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Aggarwal P, Malik R, Sarawagi R, Kumar A, Sharma J. Diffusion-Weighted MRI in Perianal Abscess: Role and Comparison With Contrast-Enhanced MRI. Cureus 2024; 16:e59035. [PMID: 38800169 PMCID: PMC11128151 DOI: 10.7759/cureus.59035] [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] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Perianal abscess is a clinical infective and/or inflammatory collection in the perianal region, one entity of a large group of anal and perianal disorders. Perianal abscesses are often seen as a complication of grade 2 and grade 4 perianal fistulas from St. James's University Hospital classification. Several imaging modalities have been tried in the past for adequate assessment of perianal abscess with contrast-enhanced magnetic resonance imaging (CE-MRI) providing the most accurate results. Diffusion-weighted imaging (DWI) is an emerging sequence that can provide comparable results to CE-MRI in diagnosing and characterizing perianal abscess. The main objective of this study is to assess the role of DWI in adequate identification and assessment of perianal abscess and compare the final results with contrast-enhanced images. METHODS Twenty patients with complicated perianal fistula with clinically suspected perianal abscess were evaluated with DWI and CE-MRI. This study was a comparative cross-sectional study conducted in the Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Bhopal, India. Chi-square test was done to find the association between categorical variables. Kappa test was used to find the agreement between two different tests. Receiver operating characteristics (ROC) analysis was done to estimate the area under the curve in predicting the outcome. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were used to measure the validity of the tests. RESULTS DWI is a very sensitive MRI sequence and is equivalent to CE-MRI to detect the location and analyzing the loco-regional extent of abscess in complicated perianal fistula cases. DWI is also very sensitive and superior to T2 short tau inversion recovery (STIR) in differentiating perianal abscess from perianal inflammation without abscess. CONCLUSION DWI can be used as an alternative to post-contrast fat-suppressed MRI in precisely defining the location and extent of anal and perianal abscesses and disease activity in complicated fistula cases.
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Affiliation(s)
- Pooja Aggarwal
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Rajesh Malik
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Radha Sarawagi
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Aman Kumar
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Jitendra Sharma
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
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Roelandt P, Bislenghi G, Coremans G, De Looze D, Denis MA, De Schepper H, Dewint P, Geldof J, Gijsen I, Komen N, Ruymbeke H, Stijns J, Surmont M, Van de Putte D, Van den Broeck S, Van Geluwe B, Wyndaele J. Belgian consensus guideline on the management of anal fissures. Acta Gastroenterol Belg 2024; 87:304-321. [PMID: 39210763 DOI: 10.51821/87.2.11787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Introduction Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.
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Affiliation(s)
- P Roelandt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Diseases (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - G Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - G Coremans
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - D De Looze
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - M A Denis
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - H De Schepper
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - P Dewint
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
- Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - J Geldof
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - I Gijsen
- Department of Gastroenterology and Hepatology, Noorderhart Hospital, Pelt, Belgium
| | - N Komen
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp RESURG Group, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - H Ruymbeke
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
- Department of Gastroenterology, VITAZ, Sint-Niklaas, Belgium
| | - J Stijns
- Department of Abdominal Surgery, University Hospital Brussels, Brussels, Belgium
| | - M Surmont
- Department of Gastroenterology and Hepatology, University Hospital Brussels, Brussels, Belgium
| | - D Van de Putte
- Department of Gastro-intestinal Surgery, University Hospital Ghent, Ghent, Belgium
| | - S Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
| | - B Van Geluwe
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery, General Hospital Groeninge, Kortrijk, Belgium
| | - J Wyndaele
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Results of surgical treatment in chronic anal fissure complicated by abscess or fistula in a retrospective cohort of patients. Updates Surg 2021; 74:179-183. [PMID: 34837605 DOI: 10.1007/s13304-021-01205-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
We report the results of the surgical treatment of anal fissures complicated by abscess or fistula and formulate hypotheses about their nature. Among patients operated between 2012 and 2020 for anal fissure resistant to medical therapy, those affected by septic complications were selected for our inquiry. Surgical treatment consisted in the drainage of the sepsis, fissurectomy, posterior sphincterotomy and anoplasty. Intra-sphincteric fistulas were removed with the fissure, whereas low trans-sphincteric tracks, including horseshoe fistulas, were partially opened and curetted. Patients were followed on post-operative days 7-10 and then until healing. Pre- and post-operative Visual Analog Scale (VAS) and Cleveland Clinic Incontinence Score (CCIS) scores were compared. Recurrence rates of disease were recorded. We operated 988 patients and 55 of them showed local sepsis (5.5%) complicating anal fissures. There were 23 abscesses and 32 fistulas. Of these latter, 17 were intra or inter-sphincteric (2 anterior) and 15 low trans-sphincteric (6 horseshoes). Pre-operative VAS score was 7.6 ± 0.9 (mean ± sd), CCIS was 0.1 ± 0.5. Complete healing occurred after a median of 6 weeks (range 3-14 weeks). Mean VAS score dropped to 2.3 ± 0.6 at first follow-up visit and CCIS rose to 0.4 ± 0.2. After a mean of 56.4 months, 41 patients agreed to a visit and 14 were interviewed by phone. At office visit no disease recurrences were observed; pain and continence scores were within normal ranges in all patients. Abscess and fistula in anal fissures are not frequent and may represent a different disease from cryptoglandular fistulas. Surgical treatment achieves higher success than that reported for cryptoglandular fistulas.
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Vollebregt PF, Vander Mijnsbrugge GJ, Molenaar CBH, Felt‐Bersma RJF. Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas. Colorectal Dis 2021; 23:2119-2126. [PMID: 33955138 PMCID: PMC8453864 DOI: 10.1111/codi.15696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/13/2021] [Accepted: 04/10/2021] [Indexed: 12/17/2022]
Abstract
AIM Injection of Permacol collagen paste can be used as a sphincter-sparing treatment for perianal fistulas. In a tertiary referral population we aimed to evaluate the efficacy of Permacol injection and the clinical and fistula-related factors associated with recurrence. METHOD This was a retrospective analysis of consecutive patients with perianal fistulas treated with Permacol injection at a specialist centre between June 2015 and April 2019. Endoanal ultrasonography was systematically reanalysed, blinded to treatment outcome. Rectovaginal, anovaginal and Crohn's disease fistulas were excluded. Healed fistulas were defined as absent anal symptoms and a closed external opening on physical examination at a minimum follow-up of 6 months. Regression analyses were performed to identify factors associated with unhealed fistulas. RESULTS A total of 90 patients (51 men; median age 45 years) were analysed. Seventy-two (80.0%) patients had complex perianal fistulas (greater than one-third sphincter involvement or multiple tracts). After a single Permacol injection, fistulas were healed in 20 (22.2%) patients at 3 months follow-up and in 18 (20.0%) patients at a median follow-up of 30 months (interquartile range 17-37). Eight (11.1%) patients with unhealed fistulas had significant improvement in their symptoms. Complex fistulas were significantly associated with unhealed status [OR 3.53 (95% CI 1.12-11.09); p = 0.031]. Twenty patients underwent subsequent Permacol injections, which were successful in six (30.0%) patients after one (n = 3) or two (n = 3) additional injections. CONCLUSION This largest study to date in patients with mainly complex perianal fistulas, demonstrated that the efficacy of a single Permacol injection was only 20%. Complex fistulas were associated with a poor outcome.
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Affiliation(s)
- Paul F. Vollebregt
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | | | - Richelle J. F. Felt‐Bersma
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands,Proctos KliniekBilthovenThe Netherlands
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FitzDowse AJ, Behrenbruch CC, Hayes IP. Combined treatment approach to chronic anal fissure with associated anal fistula. ANZ J Surg 2017; 88:775-778. [PMID: 29205737 DOI: 10.1111/ans.14292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/05/2017] [Accepted: 09/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anal fistula in association with chronic anal fissure (fissure-fistula) is infrequently described. Recognizing this association and managing both components may help prevent some treatment failures seen with chronic anal fissure. This study aims to report on the outcomes of 20 consecutive patients with fissure-fistula managed with fistulotomy and injection of botulinum A toxin. METHODS The study is a retrospective, observational study, assessing the success of symptom resolution following fistulotomy with botulinum A toxin, in patients identified as having a chronic anal fissure with associated anal fistula. The study included all patients with this condition treated with combination treatment by a single surgeon at a tertiary care hospital between January 2013 and January 2016. RESULTS Twenty patients with fissure-fistula treated with fistulotomy and botulinum toxin A were identified. The median cohort age was 44 years (range 25-78), with a predominance of males (80%) and posterior fissure position (80%). The most common presenting symptoms were anal pain (70%), rectal bleeding (55%), anal discharge (35%) and anal pruritus (35%). Mean follow-up was 10.5 weeks and all patients who attended follow-up appointments reported resolution of symptoms. There were no cases of incontinence and none of the cohort required further surgical intervention for the condition. CONCLUSION Chronic anal fissure with associated anal fistula can be successfully managed with fistulotomy and injection of botulinum toxin A. Further studies would be helpful in determining if recognition and management of the fistula component in isolation with fistulotomy is as effective as fistulotomy plus botulinum A toxin.
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Affiliation(s)
- Andrew J FitzDowse
- Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Corina C Behrenbruch
- Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Pathology, Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian P Hayes
- Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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