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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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Kumar A, Sharma A, Gupta SJ, Verma A. Complex Anal fistula treated with IFTAK (Interception of fistulous track with application of ksharsutra) technique- A case report. J Ayurveda Integr Med 2023; 14:100686. [PMID: 36758428 PMCID: PMC9939718 DOI: 10.1016/j.jaim.2023.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 10/17/2022] [Accepted: 12/23/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND An anal fistula is a common benign anorectal disease that tends to reoccur simple or low-type fistulas can be treated without affecting the sphincter mechanism; however, repairing a complex ano fistula without compromising anal continence can be difficult for a surgeon. CASE PRESENTATION Here, we present an anal fistula of complex clinical appearance managed successfully by the IFTAK (Interception of fistulous track with application of ksharsutra) technique practiced at Banaras Hindu University, Varanasi, India. The diagnosis was made via visual and bi-manual digital rectal examination then confirmed by Endoanal ultrasonography (EAUS). The patient showed remarkable improvement and the fistula healed completely in due course of time without impairing the anal continence status of the patient. At four months of follow-up the patient was healthy and no recurrence was found. CONCLUSION IFTAK is a minimally invasive technique and very effective in managing complex fistula in ano of cryptoglandular origin. The main cause of recurrence in complex anal fistula is non-identification of an infected anal crypt, secondary extensions, associated sepsis, or abscess at the time of examination or surgery. So, precise diagnosis and appropriate surgical measures play an equal role in the successful outcome of anal fistula treatment, failure to either will result in non-healing or recurrence.
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Affiliation(s)
- Anil Kumar
- Department of Shalya Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
| | - Ashish Sharma
- S.S Hospital, Banaras Hindu University, Varanasi, India
| | - S J Gupta
- Department of Shalya Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Gou B, Zhang JC, Chen L, Xin FY, Zhou JY, Xu QM, Liu J. Comparison of the Diagnostic Accuracy of Percutaneous Fistula Contrast-Enhanced Ultrasound Combined with Transrectal 360° 3-D Imaging and Conventional Transrectal Ultrasound in Complex Anal Fistula. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:2154-2161. [PMID: 35948456 DOI: 10.1016/j.ultrasmedbio.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 06/15/2023]
Abstract
This study compared the diagnostic accuracy of percutaneous fistula contrast-enhanced ultrasound (CEUS) combined with 360° 3-D transrectal ultrasound (TRUS) imaging (CEUS + 360°-TRUS) with that of conventional transrectal ultrasound in the diagnosis of complex anal fistulas. A total of 156 patients clinically diagnosed with complex anal fistula from January 2020 to December 2021 were studied and randomly divided into an experimental group (n = 82) and a control group (n = 74). Patients in the experimental group were examined by percutaneous fistula CEUS combined with CEUS + 360°-TRUS, while patients in the control group were examined using TRUS. The detection of fistulas (main tract, branch and internal orifice) and the accuracy of Parks classification were compared between the two groups. Recurrences were followed up at 1, 3 and 6 mo after the surgery. A total of 156 patients were included, aged 23-68 y (average: 37.7 ± 18.2 y). In both groups, the course of disease was <1 mo in 128 cases, 1-2 mo in 22 cases and >3 mo in 6 cases. A total of 474 fistulas were confirmed by surgery in the aforementioned patients, including 224 main fistulas, 250 branch pipes and 254 internal orifices. The CEUS + 360°-TRUS group had 96.87%, 90.41% and 90.14% diagnostic accuracy for the main tract, branch and internal orifice, which was statistically significant (p < 0.001) compared with the 85.00%, 70.00% and 72.46% for the TRUS group, respectively. The overall accuracy of Parks classification of anal fistula in the CEUS + 360°-TRUS group was significantly higher than that in the TRUS group (90.24% vs. 78.38%, p < 0.001). After 6 mo of follow-up, the recurrence rate in the CEUS + 360°-TRUS group was 4.87%, and the recurrence rate in the TRUS group was 18.91%. Percutaneous fistula CEUS combined with transrectal 360° 3-D imaging has significantly higher accuracy than conventional TRUS in the diagnosis of complex anal fistula, especially for anal fistula branches, internal openings and Parks classification and is beneficial in reducing post-operative occurrence of complex anal fistulas.
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Affiliation(s)
- Bo Gou
- Department of Ultrasound, Clinical Medical College, Chengdu, China; First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Ji-Cheng Zhang
- Department of Ultrasound, Clinical Medical College, Chengdu, China; First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Lin Chen
- First Affiliated Hospital of Chengdu Medical College, Chengdu, China; Traditional Chinese and Western Medicine Anorectal, Clinical Medical College, Chengdu, China
| | - Feng-Yue Xin
- Department of Ultrasound, Clinical Medical College, Chengdu, China; First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jiang-Ying Zhou
- Department of Ultrasound, Clinical Medical College, Chengdu, China; First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qin-Mei Xu
- Department of Ultrasound, Clinical Medical College, Chengdu, China; First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jian Liu
- Department of Ultrasound, Clinical Medical College, Chengdu, China; First Affiliated Hospital of Chengdu Medical College, Chengdu, China.
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Garg P, Kaur B, Singla K, Menon GR, Yagnik VD. A Simple Protocol to Effectively Manage Anal Fistulas with No Obvious Internal Opening. Clin Exp Gastroenterol 2021; 14:33-44. [PMID: 33564257 PMCID: PMC7866917 DOI: 10.2147/ceg.s291909] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/20/2021] [Indexed: 12/19/2022] Open
Abstract
Purpose In some anal fistulas, the internal/primary opening cannot be located even after examination and assessment on MRI or transrectal ultrasound. The efficacy of a simple new protocol to manage such therapeutically challenging fistulas was tested. Patients and Methods All anal fistula patients operated consecutively over 7 years were included in the study. A simple two-step protocol was followed for fistulas in which the internal opening was not locatable after clinical examination and MRI assessment. First, the MRI was reassessed. The site where the fistula was closest to the internal sphincter was noted. It was assumed that the internal-opening was located at that position and the fistula was treated accordingly. Second, in horseshoe anal fistulas with no apparent internal opening, it was assumed that the internal opening was located in the midline. Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. Incontinence was evaluated by objective incontinence scores (Vaizey scores). Results A total of 757 patients were operated (median follow-up-33 months). Of these, 57 patients were excluded due to short or inadequate follow-up. In 154/700 (22%) patients, the internal opening could not be located while in 546/700 (78%), the internal opening was found. Both the groups were similar in all parameters. In the "internal-opening found" group, the fistula healed completely in 486/546 (89%) and in the 'internal-opening not found group', the fistula healed in 140/156 (90.9%) (p=1.01). The objective continence scores did not change significantly after surgery in both the groups. Conclusion This new protocol seems effective as a high cure rate could be achieved in 'internal-opening not found' fistulas which was comparable to fistula healing in the 'internal-opening found' group.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali, India.,Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India
| | - Baljit Kaur
- Department of Radiology, SSRD Imaging Centre, Chandigarh, India
| | - Konica Singla
- Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India
| | - Geetha R Menon
- Department of Biostatistics, Indian Council of Medical Research, New Delhi, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
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Tantiphlachiva K, Sahakitrungruang C, Pattanaarun J, Rojanasakul A. Effects of preoperative endoanal ultrasound on functional outcome after anal fistula surgery. BMJ Open Gastroenterol 2019; 6:e000279. [PMID: 31139426 PMCID: PMC6506025 DOI: 10.1136/bmjgast-2019-000279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/17/2019] [Accepted: 02/23/2019] [Indexed: 12/12/2022] Open
Abstract
Objective Endoanal ultrasound (EAUS) is a recommended preoperative investigation for fistula-in-ano (FiA) which aims to provide the best chance of healing and preservation of continence function. This study aims are (1) to assess effect of EAUS on functional outcome and (2) to determine factors associated with clinical outcomes after FiA surgery. Design Retrospective analysis of subjects with cryptogenic FiA between January 2011 and December 2016, in a tertiary hospital, was performed by comparing EAUS and no-EAUS groups. Postoperative change in St. Mark’s faecal incontinence severity score (cFISS=FISS at 6 months after surgery–FISS before surgery) were compared. General linear model was used to determine factors associated with cFISS. Binary logistic regression was used to assess factors related to clinical outcomes. A p-value of <0.05 is considered significant. Results We enrolled 339 subjects; 109 (M:F 91:18, mean age 41.7±13.6 years) of 115 in EAUS group and 230 in no-EAUS group (M:F 195:35, mean age 42.6±13.0 years). There were higher proportions of recurrent cases (24.8% vs 13.9%, p=0.014) and complex FiA (80.7% vs 50.4%, p=0.001) in EAUS group. Postoperative FISS (mean±SE) were increased in both groups; preoperative versus postoperative FISS were 0.36±0.20 versus 0.59±0.25 in EAUS group (p=0.056) and 0.31±0.12 versus 0.76±0.17 in no-EAUS group (p<0.001). EAUS had significant effects on cFISS in both univariate analysis, F(1,261)=4.053, p=0.045; and multivariate analysis, F(3,322)=3.147, p=0.025, Wilk’s Lambda 0.972. Other associated factors included recurrent fistula (F(3,322)=0.777, p=0.007, Wilk’s Lambda 0.993) and fistula classification (F(3,322)=16.978, p<0.001, Wilk’s Lambda 0.863). After a mean follow-up of 33.6±28.6 weeks, success rate was 63.3%(EAUS) and 60% (no-EAUS), p=0.822. Factors associated with clinical outcomes were fistula complexity, number of tracts, recurrence, number of previous surgery and type of operations. Accuracy of EAUS was 90.8% and not related to clinical outcomes (p=0.522). Conclusion EAUS had favourable effects on functional outcome after FiA surgery while multiple factors were associated with clinical outcomes. EAUS is useful, accurate, inexpensive and can be the first tool for planning of complex and recurrent FiA.
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Schwandner O, Strittmatter B, Lenhard BH, Bader W, Krege S, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-016-0110-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data.
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Affiliation(s)
| | - Kyle G Cologne
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Abstract
Endoanal ultrasound is a technique that provides imaging of the anal sphincters and its surrounding structures as well as the pelvic floor. However, endoanal magnetic resonance imaging (MRI) is preferred by most physicians, although costs are higher and demand easily outgrows availability. Endoanal ultrasound is an accurate imaging modality delineating anatomy of both cryptoglandular as well as Crohn perianal fistula and abscess. Endoanal ultrasound is comparable with examination under anesthesia and equally sensitive as endoanal MRI in fistula detection. When fistula tracts or abscesses are located above the puborectal muscle, an additional endoanal MRI should be performed. Preoperative imaging is advocated in recurrent cryptoglandular fistula because a more complex pattern can be expected. Endoanal ultrasound can help avoid missing tracts during surgery, lowering the chance for the fistula to persist or recur. It can easily be performed in an outpatient setting and endosonographic skills are quickly incremented. Costs are low and endoanal ultrasound has the potential to improve outcome of patients with both cryptoglandular and fistulizing Crohn disease; therefore, it values more attention.
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Affiliation(s)
- Arjan Paul Visscher
- From the Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
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Ding JH, Bi LX, Zhao K, Feng YY, Zhu J, Zhang B, Yin SH, Zhao YJ. Impact of three-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study. Colorectal Dis 2015; 17:1104-12. [PMID: 26331275 DOI: 10.1111/codi.13108] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/23/2015] [Indexed: 02/08/2023]
Abstract
AIM The aim of the study was to evaluate the impact of three-dimensional endoanal ultrasound (3D-EAUS) on postoperative outcome in patients with anal fistula. METHOD This prospective study compared clinical and functional outcomes of patients with and without preoperative 3D-EAUS examination 1 year after anal fistula surgery. Patients were prospectively followed and evaluated by a standardized protocol including physical examination, the Wexner Incontinence Score (WIS) and anorectal manometry, at baseline and 1 year after surgery. RESULTS A total of 196 patients were enrolled. There were no significant differences in demographic and operative parameters, except for operation time, between the two groups. At 1 year follow-up, the overall recurrence rates were 8.8% (9/102) in the 3D-EAUS group and 13.8% (13/94) in the examination under anaesthesia (EUA) group. In the subgroup of patients with complex fistulae, the recurrence rate was numerically lower in the 3D-EAUS group (12.8% vs 22.5%; P = 0.26). The WIS in the EUA group significantly worsened (0.35 ± 0.94 vs 1.07 ± 1.59; P = 0.003) with a decreased the number of fully continent patients (82.5% vs 55%; P = 0.008) while neither the WIS nor the proportion of fully continent patients changed in the 3D-EAUS group. Fewer patients in the 3D-EAUS group developed incontinence postoperatively (6.7% vs 33.3%; P = 0.012) and they had better maximum resting pressure and maximum squeeze pressure than the EUA group. CONCLUSIONS Preoperative use of 3D-EAUS had a favourable impact on the outcome of surgical treatment for anal fistulae, especially in those with complex anal fistula. It should be routinely used in the clinical setting.
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Affiliation(s)
- J-H Ding
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - L-X Bi
- Department of Medicine, Second Artillery General Hospital, Beijing, China
| | - K Zhao
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - Y-Y Feng
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - J Zhu
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - B Zhang
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - S-H Yin
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
| | - Y-J Zhao
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, Beijing, China
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Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2015; 19:595-606. [PMID: 26377581 DOI: 10.1007/s10151-015-1365-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/11/2015] [Indexed: 12/14/2022]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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