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Dnyanmote AS, Am PI, Kanani R, Shree H, Pandey A, Immadi S. Retroperitoneal Extension of a Fistula-in-Ano: A Case Report. Cureus 2024; 16:e64240. [PMID: 39130908 PMCID: PMC11313158 DOI: 10.7759/cureus.64240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
Fistula-in-ano and anorectal abscesses are commonly encountered in surgical departments, but their extension into the retroperitoneum and pelvis to form an extensive collection is rare. Here, we present the case of a 66-year-old diabetic male who presented with lower abdominal pain and fever for a day, with signs of sepsis. He had a simple fistula in the perianal region for the past 15 years. Radiological studies showed that the fistulous tract was complex which extended superiorly into the supralevator space and the retroperitoneum and formed a localized collection in the pelvis. The dependent part of the collection was drained using minimally invasive techniques, and the remnant collection was surgically drained through a perianal approach. The patient's condition improved with further treatment and local wound care, and he was subsequently discharged.
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Affiliation(s)
- Anuradha S Dnyanmote
- Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Prashanth I Am
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Rushi Kanani
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Hima Shree
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Ankita Pandey
- Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Saikumar Immadi
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
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Brillantino A, Iacobellis F, Brusciano L, Giordano P, Santoro GA, Sudol-Szopinska I, Grillo M, Maglio MN, Foroni F, Palumbo A, Menna MP, Antropoli C, Docimo L, Renzi A. Impact of Preoperative Three-Dimensional Endoanal Ultrasound on the Surgical Outcome of Primary Fistula in Ano. A Multi-Center Observational Study of 253 Patients. Surg Innov 2023; 30:693-702. [PMID: 37776197 DOI: 10.1177/15533506231204821] [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] [Indexed: 10/02/2023]
Abstract
PURPOSE To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery. METHODS The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings. RESULTS A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference (P < .0001; Fisher's exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate. CONCLUSION The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.
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Affiliation(s)
| | | | - Luigi Brusciano
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, Naples, Italy
| | | | | | - Iwona Sudol-Szopinska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Diagnostic Imaging, Warsaw Medical University, Warsaw, Poland
| | | | | | | | | | | | | | - Ludovico Docimo
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, Naples, Italy
| | - Adolfo Renzi
- Surgery Department, Ospedale Buonconsiglio Fatebenefratelli, Naples, Italy
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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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Boscá MM, Alós R, Maroto N, Gisbert JP, Beltrán B, Chaparro M, Nos P, Mínguez M, Hinojosa J. Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:155-168. [PMID: 31870681 DOI: 10.1016/j.gastrohep.2019.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/12/2019] [Accepted: 09/21/2019] [Indexed: 02/06/2023]
Abstract
Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.
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Affiliation(s)
- Marta M Boscá
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, España
| | - Rafael Alós
- Servicio de Cirugía General y Digestiva, Hospital Universitario La Fe, Valencia, España
| | - Nuria Maroto
- Servicio de Medicina Digestiva, Hospital Universitario de Manises, Manises, Valencia, España
| | - Javier P Gisbert
- Servicio de Medicina Digestiva, Hospital Universitario de La Princesa, Madrid, España
| | - Belén Beltrán
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España
| | - María Chaparro
- Servicio de Medicina Digestiva, Hospital Universitario de La Princesa, Madrid, España
| | - Pilar Nos
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España
| | - Miguel Mínguez
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, España
| | - Joaquín Hinojosa
- Servicio de Medicina Digestiva, Hospital Universitario de Manises, Manises, Valencia, España.
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5
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Recommendations of the Crohn’s Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn’s disease. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.gastre.2019.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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6
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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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7
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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: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [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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Pehlivanli F, Aydin O, Karaca G, Aydin G, Erden Daphan Ç. An Extremely Rare Complication of Widespread Retroperitoneal Abscess Originating from Anorectal Horseshoe Abscess. Bull Emerg Trauma 2019; 7:72-75. [PMID: 30719470 PMCID: PMC6360016 DOI: 10.29252/beat-0701011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Faruk Pehlivanli
- Kirikkale University School of Medicine, Department of General Surgery, Kirikkale, Turkey
| | - Oktay Aydin
- Kirikkale University School of Medicine, Department of General Surgery, Kirikkale, Turkey
| | - Gökhan Karaca
- Kirikkale University School of Medicine, Department of General Surgery, Kirikkale, Turkey
| | - Gülçin Aydin
- Kirikkale University School of Medicine, Department of Anesthesiology and Reanimation, Kirikkale, Turkey
| | - Çağatay Erden Daphan
- Kirikkale University School of Medicine, Department of General Surgery, Kirikkale, Turkey
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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: 2.4] [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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10
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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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11
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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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12
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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: 2.3] [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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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: 7] [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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14
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Shin RD, Hall JF. Modern management of deep post-anal space abscess and horseshoe fistulas. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.08.010] [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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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: 1.2] [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
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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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: 1.0] [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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18
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The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship? Tech Coloproctol 2010; 14:317-21. [PMID: 20949301 DOI: 10.1007/s10151-010-0648-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 09/16/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum. METHODS we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant. RESULTS The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001). CONCLUSIONS To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.
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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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Murad-Regadas SM, Regadas FSP, Rodrigues LV, Holanda EDC, Barreto RGL, Oliveira L. The role of 3-dimensional anorectal ultrasonography in the assessment of anterior transsphincteric fistula. Dis Colon Rectum 2010; 53:1035-40. [PMID: 20551756 DOI: 10.1007/dcr.0b013e3181dce163] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this study was to evaluate the role of 3-dimensional anorectal ultrasonography in the choice of surgical technique according to the position of the fistulous tract in patients with anterior transsphincteric anal fistula. METHODS A total of 33 patients (18 male) with anterior transsphincteric fistulas were evaluated by ultrasonography. The length of the external and internal anal sphincters, the position of the internal opening, the length of the compromised sphincter, and the percentage of sphincter muscle to be transected during surgery were measured, compared between sexes, and used in planning the surgery. Postoperative incontinence symptoms were quantified with a Wexner score. RESULTS The external and internal sphincters were longer and the position of the internal opening was higher in males. The position where the tract crossed the external sphincter was in both sexes, but the percentage of compromised muscle was higher in females because of the smaller length of the external sphincter. Seton placement followed by fistulotomy or advanced flap repair were indicated in 11 of 18 males and 13 of 15 females as the tract crossed the external sphincter above 50.0%. The mean postoperative follow-up was 12 months. Overall, minor fecal incontinence symptoms were identified in 16 (48.0%) patients. Of these, 11 (73.0%) females and 5 (28.0%) males had a mean incontinence score of 2.9 and 3.0, respectively. CONCLUSIONS Three-dimensional ultrasonography was shown to be useful in the preoperative assessment of anterior transsphincteric fistulas by quantifying the length of muscle to be transected, contributing to the choice of a safe treatment approach and to the reduction of the rate of postoperative continence disorders.
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Affiliation(s)
- Sthela M Murad-Regadas
- Department of Surgery, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil.
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Abstract
Perirectal abscesses and fistulas represent the acute and chronic manifestations of the same disease process, an infected anal gland. They have beleaguered patients and physicians for millennia. A thorough understanding of the anatomy and pathophysiology of the disease process is critical for optimal diagnosis and management. Abscess management is fairly straightforward, with incision and drainage being the hallmark of therapy. Fistula management is much more complicated. It requires striking a balance between rates of healing and potential alteration of fecal continence. This, therefore, requires much more finesse. Many techniques are now available in the armamentarium of the surgeon who treats fistula-in-ano. Although no single technique is appropriate for all patients and all fistula types, appropriate selection of patients and choice of repair technique should yield higher success rates with lower associated morbidity.
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Affiliation(s)
- Mark H Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, Legacy Portland Hospitals, Portland, OR 97210, USA.
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22
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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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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: 25] [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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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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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: 2.5] [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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Magdeburg R, Grobholz R, Dornschneider G, Post S, Bussen D. Perianal abscess caused by Actinomyces: report of a case. Tech Coloproctol 2008; 12:347-9. [DOI: 10.1007/s10151-008-0446-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 09/28/2006] [Indexed: 10/21/2022]
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Davies M, Harris D, Lohana P, Chandra Sekaran TV, Morgan AR, Beynon J, Carr ND. The surgical management of fistula-in-ano in a specialist colorectal unit. Int J Colorectal Dis 2008; 23:833-8. [PMID: 18427814 DOI: 10.1007/s00384-008-0444-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2008] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Fistula-in-ano can be associated with a number of conditions, including Crohn's disease. The majority, however, are classified as idiopathic or cryptoglandular. The aim of this study was to review the outcome of surgical management of fistula-in-ano in a specialist colorectal unit. MATERIALS AND METHODS One hundred and four consecutive patients underwent surgery for anal fistulae between 1st January 2000 and December 2004. Data was analysed in two main groups, according to the aetiology, cryptoglandular (n = 86) and Crohn's disease (n = 18). Follow-up data was available on 91 patients. RESULTS In the cryptoglandular group, 62 patients had an inter-sphincteric tract, of which 48 underwent a single-stage fistulotomy. Of those patients with a trans-sphincteric tract, six patients underwent a single-stage fistulotomy, 13 had a seton and staged fistulotomy. Follow-up data revealed that two fistulae recurred. The median number of procedures in this group was 1 (range 1-3). There was a significant difference in the inpatient stay depending of Park's classification (p = 0.001). In the Crohn's group, three patients with an inter-sphincteric tract underwent a single-stage fistulotomy, two patients with a trans-sphincteric tract had single-stage fistulotomy, and five required a loose seton and staged fistulotomy. Eight patients had multiple fistulae which required long-term setons. Four patients from this group eventually required proctectomy. In the Crohn's group, there was a significantly increased complexity of surgery and higher recurrence. This was reflected in an increased inpatient length of stay and a greater reliance on imaging (p = 0.001). The median number of procedures in this group was 3 (range 1-5). DISCUSSION The majority of cryptoglandular fistula-in-ano were treated by primary fistulotomy or staged fistulotomy with a loose seton. This was associated with a low recurrence rate and low rates of faecal incontinence. There was a low reliance on imaging techniques in this group. However, we would urge caution when dealing with fistula-in-ano related to Crohn's disease. In this group of patients, the fistulae tended to be more complex and require additional imaging and multiple procedures.
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Affiliation(s)
- M Davies
- Department of Colorectal Surgery, Singleton Hospital, Sketty, Swansea, SA2 8QA, Wales, UK.
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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: 2.7] [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: 0.9] [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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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: 1.0] [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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31
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Professor Ahmed Shafik (1933–2007). Tech Coloproctol 2007. [DOI: 10.1007/s10151-007-0385-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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32
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Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:18-50. [PMID: 17880382 DOI: 10.1111/j.1463-1318.2007.01372.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- J G Williams
- McHale Centre, New Cross Hospital, Wolverhampton, UK.
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Abstract
OBJECTIVE Some conditions, previously managed by general surgeons, may be treated more successfully by colorectal specialists. This argument is well established for rectal cancer but does it also apply to benign conditions? This study compares the treatment strategies and outcomes for fistulae-in-ano by general and colorectal surgeons in a district general hospital. METHOD Patients who had surgery for fistula-in-ano from January 1992-October 2003 were identified from theatre records. Case notes were reviewed for data on type of fistula, aetiology, surgery performed and recurrence. All patients were sent a questionnaire requesting details of recurrence and incontinence. The severity of incontinence was assessed using the Faecal Incontinence Quality of Life Scale (FIQOLS) and the Faecal Incontinence Severity Index (FISI). RESULTS Eighty four patients (male = 53) were identified. Colorectal surgeons performed surgery in 34 and general surgeons in 50 patients. These groups were comparable with terms of age, gender, aetiology (colorectal: IBD = 5, cryptoglandular = 21: general IBD = 14, cryptoglandular = 24; P = 0.28; Chi-squared test), and type of fistulae (colorectal: inter-sphincteric = 20, trans-sphincteric = 13: general inter-sphincteric = 30, trans-sphincteric = 18: P = 1.0; Fisher's exact test). Colorectal surgeons carried out fewer fistulotomies (47.1%vs 84.0%; P < 0.001; Fisher's exact test), more staged fistulotomies with Setons (44.1%vs 10.0%: P < 0.001; Fisher's exact test), and had fewer recurrences (9.7%vs 30.0%: P < 0.05; Fisher's exact test) when compared with general surgeons. Five patients with recurrence from the general surgery group were subsequently referred to the colorectal surgeons; four patients had further surgery (fistulotomy = 2; staged fistulotomy = 2) with no recurrence to date; one patient required proctectomy. Forty seven (64.4%) patients answered the questionnaire. There was no difference between patients operated on by colorectal or general surgeons with regards the frequency (43.5%vs 62.5%: P = 0.25; Fisher's exact test) or severity [FISI 26 (21-38); median (inter-quartile range) vs 26 (17-38); median (inter-quartile range: P = 0.85; Mann-Whitney test) of faecal incontinence. There was no difference between the groups with regards any of the four scales that comprised the FIQOLS. CONCLUSIONS The number of included patients is far too low to draw any conclusions but there were some interesting trends. For similar patient samples, colorectal surgeons seem to adopt a more conservative approach and have fewer recurrences than general surgeons. These differences are not reflected in the frequency or severity of postoperative incontinence.
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Affiliation(s)
- N Nwaejike
- Department of Surgery, Altnagelvin Hospital, Londonderry, UK
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Knechtges P, Buchanan GN, Willatt J, Williams AB, Francis IR. Fistula-in-Ano: The Role of Imaging in Diagnosis and Presurgical Planning. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2007.03.005] [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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Santoro GA, Fortling B. The advantages of volume rendering in three-dimensional endosonography of the anorectum. Dis Colon Rectum 2007; 50:359-68. [PMID: 17237912 DOI: 10.1007/s10350-006-0767-z] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Anorectal diseases require imaging for proper case management. At present, endoanal ultrasonography and endorectal ultrasonography have become important parts of diagnostic workup of patients with fecal incontinence, perianal fistulas, and rectal cancer and provides sufficient information for clinical decision-making in many cases. However, with the currently available ultrasonographic equipment and techniques, a good deal of relevant information may remain hidden. The advent of high-resolution three-dimensional endoluminal ultrasound, constructed from a synthesis of standard two-dimensional cross-sectional images, and of "Volume Render Mode," a technique to analyze information inside a three-dimensional volume by digitally enhancing individual voxels, promises to revolutionize diagnosis of pelvic floor disorders. By use of the different postprocessing display parameters, the volume-rendered image provides better visualization performance when there are not large differences in the signal levels of pathologic structures compared with surrounding tissues. The anatomic structures in the pelvis, the axial and longitudinal extension of anal sphincter defects, the anatomy of the fistulous tract in complex perianal sepsis, and the presence of slight or massive submucosal invasion in early rectal cancer may be imaged in greater detail. This additional information will bring an improvement for both planning and conduct of surgical procedures.
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Affiliation(s)
- Giulio A Santoro
- Section of Anal Physiology and Ultrasound, Coloproctology Service, Department of Surgery, Regional Hospital, Treviso, Italy.
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Abstract
OBJECTIVE To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment. PATIENTS AND METHODS One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test. RESULTS The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule. CONCLUSION Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.
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Affiliation(s)
- A Becker
- Department of Surgery, Haemek Medical Center, Afula, Israel
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Tilney HS, Heriot AG, Trickett JP, Massouh H, Edwards DP, Mellor SG, Gudgeon AM. The use of intra-operative endo-anal ultrasound in perianal disease. Colorectal Dis 2006; 8:338-41. [PMID: 16630240 DOI: 10.1111/j.1463-1318.2006.00927.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endoanal ultrasound (EAUS) has demonstrated high sensitivity and specificity for the structural imaging of anorectal pathology. This study prospectively assessed the impact of intra-operative EAUS on the surgical management of perianal disease. METHODS EAUS was performed prior to and after examination under anaesthesia (EUA) in a consecutive series of patients with perianal disease. The impact of EAUS on the surgery performed was identified. RESULTS Forty-three procedures have been performed in 38 patients (21 male, 17 female; mean age 42.7 years, range 6-76 years) over a three year period. Pathologies encountered were fistula-in-ano (42%), fissure-in-ano (26%), complicated perianal sepsis (16%) and carcinoma (5%). No specific abnormality was identified in 5 symptomatic patients (12%). Four patients with fissures had undergone previous sphincterotomy. In 22 cases (51.2%) the EAUS findings affected the surgical management (extent of muscle above a fistula 9 cases, extent of sphincterotomy 7 cases, site of sepsis identified 2 cases, exclusion of sepsis 2 cases, assessment of cancer resectability 1 case, biopsy of intersphincteric lesion 1 case). CONCLUSION Intra-operative EAUS accurately identifies perianal disease and influences the surgical procedure performed. While not essential, it is a useful adjunct especially in recurrent perianal sepsis, undiagnosed anorectal pain and anal fissure.
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Affiliation(s)
- H S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Frimley, UK
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Gonzalez-Ruiz C, Kaiser AM, Vukasin P, Beart RW, Ortega AE. Intraoperative Physical Diagnosis in the Management of Anal Fistula. Am Surg 2006. [DOI: 10.1177/000313480607200103] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This report reviews a prospective database applying a systematic fistulomy technique in 101 patients requiring surgery for fistula in ano at LAC+USC Medical Center during a 15-month period. Data were collected for the reliability of primary crypt palpation, success of tract injection with peroxide/methylene blue, and the accuracy of Goodsall's rule. Time to healing, recurrence, and incontinence according to type of procedure were also recorded. Palpation of the primary crypt was possible in 93 per cent. Hydrogen peroxide/methylene blue injection successfully delineated the tract in 83 per cent. Goodsall's rule was correct in 81 per cent. Each fistula was categorized as intersphincteric (n = 72), transphincteric (n = 33), extrasphincteric (n = 1), or sub-mucosal (n = 6). At a mean follow-up period of 44 weeks, 89.2 per cent of patients were cured. Reasons for recurrence included wound bridging (n = 6), misdiagnosis of the tract (n = 3), and two blind-ended fistulae (n = 2). Time to healing in weeks was (mean, range): simple fistulotomy (12, 3–21), seton (16, 4–28), Hanley procedure (28, 8–48). Patients with a marsupialized tract healed at an average of 6 weeks (range 4–8). Four (3.9%) patients reported postoperative incontinence (1 gas, 3 liquid, 0 solids).
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Affiliation(s)
- Claudia Gonzalez-Ruiz
- From the Departments of Surgery and Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andreas M. Kaiser
- From the Departments of Surgery and Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Petar Vukasin
- From the Departments of Surgery and Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Robert W. Beart
- From the Departments of Surgery and Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Adrian E. Ortega
- From the Departments of Surgery and Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Engin G. Endosonographic imaging of anorectal diseases. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2006; 25:57-73. [PMID: 16371556 DOI: 10.7863/jum.2006.25.1.57] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography compared with magnetic resonance imaging are reviewed. Methods. Endosonographic imaging was performed with a Siemens (Erlangen, Germany) FI 400 ultrasound scanner with an end-fire 7.5-MHz biplane endorectal probe and a B-K Medical (Sandhoften, Denmark) scanner with an 1850 axial-type side-fire 5.0- to 10.0-MHz rotating endoscopic probe. RESULTS Rectal carcinoma appears on endorectal sonography as a low-echogenicity lesion that abruptly interrupts the normal sequence of layers. The internal anal sphincter is seen very clearly on endoanal sonography, and it is easy to appreciate atrophy and small tears of this sphincter. Endoanal sonography cannot accurately show thinning of the external anal sphincter. Peroxide-enhanced endoanal sonography is especially useful for patients with recurrent perianal fistulas in whom scarring should be distinguished from recurrent fistulas and detection of the internal opening. However, sonography does not provide an adequate deep and global display of all adjacent pelvic and perineal spaces. CONCLUSIONS Endosonography can accurately stage primary rectal tumors and assess the internal anal sphincter. Peroxide-enhanced 3-dimensional imaging can increase the utility of endoanal sonography in detection and characterization of perianal fistulas and planning of optimal therapy. However, magnetic resonance imaging can be used a complementary modality to endosonography, especially for evaluation of external anal sphincter atrophy and deep pelvic inflammation.
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Affiliation(s)
- Gulgun Engin
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Capa, Turkey.
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Esclapez-Valero JP, García-Botello S. Valor actual de la ecografía endoanal en el diagnóstico de la enfermedad proctológica benigna. Cir Esp 2005; 78 Suppl 3:8-14. [PMID: 16478610 DOI: 10.1016/s0009-739x(05)74638-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Endoanal ultrasound is undoubtedly one of the major advances that has taken place in the evaluation of anorectal disease and pelvic floor disorders in the last decade. The main indications for endoanal ultrasound are evaluation of the morphology of the sphincteric apparatus in patients with fecal incontinence, the localization of perianal abscesses and fistulas, the staging of anal cancer and follow-up of squamous cell carcinoma after conservative treatment, and the study and morphological confirmation of lateral internal sphincterotomy in patients with fissure-in-ano, amongst others. In this article we review the main indications and use of endoanal ultrasound in the diagnosis of benign proctological disease.
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Affiliation(s)
- José Pedro Esclapez-Valero
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Clínico Universitario, Avda. Blasco Ibáñez 17, 46010 Valencia, Spain.
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Whiteford MH, Kilkenny J, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005; 48:1337-42. [PMID: 15933794 DOI: 10.1007/s10350-005-0055-3] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
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Abstract
Anal abscesses and fistulas are a common part of surgical practice. Most abscesses simply need to be drained and most fistulas can be safely laid open. Excessive probing should not be attempted when draining abscesses as this may lead to iatrogenic fistulas. A small percentage of fistulas are complex and very challenging to manage. Management involves an accurate diagnosis and a balance between eradication of the fistula and maintenance of continence. A decision should be made, based on clinical evaluation and anal ultrasound (if available), whether the fistula can be laid open. If it cannot be laid open, a loose seton is placed and the sepsis is allowed to settle. Once the sepsis is quiescent, a definitive repair can be attempted. There are various techniques available including rectal advancement flap, fibrin glue and cutaneous flaps all of which are discussed.
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Affiliation(s)
- Matthew J F X Rickard
- Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales 2137, Australia.
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Maor Y, Chowers Y, Koller M, Zmora O, Bar-Meir S, Avidan B. Endosonographic evaluation of perianal fistulas and abscesses: comparison of two instruments and assessment of the role of hydrogen peroxide injection. JOURNAL OF CLINICAL ULTRASOUND : JCU 2005; 33:226-32. [PMID: 16047390 DOI: 10.1002/jcu.20120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE The aims of this study were to compare the performance of a mechanical radial endosonoscope and an endorectal electronic probe and to evaluate the value of hydrogen peroxide (H(2)O(2)) injection in the diagnosis of perianal fistulas. PATIENTS AND METHODS Sixty-one patients underwent clinical and endosonographic studies for suspected perianal fistulas or abscesses. Endosonography was performed using two instruments: a mechanical radial endosonoscope (Olympus GF-UM20) and an electronic endorectal probe (Hitachi EUP-R53). The patients were re-examined during and following H(2)O(2) injection using both systems. RESULTS Thirty-seven fistulous tracts were visualized with the electronic endorectal probe versus only 9 with the mechanical radial endosonoscope. Four patients had anal stenosis, precluding the use of the larger electronic probe. Three fistulas were detected in these patients using the mechanical radial endosonoscope. H(2)O(2) injection was not feasible in 26 patients (43%). Visualization of 11 (31%) fistulas improved after administration of H(2)O(2). Six fistulous tracts not detected before H(2)O(2) administration were clearly visualized during injection and for several minutes thereafter. CONCLUSIONS Work-up of perianal fistula should be preferably performed using the endorectal electronic probe. However, the mechanical radial endoscope is preferred in patients with anal stricture. H(2)O(2) injection should become an integral part of every sonographic study of perianal fistulas.
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Affiliation(s)
- Yaakov Maor
- Department of Gastroenterology and Hepatology and Department of Surgery, Sheba Medical Center, Tel-Hashomer, Israel
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Coremans G, Margaritis V, Van Poppel HP, Christiaens MR, Gruwez J, Geboes K, Wyndaele J, Vanbeckevoort D, Janssens J. Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature. Dis Colon Rectum 2005; 48:575-81. [PMID: 15875298 DOI: 10.1007/s10350-004-0809-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.
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Affiliation(s)
- G Coremans
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.
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Buchanan GN, Bartram CI, Williams AB, Halligan S, Cohen CRG. Value of hydrogen peroxide enhancement of three-dimensional endoanal ultrasound in fistula-in-ano. Dis Colon Rectum 2005; 48:141-7. [PMID: 15690671 DOI: 10.1007/s10350-004-0752-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this prospective study was to compare the accuracy of three-dimensional endoanal ultrasound with that of hydrogen peroxide enhanced three-dimensional endoanal ultrasound in diagnosing recurrent or complex fistula-in-ano. METHODS Three-dimensional endoanal ultrasound reconstructions were performed before and after hydrogen peroxide enhancement in 19 patients with suspected recurrent or complex fistula-in-ano. Two experienced observers derived a consensus fistula classification after a blinded random review of the data sets. The accuracy of three-dimensional endoanal ultrasound and that of hydrogen peroxide-enhanced three-dimensional endoanal ultrasound were compared with a reference standard derived from surgical findings and magnetic resonance imaging and modified by outcome over a median follow-up of 13 months. RESULTS Patients had previously undergone a median of three fistula operations. Four had Crohn's disease. There were 21 internal openings and primary tracks in 19 patients: 1 superficial, 1 intersphincteric, 18 transsphincteric, and 1 extrasphincteric. Fourteen patients had 19 secondary tracks. Both techniques detected fistula tracks in 19 of 21 (90 percent) patients. There was no significant difference between three-dimensional endoanal ultrasound and hydrogen peroxide-enhanced three-dimensional endoanal ultrasound in classifying internal openings (19/21 (90 percent) vs. 18/21 (86 percent)), primary tracks (17/21 (81 percent) vs. 15/21 (71 percent)), or secondary tracks (13/19 (68 percent) vs. 12/19 (63 percent)). Where three-dimensional endoanal ultrasound correctly detected an internal opening, gas from hydrogen peroxide enhancement was present in 8 of 18 (44 percent) studies. Similarly, gas made primary tracks more conspicuous in 6 of 19 (32 percent) and secondary tracks in 6 of 13 (46 percent) of those detected. CONCLUSIONS In recurrent or complex fistula-in-ano, endoanal ultrasound proved more accurate for detecting primary tracks and internal openings than for detecting extensions. Hydrogen peroxide improved conspicuity of some tracks and internal openings and so may be helpful in difficult cases, although no overall diagnostic benefit was demonstrated.
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West RL, Dwarkasing S, Felt-Bersma RJF, Schouten WR, Hop WCJ, Hussain SM, Kuipers EJ. Hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in evaluating perianal fistulas: agreement and patient preference. Eur J Gastroenterol Hepatol 2004; 16:1319-24. [PMID: 15618839 DOI: 10.1097/00042737-200412000-00014] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine agreement between hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography (3D HPUS) and endoanal magnetic resonance imaging (MRI) in preoperative assessment of perianal fistulas, and to assess patient preference with regard to these techniques. METHODS Forty patients (31 males, aged 21-70 years) with symptoms of a perianal fistula and a visible external opening underwent preoperative 3D HPUS and endoanal MRI. The results were assessed separately by experienced observers. Fistulas were described according to the following characteristics: classification of the primary fistula tract according to Parks, location of the internal opening, presence of secondary tracts and fluid collections. Patients were asked to score the amount of discomfort experienced during both procedures and express their preference for either method. RESULTS The median time interval between 3D HPUS and endoanal MRI was 14 days (range, 0-91 days). The methods agreed in 88% (35/40, kappa = 0.45) for the primary fistula tract, in 90% (36/40, kappa = 0.83) for the location of the internal opening, in 78% (31/40, kappa = 0.62) for secondary tracts, and in 88% (35/40, kappa = 0.63) for fluid collections. Both methods were associated with similar discomfort, and there was no patient preference for one procedure over the other. CONCLUSIONS 3D HPUS and endoanal MRI are equally adequate for the evaluation of perianal fistulas. Both methods are associated with similar discomfort and patients have no preference for either procedure.
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Affiliation(s)
- Rachel L West
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, The Netherlands.
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Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CRG. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004; 233:674-81. [PMID: 15498901 DOI: 10.1148/radiol.2333031724] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To prospectively evaluate the relative accuracy of digital examination, anal endosonography, and magnetic resonance (MR) imaging for preoperative assessment of fistula in ano by comparison to an outcome-derived reference standard. MATERIALS AND METHODS Ethical committee approval and informed consent were obtained. A total of 104 patients who were suspected of having fistula in ano underwent preoperative digital examination, 10-MHz anal endosonography, and body-coil MR imaging. Fistula classification was determined with each modality, with reviewers blinded to findings of other assessments. For fistula classification, an outcome-derived reference standard was based on a combination of subsequent surgical and MR imaging findings and clinical outcome after surgery. The proportion of patients correctly classified and agreement between the preoperative assessment and reference standard were determined with trend tests and kappa statistics, respectively. RESULTS There was a significant linear trend (P < .001) in the proportion of fistula tracks (n = 108) correctly classified with each modality, as follows: clinical examination, 66 (61%) patients; endosonography, 87 (81%) patients; MR imaging, 97 (90%) patients. Similar trends were found for the correct anatomic classification of abscesses (P < .001), horseshoe extensions (P = .003), and internal openings (n = 99, P < .001); endosonography was used to correctly identify the internal opening in 90 (91%) patients versus 96 (97%) patients with MR imaging. Agreement between the outcome-derived reference standard and digital examination, endosonography, and MR imaging for classification of the primary track was fair (kappa = 0.38), good (kappa = 0.68), and very good (kappa = 0.84), respectively, and fair (kappa = 0.29), good (kappa = 0.64), and very good (kappa = 0.88), respectively, for classification of abscesses and horseshoe extensions combined. CONCLUSION Endosonography with a high-frequency transducer is superior to digital examination for the preoperative classification of fistula in ano. While MR imaging remains superior in all respects, endosonography is a viable alternative for identification of the internal opening.
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Affiliation(s)
- Gordon N Buchanan
- Departments of Surgery and Intestinal Imaging, St. Mark's Hospital, Level 4V, Watford Road, Northwick Park, Harrow, London HA1 3UJ, England
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Abstract
Endorectal (ERUS) and endoanal (EAUS) ultrasound imaging is increasingly being performed by surgeons in the office and outpatient setting for the assessment of both benign and malignant disease. Multiple studies have demonstrated the accuracy of these modalities in identifying pertinent anatomy and anatomic abnormalities. The ultrasound is easily tolerated by most patients, and is easily performed with minimal preparation on the patient's part. The ability of the surgeon to perform and interpret this straight forward diagnostic procedure allows for the simplification of the diagnostic process and a more rapid determination of treatment options for the patient.
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Affiliation(s)
- David M Schaffzin
- Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, C1083, New York, NY 10021, USA
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Sudol-Szopinska I, Szczepkowski M, Panorska AK, Szopiński T, Jakubowski W. Comparison of contrast-enhanced with non-contrast endosonography in the diagnostics of anal fistulas. Eur Radiol 2004; 14:2236-41. [PMID: 15300394 DOI: 10.1007/s00330-004-2415-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Revised: 05/18/2004] [Accepted: 06/07/2004] [Indexed: 12/14/2022]
Abstract
The objective of this paper is to compare the accuracy of standard, non-contrast endosonography (EAS) with contrast-enhanced endosonography (CE-EAS) in the diagnosis of anal fistulas. The group consisted of 126 patients (mean age: 43.1 years) with the clinical diagnosis of anal fistula. For anal endosonography, a Bruel & Kjaer unit with a 7.0-MHz transducer was used with a 3% solution of hydrogen peroxide as the contrast agent (1, 2, 3). In each case, EAS and CE-EAS diagnoses of the type and complexity of anal fistula, as well as the location of the internal opening, were determined. Results showed that CE-EAS was significantly more accurate in diagnosing the type of anal fistulas than NC-EAS (97 vs. 94%, respectively; P=02275), and in differentiating simple from complex tracks (92 vs. 75%, respectively; P<0.00001). CE-EAS was much more accurate in patients with recurrent fistulas (57 vs. 92%, respectively; P<0.00006), whereas in a subgroup of primary tracks, both methods were of comparable accuracy. Sensitivities of CE-EAS and EAS for internal opening were 89 and 65%, respectively. The conclusion of this paper is that CE-EAS significantly increases the accuracy of standard non-contrast EAS and is especially beneficial for the differentiation between simple and complex tracks.
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Affiliation(s)
- Iwona Sudol-Szopinska
- Department of Diagnostic Imaging, Medical University, ul. Kondratowicza 8, 03-285 Warsaw, Poland.
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Abstract
BACKGROUND The management of perianal Crohn's disease is difficult. A wide variety of treatment options exist although few are evidence based. METHODS A search was conducted using the National Library of Medicine for articles on perianal Crohn's disease and its incidence, classification, assessment and management. RESULTS AND CONCLUSION Perianal Crohn's disease can manifest as skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Improved radiological imaging with endoanal anal ultrasonography and magnetic resonance imaging has improved its assessment and may be used to predict outcome after surgery. Many treatment options exist. During acute complications they are generally aimed at resolving the immediate problem and limiting damage to anal and perianal tissues; this may be a 'bridge' to definitive treatment. The likelihood of success of definitive treatment must be weighed against the risk of complications, especially faecal incontinence.
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Affiliation(s)
- B Singh
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
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