1
|
Iqbal N, Astrid MJHM, Merel L K, Gillian K, Rebecca W, Ugo G, Phil J T, Stéphanie O B. AFCOS: The Development of a Cryptoglandular Anal Fistula Core Outcome Set. Ann Surg 2023; 277:e1045-e1050. [PMID: 35815887 PMCID: PMC10082062 DOI: 10.1097/sla.0000000000005462] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a cryptoglandular Anal Fistula Core Outcome Set: a minimum set of outcomes that should be measured in all studies of cryptoglandular anal fistula treatment. BACKGROUND Variability in the outcomes that are reported in studies of cryptoglandular anal fistula treatment hampers systematic evidence synthesis to identify the best treatment. METHODS This study followed guidance from the Core Outcome Measures in Effectiveness Trials initiative and consisted of three stages: (1) generation of candidate outcomes through systematic review of the literature and qualitative patient interviews; (2) prioritization of outcomes by key stakeholders, including patients, surgeons, gastroenterologists, and radiologists in an online Delphi consensus process; and (3) determination of the final Core Outcome Set (COS) in a consensus meeting attended by patients and clinicians. RESULTS Sixty-four outcomes were presented in the first Delphi survey round. A total of 191 participants from over 30 countries ranked these outcomes according to their importance in defining treatment success (57.6% surgeons and gastroenterologists, 8.9% radiologists, and 33.5% patients). After two rounds, 53 outcomes were identified as important and discussed in the consensus meeting attended by 10 patients and 12 clinicians. A final 10 outcomes were voted into the COS: clinical fistula healing, radiological healing, recurrence, development of additional fistulas, fistula symptoms, incontinence, psychological impact of treatment, complications and reinterventions, patient satisfaction, and quality of life. CONCLUSION The final COS represents an international, multidisciplinary, patient-centered attempt to establish consistency in fistula research, with a substantial focus on patient priorities for treatment.
Collapse
Affiliation(s)
- Nusrat Iqbal
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, UK
| | - Machielsen J H M Astrid
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre+, The Netherlands
- Faculty of Health, Medicine & Life Sciences, Maastricht University, The Netherlands
| | - Kimman Merel L
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre+, The Netherlands
| | | | | | - Grossi Ugo
- Tertiary Referral Pelvic Floor and Incontinence Centre, Regional Hospital Treviso, Italy
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, Italy
| | - Tozer Phil J
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, UK
| | - Breukink Stéphanie O
- Department of Surgery and Colorectal Surgery, NUTRIM, School of Nutrition and Translational Research in Metabolism, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, The Netherlands
| |
Collapse
|
2
|
Iqbal N, Sackitey C, Gupta A, Tolan D, Plumb A, Godfrey E, Grierson C, Williams A, Brown S, Maxwell-Armstrong C, Anderson I, Selinger C, Lobo A, Hart A, Tozer P, Lung P. The development of a minimum dataset for MRI reporting of anorectal fistula: a multi-disciplinary, expert consensus process. Eur Radiol 2022; 32:8306-8316. [PMID: 35732929 DOI: 10.1007/s00330-022-08931-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/08/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
Abstract
There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features of fistula anatomy. Magnetic resonance imaging (MRI) is the gold standard modality for assessing anorectal fistula. To maximise clinical utility, the MRI report should accurately describe these clinically relevant features. We aimed to develop a minimum dataset for reporting MRI of anorectal fistula, in order to improve the assessment and management of these patients. A longlist of 70 potential items for the minimum dataset was generated through systematic review of the literature. This longlist was presented to radiologists, surgeons and gastroenterologists in an online survey to understand the features that shape current clinical practice. The longlist and survey results were then presented to an expert consensus panel to generate the final minimum dataset through discussion and anonymous voting. The final minimum dataset details the general characteristics, features of the internal and external openings, path of the fistula through the sphincters and any associated extensions and collections that should be described in all MRI reports for anal fistula. Additional surgical and perianal Crohn's disease subsets were developed to indicate the features that aid decision-making for these patients, in addition to a minimum dataset for the clinical request. This study represents a multi-disciplinary approach to developing a minimum dataset for MRI reporting of anal fistula, highlighting the most important features to report that can assist in clinical decision-making. KEY POINTS: • This paper recommends the minimum features that should be included in all MRI reports for the assessment of anal fistula, including Parks classification, number of tracts, features of the internal and external opening, path of the tract through the sphincters, the presence and features of extensions and collections. • Additional features that aid decision-making for surgery or in the presence of Crohn's disease have been identified. • The items that should be included when requesting an MRI are specified.
Collapse
Affiliation(s)
- Nusrat Iqbal
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | - Charlene Sackitey
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | | | | | | | | | | | - Andrew Williams
- Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Steven Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | | | - Alan Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ailsa Hart
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | - Phil Tozer
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | - Phillip Lung
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK.
| |
Collapse
|
3
|
Sharma A, Yadav P, Sahu M, Verma A. Current imaging techniques for evaluation of fistula in ano: a review. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00252-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Abstract
Background
Fistula in ano is one of the common anorectal disorders which have a tendency to recur specially in complex cases usually due to missed or undetected sepsis at the time of examination or surgery. A correct identification of the primary source of crypt infection along with a complete understanding of the anatomical course of primary and secondary tracks and abscesses is a prerequisite for the successful management of fistula. Preoperative evaluation of fistula in ano using radio-imaging techniques provides a handy insight of fistula anatomy and helps in planning the appropriate treatment strategy. The objective of this article is to review the role of different radio-imaging techniques in the diagnosis and evaluation of fistula in ano along with their advantages and disadvantages over one another.
Main text
A comprehensive literature review was performed searching through the electronic databases as well as the standard textbooks of colorectal surgery. X-rays (plain radiographs and contrast fistulography), computed tomography (CT) scanning, anal endosonography, and magnetic resonance (MR) imaging are the modalities used for preoperative imaging of fistula in ano. Due to low accuracy, X-ray fistulography is not used now for fistula imaging. CT fistulography can be more accurate in cases associated with acute inflammations and abscesses and the fistulas related with inflammatory bowel disease. Anal endosonography and MRI are two of the mostly used and reliable imaging techniques for fistula in ano. Though the use of a 3D technology has improved the accuracy of anal endosonography, MRI is the preferred choice by many. However, various reports have depicted comparable accuracies for both MRI and anal endosonography showing both to be equally sensitive but MRI to be more specific. 3D endoanal ultrasound, on the other hand, is more rapid and can also be used intraoperatively to provide live imaging during surgical exploration.
Conclusion
Complex and recurrent fistula cases should undergo a preoperative imaging to reduce the chances of recurrence. MRI is recommended as the imaging modality of choice for such cases. 3D anal endosonography may however be a good option over MRI owing to its rapidity, availability, and potential of intraoperative assistance during surgery.
Collapse
|
4
|
Liu X, Wang Z, Ren H, Ren A, Wang W, Yang X, Shi S. Evaluating postoperative anal fistula prognosis by diffusion-weighted MRI. Eur J Radiol 2020; 132:109294. [PMID: 33038577 DOI: 10.1016/j.ejrad.2020.109294] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/20/2020] [Accepted: 09/10/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to explore whether preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) can be used to evaluate the prognosis of anal fistula and identify the influence factors of postoperative recurrence. METHODS This is a retrospective study of 117 patients with anal fistula who have undergone preoperative DW-MRI and surgery. All patients were followed up by telephone or reexamination within 2 years after surgery. Of the 117 patients, 35 were excluded due to loss of follow-up and only 82 were included in this study. MRI fistula imaging-related data were analyzed, and fistula severity was scored using criteria of both local extension of fistulas and active inflammation for a total maximum score of 22. The apparent diffusion coefficient (ADC) value of the fistula in patients with anal fistula during preoperative MRI examination was measured. According to whether anal fistula patients are accompanied by perianal abscess, they are divided into two groups, namely anal fistula group and anal fistula with abscess group. Based on whether patients with anal fistula recur after surgery, they were further divided into recurrent group and non-recurrent group. RESULTS 82 patients with anal fistula were included in this analysis, 23 of them recurred and 59 were cured. Among patients with perianal abscess, the mean ADC value of the recurrent group was (1.19 ± 0.21)×10-3 mm2/s, which is significantly lower than that of the non-recurrent group (1.36 ± 0.19)×10-3 mm2/s. There were significant statistical differences in ADC values between the two groups (p = 0.03). Among patients with anal fistulas without abscesses, 15 patients recurred after surgery, with a mean ADC value of (1.45 ± 0.27) ×10-3 mm2/s, and 33 patients didn't occur, with a mean ADC value of (1.44 ± 0.31)×10-3 mm2/s. The ADC value of preoperative fistula in patients was negative significant correlation with MRI findings score (r= -0.332, P = 0.002). Risk factors for the recurrence after anal fistula surgery include the time interval between MRI and operation, multiple fistula tracks. Fatigue, excessive intake of spicy or greasy food and diarrhea may also be external risk factors for postoperative recurrence of patients with anal fistula. CONCLUSIONS DW-MRI has important application value for the prognosis evaluation of anal fistula. Complex type of anal fistula and improper lifestyle are the main risk factors affecting the recurrence after anal fistula surgery.
Collapse
Affiliation(s)
- Xiuxiang Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China; Department of Radiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Hua Ren
- Department of Radiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ahong Ren
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wensheng Wang
- Department of Radiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xuedong Yang
- Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shan Shi
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China; Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| |
Collapse
|
5
|
Revzin MV, Moshiri M, Bokhari J, Pellerito JS, Menias C. Sonographic assessment of infectious diseases of the gastrointestinal tract: from scanning to diagnosis. Abdom Radiol (NY) 2020; 45:261-292. [PMID: 31960117 DOI: 10.1007/s00261-019-02358-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sonography of the gastrointestinal (GI) tract is a practical, safe, inexpensive, and reproducible diagnostic tool for the evaluation, diagnosis, and follow-up of infectious bowel disease. The modality is rapidly gaining prominence among clinicians on a global scale. In the United States, however, ultrasound of the bowel remains underutilized primarily due to insufficient experience among radiologists and sonographers in performing sonographic bowel assessment. This lack of experience and knowledge results in misinterpretations, missed diagnoses, and underutilization of this modality in patients with acute abdomen, with the majority of GI pathology on sonography discovered incidentally. OBJECTIVES This article aims to demonstrate the characteristic sonographic findings associated with GI infectious processes as well as provide dedicated ultrasound protocols for evaluation of the GI tract. CONCLUSION This article serves a twofold purpose, raising awareness of the utility of this imaging modality within the radiology community and also providing practical teaching points for sonographic evaluation of infectious disorders of the GI tract.
Collapse
Affiliation(s)
- Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, PO Box 208042, Room TE-2, New Haven, CT, 06520, USA.
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Jamal Bokhari
- Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208042, Room TE-2, New Haven, CT, 06520, USA
| | - John S Pellerito
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Christine Menias
- Radiology, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| |
Collapse
|
6
|
Abstract
This article explains the pathogenesis of fistula-in-ano and details the different classifications of fistula encountered, describe their features on MR imaging, and explains how imaging influences subsequent surgical treatment and ultimate clinical outcome. Precise preoperative characterization of the anatomic course of the fistula and all associated infection via MR imaging is critical for surgery to be most effective. MR imaging is the preeminent imaging modality used to answer pertinent surgical questions.
Collapse
Affiliation(s)
- Steve Halligan
- UCL Department of Imaging, UCL Centre for Medical Imaging, Second Floor, Charles Bell House, 43-45 Foley Street, London W1W 7TS, UK.
| |
Collapse
|
7
|
Konan A, Onur MR, Özmen MN. The contribution of preoperative MRI to the surgical management of anal fistulas. Diagn Interv Radiol 2018; 24:321-327. [PMID: 30272562 PMCID: PMC6223824 DOI: 10.5152/dir.2018.18340] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Anal fistula is an abnormal tract or cavity between the anal canal and perianal skin. Surgical treatment of anal fistulas requires the identification of the course of the primary and secondary tracts and their relation with the sphincter musculature in order to appropriately manage them and drain any abscess. Physical examination alone is not as accurate as imaging modalities in detecting these features of the fistula, and recurrences are usually due to missed or inadequately managed infective components. Magnetic resonance imaging (MRI) is the preferred imaging modality for detecting anal fistulas, but which patient group should undergo preoperative MRI is a matter of debate. The aim of this study was to determine the contribution of MRI in the surgical management of anal fistulas. METHODS Medical records of patients who underwent surgery for primary anal fistula and preoperative MRI in our University Hospitals from January 1, 2008 to April 15, 2018 were collected anonymously and retrospectively. Any discrepancies between operative findings and MRI reports were noted. Two study groups were formed as per the contribution of preoperative MRI: significant and nonsignificant contribution groups. The significant contribution group included patients with secondary (blind) tracts, horseshoe fistulas, or abscesses undiagnosed at physical examination and examination under anesthesia; those with the location of the internal orifice different from that identified by physical examination; or those with the grade of the fistula assessed to be more advanced after preoperative MRI. RESULTS The total number of surgeries was 136. Mean patient age was 43±13 years. There were 106 males. In total, 47 patients suffered from recurrent fistulas. MRI contribution to clinical evaluation was significant in 33.8% of the patients. MRI more frequently provided significant information for complex fistulas than for simple fistulas. Significant preoperative MRI contribution was more frequent if the external opening was more than 2 cm away from the anal canal or when a horseshoe fistula was present. CONCLUSION Our study is valuable in linking physical examination findings with preoperative MRI findings. The distance of the external opening from the anal canal was not studied in the literature; our findings support the use of MRI for fistulas with external opening located more than 2 cm from the anus. These fistulas also tend to be complex and have a higher grade. In recurrent cases, MRI contributes not only by establishing the fistula anatomy but also by identifying possible sphincter damage.
Collapse
Affiliation(s)
- Ali Konan
- Department of General Surgery Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehmet Ruhi Onur
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mustafa Nasuh Özmen
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| |
Collapse
|
8
|
Bi H, Li J, Xue C, Marks M. Early Closure of Infected Laparotomy Wound with Negative-Pressure Wound Therapy: Safety and Efficacy in 42 Consecutive Cases. Am Surg 2018. [DOI: 10.1177/000313481808400645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative surgical site infections (SSIs) are one of the most common complications. SSIs after laparotomy have a high incidence and are complicated and expensive to heal. The aim of this study was to evaluate the safety and efficacy of a novel therapy of early closure of open abdominal SSIs wound combining wound irrigation with negative pressure wound therapy (NPWT). Open abdominal SSIs wounds were closed with sutures in 42 consecutive patients. Topical NPWT was applied over a closed wound with a deep drain to allow dynamic drainage and wound irrigation. CT scan with contrast medium injected through the deep drain was performed in patients with suspicious tracts detected during debridement surgery three days after surgery to identify a potential fistula. Wound healing and safety of the therapy was evaluated during an average six months follow-up. Closed wounds healed successfully in all the patients without recurrence of wound infection. Fistulas were easily diagnosed in all four fistula patients by using CTscan with contrast medium injection through the wound. Fistula was confirmed in these four patients at re-exploration. All the drain tube wounds healed spontaneously after drain removal. No severe adverse event occurred during therapy in any patients. With the aid of topical NPWT and deep drainage and irrigation, early closure of open SSIs wound can be done safely. We were also able to diagnose gastrointestinal fistulas at an early stage with the use of CTscan imaging after contrast injection into the wound.
Collapse
Affiliation(s)
- Hongda Bi
- Department of Plastic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junhui Li
- Department of Plastic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chunyu Xue
- Department of Plastic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Malcolm Marks
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| |
Collapse
|
9
|
Abstract
Multiple imaging modalities exist for inflammatory bowel disease. This article explores the use of plain radiographs, contrast radiologic imaging, computed tomography, MRI, ultrasound, and capsule endoscopy. History, technique, indications for use, limitations, and future directions are discussed for each modality.
Collapse
|
10
|
Hammer MR, Dillman JR, Smith EA, Al-Hawary MM. Magnetic resonance imaging of perianal and perineal crohn disease in children and adolescents. Magn Reson Imaging Clin N Am 2014; 21:813-28. [PMID: 24183527 DOI: 10.1016/j.mric.2013.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Noninvasive, nonionizing, multiparametric magnetic resonance (MR) imaging of the pelvis using a field strength of 3 T now provides a comprehensive assessment of perineal involvement in pediatric Crohn disease. MR imaging accurately evaluates inflammatory disease activity, and allows determination of the number and course of fistula tracts as well as their relationships to vital perianal structures, including the external anal sphincter, helping to guide surgical management and improve outcomes. This article provides an up-to-date review of perineal MR imaging findings of Crohn disease in the pediatric population, including fistulous disease, abscesses, and skin manifestations. Imaging technique is also discussed.
Collapse
Affiliation(s)
- Matthew R Hammer
- Section of Pediatric Radiology, Department of Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1540 East Hospital Drive, Room 3-220, Ann Arbor, MI 48109-4252, USA.
| | | | | | | |
Collapse
|
11
|
Herráiz Hidalgo L, Cano Alonso R, Carrascoso Arranz J, Alvarez Moreno E, Martínez de Vega Fernández V. 3.0T MRI with a high resolution protocol for the study of benign disease of the anus and rectum. Part 2: Anorectal inflammatory disease. Postsurgical anatomy and complications after treatment. RADIOLOGIA 2014. [DOI: 10.1016/j.rxeng.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
12
|
Yacoub JH, Oto A. New Magnetic Resonance Imaging Modalities for Crohn Disease. Magn Reson Imaging Clin N Am 2014; 22:35-50. [DOI: 10.1016/j.mric.2013.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
13
|
Yacoub JH, Obara P, Oto A. Evolving role of MRI in Crohn's disease. J Magn Reson Imaging 2014; 37:1277-89. [PMID: 23712842 DOI: 10.1002/jmri.24081] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 01/22/2013] [Indexed: 12/18/2022] Open
Abstract
MR enterography is playing an evolving role in the evaluation of small bowel Crohn's disease (CD). Standard MR enterography includes a combination of rapidly acquired T2 sequence, balanced steady-state acquisition, and contrast enhanced T1-weighted gradient echo sequence. The diagnostic performance of these sequences has been shown to be comparable, and in some respects superior, to other small bowel imaging modalities. The findings of CD on MR enterography have been well described in the literature. New and emerging techniques such as diffusion-weighted imaging (DWI), dynamic contrast enhanced MRI (DCE-MRI), cinematography, and magnetization transfer, may lead to improved accuracy in characterizing the disease. These advanced techniques can provide quantitative parameters that may prove to be useful in assessing disease activity, severity, and response to treatment. In the future, MR enterography may play an increasing role in management decisions for patients with small bowel CD; however, larger studies are needed to validate these emerging MRI parameters as imaging biomarkers.
Collapse
Affiliation(s)
- Joseph H Yacoub
- Department of Radiology, University of Chicago, Chicago, Illinois 60637, USA
| | | | | |
Collapse
|
14
|
Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, Danese S, Halligan S, Marincek B, Matos C, Peyrin-Biroulet L, Rimola J, Rogler G, van Assche G, Ardizzone S, Ba-Ssalamah A, Bali MA, Bellini D, Biancone L, Castiglione F, Ehehalt R, Grassi R, Kucharzik T, Maccioni F, Maconi G, Magro F, Martín-Comín J, Morana G, Pendsé D, Sebastian S, Signore A, Tolan D, Tielbeek JA, Weishaupt D, Wiarda B, Laghi A. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis 2013; 7:556-85. [PMID: 23583097 DOI: 10.1016/j.crohns.2013.02.020] [Citation(s) in RCA: 441] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 12/12/2022]
Abstract
The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.
Collapse
Affiliation(s)
- J Panes
- Gastroenterology Department, Hospital Clinic Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
INTRODUCTION Management of fistula-in-ano requires understanding of both perianal and rectal anatomy, as well as the surgical approaches available to ensure the highest possible postoperative continence and wound healing. Further, high rates of recurrence with medical management commonly bring these patients under the care of the colorectal surgeon after variable periods of failed conservative management. Novel techniques provide surgeons with tools to treat increasingly complex fistulas with a focus on maintaining sphincteric functionality and limiting recurrence. METHOD This manuscript presents our practice, including perioperative decision making regarding surgical approach, in managing patients with fistula-in-ano. CONCLUSION Familiarity with these techniques prepares the general surgeon and colorectal surgeon to improve wound healing and functional outcomes in these patients, especially with complex disease involving the external and internal anal sphincters.
Collapse
|
16
|
Herráiz Hidalgo L, Cano Alonso R, Carrascoso Arranz J, Alvarez Moreno E, Martínez de Vega Fernández V. [3.0T MRI with a high resolution protocol for the study of benign disease of the anus and rectum. Part 2: Anorectal inflammatory disease. Postsurgical anatomy and complications after treatment]. RADIOLOGIA 2012; 56:206-18. [PMID: 23102780 DOI: 10.1016/j.rx.2012.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 06/27/2012] [Accepted: 07/05/2012] [Indexed: 01/06/2023]
Abstract
Benign anorectal disease comprises a broad group of processes with very diverse origins; these processes may be congenital or acquired as well as inflammatory or tumor related. However, benign anorectal disease has received less attention in the scientific literature than malignant disease. In this second part of this image-based review of benign anorectal disease, we describe the most common inflammatory and fistulous diseases, the postsurgical anatomy, and complications that can occur after surgical treatment or radiotherapy for anorectal disease.
Collapse
Affiliation(s)
- L Herráiz Hidalgo
- Departamento de Diagnóstico por la Imagen, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, España.
| | - R Cano Alonso
- Departamento de Diagnóstico por la Imagen, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, España
| | - J Carrascoso Arranz
- Departamento de Diagnóstico por la Imagen, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, España
| | - E Alvarez Moreno
- Departamento de Diagnóstico por la Imagen, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, España
| | - V Martínez de Vega Fernández
- Departamento de Diagnóstico por la Imagen, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, España
| |
Collapse
|
17
|
de Miguel Criado J, del Salto LG, Rivas PF, del Hoyo LFA, Velasco LG, de las Vacas MIDP, Marco Sanz AG, Paradela MM, Moreno EF. MR imaging evaluation of perianal fistulas: spectrum of imaging features. Radiographics 2012; 32:175-94. [PMID: 22236900 DOI: 10.1148/rg.321115040] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perianal fistulization is an inflammatory condition that affects the region around the anal canal, causing significant morbidity and often requiring repeated surgical treatments due to its high tendency to recur. To adopt the best surgical strategy and avoid recurrences, it is necessary to obtain precise radiologic information about the location of the fistulous track and the affected pelvic structures. Until recently, imaging techniques played a limited role in evaluation of perianal fistulas. However, magnetic resonance (MR) imaging now provides more precise information on the anatomy of the anal canal, the anal sphincter complex, and the relationships of the fistula to the pelvic floor structures and the plane of the levator ani muscle. MR imaging allows precise definition of the fistulous track and identification of secondary fistulas or abscesses. It provides accurate information for appropriate surgical treatment, decreasing the incidence of recurrence and allowing side effects such as fecal incontinence to be avoided. Radiologists should be familiar with the anatomic and pathologic findings of perianal fistulas and classify them using the St James's University Hospital MR imaging-based grading system.
Collapse
Affiliation(s)
- Jaime de Miguel Criado
- Department of Radiology, Central Radiodiagnostic Unit, Hospital del Henares, 28822 Coslada, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
Inflammatory bowel disease (IBD) affects ≈1.4 million people in North America and, because of its typical early age of onset and episodic disease course, IBD patients often undergo numerous imaging studies over the course of their lifetimes. Computed tomography (CT) has become the standard imaging modality for assessment of IBD patients because of its widespread availability, rapid image acquisition, and ability to evaluate intraluminal and extraluminal disease. However, repetitive CT imaging has been associated with a significant ionizing radiation risk to patients, making MRI an appealing alternative IBD imaging modality. Pelvic MRI is currently the imaging gold standard for detecting perianal disease, while recent studies indicate that MRI bowel-directed techniques (enteroclysis, enterography, colonography) can accurately evaluate bowel inflammation in IBD. With recent technical innovations leading to faster and higher resolution body MRI, the role of MRI in IBD evaluation is likely to continue to expand. Future applications include surveillance imaging, detection of mural fibrosis, and early assessment of therapy response.
Collapse
Affiliation(s)
- Michael S Gee
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
| | | |
Collapse
|
19
|
Ozkavukcu E, Haliloglu N, Erden A. Frequencies of perianal fistula types using two classification systems. Jpn J Radiol 2011; 29:293-300. [DOI: 10.1007/s11604-010-0556-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 12/21/2010] [Indexed: 12/17/2022]
|
20
|
Joyce M, Veniero JC, Kiran RP. Magnetic resonance imaging in the management of anal fistula and anorectal sepsis. Clin Colon Rectal Surg 2010; 21:213-9. [PMID: 20011419 DOI: 10.1055/s-2008-1081000] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complex perianal disease may be extremely debilitating for the patient with significant impingement on quality of life. The accurate identification of anatomical areas of involvement and subsequent appropriate management is crucial to achieving a successful outcome when treating anorectal sepsis and anal fistulae. Magnetic resonance imaging (MRI) has become a powerful tool in the evaluation of anal anatomy. In patients with complex disease MRI is an important adjunct in delineating disease location and extent, its relationship to sphincter muscles, and in planning management. MRI also plays an important role in evaluating the response to medical and surgical therapies.
Collapse
Affiliation(s)
- Myles Joyce
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | | |
Collapse
|
21
|
Torkzad MR, Karlbom U. MRI for assessment of anal fistula. Insights Imaging 2010; 1:62-71. [PMID: 22347906 PMCID: PMC3259332 DOI: 10.1007/s13244-010-0022-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/16/2010] [Accepted: 04/28/2010] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance imaging (MRI) is the best imaging modality for preoperative assessment of patients with anal fistula. MRI helps to accurately demonstrate disease extension and predict prognosis. This in turn helps make therapy decisions and monitor therapy. The pertinent anatomy, fistula classification and MRI findings will be discussed.
Collapse
Affiliation(s)
- Michael R. Torkzad
- Department of Radiology, Uppsala University Hospital, 751 85 Uppsala, Sweden
- Department of Oncology, Radiology and Clinical Immunology Section of Radiology, Uppsala University, 751 85 Uppsala, Sweden
| | - Urban Karlbom
- Department of surgery, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
22
|
|
23
|
Dagia C, Ditchfield M, Kean M, Catto-Smith T. Imaging for Crohn disease: use of 3-T MRI in a paediatric setting. J Med Imaging Radiat Oncol 2009; 52:480-8. [PMID: 19032394 DOI: 10.1111/j.1440-1673.2008.01993.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study was carried out to review our experience with 3-T MRI in the assessment of Crohn disease in a paediatric population. Twenty-four patients with biopsy proven Crohn disease identified on the radiology information system underwent abdominal MRI, with or without pelvic MRI. Twenty-eight studies were carried out on a 3-T scanner at a tertiary paediatric hospital. Eight of 24 of these (30%) had a gastrointestinal barium study, 2 of 24 (8%) a CT and 9 of 24 (38%) an abdominal ultrasound. The different MRI sequences were rated for observation of the bowel wall and abnormalities (0-5). The findings were correlated to relevant findings on endoscopy, examination under anaesthesia (EUA) and where available surgery, barium studies, CT and ultrasound. In this study, the colon was involved in 5 of 28 (18%), small bowel in 7 of 28 (25%), terminal ileum in 5 of 28 (18%). All the perineal studies (9 of 9) showed abnormalities. Sinus tracts or fistulas were identified in 7 of 28 (25%) studies. The mean rating of the different MRI sequences in showing bowel wall and changes of Crohn disease was T2 TSE 3.6, T2 half fourier aquisition single shot turbo spin echo (HASTE) with a long TE 3.6, T2 HASTE with short TE 3.4, true fast imaging with steady state precession (FISP) 2.7, T1 4.1 and Post-contrast T1 4.3. The T2 HASTE sequences with thinner slices improved observation. Detection of superficial abnormalities was similar on the 3D VIBE images and on the post-contrast T1 spin-echo (SE) sequences. In five of nine (56%) of those that had ultrasound, both studies were abnormal, with incomplete correlation of the abnormalities. Computed tomography and MRI were abnormal in two of two (100%) patients with good correlation of the abnormalities in one; in the other there was a minimal discrepancy in the estimation of the length of involved bowel. In 7 of 11 (64%) the barium study was abnormal. Good correlation to MRI findings was found in five of seven (71%) of patients. In two of seven (29%) both studies were abnormal, with incomplete correlation of the abnormalities. Barium underestimated the length of involved segment in these patients with inflammatory ileal thickening and ulceration. Notably, in both studies compression was limited because of patient discomfort and the involved segments obscured by overlap. Abdominal and pelvic MRI at 3 T is a useful imaging technique for evaluation of Crohn disease in the children. The extent of bowel wall involvement and extra-intestinal complications, such as abscesses and fistulas can be accurately assessed non-invasively, without the use of ionizing radiation or sedation.
Collapse
Affiliation(s)
- C Dagia
- Department of Medical Imaging, The Royal Children's Hospital, Melbourne, Australia
| | | | | | | |
Collapse
|
24
|
Garcia-Olmo D, Garcia-Arranz M, Herreros D. Expanded adipose-derived stem cells for the treatment of complex perianal fistula including Crohn's disease. Expert Opin Biol Ther 2008; 8:1417-23. [PMID: 18694359 DOI: 10.1517/14712598.8.9.1417] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complex perianal fistulising disease is a distressing condition. In patients without Crohn's disease, surgery is the mainstay treatment but faecal incontinence and recurrence are high. Infliximab is used in Crohn's patients but not all respond to therapy. OBJECTIVE After an evaluation of the current treatment options, we discuss studies of adipose-derived stem cell (ASC) therapy, a novel approach for treating complex perianal fistulas. METHODS ASCs are obtained from a liposuction procedure and a subsequent expansion process. They are administered according to a strict protocol which involves infusion of the cells into the target lesion along with fibrin glue. RESULTS/CONCLUSIONS A Phase IIb study comparing ASC and fibrin glue therapy with fibrin glue therapy alone showed that ASCs were effective at inducing healing in complex perianal fistulas.
Collapse
Affiliation(s)
- Damian Garcia-Olmo
- Hospital Universitario La Paz, Servicio de Cirugía General, Paseo de la Castellana 261, 28046 Madrid, Spain.
| | | | | |
Collapse
|
25
|
3-T MRI of rectal carcinoma: preoperative diagnosis, staging, and planning of sphincter-sparing surgery. AJR Am J Roentgenol 2008; 190:1271-8. [PMID: 18430843 DOI: 10.2214/ajr.07.2505] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the accuracy of 3-T MRI in the preoperative diagnosis, staging, and planning of surgical management of rectal carcinoma. SUBJECTS AND METHODS Thirty-eight patients (23 men, 15 women) with clinically suspected rectal carcinoma underwent 3-T MRI. Coronal, axial, and sagittal T2-weighted sequences with and without fat suppression; axial T1-weighted spin-echo sequences; axial T1-weighted gradient-echo sequences with and without fat suppression; oblique 2D MR hydrography; and 3D fat-suppressed dynamic contrast-enhanced MRI were performed. Image quality with these sequences was evaluated by three radiologists experienced in body MRI. The significance of difference in results with the sequences was tested. The manner in which MRI staging and feasibility of sphincter-sparing surgery agreed with operative and pathologic findings was evaluated with kappa statistics. RESULTS Rectal carcinoma was identified on MRI and confirmed histologically in all 38 patients. MRI findings were correctly predictive of T category in 35 cases (accuracy, 92.1%). In 31 (96.9%) of 32 resectable cases,sphincter-sparing surgical approaches were accurately chosen on the basis of MRI findings. Among the 11 sequences, 3D fat-suppressed dynamic contrast-enhanced MRI best delineated tumor margins. Coronal and axial T2-weighted images also well depicted tumor margins with minimal artifact. T2-weighted images were superior to unenhanced T1-weighted images. CONCLUSION MRI of rectal cancer at 3 T is accurate for prediction of T category and the feasibility of sphincter-sparing surgery. The best images were obtained with coronal, sagittal, and axial T2-weighted sequences and 3D fat-suppressed dynamic contrast-enhanced MRI.
Collapse
|
26
|
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]
|
27
|
Szurowska E, Wypych J, Izycka-Swieszewska E. Perianal fistulas in Crohn's disease: MRI diagnosis and surgical planning: MRI in fistulazing perianal Crohn's disease. ACTA ACUST UNITED AC 2007; 32:705-18. [PMID: 17334876 DOI: 10.1007/s00261-007-9188-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Crohn's disease is a chronic, transmural inflammatory process of the gastrointestinal tract. It often affects the colon with the perianal area. The most common intestinal manifestations include external and/or internal fistulas and abscesses. Assessment of the activity of perianal fistulas in the course of Crohn's disease seems to be an important factor influencing therapeutic approach. Fistula's activity is evaluated by such methods as magnetic resonance imaging, anal ultrasound and examination under anaesthesia. Usefulness of imaging methods in the diagnosis of fistulas still remains to be defined.MRI is used to present a wide spectrum of perianal fistulazing Crohn's disease. Additionally, it is an important instrument revealing location, extent and severity of inflammation. It is also very helpful to detect clinically silent sepsis related to small, local inflammation. The most common method used in MR imaging to assess topography of a fistula's track, is Parks' classification.Clinical indications to MRI may include follow-up studies of a diagnosed disease, classification of fistulas' subtypes in the course of Crohn's disease, determination of the extent of fistulas' tracts and spread of an inflammatory process what can guide surgical procedures.
Collapse
Affiliation(s)
- Edyta Szurowska
- Department of Radiology Medical, University of Gdansk, Debinki St 7, 80-211, Gdansk, Poland.
| | | | | |
Collapse
|
28
|
Abstract
Intestinal failure is a specific disease entity resulting from intestinal resection or disease-associated malabsorption and characterized by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balance. We performed a MEDLINE search (1966-2006) to identify relevant articles, using keywords intestinal failure, parenteral or enteral nutrition, intestinal fistula and short bowel syndrome. Causes of intestinal failure are varied, with self-limiting or 'Type 1' intestinal failure occurring relatively commonly following abdominal surgery, necessitating short-term fluid or nutritional support. The rarer, 'Type 2' intestinal failure, is associated with septic, metabolic and complex nutritional complications, usually following surgical resection in patients with Crohn's or mesenteric vascular disease. A multidisciplinary approach to the management of patients with Type 2 intestinal failure is crucial: resolution of sepsis is required before adequate nutritional repletion can be achieved, and it is important to optimize nutritional status, not only through enteral or parenteral supplementation, but also by addressing complications of short bowel syndrome, before considering definitive surgical reconstruction. A structured approach to the management of Type 2 intestinal failure should reduce the likelihood of these complex patients developing 'Type 3' intestinal failure, which is characterized by the need for long-term parenteral nutrition.
Collapse
Affiliation(s)
- S Lal
- Intestinal Failure Unit, Hope Hospital, Salford, UK
| | | | | |
Collapse
|
29
|
Abstract
Technological developments have extended the role of MRI in the evaluation of the gastrointestinal tract. The potential of MRI to evaluate disease activity in Crohn's disease has been investigated extensively, as MRI has intrinsic advantages over other techniques, including noninvasiveness and the absence of ionizing radiation. For perianal fistulizing disease MRI has become a mainstay in evaluation of disease, as localization and extent of disease can be very well appreciated using both T2-weighted and T1-weighted sequences, fat suppression, and intravenous contrast medium. Imaging of the small bowel and colon in Crohn's disease is more complicated due to bowel peristalsis and respiratory movement. However, using fast breathhold sequences and intravenous spasmolytic medication, images of good diagnostic quality can be acquired. To obtain sufficiently distended bowel, which in our estimation is a prerequisite for evaluation of the bowel, MR enteroclysis can be performed. However, applicability of different oral contrast media has been studied, as a noninvasive method for bowel distension would be preferable. Abdominal MRI is a valuable imaging technique for evaluation of luminal, transmural, and extraintestinal manifestations of Crohn's disease as degree of disease activity, presence of luminal pathology (e.g., stenoses), and extraintestinal manifestations of disease (e.g., abscesses, fistulas) can be accurately assessed.
Collapse
Affiliation(s)
- Karin Horsthuis
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.
| | | | | |
Collapse
|
30
|
Affiliation(s)
- Karin Horsthuis
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | | |
Collapse
|