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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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Kumar S, Chaudhary RK, Shah SS, Kumar D, Nepal P, Ojili V. Current update on the role of endoanal ultrasound: a primer for radiologists. Abdom Radiol (NY) 2024; 49:2873-2890. [PMID: 38580791 DOI: 10.1007/s00261-024-04300-0] [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: 01/07/2024] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 04/07/2024]
Abstract
Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.
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Affiliation(s)
- Shruti Kumar
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St, Slot 556, Little Rock, AR, 72205, USA.
| | - Ranjit K Chaudhary
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Samir S Shah
- Department of Radiology, Canpic Medical and Education Foundation, Pune, India
| | - Devendra Kumar
- Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
| | - Pankaj Nepal
- Department of Radiology, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Vijayanadh Ojili
- Department of Radiology, University of Texas Health, San Antonio, TX, USA
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The Use of Endoscopic Ultrasonography in Inflammatory Bowel Disease: A Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13030568. [PMID: 36766671 PMCID: PMC9914551 DOI: 10.3390/diagnostics13030568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/27/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
The diagnosis of inflammatory bowel disease (IBD) can sometimes be challenging. By corroborating clinical, imaging and histological data, the two main entities of IBD, ulcerative colitis and Crohn's disease (CD), can be differentiated in most cases. However, there remains 10-20% of patients where the diagnosis cannot be accurately established, in which case the term "IBD unclassified" is used. The imaging techniques most used to evaluate patients with IBD include colonoscopy, ultrasonography and magnetic resonance imaging. Endoscopic ultrasonography is mainly recommended for the evaluation of perianal CD. Through this work, we aim to identify other uses of this method in the case of patients with IBD.
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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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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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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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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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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Mahmoud NN, Halwani Y, Montbrun SD, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP. Current management of perianal Crohn’s disease. Curr Probl Surg 2017; 54:262-298. [DOI: 10.1067/j.cpsurg.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/04/2017] [Indexed: 12/11/2022]
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Dziki Ł, Mik M, Trzciński R, Włodarczyk M, Skoneczny M, Dziki A. Treatment of Perianal Fistulas in Poland. POLISH JOURNAL OF SURGERY 2017; 87:614-9. [PMID: 26963055 DOI: 10.1515/pjs-2016-0012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Indexed: 11/15/2022]
Abstract
UNLABELLED A perianal fistula is a pathological canal covered by granulation tissue connecting the anal canal and perianal area epidermis. The above-mentioned problem is the reason for the patient to visit the surgeonproctologist. Unfortunately, the disease is characterized by a high recurrence rate, even despite proper management. The aim of the study was to determine the current condition of perianal fistula treatment methods in everyday surgical practice, considering members of the Society of Polish Surgeons. MATERIAL AND METHODS 1523 members of the Society of Polish Surgeons received an anonymous questionnaire comprising 15 questions regarding perianal fistula treatment in everyday practice. RESULTS Results were obtained from 807 (53%) members. After receiving answers, questionnaire results were collected, analysed, and presented in a descriptive form. CONCLUSIONS Study results showed that most Polish surgeons choose the fistulectomy/fistulotomy method. Considering treatment of perianal fistulas the most important issue is to find the correct, primary fistula canal. Further methods should be individually selected for each patient. One should also remember that every fistula is different. Surgical departments that operate a small number of perianal fistulas should direct such patients to reference centers.
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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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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Visscher AP, Schuur D, Slooff RAE, Meijerink WJHJ, Deen-Molenaar CBH, Felt-Bersma RJF. Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound. Colorectal Dis 2016; 18:503-9. [PMID: 26558554 DOI: 10.1111/codi.13211] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/06/2015] [Indexed: 02/08/2023]
Abstract
AIM Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS). METHOD Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula. RESULTS There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%. CONCLUSION The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.
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Affiliation(s)
- A P Visscher
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - D Schuur
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - R A E Slooff
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - W J H J Meijerink
- Department of Gastro-Intestinal Surgery and Advanced Laparoscopy, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - R J F Felt-Bersma
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
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Yin HQ, Wang C, Peng X, Xu F, Ren YJ, Chao YQ, Lu JG, Wang S, Xiao HS. Clinical value of endoluminal ultrasonography in the diagnosis of rectovaginal fistula. BMC Med Imaging 2016; 16:29. [PMID: 27053063 PMCID: PMC4823858 DOI: 10.1186/s12880-016-0131-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 04/04/2016] [Indexed: 01/09/2023] Open
Abstract
Background Rectovaginal fistula (RVF) refers to a pathological passage between the rectum and vagina, which is a public health challenge. This study was aimed to explore the clinical value of endoluminal biplane ultrasonography in the diagnosis of rectovaginal fistula (RVF). Methods Thirty inpatients and outpatients with suspected RVF from January 2006 to June 2013 were included in the study, among whom 28 underwent surgical repair. All 28 patients underwent preoperative endoluminal ultrasonography, and the obtained diagnostic results were compared with the corresponding surgical results. Results All of the internal openings located at the anal canal and rectum of the 28 patients and confirmed during surgery were revealed by preoperative endosonography, which showed a positive predictive value of 100 %. Regarding the 30 internal openings located in the vagina during surgery, the positive predictive value of preoperative endosonography was 93 %. The six cases of simple fistulas confirmed during surgery were revealed by endosonography; for the 22 cases of complex fistula confirmed during surgery, the positive predictive value of endosonography was 90 %. Surgery confirmed 14 cases of anal fistula and 14 cases of RVF, whereas preoperative endoluminal ultrasonography suggested 16 cases of anal fistula and 12 cases of RVF, resulting in positive predictive values of 92.3 and 93 %, respectively. Conclusion The use of endoluminal biplane ultrasonography in the diagnosis of RVF can accurately determine the internal openings in the rectum or vagina and can relatively accurately identify concomitant branches and abscesses located in the rectovaginal septum. Thus, it is a good imaging tool for examining internal and external anal sphincter injuries and provides useful information for preoperative preparation and postoperative evaluation.
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Affiliation(s)
- Hao-Qiang Yin
- Department of Ultrasonic Diagnosis, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Chen Wang
- Department of Anorectal Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xin Peng
- Department of Ultrasonic Diagnosis, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Fang Xu
- Department of Ultrasonic Diagnosis, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Ya-Juan Ren
- Department of Ultrasonic Diagnosis, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Yong-Qing Chao
- Department of Anorectal Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jin-Gen Lu
- Department of Anorectal Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Song Wang
- Department of Radiology, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Hu-Sheng Xiao
- Department of Ultrasonic Diagnosis, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
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15
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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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16
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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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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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18
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Tegon G, Nicholls RJ. Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2015; 19:595-606. [PMID: 26377581 DOI: 10.1007/s10151-015-1365-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/11/2015] [Indexed: 12/14/2022]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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Affiliation(s)
- A Amato
- Department of Surgery, Coloproctology Unit, Hospital of Sanremo, Via Borea, 56, Sanremo, IM, Italy.
| | - C Bottini
- Deparment of Surgery, Hospital S. Antonio Abate, Gallarate, VA, Italy
| | - P De Nardi
- Division of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - P Giamundo
- Deparment of General Surgery, Hospital Santo Spirito, Bra, CN, Italy
| | - A Lauretta
- Department General Surgery, Hospital Santa Maria dei Battuti, San Vito al Tagliamento, PD, Italy
| | - A Realis Luc
- Coloproctology Unit, Hospital S. Rita, Vercelli, Italy
| | - G Tegon
- Proctology Unit, Hospital S. Camillo, Treviso, Italy
| | - R J Nicholls
- Emeritus Consultant Surgeon, St Mark's Hospital, London, England, UK
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Cadeddu F, Salis F, Lisi G, Ciangola I, Milito G. Complex anal fistula remains a challenge for colorectal surgeon. Int J Colorectal Dis 2015; 30:595-603. [PMID: 25566951 DOI: 10.1007/s00384-014-2104-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2014] [Indexed: 02/04/2023]
Abstract
AIM Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. MATERIAL AND METHODS A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm. RESULTS The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities. CONCLUSIONS Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.
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Affiliation(s)
- F Cadeddu
- Department of Surgery, San Francesco Hospital, Via Mannironi, 08020, Nuoro, Italy,
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20
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Waniczek D, Adamczyk T, Arendt J, Kluczewska E. Direct MRI fistulography with hydrogen peroxide in patients with recurrent perianal fistulas: a new proposal of extended diagnostics. Med Sci Monit 2015; 21:439-45. [PMID: 25666910 PMCID: PMC4334356 DOI: 10.12659/msm.891232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Perianal fistulas are malformations of the anorectal area. Accurate preoperative assessment of perianal fistula tract is a main assumption in diagnosis of the disease, affecting the operation efficiency. The aim of the study was to present our experience in application of a new diagnostic protocol based on the magnetic resonance imaging (MRI) examination using a mixture of hydrogen peroxide (HP) and gadolinium as a direct contrast medium in evaluation of recurrent fistulas tract. The method is referred to as HPMRI. Material/Methods The study group consisted of 12 subjects operated on from 2011. Direct HPMRI fistulography was performed in all subjects before the operation. All types of fistulas were precisely evaluated by HPMRI examination. Results Intraoperative state confirmed complete course of fistulas in 11 cases. In 1 case, an internal opening was not found. Conclusions We suggest that this new method of direct HPMRI fistulography may improve visualization of the tracts of recurrent fistulas and improve efficacy of surgical procedures.
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Affiliation(s)
- Dariusz Waniczek
- Department of Surgery Propedeutics, Clinical Department of General, Colorectal and Trauma Surgery, Medical University of Silesia, Sosnowiec, Poland
| | - Tomasz Adamczyk
- Magnetic Resonance Unit, Medical Diagnostic Centre Voxel, Bytom, Poland
| | - Jerzy Arendt
- Department of Surgery Propedeutics, Clinical Department of General, Colorectal and Trauma Surgery, Medical University of Silesia, Bytom, Poland
| | - Ewa Kluczewska
- Department and Institute of Medical Radiology and Radiodiagnostics, Medical University of Silesia, Zabrze, Poland
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21
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Smith RK, Carter Paulson E. Perianal fistulas in patients with inflammatory bowel disease. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.08.011] [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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22
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Valente MA, Hull TL. Contemporary surgical management of rectovaginal fistula in Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:487-495. [PMID: 25400993 PMCID: PMC4231514 DOI: 10.4291/wjgp.v5.i4.487] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/27/2014] [Accepted: 07/17/2014] [Indexed: 02/07/2023] Open
Abstract
Rectovaginal fistula is a disastrous complication of Crohn’s disease (CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a women’s quality of life. Successful management is possible only after accurate and complete assessment of the entire gastrointestinal tract has been performed. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics. Before treatment is undertaken, establishing reasonable goals and expectations of therapy is essential for both the patient and surgeon. This article aims to highlight the various surgical techniques and their outcomes for repair of CD associated rectovaginal fistula.
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23
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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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24
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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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25
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Mandato Y, Reginelli A, Galasso R, Iacobellis F, Berritto D, Cappabianca S. Errors in the Radiological Evaluation of the Alimentary Tract: Part I. Semin Ultrasound CT MR 2012; 33:300-7. [DOI: 10.1053/j.sult.2012.01.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Wise PE, Schwartz DA. The evaluation and treatment of Crohn perianal fistulae: EUA, EUS, MRI, and other imaging modalities. Gastroenterol Clin North Am 2012; 41:379-91. [PMID: 22500524 DOI: 10.1016/j.gtc.2012.01.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Perianal fistulizing disease is a common complication of CD that requires a multidisciplinary collaboration between gastroenterology, surgery, and radiology professionals for successful assessment and treatment. Optimal success comes from a combined medical and surgical approach to treat the fistulizing disease (see Fig. 1). Unfortunately, even with a variety of surgical options, a subset of patients require permanent fecal diversion and/or proctectomy to successfully treat their disease. Further studies (likely requiring large, multicenter trials) of novel medical and surgical treatments are still warranted to formulate optimal management of this complex condition.
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Affiliation(s)
- Paul E Wise
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37232-0252, USA
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27
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Abstract
Perianal Crohn’s Disease (CD) is a significant cause of morbidity in CD patients. Accurate identification of perianal involvement requires advanced imaging techniques in addition to physical exam. Treatment of the disease is aimed at improving both the perianal and intestinal manifestations. Proper treatment depends upon the severity of the disease and combines current medical and surgical therapies to maximize response. The ability to improve perianal disease has grown significantly since the introduction of anti-TNF agents which are now a mainstay of treatment along with antibiotics and immunomodulators. New experimental therapies are limited by lack of research to support their use.
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Affiliation(s)
- Dawn M Wiese
- Vanderbilt University Medical Center, Nashville, TN 37232-5283, USA.
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28
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Minimally invasive surgical technique in the management of perianal fistulas using the Surgisis® AFP material. POLISH JOURNAL OF SURGERY 2011; 83:392-402. [PMID: 22166669 DOI: 10.2478/v10035-011-0063-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lim CH, Lee HY, Kim WC, Cho SH, Jeong HS, Jeon YJ, Lee JE, Kim SW. [A case of chemical colitis caused by hydrogen peroxide enema]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 58:100-2. [PMID: 21873825 DOI: 10.4166/kjg.2011.58.2.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Hydrogen peroxide is commonly used as a disinfectant that has been reported to cause chemical colitis. We report a case of 49 year-old man who presented with chemical colitis caused by self-inflicted hydrogen peroxide enema. In the sigmoidoscopic examination, diffuse erythematous and edematous mucosal change with multiple ulcerations and easy touch bleeding was noted from the rectum to the proximal sigmoid colon. Abdominal computed tomography showed diffuse wall thickening of the rectum and the sigmoid colon with inflammatory and reactive change at surrounding. The patient was treated with NPO, intravenous fluid, and antibiotic therapy. On 5th hospital day, abdominal pain and bloody stool disappeared, and the patient started oral feeding. He discharged on 6th hospital day with fully recovered state.
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Affiliation(s)
- Chul Hyun Lim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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30
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Abstract
Endoanorectal ultrasonography (EARUS) may be used for diagnosing various anorectal disorders. EARUS is easy to perform, has a short learning curve, and causes less discomfort than routine digital examination. Anal sphincters can be clearly visualized, and one can easily distinguish between the internal (hypoechoic) and external (hyperechoic) anal sphincters. Other pelvic floor structures, like the puborectalis muscle, can also be visualized. The use of contrast agents can increase the accuracy of EARUS in the assessment of perianal fistulae. In addition, EARUS is an excellent alternative to expensive magnetic resonance imaging. Besides its use in incontinence and perianal sepsis, the presence of slight or massive submucosal invasion in early rectal cancer may be imaged in greater detail. With 3-dimensional EARUS, it is possible to diagnose the anorectal diseases, in multiplane, with high spatial resolution, adding important information about the therapeutic decision. The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography with complementary techniques such as transvaginal and transperineal ultrasound are reviewed in this article.
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Sileri P, Cadeddu F, D'Ugo S, Franceschilli L, Del Vecchio Blanco G, De Luca E, Calabrese E, Capperucci SM, Fiaschetti V, Milito G, Gaspari AL. Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal. BMC Gastroenterol 2011; 11:120. [PMID: 22070555 PMCID: PMC3235969 DOI: 10.1186/1471-230x-11-120] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 11/09/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period. METHODS Between 1st January 2005 and 31st March 2011,247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence. RESULTS Etiologies of fistulas were cryptoglandular (n = 218), Crohn's disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohn's patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohn's patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter. CONCLUSIONS This prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.
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Affiliation(s)
- Pierpaolo Sileri
- Department of Surgery, University Hospital Tor Vergata, Rome, Italy
| | - Federica Cadeddu
- Department of Surgery, University Hospital Tor Vergata, Rome, Italy
| | - Stefano D'Ugo
- Department of Surgery, University Hospital Tor Vergata, Rome, Italy
| | | | | | | | - Emma Calabrese
- Department of Gastroenterology, University Hospital Tor Vergata, Rome, Italy
| | | | | | - Giovanni Milito
- Department of Surgery, University Hospital Tor Vergata, Rome, Italy
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Sudoł-Szopińska I, Kołodziejczak M, Szopiński TR. The accuracy of a postprocessing technique--volume render mode--in three-dimensional endoanal ultrasonography of anal abscesses and fistulas. Dis Colon Rectum 2011; 54:238-44. [PMID: 21228675 DOI: 10.1007/dcr.0b013e3181ff44de] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study aimed to evaluate the accuracy of a 3-dimensional volume render mode endoanal ultrasonography in the assessment of anal abscesses and fistulas. PATIENTS AND METHODS Three-dimensional endoanal ultrasonography was performed preoperatively in 62 patients with clinical diagnoses of an anal abscess and/or an anal fistula. The accuracy of a volume render mode endoanal ultrasonography was evaluated blindly by 2 observers through a retrospective analysis of all the stored images of anal abscesses and fistulas. Differences in classification of the type of anal abscesses and in determination of the type and location of internal openings of anal fistulas were assessed. RESULTS In classification of the primary tract, the agreement between the volume render mode endoanal ultrasonography and surgery was much higher than that for the 3-dimensional endoanal ultrasonography (marginal homogeneity test P > .1, κ = 0.96, and marginal homogeneity test P = .0048, κ = 0.28, respectively). In localizing the internal openings and in classifying anal abscesses, the agreement for both methods with surgery was identical. The interobserver agreement showed complete agreement (100%) with regard to luminance and thickness parameters and very high accuracy for the opacity and filter parameters. CONCLUSIONS This study demonstrated that volume render mode endoanal ultrasonography is a useful adjunct method to the 3-dimensional endoanal ultrasonography, showing better classification results of the types of anal fistulas.
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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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35
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Joyce M, Veniero JC, Kiran RP. Magnetic resonance imaging in the management of anal fistula and anorectal sepsis. Clin Colon Rectal Surg 2010; 21:213-9. [PMID: 20011419 DOI: 10.1055/s-2008-1081000] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complex perianal disease may be extremely debilitating for the patient with significant impingement on quality of life. The accurate identification of anatomical areas of involvement and subsequent appropriate management is crucial to achieving a successful outcome when treating anorectal sepsis and anal fistulae. Magnetic resonance imaging (MRI) has become a powerful tool in the evaluation of anal anatomy. In patients with complex disease MRI is an important adjunct in delineating disease location and extent, its relationship to sphincter muscles, and in planning management. MRI also plays an important role in evaluating the response to medical and surgical therapies.
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Affiliation(s)
- Myles Joyce
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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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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Abstract
Despite the prevalence and severe implications of rectovaginal fistula, there is no universally accepted evidence-based approach to surgical management. This article offers a disease-based review of traditional management strategies and highlights the variety of technical approaches that are currently effective for the eradication of this socially disabling condition.
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Affiliation(s)
- Bradley J Champagne
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA.
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Abstract
Crohn's disease manifests with perianal or rectal symptoms in approximately one-third of patients, and is associated with a more aggressive natural history. Due to the chronic relapsing nature of the disease, surgery has been traditionally avoided. However, combined medical and surgical intervention when treating perianal fistulae has been shown to offer the best chance for success. Endoanal ultrasound examination or pelvic magnetic resonance imaging should be done in conjunction with an examination under anesthesia to characterize the disease. Any abscess should be drained and setons placed if there is active rectal inflammation or complex fistulae. Antibiotics and immunosuppressive therapy (especially with infliximab) should also be initiated. Simple fistulae can be treated surgically by fistulotomy or anal fistula plug. Complex fistulae can be closed with either an anal fistula plug or covered with flaps. Up to 20% of patients anorectal Crohn's disease require proctectomy for persistent and disabling disease.
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Affiliation(s)
- Robert T Lewis
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
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40
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Kim Y, Park YJ. Three-dimensional endoanal ultrasonographic assessment of an anal fistula with and without H 2O 2 enhancement. World J Gastroenterol 2009; 15:4810-5. [PMID: 19824116 PMCID: PMC2761560 DOI: 10.3748/wjg.15.4810] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effectiveness of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of anal fistulae with and without H2O2 enhancement.
METHODS: Sixty-one patients (37 males, aged 17-74 years) with anal fistulae, which were not simple low types, were evaluated by physical examination and 3D-EAUS with and without enhancement. Fistula classification was determined with each modality and compared to operative findings as the reference standard.
RESULTS: The accuracy of 3D-EAUS was significantly higher than that of physical examination in detecting the primary tract (84.4% vs 68.7%, P = 0.037) and secondary extension (81.8% vs 62.1%, P = 0.01) and localizing the internal opening (84.2% vs 59.7%, P = 0.004). A contrast study with H2O2 detected several more fistula components including two primary suprasphincteric fistula tracks and one supralevator secondary extension, which were not detected on non-contrast study. However, there was no significant difference in accuracy between 3D-EAUS and H2O2-enhanced 3D-EAUS with respect to classification of the primary tract (84.4% vs 89.1%, P = 0.435) or secondary extension (81.8% vs 86.4%, P = 0.435) or localization of the internal opening (84.2% vs 89.5%, P = 0.406).
CONCLUSION: 3D-EAUS was highly reliable in the diagnosis of an anal fistula. H2O2 enhancement was helpful at times and selective use in difficult cases may be economical and reliable.
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Imaging of perianal fistulas. Clin Gastroenterol Hepatol 2009; 7:1037-45. [PMID: 19602450 DOI: 10.1016/j.cgh.2009.06.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 06/17/2009] [Accepted: 06/20/2009] [Indexed: 02/07/2023]
Abstract
Perianal fistulas, cryptoglandular or Crohn's disease-related, have a tendency to recur. Recurrence usually is owing to missed infection during surgery for cryptoglandular fistulas or insufficient response to medical treatment in Crohn's disease. It is now recognized that preoperative imaging (endoanal ultrasound and magnetic resonance imaging) can help to identify extensions that otherwise would be missed during surgery and therefore prevent recurrence. For medical therapy, the extent of the disease and the presence of abscesses are identified with imaging and therapy response can be monitored. The purpose of this review is to give an up-to-date overview of the anal anatomy, classification of perianal fistulas, and the role of imaging modalities in the management of patients with perianal fistulas.
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42
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Haemorrhoids, rectal prolapse, anal fissure, peri-anal fistulae and sexually transmitted diseases. Best Pract Res Clin Gastroenterol 2009; 23:575-92. [PMID: 19647691 DOI: 10.1016/j.bpg.2009.04.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anorectal disorders like haemorrhoids, rectal prolapse, anal fissures, peri-anal fistulae and sexually transmitted diseases are bothersome benign conditions that warrant special attention. They, however, can all be diagnosed by inspection or proctoscopy (sexually transmitted proctitis). Constipation can play an underlying role in haemorrhoids, rectal prolapse and anal fissures, and it is important to treat these conditions in order to avoid recurrences. Haemorrhoids and anal fissures are generally treated conservatively and surgery is seldom required. Rectal prolapse and cryptoglandular peri-anal fistulae are treated surgically. In a recurrent peri-anal fistula, the fistular tract needs to be visualised with anal ultrasound or magnetic resonance imaging (MRI). There are different techniques available for this evaluation, and care must be taken not to damage the anal sphincter. Peri-anal fistulae in Crohn's disease are treated conservatively and surgery is only required in cases with abscesses. Sexually transmitted proctitis needs to be adequately recognised and treated according to the infectious agent.
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Importancia de la exploración física y técnicas de imagen en la valoración diagnóstica de las fístulas de ano. Cir Esp 2009; 85:238-45. [DOI: 10.1016/j.ciresp.2008.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 10/30/2008] [Indexed: 12/18/2022]
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Bartumeus P, Gómez Abril SA, Ripollés T, Martínez Pérez MJ, Cogollos J. [Comparison of hydrogen peroxide-enhanced ultrasound with surgery in the diagnosis of perianal fistulas]. Cir Esp 2009; 85:171-7. [PMID: 19268921 DOI: 10.1016/j.ciresp.2008.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Accepted: 11/25/2008] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the usefulness of hydrogen peroxide-enhanced ultrasound (H(2)O(2)) in the preoperative assessment of perianal fistulas and to compare these results with unenhanced ultrasound findings. METHODS All patients with surgically confirmed perianal fistula who underwent preoperative enhanced and unenhanced ultrasound were included. We compared enhanced and unenhanced ultrasound findings with surgical results (chi(2) and McNemar tests). RESULTS A total of 44 surgically treated patients were analysed. Hydrogen peroxide-enhanced ultrasound correctly identified primary fistula tracks in 34 patients (sensitivity of 77%), 100% of abscesses and the internal opening in 29 out of 37 identified with surgery (sensitivity of 78% and specificity of 70%). The use of hydrogen peroxide provided additional information to the ultrasound performed without the use of contrast enhancement in 32 of the 44 patients (73%). H(2)O(2) increased the number of fistula tracts correctly detected (77% vs 45%; p<0.003), particularly suprasphincteric fistulas, as well as internal openings (78% vs 22%; p<0.001) and secondary tracks (70% vs 0%). Additional detection of fistula tracks after H(2)O(2) injection was higher in patients with previous surgery (68% vs 35%; p<0.05). CONCLUSIONS Hydrogen peroxide-enhanced ultrasound shows good agreement compared with surgical findings in the assessment of perianal fistulas. H(2)O(2) improves conventional ultrasound results, increasing the detection of fistula tracks and internal openings, and also providing additional information, particularly in previously operated patients.
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Affiliation(s)
- Paula Bartumeus
- Servicio de Radiodiagnóstico, Hospital Universitario Doctor Peset, Valencia, Spain.
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45
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Sun MRM, Smith MP, Kane RA. Current techniques in imaging of fistula in ano: three-dimensional endoanal ultrasound and magnetic resonance imaging. Semin Ultrasound CT MR 2009; 29:454-71. [PMID: 19166042 DOI: 10.1053/j.sult.2008.10.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perianal fistula is an abnormal communication between the anal canal and perianal skin. The majority of perianal fistulous disease results from either cryptoglandular inflammation or Crohn's disease. These groups differ in pathophysiology, prognosis, and strategies for imaging and treatment. Endoanal ultrasound and magnetic resonance imaging represent current imaging strategies for evaluating perianal fistulas and may be used alone or in combination. The use of three-dimensional technique and peroxide fistulography optimize the ultrasound evaluation of perianal fistula. The use of multiple imaging planes and sequences including fat suppression and contrast enhancement optimize the magnetic resonance imaging protocol. Examples of the imaging appearance of perianal fistulas and a proposed flowchart for imaging modality selection are provided.
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Affiliation(s)
- Maryellen R M Sun
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA.
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46
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47
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Hannaway CD, Hull TL. Current considerations in the management of rectovaginal fistula from Crohn's disease. Colorectal Dis 2008; 10:747-55; discussion 755-6. [PMID: 18462243 DOI: 10.1111/j.1463-1318.2008.01552.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Rectovaginal fistulas are dreaded complications of Crohn's disease. Accurate assessment is essential for planning management. Treatment options range from observation to medical therapeutics to the need for surgical intervention. Ultimately, establishing reasonable expectations is mandatory when treatment algorithms are considered. In this article, we review the evaluation of these fistulas and the current options to consider in the treatment of Crohn's related rectovaginal fistula.
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Affiliation(s)
- C D Hannaway
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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48
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Toyonaga T, Tanaka Y, Song JF, Katori R, Sogawa N, Kanyama H, Hatakeyama T, Matsushima M, Suzuki S, Mibu R, Tanaka M. Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula. Tech Coloproctol 2008; 12:217-23. [PMID: 18679573 DOI: 10.1007/s10151-008-0424-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 06/10/2008] [Indexed: 01/05/2023]
Abstract
BACKGROUND This study was undertaken to evaluate the accuracy of endoanal ultrasonography for preoperative assessment of anal fistula, with special reference to the difference between acute and chronic fistula. METHODS The subjects comprised 401 patients treated for acute or chronic anorectal sepsis of cryptoglandular origin during the period January through December 2005. All patients underwent physical examination and endoanal ultrasonography. Agreement between the physical and endosonographic findings and the definitive surgical findings were evaluated with special reference to classification of the primary tract and horseshoe extension and localization of the internal opening. The difference in accuracy of endosonographic assessment between acute and chronic fistula was also evaluated. RESULTS The accuracy of endoanal ultrasonography was significantly higher than that of physical examination in detecting the primary tract (88.8% vs. 85.0%, p=0.0287) and horseshoe extension (85.7% vs. 58.7%, p<0.0001) and in localizing the internal opening (85.5% vs. 69.1%, p<0.0001). Furthermore, localization of the internal opening by endosonography was significantly more accurate in chronic fistula than in acute fistula (89.5 % vs. 76.8%, p<0.0001), although the accuracy in detecting the primary tract and horseshoe extension was not significantly different. CONCLUSIONS Endoanal ultrasonography is reliable and useful for preoperative assessment of anal fistula, particularly for detecting horseshoe extension and localizing the internal opening. Endosonographic assessment provides clearer depiction of the internal opening during periods of quiescence than during the period of abscess formation. For patients with acute anorectal sepsis, initial surgical drainage and subsequent fistula surgery, rather than one-stage fistula surgery, may be advisable to avoid misidentification of the internal opening.
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Affiliation(s)
- T Toyonaga
- Matsushima Hospital Colo-Proctology Center, 19-11 Tobehoncho, Nishi-ku, Yokohama, Japan.
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Felt-Bersma RJF. Endoanal ultrasound in benign anorectal disorders: clinical relevance and possibilities. Expert Rev Gastroenterol Hepatol 2008; 2:587-606. [PMID: 19072406 DOI: 10.1586/17474124.2.4.587] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Endoanal ultrasound is a well-established technique used to evaluate benign anorectal disorders. The technique is easy to perform, has a short learning curve and causes very little discomfort. Reconstruction of 3D images is possible. The clinical indications for endoanal ultrasound in benign anorectal diseases are fecal incontinence and peri-anal fistula. Sphincter defects can be depicted with precision and correlate perfectly with surgical findings. Furthermore, an impression of sphincter atrophy can be established. With perianal fistula the tracts can be visualized. Introducing hydrogen peroxide via the external fistula opening improves imaging. Endoanal ultrasound and MRI have comparable results in diagnosing anorectal disorders.
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Affiliation(s)
- Richelle J F Felt-Bersma
- VU University Medical Center, Department of Gastroenterology and Hepatology, De Boelelaan 1117, 1081 HV, PO Box 7057, Amsterdam, The Netherlands.
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50
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Weisman N, Abbas MA. Prognostic value of endoanal ultrasound for fistula-in-ano: a retrospective analysis. Dis Colon Rectum 2008; 51:1089-92. [PMID: 18461397 DOI: 10.1007/s10350-008-9284-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 11/29/2007] [Accepted: 12/19/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess whether preoperative endoanal ultrasound plays a prognostic role in the surgical outcome of anal fistula. METHODS A retrospective review was conducted at a single institution. RESULTS Sixty-nine patients underwent 83 studies. Indications for endoanal ultrasound included complex fistulas and tracts, multiple external openings, recurrent fistulas, and/or failed previous surgical intervention. Mean age was 51.7 years. Fifty-three patients (77 percent) were men. Mean duration of symptoms was 3.1 years. Forty-nine patients (71 percent) had undergone previous surgical intervention to eradicate sepsis or fistula. Sixty patients (87 percent) underwent surgical interventions and were divided into two groups: Group A (73.3 percent), concordance with ultrasound findings; and Group B (26.7 percent), nonconcordance. Mean follow-up in the surgical group was 15.6 months. Measured outcome was total number of operations per patient and failure rate of primary surgical intervention. No difference was noted in mean total number of operations between Group A (1.57) and Group B (1.69) (P = 0.71). There was a statistically nonsignificant trend toward a higher failure rate of the primary intervention in the nonconcordance group [failure rate 18.2 percent in Group A vs. 25 percent in Group B (P = 0.72)]. CONCLUSIONS The findings and accuracy of preoperative endoanal ultrasound did not influence postoperative outcome.
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Affiliation(s)
- Nicholas Weisman
- Colon and Rectal Surgery, Department of Surgery, Kaiser Permanente, 4760 Sunset Boulevard, Los Angeles, California 90027, California
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