.1007/s11547-018-0975-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of the study is to evaluate the diagnostic value of tridimensional endoanal ultrasound (3D-EAUS) and magnetic resonance (MR) in the preoperative assessment of both simple and complex anorectal fistulas. METHODS All the patients referred for the treatment of anal fistulas were enrolled in this study and underwent, as preoperative assessment, anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS and MR. The results of imaging evaluation were compared with surgical findings, considered as reference standard. RESULTS During the study period, 124 patients operated on for anal fistulas underwent complete preoperative imaging assessment. Perfect agreement between 3D-EAUS and surgery in the anal fistulas' severity grading was found (K = 1). The fistulas were classified as simple in 68/126 (53.9%) and complex in 58/126 (46.03%) cases, according to fistulas' Parks' classification and the most recent American Guidelines. In both simple and complex anal fistulas, 3D-EAUS did not show a significantly higher accuracy in the evaluation of internal openings, if compared with MR (P = 0.47; McNemar's Chi-square test). In the complex anal fistulas, MR showed a significantly higher accuracy in the evaluation of secondary extensions if compared with 3D-EAUS (P = 0.041; McNemar's Chi-square test), whereas in the simple anal fistulas, no significant difference was found. CONCLUSION In the preoperative work-up of patients with anorectal fistulas, 3D-EAUS may represent the first-line diagnostic tool. In cases of fistulas classified as complex by 3D-EAUS, MR may be indicated as adjunctive diagnostic imaging examination, to more carefully describe the fistulas' complete anatomy.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Francesca Iacobellis
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy.
| | - Alfonso Reginelli
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Luigi Monaco
- Department of Surgery, "Villa Esther" Hospital, Via Due Principati 169, 83100, Avellino, Italy
| | - Biagio Sodano
- Department of Surgery, "Pellegrini" Hospital, ASL NA1 Centro, via Portamedina alla Pignasecca 41, 80134, Naples, Italy
| | - Giuseppe Tufano
- Department of Surgery, "Pellegrini" Hospital, ASL NA1 Centro, via Portamedina alla Pignasecca 41, 80134, Naples, Italy
| | - Antonio Tufano
- Department of Surgery, "Pellegrini" Hospital, ASL NA1 Centro, via Portamedina alla Pignasecca 41, 80134, Naples, Italy
| | - Mauro Maglio
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Maurizio De Palma
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Natale Di Martino
- Department of Surgery, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Adolfo Renzi
- "Villa delle Querce" Hospital, Via Battistello Caracciolo 48, 80136, Naples, Italy
| | - Roberto Grassi
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
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Witte M, Schwandner F, Klar E. Before and after Anorectal Surgery: Which Information Is Needed from the Functional Laboratory? Visc Med 2018; 34:128-133. [PMID: 29888242 DOI: 10.1159/000486693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Anorectal surgery covers a wide spectrum of surgery. Diagnostic workup of anorectal disease is based on clinical examination with basic functional tests followed by more elaborate diagnostic tests. Since the incidence of anorectal disorders increases with age, more patients will present in outpatient clinics, thus underlining the relevance of this topic. Methods A PubMed literature search was performed using the terms 'anal incontinence', 'anal and rectal surgery', 'functional diagnostics', and combinations of these terms. No restriction regarding publication year or publication type was applied but randomized trials, 'metanalyses', or guidelines were ranked higher. Only articles in English or German were included. Results The diagnostic value of digital rectal examination, anal manometry and endosonography, the water holding procedure, contrast enema, and incontinence scores is summarized. Conclusion The article focusses on basic clinical and functional diagnostic tests which can be easily applied in the pre- and postoperative setting to evaluate the postoperative outcome.
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Affiliation(s)
- Maria Witte
- Department of General, Thoracic-, Vascular and Transplant Surgery, University Medical Department Rostock, Rostock, Germany
| | - Frank Schwandner
- Department of General, Thoracic-, Vascular and Transplant Surgery, University Medical Department Rostock, Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic-, Vascular and Transplant Surgery, University Medical Department Rostock, Rostock, Germany
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Toyonaga T, Mibu R, Matsuda H, Tominaga Y, Hirata K, Takeyoshi M, Tsuneyoshi M, Matsushima M. Endoanal Ultrasonography of Mucinous Adenocarcinoma Arising from Chronic Fistula-in-ano: Three Case Reports. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 1:100-105. [PMID: 31583308 PMCID: PMC6768671 DOI: 10.23922/jarc.2017-011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/04/2017] [Indexed: 01/06/2023]
Abstract
Mucinous adenocarcinoma arising in chronic fistula-in-ano is rare, and diagnosing it at an early stage is difficult. The role of endoanal ultrasonography in diagnosing the condition has not been discussed in the study. Herein, we report three cases of mucinous adenocarcinoma arising from anal fistulas in which endosonography played an important role in diagnosing malignant change. Three male patients with a 5- to 20-year history of anal fistula were referred to our hospital due to perianal induration, progressive anal pain, or mucopurulent secretion. In all three patients, endosonography revealed a multiloculated complex echoic mass with isoechoic solid components communicating with a trans-sphincteric fistula and sonography-guided biopsy under anesthesia revealed mucinous adenocarcinoma. All patients underwent abdominoperineal resection with lymph node dissection. One patient with a local recurrence died 3 years after surgery and two have remained disease-free for >6 years. These observations suggest that endosonography may be a reliable technique for the diagnosis of mucinous adenocarcinoma arising from chronic fistula-in-ano. Sonography-guided biopsy is useful for the definitive diagnosis of malignancy. Therefore, periodic endosonography assessment should be recommended for patients with persistent anal fistula, especially those with progressive clinical symptoms. Once malignancy is suspected, aggressive sonography-guided biopsy under anesthesia should be performed, which may enable an early diagnosis, curative treatment, and favorable long-term results.
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Affiliation(s)
| | - Ryuichi Mibu
- Department of Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan
| | | | - Yohei Tominaga
- Department of Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Keiji Hirata
- Department of Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan
| | | | | | - Makoto Matsushima
- Department of Surgery, Matsushima Hospital Coloproctology Center, Yokohama, Japan
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Emile SH, Magdy A, Youssef M, Thabet W, Abdelnaby M, Omar W, Khafagy W. Utility of Endoanal Ultrasonography in Assessment of Primary and Recurrent Anal Fistulas and for Detection of Associated Anal Sphincter Defects. J Gastrointest Surg 2017; 21:1879-1887. [PMID: 28895031 DOI: 10.1007/s11605-017-3574-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/30/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tridimensional endoanal ultrasonography (3D-EAUS) has been used for the assessment of various anorectal lesions. Previous studies have reported good accuracy of 3D-EAUS in preoperative assessment of fistula-in-ano (FIA). This study aimed to assess the diagnostic utility of 3D-EAUS in preoperative evaluation of primary and recurrent FIA and its role in detection of associated anal sphincter (AS) defects. PATIENTS AND METHODS Prospectively collected data of patients with FIA who were investigated with 3D-EAUS were reviewed. The findings of EAUS were compared with the intraoperative findings, the reference standard, to find the degree of agreement regarding the position of the internal opening (IO) and primary tract (PT), and presence of secondary tracts using kappa (k) coefficient test. A subgroup analysis was performed to compare the accuracy and sensitivity of EAUS for primary and recurrent FIA. RESULTS Of the patients, 131 were included to the study. EAUS had an overall accuracy of 87, 88.5, and 89.5% in detection of IO, PT, and AS defects, respectively. There was very good concordance between the findings of EAUS and intraoperative findings for the investigated parameters (kappa = 0.748, 0.83, 0.935), respectively. Accuracy and sensitivity of EAUS in recurrent FIA were insignificantly lower than primary cases. EAUS detected occult AS defects in 5.3% of the patients studied. CONCLUSION The diagnostic utility of 3D-EAUS was comparable in primary and recurrent FIA. 3D-EAUS was able to detect symptomatic and occult AS defects with higher accuracy than clinical examination.
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Affiliation(s)
- Sameh Hany Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt.
| | - Alaa Magdy
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Mohamed Youssef
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Waleed Thabet
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Mahmoud Abdelnaby
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Waleed Omar
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Wael Khafagy
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
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Bezzio C, Bryant RV, Manes G, Maconi G, Saibeni S. New horizons in the imaging of perianal Crohn's disease: transperineal ultrasonography. Expert Rev Gastroenterol Hepatol 2017; 11:523-530. [PMID: 28319427 DOI: 10.1080/17474124.2017.1309285] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
perianal disease, most commonly manifest as fistula or abscess formation, affects up to 40% of patients with crohn's disease. perianal crohn's disease is disabling, associated with poor outcomes, and represents a therapeutic challenge for physicians. correct diagnosis and classification of perianal disease is the first crucial step for appropriate multidisciplinary management. Areas covered: A literature search was performed of the PubMed database using the terms 'transperineal ultrasonography', 'transperineal ultrasound', 'perianal disease', 'perianal fistula', 'perianal abscess', 'magnetic resonance', 'endoanal ultrasonography', 'endoscopic ultrasound' in combination with 'Crohn's disease'. A comprehensive review of the relative advantages and disadvantages of the various methods of evaluation of perianal Crohn's disease is provided. A particular focus is placed on transperineal ultrasonography, including historical and technical factors, advantages and limitations, and its current role in practice. An algorithm for integration of transperineal ultrasound into the management of perianal Crohn's disease into clinical practice is proposed, along with future areas research. Expert commentary: Transperineal ultrasound is a simple, safe, cheap and reliable imaging technique for evaluation of perianal Crohn's disease, which should be used more frequently in clinical practice.
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Affiliation(s)
- Cristina Bezzio
- a Gastroenterology Unit , Rho Hospital, ASST Rhodense , Garbagnate Milanese , Italy
| | - Robert V Bryant
- b Department of Gastroenterology and Hepatology , Royal Adelaide Hospital , Adelaide , Australia
| | - Gianpiero Manes
- a Gastroenterology Unit , Rho Hospital, ASST Rhodense , Garbagnate Milanese , Italy
| | - Giovanni Maconi
- c Gastroenterology Unit , Sacco Hospital, ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Simone Saibeni
- a Gastroenterology Unit , Rho Hospital, ASST Rhodense , Garbagnate Milanese , Italy
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Kołodziejczak M, Santoro GA, Obcowska A, Lorenc Z, Mańczak M, Sudoł-Szopińska I. Three-dimensional endoanal ultrasound is accurate and reproducible in determining type and height of anal fistulas. Colorectal Dis 2017; 19:378-384. [PMID: 27943527 DOI: 10.1111/codi.13580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/13/2016] [Indexed: 12/14/2022]
Abstract
AIM Surgical treatment of high anal fistulas is associated with the potential risk of faecal incontinence and recurrence. The primary aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of height and type of anal fistulas, compared to the intra-operative findings (gold standard). The secondary aim was to evaluate the inter-observer reproducibility of 3D-EAUS. METHOD The study design was a prospective analysis of retrospective data. 299 patients (202 men), mean age 45.3 years, who underwent surgery for anal fistulas, were included. All patients were preoperatively assessed by 3D-EAUS. Two readers independently reviewed the volumes to determine the type and height of fistulas. Sensitivity, specificity, positive and negative predictive values, proportion of agreements and Cohen's kappa coefficient (κ) were calculated for both examiners. Ultrasound findings were compared with intra-operative data (reference standard), evaluated blindly by the surgeons. RESULTS At surgery, 201 (67%) were transsphincteric, 49 (16%) suprasphincteric, 47 (16%) intersphincteric and two (1%) extrasphincteric fistulas. Intra-operatively, 177 (59%) were low and 122 (41%) high fistulas. The overall accuracy of 3D-EAUS was 91% for fistula type (271/299 fistulas: 97% transsphincteric, 100% intersphincteric, 57% suprasphincteric, 0% extrasphincteric) and 92% for fistula height (275/299 fistulas: 80% high and 100% low). Both readers reported very good agreement with surgery in the assessment of fistula type (proportion of agreement 0.88, κ = 0.89) and height (proportion of agreement 0.90, κ = 0.91). CONCLUSIONS 3D-EAUS is an accurate and reproducible modality for the assessment of type and height of anal fistulas.
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Affiliation(s)
- M Kołodziejczak
- Warsaw Proctology Centre, Saint Elisabeth Hospital, Warsaw, Poland
| | - G A Santoro
- Colorectal and Pelvic Floor Unit, Department of General Surgery, Regional Hospital, Treviso, Italy
| | - A Obcowska
- Department of General and Oncological Surgery with the Subunit of Vascular Surgery, Lord's Transfiguration Hospital, Warsaw, Poland
| | - Z Lorenc
- Warsaw Proctology Centre, Saint Elisabeth Hospital, Warsaw, Poland
- Clinical Department of General and Colorectal Surgery and Multiple Trauma, St Barbara Regional Specialist Hospital No. 5, Sosnowiec, Poland
| | - M Mańczak
- Department of Gerontology and Public Health, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - I Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Department of Diagnostic Imaging, Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
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Mascagni D, Pironi D, Pontone S, Tonda M, Eberspacher C, Panarese A, Miscusi G, Grimaldi G, Catania A, Santoro A, Filippini A, Sorrenti S. Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient. Aging Clin Exp Res 2017; 29:101-108. [PMID: 27830517 DOI: 10.1007/s40520-016-0652-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. AIMS The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. METHODS A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. RESULTS Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. DISCUSSION Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. CONCLUSIONS Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.
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Affiliation(s)
| | - Daniele Pironi
- Department of Surgical Sciences, Sapienza University, Rome, Italy.
| | - Stefano Pontone
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Maya Tonda
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | | | | | | | | | - Antonio Catania
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Alberto Santoro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Angelo Filippini
- Department of Surgical Sciences, Sapienza University, Rome, Italy
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Kucharzik T, Kannengiesser K, Petersen F. The use of ultrasound in inflammatory bowel disease. Ann Gastroenterol 2016; 30:135-144. [PMID: 28243033 PMCID: PMC5320025 DOI: 10.20524/aog.2016.0105] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 10/18/2016] [Indexed: 02/07/2023] Open
Abstract
Imaging in inflammatory bowel disease (IBD) plays a pivotal role in the primary diagnosis, as well as during the management of patients with known IBD. The evolution of ultrasound equipment and the growing expertise of examiners have both enhanced the role of intestinal ultrasound in the assessment of the gastrointestinal tract in IBD patients. Intestinal ultrasound has been shown to have high sensitivity and specificity, as well as high positive and negative predictive value, in the detection or exclusion of intestinal inflammatory activity in IBD. The obvious advantages of intestinal ultrasound over other imaging modalities include non-invasiveness, rapid availability and low costs. This review summarizes the current developments in the use of intestinal ultrasound for the detection of IBD and its complications, and discusses its use in the management of patients with IBD. Indications for the use of intestinal ultrasound in daily practice are presented, expanded by new developments such as contrast-enhanced ultrasonography and elastography.
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Affiliation(s)
- Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Germany
| | - Klaus Kannengiesser
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Germany
| | - Frauke Petersen
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Germany
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Garcés-Albir M, García-Botello SA, Espi A, Pla-Martí V, Martin-Arevalo J, Moro-Valdezate D, Ortega J. Three-dimensional endoanal ultrasound for diagnosis of perianal fistulas: Reliable and objective technique. World J Gastrointest Surg 2016; 8:513-520. [PMID: 27462394 PMCID: PMC4942752 DOI: 10.4240/wjgs.v8.i7.513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/03/2016] [Accepted: 04/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate accuracy of three-dimensional endoanal ultrasound (3D-EAUS) as compared to 2D-EAUS and physical examination (PE) in diagnosis of perianal fistulas and correlate with intraoperative findings.
METHODS: A prospective observational consecutive study was performed with patients included over a two years period. All patients were studied and operated on by the Colorectal Unit surgeons. The inclusion criteria were patients over 18, diagnosed with a criptoglandular perianal fistula. The PE, 2D-EAUS and 3D-EAUS was performed preoperatively by the same colorectal surgeon at the outpatient clinic prior to surgery and the fistula anatomy was defined and they were classified in intersphincteric, high or low transsphincteric, suprasphincteric and extrasphincteric. Special attention was paid to the presence of a secondary tract, the location of the internal opening (IO) and the site of external opening. The results of these different examinations were compared to the intraoperative findings. Data regarding location of the IO, primary tract, secondary tract, and the presence of abscesses or cavities was analysed.
RESULTS: Seventy patients with a mean age of 47 years (range 21-77), 51 male were included. Low transsphincteric fistulas were the most frequent type found (33, 47.1%) followed by high transsphincteric (24, 34.3%) and intersphincteric fistulas (13, 18.6%). There are no significant differences between the number of IO diagnosed by the different techniques employed and surgery (P > 0.05) and, there is a good concordance between intraoperative findings and the 2D-EAUS (k = 0.67) and 3D-EAUS (k = 0.75) for the diagnosis of the primary tract. The ROC curves for the diagnosis of transsphincteric fistulas show that both ultrasound techniques are adequate for the diagnosis of low transsphincteric fistulas, 3D-EAUS is superior for the diagnosis of high transsphincteric fistulas and PE is weak for the diagnosis of both types.
CONCLUSION: 3D-EAUS shows a higher accuracy than 2D-EAUS for assessing height of primary tract in transsphincteric fistulas. Both techniques show a good concordance with intraoperative finding for diagnosis of primary tracts.
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de Groof EJ, Cabral VN, Buskens CJ, Morton DG, Hahnloser D, Bemelman WA. Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines. Colorectal Dis 2016; 18:O119-34. [PMID: 26847796 DOI: 10.1111/codi.13286] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 01/04/2016] [Indexed: 12/29/2022]
Abstract
AIM Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research. METHOD MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient. RESULTS Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence. CONCLUSION Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.
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Affiliation(s)
- E J de Groof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - V N Cabral
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D G Morton
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
Endoanal ultrasound is a technique that provides imaging of the anal sphincters and its surrounding structures as well as the pelvic floor. However, endoanal magnetic resonance imaging (MRI) is preferred by most physicians, although costs are higher and demand easily outgrows availability. Endoanal ultrasound is an accurate imaging modality delineating anatomy of both cryptoglandular as well as Crohn perianal fistula and abscess. Endoanal ultrasound is comparable with examination under anesthesia and equally sensitive as endoanal MRI in fistula detection. When fistula tracts or abscesses are located above the puborectal muscle, an additional endoanal MRI should be performed. Preoperative imaging is advocated in recurrent cryptoglandular fistula because a more complex pattern can be expected. Endoanal ultrasound can help avoid missing tracts during surgery, lowering the chance for the fistula to persist or recur. It can easily be performed in an outpatient setting and endosonographic skills are quickly incremented. Costs are low and endoanal ultrasound has the potential to improve outcome of patients with both cryptoglandular and fistulizing Crohn disease; therefore, it values more attention.
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Affiliation(s)
- Arjan Paul Visscher
- From the Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
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30
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Magnetic resonance imaging and peroxide-enhanced anal endosonography in assessment of fistula in anus: comparison with surgery. Eur Surg 2016. [DOI: 10.1007/s10353-015-0380-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Use of a Balloon Rectal Catheter in Magnetic Resonance Imaging of Complex Anal Fistula to Improve Detection of Internal Openings. J Comput Assist Tomogr 2016; 40:543-50. [DOI: 10.1097/rct.0000000000000400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Regadas FSP, Murad-Regadas SM. Commentary on 'Impact of 3-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study'. Colorectal Dis 2015; 17:1112-3. [PMID: 26547818 DOI: 10.1111/codi.13140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Ding JH, Bi LX, Zhao K, Feng YY, Zhu J, Zhang B, Yin SH, Zhao YJ. Impact of three-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study. Colorectal Dis 2015; 17:1104-12. [PMID: 26331275 DOI: 10.1111/codi.13108] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/23/2015] [Indexed: 02/08/2023]
Abstract
AIM The aim of the study was to evaluate the impact of three-dimensional endoanal ultrasound (3D-EAUS) on postoperative outcome in patients with anal fistula. METHOD This prospective study compared clinical and functional outcomes of patients with and without preoperative 3D-EAUS examination 1 year after anal fistula surgery. Patients were prospectively followed and evaluated by a standardized protocol including physical examination, the Wexner Incontinence Score (WIS) and anorectal manometry, at baseline and 1 year after surgery. RESULTS A total of 196 patients were enrolled. There were no significant differences in demographic and operative parameters, except for operation time, between the two groups. At 1 year follow-up, the overall recurrence rates were 8.8% (9/102) in the 3D-EAUS group and 13.8% (13/94) in the examination under anaesthesia (EUA) group. In the subgroup of patients with complex fistulae, the recurrence rate was numerically lower in the 3D-EAUS group (12.8% vs 22.5%; P = 0.26). The WIS in the EUA group significantly worsened (0.35 ± 0.94 vs 1.07 ± 1.59; P = 0.003) with a decreased the number of fully continent patients (82.5% vs 55%; P = 0.008) while neither the WIS nor the proportion of fully continent patients changed in the 3D-EAUS group. Fewer patients in the 3D-EAUS group developed incontinence postoperatively (6.7% vs 33.3%; P = 0.012) and they had better maximum resting pressure and maximum squeeze pressure than the EUA group. CONCLUSIONS Preoperative use of 3D-EAUS had a favourable impact on the outcome of surgical treatment for anal fistulae, especially in those with complex anal fistula. It should be routinely used in the clinical setting.
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Affiliation(s)
- J-H Ding
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - L-X Bi
- Department of Medicine, Second Artillery General Hospital, Beijing, China
| | - K Zhao
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - Y-Y Feng
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - J Zhu
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - B Zhang
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - S-H Yin
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - Y-J Zhao
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
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Brillantino A, Iacobellis F, Di Sarno G, D'Aniello F, Izzo D, Paladino F, De Palma M, Castriconi M, Grassi R, Di Martino N, Renzi A. Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis. Int J Colorectal Dis 2015; 30:535-42. [PMID: 25728829 DOI: 10.1007/s00384-015-2167-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard. METHODS From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results. RESULTS A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively. CONCLUSION 3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.
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Affiliation(s)
- Antonio Brillantino
- Emergency Department "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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Kim MJ. Transrectal ultrasonography of anorectal diseases: advantages and disadvantages. Ultrasonography 2014; 34:19-31. [PMID: 25492891 PMCID: PMC4282231 DOI: 10.14366/usg.14051] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 11/17/2014] [Accepted: 11/19/2014] [Indexed: 12/17/2022] Open
Abstract
Transrectal ultrasonography (TRUS) has been widely accepted as a popular imaging modality for evaluating the lower rectum, anal sphincters, and pelvic floor in patients with various anorectal diseases. It provides excellent visualization of the layers of the rectal wall and of the anatomy of the anal canal. TRUS is an accurate tool for the staging of primary rectal cancer, especially for early stages. Although magnetic resonance imaging is a modality complementary to TRUS with advantages for evaluating the mesorectum, external sphincter, and deep pelvic inflammation, three-dimensional ultrasonography improves the detection and characterization of perianal fistulas and therefore plays a crucial role in optimal treatment planning. The operator should be familiar with the anatomy of the rectum and pelvic structures relevant to the preoperative evaluation of rectal cancer and other anal canal diseases, and should have technical proficiency in the use of TRUS combined with an awareness of its limitations compared to magnetic resonance imaging.
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Affiliation(s)
- Min Ju Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Pellino G, Selvaggi F. Surgical treatment of perianal fistulizing Crohn's disease: from lay-open to cell-based therapy--an overview. ScientificWorldJournal 2014; 2014:146281. [PMID: 25431776 PMCID: PMC4241327 DOI: 10.1155/2014/146281] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perianal Crohn's disease (CD) can be challenging. Despite the high incidence of fistulizing CD, literature lacks clear guidelines. Several medical, surgical, and combined treatment modalities have been proposed, but evidences are scarce. METHODS We searched the literature to assess the facets of perianal CD, with particular focus on complex fistulae. Disease epidemiology, classification, diagnosis, activity scoring systems, and medical-surgical treatments were assessed. RESULTS Perianal fistulizing CD is common, frequently associated with upper gastrointestinal and colorectal CD. Complex fistulas often require repeated treatments. Continence is a major concern when dealing with repeated procedures. A prudent pathway is to resolve active sepsis and to limit damages, delaying a definitive treatment to the time when acute phase has been controlled. The improved diagnostic techniques allow better preoperative planning and are useful in monitoring the response to treatment. Besides newer devices, cell-based treatments are promising tools which have recently enriched the treatment portfolio. However, the need for proctectomy is still disturbingly high in CD patients with complex perianal fistulae. CONCLUSIONS Perianal CD can impair quality of life and lead to need for proctectomy. A staged approach is reasonable. Treatment success can be improved by multimodal treatment and collaborative management by experienced gastroenterologists and surgeons.
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Affiliation(s)
- Gianluca Pellino
- Unit of General Surgery, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
| | - Francesco Selvaggi
- Unit of General Surgery, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
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Sudoł-Szopińska I, Kucharczyk A, Kołodziejczak M, Warczyńska A, Pracoń G, Wiączek A. Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison. J Ultrason 2014; 14:142-51. [PMID: 26676232 PMCID: PMC4579692 DOI: 10.15557/jou.2014.0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/12/2014] [Accepted: 06/19/2014] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected. THE AIM OF THIS PAPER The aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae. MATERIAL AND METHODS The results of endosonographic and magnetic resonance examinations performed in 2011-2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case. RESULTS In determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment - 41% and between endosonography and magnetic resonance - 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%. CONCLUSIONS Magnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53-67%; the highest level of agreement was noted for the assessment of branching.
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Affiliation(s)
- Iwona Sudoł-Szopińska
- Zakład Radiologii, Instytut Reumatologii, Warszawa, Polska ; Zakład Diagnostyki Obrazowej, Warszawski Uniwersytet Medyczny, Warszawa, Polska ; Pododdział Proktologii, Szpital na Solcu, Warszawa, Polska
| | | | | | | | | | - Anna Wiączek
- Pododdział Proktologii, Szpital na Solcu, Warszawa, Polska
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Abstract
Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.
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Nagendranath C, Saravanan MN, Sridhar C, Varughese M. Peroxide-enhanced endoanal ultrasound in preoperative assessment of complex fistula-in-ano. Tech Coloproctol 2013; 18:433-8. [PMID: 24030783 DOI: 10.1007/s10151-013-1067-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 08/26/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND In complex fistula-in-ano, preoperative imaging can help identify secondary tracts and abscesses that can be missed, leading to recurrence. We evaluated hydrogen peroxide-enhanced endoanal ultrasound (PEEUS) in the characterization of fistula compared with standard clinical and operative assessment. METHODS Patients with complex fistula-in-ano treated between February 2008 and May 2009 at our institution were prospectively evaluated by PEEUS with recording of the preoperative clinical examination and intraoperative details of the fistula. Of the 135 patients with fistula-in-ano, 68 met the inclusion criteria for complex fistula-in-ano. Correlation of clinical findings and PEEUS to the gold standard intraoperative findings was assessed in characterizing the fistula. The percent agreement between the clinical and PEEUS findings against the gold standard was derived, and the kappa statistic for agreement was determined. RESULTS The mean age of the cohort was 42.54 ± 10.86 years. The fistula tracts were curvilinear, high, and transsphincteric in 16 (23.53%), 8 (11.76%), and 42 (61.76%) patients, respectively. Secondary tracts and associated abscess cavities were seen in 28 (33.82%) and 35 (51.47%) patients, respectively. PEEUS correlated better than clinical examination with regard to site (92.65 vs 79.41%; p < 0.001) and course (91.18 vs 77.94%; p < 0.001) of secondary tract and associated abscesses (89.71 vs 80.88%; p = 0.02). There was a trend of better correlation of PEEUS compared to clinical examination in classifying the primary tract as per Park's system (88.24 vs 79.41%; p = 0.06), but it did not reach statistical significance. PEEUS and clinical examination were comparable in correlation of the level of the primary tract (kappa: 0.86 vs 0.78; p = 0.22) and the site of internal opening (kappa: 0.97 vs 0.89; p = 0.22). The operative decision was changed in 13 (19.12%) subjects based on PEEUS findings. CONCLUSIONS PEEUS is a feasible and efficient tool in the routine preoperative assessment of complex fistula-in-ano.
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Affiliation(s)
- C Nagendranath
- Colorectal Unit, Department of Surgical Gastroenterology, Global Hospitals, Hyderabad, Andhra Pradesh, India
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Abstract
OBJECTIVE The purpose of this study was to assess the diagnostic value of anorectal MRI in the care of patients with chronic anal and perianal pain but without findings of abnormalities in the clinical workup. MATERIALS AND METHODS Patients referred from a tertiary department of colorectal surgery to the MRI unit with clinically occult chronic anal and perianal pain were included. MRI of the anorectum was performed with an endoanal or pelvic phased-array coil. The images from all examinations were read by two radiologists. MRI findings were correlated with clinical follow-up data. RESULTS The study group (103 patients) was stratified into patients with no history of anorectal disease (n = 60) and those who had a history of surgery for anorectal disease (n = 43). MRI findings suggested the final diagnoses in 40 patients (39%). These diagnoses were 28 cases of suppurative lesions (27%), 11 cases of painful scarring of the anus (11%), and one case of metastasis to the sacrum (1%). Suppurative lesions were surgically proved with marked relief of pain after surgery. In the other patients the final diagnoses were 37 cases of levator ani syndrome (36%) and 26 cases of unspecified functional anorectal pain (25%). No MRI abnormalities were found in 33 of the patients with levator ani syndrome and 26 of the patients with unspecified anorectal pain. The two readers had very good agreement (κ = 0.92). The patients with a history of anorectal disease had significantly more MRI findings of abnormalities (60%) than did patients without a history of anorectal disease (23%). The positive predictive value of MRI was 91%, and the negative predictive value was 100%. CONCLUSION In 39% of patients, MRI showed abnormalities that were clinically confirmed as the final diagnosis. Surgical treatment will especially benefit patients with suppurative lesions, resulting in relief of pain.
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Abstract
INTRODUCTION Management of fistula-in-ano requires understanding of both perianal and rectal anatomy, as well as the surgical approaches available to ensure the highest possible postoperative continence and wound healing. Further, high rates of recurrence with medical management commonly bring these patients under the care of the colorectal surgeon after variable periods of failed conservative management. Novel techniques provide surgeons with tools to treat increasingly complex fistulas with a focus on maintaining sphincteric functionality and limiting recurrence. METHOD This manuscript presents our practice, including perioperative decision making regarding surgical approach, in managing patients with fistula-in-ano. CONCLUSION Familiarity with these techniques prepares the general surgeon and colorectal surgeon to improve wound healing and functional outcomes in these patients, especially with complex disease involving the external and internal anal sphincters.
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Abstract
BACKGROUND Imaging modalities such as endoanal ultrasound or MRI can be useful preoperative adjuncts before the appropriate surgical intervention for perianal fistulas. OBJECTIVES We present a systematic review of published literature comparing endoanal ultrasound with MRI for the assessment of idiopathic and Crohn's perianal fistulas. DESIGN A meta-analysis was performed to obtain pooled values for specificity and sensitivity. SETTINGS Electronic databases were searched from January 1970 to October 2010 for published studies. PATIENTS AND INTERVENTIONS Four studies were used in our analysis. There were 241 fistulas in the ultrasound group and 240 in the magnetic resonance group. RESULTS The combined sensitivity and specificity of magnetic resonance for fistula detection were 0.87 (95% CI: 0.63-0.96) and 0.69 (95% CI: 0.51-0.82). There was a high degree of heterogeneity between studies reporting on MRI sensitivity (df = 3, I = 93%). This compares to a sensitivity and specificity for endoanal ultrasound of 0.87 (95% CI: 0.70-0.95) and 0.43 (95% CI: 0.21-0.69). There was a high degree of heterogeneity between studies reporting on endoanal ultrasound sensitivity (df = 3, I = 92%). CONCLUSIONS From the available literature, the summarized performance characteristics for MRI and endoanal ultrasound demonstrate comparable sensitivities at detecting perianal fistulas, although the specificity for MRI was higher than that for endoanal ultrasound. Both specificity values are considered to be diagnostically poor, however. The high degree of data heterogeneity and the shortage of applicable studies precludes any firm conclusions being made for clinical practice. Future trials with improved study design (including prospective data collection and consideration of verification bias) may help to further clarify the role of MRI in the assessment and treatment response monitoring of perianal fistulas (particularly in patients with Crohn's disease).
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Etienney I, de Parades V. Three-dimensional endoanal ultrasonography in daily proctological practice. Clin Res Hepatol Gastroenterol 2011; 35:260-70. [PMID: 21393087 DOI: 10.1016/j.clinre.2010.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 02/10/2010] [Accepted: 10/18/2010] [Indexed: 02/04/2023]
Abstract
Three-dimensional endoanal ultrasonography (3D-EAUS) provides unequalled quality in terms of the anatomical image of the anal canal and sphincter complex. In less than one minute it produces a three-dimensional "cube" that can be manipulated in all spatial dimensions, then archived. In just a few years it has become a new gold standard exploration in proctology. In addition to image quality, 3D-EAUS has the advantage of being easily and rapidly performed, well-tolerated and moderate in cost. For anal incontinence, 3D-EAUS contributes to the identification of sphincter defects. The anatomy of the sphincters can be evaluated spatially. Simple scoring systems with good reproducibility and readily applicable in routine practice can be used to evaluate the "damaged" sphincter volume. For the management of anoperineal suppurations, 3D-EAUS provides information on the fistulous track(s) and on potential collections. These data are crucial as the choice of treatment and its efficacy depend on accurate topographic assessment of the suppuration and the state of the sphincter apparatus.
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Affiliation(s)
- Isabelle Etienney
- Proctologie médico-interventionnelle, centre hospitalier Diaconesses-Croix-Saint-Simon, site Reuilly, 18, rue du Sergent-Bauchat, 75012 Paris, France.
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Poggio J. Current Techniques in Evaluating Fistula-in-Ano and Perianal Sepsis: Endorectal Ultrasound Technique and Comparison in Accuracy With Surgery and Magnetic Resonance Imaging. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pinsk I, Seppala R, Friedlich MS. Anography: a technique for determining the location of the internal opening in perianal fistula. Colorectal Dis 2010; 12:896-900. [PMID: 19614670 DOI: 10.1111/j.1463-1318.2009.02011.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Anography is a radiological investigation for fistula-in-ano that identifies the primary fistula track through the internal opening. The efficacy of anography as a radiological method of identifying the location of the internal opening was investigated. METHOD A retrospective study of 50 patients with a clinical diagnosis of fistula-in-ano of criptoglandular aetiology was performed. During anography, the location of the internal opening was recorded with respect to the quadrant of anal canal and distance from the anal verge. These data were compared with the findings during examination under anaesthesia (EUA), which was used as the gold standard for the identification of the internal opening. RESULTS The sensitivity of anography for identifying a patent internal opening was 91% and specificity 100%. There was complete agreement between anography reports and findings at EUA regarding the quadrant of anal canal in which the internal opening was located. In more than 90% of patients, the internal opening was found at EUA within 1 cm from the site described on anography. CONCLUSION Anography is an accurate test for predicting the exact quadrant of the anal canal in which the internal opening is located, as well as the distance of the internal opening from the anal verge. This inexpensive and simple radiological investigation should be the test of first choice in the evaluation of patients with fistula-in-ano when difficulty is anticipated in identifying the internal opening.
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Affiliation(s)
- I Pinsk
- Surgery B Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Torkzad MR, Karlbom U. MRI for assessment of anal fistula. Insights Imaging 2010; 1:62-71. [PMID: 22347906 PMCID: PMC3259332 DOI: 10.1007/s13244-010-0022-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/16/2010] [Accepted: 04/28/2010] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance imaging (MRI) is the best imaging modality for preoperative assessment of patients with anal fistula. MRI helps to accurately demonstrate disease extension and predict prognosis. This in turn helps make therapy decisions and monitor therapy. The pertinent anatomy, fistula classification and MRI findings will be discussed.
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Affiliation(s)
- Michael R. Torkzad
- Department of Radiology, Uppsala University Hospital, 751 85 Uppsala, Sweden
- Department of Oncology, Radiology and Clinical Immunology Section of Radiology, Uppsala University, 751 85 Uppsala, Sweden
| | - Urban Karlbom
- Department of surgery, Uppsala University Hospital, Uppsala, Sweden
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Garcés Albir M, García Botello S, Esclápez Valero P, Sanahuja Santafé A, Espí Macías A, Flor Lorente B, García-Granero E. [Evaluation of three-dimensional endoanal endosonography of perianal fistulas and correlation with surgical findings]. Cir Esp 2010; 87:299-305. [PMID: 20392442 DOI: 10.1016/j.ciresp.2010.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 02/09/2010] [Accepted: 02/15/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study aims to assess the accuracy of three-dimensional endoanal ultrasound (3D-US), two-dimensional ultrasound (2D-US) and physical examination (PE) for the diagnosis of perianal fistulas and correlate the results with intraoperative findings. MATERIALS AND METHODS A prospective, observational study with consecutive inclusion of patients was performed between December 2008 and August 2009. Twenty-nine patients diagnosed with a perianal fistula due to undergo surgery were included. All patients underwent PE, 2D-US and 3D-US, and the results were compared to intraoperative findings. The examinations were repeated with hydrogen peroxide instilled through the external opening. RESULTS Internal opening (IO): no significant differences with regards to the number of IO diagnosed by PE and 2D-US or 3D-US (P>0.05). Primary tract: good concordance between 3D US and surgery (k=0.61), and this was higher than any of the other techniques used (PE: k=0.41; 2D-US: k=0.56). Secondary tracts: both 2D and 3D-US show good concordance with surgery (86%, k=0.66; 90%, k=0.73, respectively). Abscesses/cavities: The ultrasound examinations showed a moderate concordance with surgery (k=0.438, k=0.540, respectively). CONCLUSIONS 3D-US shows a higher diagnostic accuracy than 2D-US when compared with surgery to estimate primary fistula height in transphincteric fistulas. 3D-US shows good concordance with surgery for diagnosing primary and secondary tracts and a high sensitivity and specificity for diagnosis of the IO. There was a tendency to overestimate fistula height with 2D-US as shown by the lower specificity of 2D-US for the diagnosis of high transphincteric fistulas and lower sensitivity of 2D-US for low transphincteric fistulas.
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Affiliation(s)
- Marina Garcés Albir
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitari, Universidad de Valencia, Valencia, España.
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Cellini C, Safar B, Fleshman J. Surgical management of pyogenic complications of Crohn's disease. Inflamm Bowel Dis 2010; 16:512-7. [PMID: 20049952 DOI: 10.1002/ibd.20984] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with Crohn's disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohn's disease.
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Anal endosonography and fistulography for fistula-in-ano. Radiol Med 2010; 115:771-83. [DOI: 10.1007/s11547-010-0524-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 09/17/2009] [Indexed: 02/08/2023]
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