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Akhoundi N, Bozchelouei JK, Abrishami A, Frootan M, Siami A, Alimadadi E, Saba GB, Rezazadeh E, Amerifar M, Eghdami E. Comparison of MRI and Endoanal Ultrasound in Assessing Intersphincteric, Transsphincteric, and Suprasphincteric Perianal Fistula. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2057-2064. [PMID: 37040280 DOI: 10.1002/jum.16225] [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: 12/13/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Perianal fistula is a common disorder characterized by an anomalous perianal track connecting two epithelialized surfaces, most commonly the anal canal and the perianal skin. Although each has its limitations, magnetic resonance imaging (MRI) and endoanal ultrasound are currently two acceptable modalities for assessing perianal fistula. This study aimed to evaluate the accuracy of MRI and endoanal ultrasonography in diagosing perianal fistula, considering the surgical results as the references. METHODS This prospective cohort study was performed on patients with symptomatic perianal fistulas. MRI results of patients reported by the radiologist were collected along with the findings of endoanal ultrasonography performed by a gastroenterologist. These results were compared with surgical findings as the reference standard. RESULTS The study enrolled 126 patients. Exactly 222 definitive fistulas were identified during surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound for perianal fistula were 87.38, 38.46, 92.38, 26.31, and 82.25% respectively; and for MRI were 76.12, 57.69, 93.88, 22.05, and 74.19% respectively. The accuracy of endoanal ultrasound for detecting transsphincteric and intersphincteric fistulas was higher than MRI. In contrast, the diagnostic value of MRI for detecting suprasphincteric fistulas was higher than endoanal ultrasound. CONCLUSIONS Using endoanal ultrasonography to diagnose perianal fistulas is a relatively accurate method. This method may be more sensitive than MRI in detecting patients with perianal fistulas and abscesses.
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Affiliation(s)
- Neda Akhoundi
- Radiology Department, Hillcrest Hospital, University of California San Diego, San Diego, USA
| | - Javad Komijani Bozchelouei
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Abrishami
- Labbafinezhad Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mojgan Frootan
- Gastroenterology Department, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Siami
- Biostatistical Analyzer, Amirkabir University of Technology, Tehran, Iran
| | - Elahe Alimadadi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Gholamreza Bagherzadeh Saba
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Elmira Rezazadeh
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Maryam Amerifar
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Ebrahim Eghdami
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
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Wang H, Jiang HY, Zhang YX, Jin HY, Fei BY, Jiang JL. Mesenchymal stem cells transplantation for perianal fistulas: a systematic review and meta-analysis of clinical trials. Stem Cell Res Ther 2023; 14:103. [PMID: 37101285 PMCID: PMC10134595 DOI: 10.1186/s13287-023-03331-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/06/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Perianal fistulas, characterised as granulomatous inflammation of fistulas around the anal canal, are associated with significant morbidity resulting in a negative impact on quality of life and a tremendous burden to the healthcare system. Treatment of anal fistulas usually consists of anal surgery; however, results of closure rates are not satisfactory especially with complex perianal fistulas, after which many patients may suffer from anal incontinence. Recently, the administration of mesenchymal stem cells (MSCs) has shown promising efficacy. Herein, we aim to explore whether MSCs are effective for complex perianal fistulas and if they have either short-term, medium-term, long-term or over-long-term efficacy. Additionally, we want to elucidate whether factors such as drug dosage, MSC source, cell type, and disease aetiology influence treatment efficacy. We searched four online databases and analysed data based on information within the clinical trials registry. The outcomes of eligible trials were analysed with Review Manager 5.4.1. Relative risk and related 95% confidence interval were calculated to compare the effect between the MSCs and control groups. In addition, the Cochrane risk of bias tool was applied to evaluate the bias risk of eligible studies. Meta-analyses showed that therapy with MSCs was superior to conventional treatment for complex perianal fistulas in short-, long- and over-long-term follow-up phases. However, there was no statistical difference in treatment efficacy in the medium term between the two methods. Subgroup meta-analyses showed factors including cell type, cell source and cell dosage were superior compared to the control, but there was no significant difference between different experimental groups of those factors. Besides, local MSCs therapy has shown more promising results for fistulas as a result of Crohn's Disease (CD). Although we tend to maintain that MSCs therapy is effective for cryptoglandular fistulas equally, more studies are needed to confirm this conclusion in the future. SHORT CONCLUSION MSCs Transplantation could be a new therapeutic method for complex perianal fistulas of both cryptoglandular and CD origin showing high efficacy in the short-term to over-long-term phases, as well as high efficacy in sustained healing. The difference in cell types, cell sources and cell dosages did not influence MSCs' efficacy.
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Affiliation(s)
- H Wang
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, China
| | - H Y Jiang
- Life Spring AKY Pharmaceuticals, Changchun, China
| | - Y X Zhang
- Changchun University of Chinese Medicine, Changchun, China
| | - H Y Jin
- Department of Gastrointestinal Colorectal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - B Y Fei
- Department of Gastrointestinal Colorectal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China.
| | - J L Jiang
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, China.
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Bae SU. What Does Puborectalis Muscle Involvement on Magnetic Resonance Imaging Indicate in Patients With Complex Anal Fistula? Ann Coloproctol 2021; 37:3-4. [PMID: 33730795 PMCID: PMC7989564 DOI: 10.3393/ac.2021.02.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sung Uk Bae
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Das GC, Chakrabartty DK. Best non-contrast magnetic resonance imaging sequence and role of intravenous contrast administration in evaluation of perianal fistula with surgical correlation. Abdom Radiol (NY) 2021; 46:469-475. [PMID: 32734352 DOI: 10.1007/s00261-020-02616-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the best non-contrast magnetic resonance imaging (MRI) sequence and role of intravenous contrast administration in preoperative characterization and classification of perianal fistulae, keeping surgery as gold standard. METHODS This prospective study comprised of forty-five consecutive patients with actively draining external perianal opening. MRI was performed on a 1.5 T scanner using non-contrast and contrast enhanced sequences in multiple planes. St. James's University Hospital MRI based classification system was used to classify the fistulae into five grades. Taking surgery as gold standard, association between surgical and MRI findings was statistically analysed. RESULTS Of the 45 patients recruited, forty were deemed eligible for inclusion. Mean age was 39.7 ± 11.7 years with male preponderance (M: F = 8:1). Commonest type was Grade 1 (40%). The best sequences in terms of overall accuracy were axial & coronal planes of contrast enhanced fat suppressed (FS) T1W turbo spin echo (TSE) (95.7%) followed by FS T2W TSE (94.1%) while sagittal T2W TSE sequence with or without fat suppression had the lowest accuracy (90.13%). The difference in overall diagnostic accuracy of FS T2W TSE and contrast enhanced FS T1W TSE sequence for evaluating perianal fistula was not statistically significant (p = 0.52). However, contrast study had a better accuracy in detecting internal openings and secondary tract of recurrent/ post-operative cases. CONCLUSION Best non-contrast MRI sequence is FS T2W TSE (axial and coronal). Non-contrast MRI is equally efficient to contrast study while evaluating primary/previously unoperated cases thereby eliminating the role of contrast in such cases. However, intravenous contrast should be administered for evaluating post-operative cases with recurrence.
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Affiliation(s)
- Gaurav Chayan Das
- Department of Radiology, Silchar Medical College & Hospital, Silchar, Assam, 788014, India.
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Chandigarh, 160012, India.
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Jabeen N, Qureshi R, Sattar A, Baloch M. Diagnostic Accuracy of Short Tau Inversion Recovery as a Limited Protocol for Diagnosing Perianal Fistula. Cureus 2019; 11:e6398. [PMID: 31942266 PMCID: PMC6961795 DOI: 10.7759/cureus.6398] [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] [Indexed: 11/11/2022] Open
Abstract
Introduction Perianal fistula refers to abnormal communication between perianal skin and anal canal. Magnetic resonance imaging (MRI) and endoanal ultrasound have been used in the evaluation of perianal fistula. Endoanal ultrasound is a cost-effective but operator-dependent technique. MRI provides accurate details regarding anal canal anatomy and effectively identifies the fistulae. For evidence-based care, a cost-effective and an accurate imaging modality is required in a developing country. Therefore, the aim of this study was to determine the diagnostic accuracy of short tau inversion recovery (STIR) as a limited protocol MRI pelvis in diagnosing perianal fistula taking surgical findings as the gold standard. Materials and methods A retrospective review of MRI pelvis from 1st February 2018 to 1st July 2018 was undertaken. Patients of any age or gender suspected to have perianal fistula were included. One radiologist interpreted the complete MRI pelvis and the other radiologist only viewed axial and coronal STIR sequences as a limited protocol. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of axial and coronal STIR sequence were calculated taking surgical findings as the gold standard. Results In total, 150 patients were included in this study. The mean age of the patients was 43.20 ± 13.75 years. In total, 122 (81.3%) were males and 28 (18.7%) were females. Using STIR as a limited protocol, fistulae were found in 125 (83.3%) patients, whereas on surgery, the fistulae were found in 119 (79.3%) patients. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy of STIR as limited protocol MRI pelvis in diagnosing perianal fistulae was found to be 96.6%, 67.7%, 92.0%, 84.0%, and 90.6%, respectively, taking surgical findings as the gold standard. Conclusion STIR has high sensitivity and diagnostic accuracy in diagnosing in the perianal fistula. Using STIR as a limited protocol in a developing country can help improving patient care by accurately diagnosing perianal fistulae. Moreover, it is recommended that further studies for identifying internal opening on STIR should also be carried out to improve patient care.
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Affiliation(s)
- Naila Jabeen
- Radiology, Dow University of Health Sciences, Karachi, PAK
| | - Ruby Qureshi
- Radiology, Dow University of Health Sciences, Karachi, PAK
| | - Amjad Sattar
- Radiology, Dow University of Health Sciences, Karachi, PAK
| | - Musarat Baloch
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
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Thipphavong S, Costa AF, Ali HA, Wang DC, Brar MS, Jhaveri KS. Structured reporting of MRI for perianal fistula. Abdom Radiol (NY) 2019; 44:1295-1305. [PMID: 30474723 DOI: 10.1007/s00261-018-1839-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to review MRI technique, relevant anatomy, and MRI classification systems for the assessment of perianal fistulising disease. We present a stepwise approach to the assessment of perianal fistulas on MRI utilizing a systematic reporting format. CONCLUSION MRI is invaluable for the assessment of perianal fistulas. A systematic report can help communicate the anatomy of complex fistulising disease to assist with optimal management.
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Affiliation(s)
- Seng Thipphavong
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
| | - Andreu F Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Bldg, 3rd Fl, 1276 S Park St, Halifax, NS, B3H 2Y9, Canada
| | - Hamideh Ale Ali
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - David Chenhan Wang
- Department of Medical Imaging, University of Toronto, 4th Floor, 263 McCaul Street, Toronto, ON, M5T 1W7, Canada
| | - Mantaj S Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 451, Toronto, ON, M5G 1X5, Canada
| | - Kartik S Jhaveri
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
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Comparison of T2-weighted imaging, diffusion-weighted imaging and contrast-enhanced T1-weighted MR imaging for evaluating perianal fistulas. Clin Imaging 2017; 44:16-21. [PMID: 28395191 DOI: 10.1016/j.clinimag.2017.03.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 03/01/2017] [Accepted: 03/29/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare the lesion conspicuity and diagnostic performance of three imaging data sets (T2WI, combined T2WI and DWI [combined DWI], contrast-enhanced (CE)-T1WI) in assessing perianal fistulas. METHODS Two radiologists with 7 and 15years of experience assessed 28 fistulas from 24 patients in each image set. RESULTS The lesion conspicuity was improved for only one reader after reading the combined DWI (P=0.0039) and CE-T1WI (P=0.0215). The accuracy was stationary for fistula type (reader 1, all 93%; reader 2, all 89%) or for direction of internal opening (96% for all sets; 92% for CE-T1WI). CONCLUSION Although combined DWI and CE-T1WI might improve fistula conspicuity, they showed comparable diagnostic performance to T2WI.
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The comparison of CT fistulography and MR imaging of perianal fistulae with surgical findings: a case-control study. Abdom Radiol (NY) 2016; 41:1474-83. [PMID: 27034072 DOI: 10.1007/s00261-016-0722-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the diagnostic efficacies of CT fistulography and MRI, in the diagnostic work-up of perianal fistula patients. MATERIALS AND METHODS All 41 patients who were included in the study (36 males and 5 females, with an average age of 41 years) underwent CT fistulography and MRI examinations prior to surgery. The fistula characteristics obtained from these examinations were compared with the surgical findings. The comparative results were evaluated by means of the Kappa analysis method. RESULTS CT fistulography predicted the correct perianal fistula classification in 30 (73.1%) of the 41 patients, whereas MRI correctly defined fistula classification in 38 (92.7%) of these patients (the K values were 0.621 and 0.896, respectively; with p < 0.001). CT fistulography depicted 29 secondary extensions in 16 patients, whereas MR imaging revealed 28 secondary extensions in 15 patients. A substantial agreement was found between surgical findings and two modalities (K value was 0.789 and 0.793 for CT fistulography and MRI, respectively, with a p value < 0.001). In terms of locations of internal openings, CT fistulography was able to detect the locations in 28 patients (68.2%), whereas MRI was more successful in this aspect, with a number of 35 patients (85.3%). Granulation tissues, inflammation and edema around the fistula, abscesses, and fistular wall fibrosis were also evaluated. CONCLUSION CT fistulography and MRI have different advantages in the diagnosis of perianal fistulas. A good command of knowledge concerning the issue may be a key factor in modality decision.
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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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Singh K, Singh N, Thukral C, Singh KP, Bhalla V. Magnetic resonance imaging (MRI) evaluation of perianal fistulae with surgical correlation. J Clin Diagn Res 2014; 8:RC01-4. [PMID: 25121040 DOI: 10.7860/jcdr/2014/7328.4417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 04/29/2014] [Indexed: 12/14/2022]
Abstract
AIMS The purpose of the study was to evaluate the role of Magnetic Resonance Imaging in detection and characterization of perianal fistulae and correlating it with surgical findings. METHODS Fifty consecutive patients with suspected perianal fistulae having one or more external openings were prospectively selected for MRI evaluation. Previously operated or patients with recurrent perianal disease were excluded from the study. MRI findings were recorded according to "St. James's University Hospital MR Imaging Classification of Perianal Fistulae" and correlated with surgical observations. Finally, comparison between T2-weighted fat saturated and postcontrast T1-weighted fat saturated sequences was done. RESULTS Amongst the total of 50 patients, per-operative findings confirmed perianal fistulae in 45 patients. The sensitivity and specificity of MRI in correctly detecting and grading the primary tract was found to be 95.56% and 80% respectively; for abscess, it was 87.50% and 95.24% respectively. High sensitivity was also discerned in identification of secondary tract (93.75%), correct localization of internal opening (95.83%) and for correctly detecting the horse-shoeing (87.50%). Our assumption of null hypothesis was accepted on comparing results of T2-weighted fat saturated sequences and postcontrast T1-weighted fat saturated sequences. CONCLUSION Magnetic Resonance Imaging (MRI) was highly accurate in assessment of surgically important parameters (primary tract and its grading, internal opening, secondary tract, abscess, horseshoeing) of perianal fistulae. Comparison of results of imaging findings on T2-weighted and postcontrast T1-weighted fat saturated sequences were statistically similar, so contrast study can be omitted, particularly while evaluating primary / previously unoperated perianal fistulae.
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Affiliation(s)
- Kulvinder Singh
- Associate Professor, Department of Radiodiagnosis and Imaging, SGRD institute of Medical Sciences and Research , Amritsar, Punjab, India
| | - Navdeep Singh
- Senior Resident, Department of Radiodiagnosis and Imaging, Dayanand Medical College and Hospital , Ludhiana, Punjab, India
| | - Cl Thukral
- Professor, Department of Radiodiagnosis and Imaging, SGRD institute of Medical Sciences and Research , Amritsar, Punjab, India
| | - Kunwar Pal Singh
- Assistant Professor, Department of Radiodiagnosis and Imaging, SGRD institute of Medical Sciences and Research , Amritsar, Punjab, India
| | - Varun Bhalla
- Senior Resident, Department of Radiodiagnosis and Imaging, SGRD institute of Medical Sciences and Research , Amritsar, Punjab, India
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Abstract
BACKGROUND Imaging modalities such as endoanal ultrasound or MRI can be useful preoperative adjuncts before the appropriate surgical intervention for perianal fistulas. OBJECTIVES We present a systematic review of published literature comparing endoanal ultrasound with MRI for the assessment of idiopathic and Crohn's perianal fistulas. DESIGN A meta-analysis was performed to obtain pooled values for specificity and sensitivity. SETTINGS Electronic databases were searched from January 1970 to October 2010 for published studies. PATIENTS AND INTERVENTIONS Four studies were used in our analysis. There were 241 fistulas in the ultrasound group and 240 in the magnetic resonance group. RESULTS The combined sensitivity and specificity of magnetic resonance for fistula detection were 0.87 (95% CI: 0.63-0.96) and 0.69 (95% CI: 0.51-0.82). There was a high degree of heterogeneity between studies reporting on MRI sensitivity (df = 3, I = 93%). This compares to a sensitivity and specificity for endoanal ultrasound of 0.87 (95% CI: 0.70-0.95) and 0.43 (95% CI: 0.21-0.69). There was a high degree of heterogeneity between studies reporting on endoanal ultrasound sensitivity (df = 3, I = 92%). CONCLUSIONS From the available literature, the summarized performance characteristics for MRI and endoanal ultrasound demonstrate comparable sensitivities at detecting perianal fistulas, although the specificity for MRI was higher than that for endoanal ultrasound. Both specificity values are considered to be diagnostically poor, however. The high degree of data heterogeneity and the shortage of applicable studies precludes any firm conclusions being made for clinical practice. Future trials with improved study design (including prospective data collection and consideration of verification bias) may help to further clarify the role of MRI in the assessment and treatment response monitoring of perianal fistulas (particularly in patients with Crohn's disease).
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Abstract
BACKGROUND Successful surgery for perianal fistula is contingent upon accurate pre-operative classification of the primary tract and its extensions. We aimed to find, using "evidence based medicine" (EBM) methods, the optimal technique for fistula classification: MRI, anal endosonography (AES) or clinical examination. METHODS A clinical question was derived, "In patients suspected of having perianal fistula, how does MRI compare to AES and clinical assessment for discriminating simple from complex disease". A search of primary literature and secondary evidence resources was performed and expert opinion sought. Inclusion criteria were blinded prospective studies (level 2b +) of patients undergoing preoperative MRI, clinical examination +/- AES using a clinical outcome based reference standard. Retrieved literature was appraised using EBM methods. RESULTS The highest-ranking evidence found was level 1b. MRI is more sensitive 0.97(CI 0.92-1.01) than clinical examination, 0.75(0.65-0.86) but comparable to AES, 0.92(0.85-0.99) for discriminating complex from simple disease. The positive LR for MRI confirming complex disease is 22.7 compared to 2.1 and 6.2 for clinical examination and AES, respectively. CONCLUSION MRI is the optimal technique for discriminating complex from simple perianal fistula, although AES is superior to clinical examination, and may be used if MRI availability is restricted.
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Affiliation(s)
- Vikram A Sahni
- Intestinal Imaging Centre, Level 4V, St Mark's Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom
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Ardizzone S, Maconi G, Cassinotti A, Massari A, Porro GB. Imaging of perianal Crohn's disease. Dig Liver Dis 2007; 39:970-8. [PMID: 17720640 DOI: 10.1016/j.dld.2007.07.155] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 02/07/2023]
Abstract
Perianal fistulas and abscesses are common complications of Crohn's disease, affecting up to 50% of patients during their disease course. Accurate diagnosis and classification of perianal disease is crucial before and during treatment to plan an adequate approach for each patient and to avoid irreversible functional consequences. Although examination under anaesthesia has been considered the gold standard for diagnosis and classification of Crohn's disease perianal fistulas, taken alone it does not have perfect accuracy, stressing the need for concomitant or alternative, non-invasive, methods of evaluation. In this context, imaging modalities assessed for diagnosis, classification and monitoring of Crohn's disease perianal fistulas include pelvic magnetic resonance imaging, anorectal endoscopic ultrasonography, transcutaneous perianal ultrasound, fistulography and computed tomography. In particular, magnetic resonance imaging and endoscopic ultrasonography findings have shown the best accuracy, and the ability to influence therapeutic management of these patients. For transcutaneous perianal ultrasound too, good preliminary data have been reported. This paper reviews the available data on imaging methods for the management of perianal Crohn's disease.
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Affiliation(s)
- S Ardizzone
- Department of Clinical Science, L. Sacco University Hospital, Milan, Italy.
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