Magnetic resonance imaging of perianal fistulas in clinically symptomatic patients and the correlation among plain, contrast, and post jelly MRI fistulography

Abstract Objectives To evaluate different types of perianal fistulas and their complications on magnetic resonance imaging (MRI) and to compare plain, contrast, and jelly magnetic resonance fistulography findings. Materials and Methods This prospective study was performed in 30 patients who presented with perianal pus discharge or external fistulous opening. Magnetic resonance imaging of the perianal region before and after giving intravenous contrast and after injecting jelly through a percutaneous opening was performed on a 3T scanner and the results were correlated. Results The mean age of the patients was 40.13±13.88 years (range 19-75 years). The male to female ratio was 14:1. The most common type of fistula was St. James classification type I, which was seen in 13 patients (43%), followed by type IV in 30%, type III in 16%, type II in 6.66%, and type V in 3.33% of the patients. Using agreement analysis, we compared the number of primary and secondary tracts, internal openings, and horseshoe tracts and found a significant agreement between plain and post Jelly MRI fistulography (kappa statistic close to 1).When comparing plain and contrast MRI, there was significant agreement in the primary and secondary tracts, while statistically insignificant results were obtained (p>0.05) for the horseshoe tract and internal openings. Contrast injection was helpful in 7 subjects (23.3%) as peripheral enhancement of abscesses were better delineated. Conclusion Magnetic resonance imaging is the one stop diagnostic modality for perianal fistulas. Acquisition of axial (Ax) T2, axial T2 FS, coronal T2 and coronal T2 FS sequences without administering intravenous contrast or jelly is usually sufficient for the diagnosis of fistulas and their complications.

Comparison between conventional and structured magnetic resonance imaging reports in perianal fistula / Comparação entre laudo convencional e estruturado de ressonância magnética na fístula perianal

Abstract Rationale: Very often magnetic resonance imaging is used in the study of complex anal fistulae, but conventional reports may contribute little to what really matters to the coloproctologist. Objective: To compare the clarity and usefulness of the conventional report compared to structured magnetic resonance imaging in cases of anal fistula. Method: 30 magnetic resonance exams already performed with an evaluation of anal fistula were again evaluated without the radiologist having access to the old report and a new structured report was prepared. Five proctologists evaluated the 30 conventional and 30 structured reports and answered questionnaires with eight questions comparing their practical aspects. The results were tabulated and submitted to statistical treatment considering a significant p<0.05. Results: There was a statistically significant difference in favor of the structured report in the questions "clearly defines whether it is an active fistula or fibrosis", "clearly states whether the tract is single or multiple", "whether the patient has anal fistula or not". The other questions did not present differences between the groups. Conclusion: The structured magnetic resonance report presented clearer information and was better evaluated in relation to the conventional one in the analysis of proctologists in the study of anal fistulae.

Resumo Racional: Com muita frequência utiliza-se ressonância magnética no estudo de fístulas anais complexas, porém, laudos convencionais podem contribuir pouco para o que realmente importa ao coloproctologista. Objetivo: Comparar a clareza e utilidade do laudo convencional com uma proposta de laudo estruturado de ressonância magnética em casos de fístula anal. Método: 30 exames de ressonância magnética já com laudo realizados para avaliação de fístula anal foram novamente avaliados sem que o radiologista tivesse acesso ao laudo antigo e foi confeccionado novo laudo estruturado. Cinco médicos proctologistas avaliaram os 30 laudos convencionais e os 30 estruturados e responderam a questionários com oito questões comparando aspectos práticos dos mesmos. Os resultados foram tabulados e submetidos a tratamento estatístico considerando-se significante p<0,05. Resultados: Houve diferença estatisticamente significante em favor do laudo estruturado nos quesitos "define claramente se é fistula ativa ou fibrose", "declara claramente se o trajeto é único ou múltiplo", "fica clara a informação se o paciente tem ou não fistula anal". Os demais quesitos não apresentaram diferença entre os grupos. Conclusão: O laudo estruturado de ressonância magnética apresentou informações mais claras e foi melhor avaliado em relação ao convencional na análise dos proctologistas no estudo de fístulas anais.

O ultrassom anorretal tridimensional pode ser incluído como um método diagnóstico na avaliação da fístula anal antes e após o tratamento cirúrgico? / Can three-dimensional anorectal ultrasonography be included as a diagnostic tool for the assessment of anal fistula before and after surgical treatment?

ABSTRACT BACKGROUND: There is no a clear knowledge concerning the division of any part of the anal sphincter complex and the effect of this procedure on the function of the anal canal during the treatment of perianal fistula. OBJECTIVE: To evaluate the usefulness of 3D anorectal ultrasound in the assessment of anal fistula, quantifying the length of the sphincter muscle to be transected, selecting patients for different approaches and identifying healing, failure or recurrence after the surgical treatment. METHODS: A prospective study included patients with primarily cryptogenic transsphincteric anal fistula assessed by fecal Incontinence score, tri-dimensional anorectal ultrasound and anal manometry before and after surgery. Based on 3D-AUS, patients with ≥50% external sphincter or external sphincter+puborectalis muscle involvement in males and ≥40% external sphincter or external sphincter+puborectalis muscle in females were referred for the ligation of the intersphincteric tract (LIFT) or seton placement and subsequent fistulotomy; and with <50% involvement in males and <40% in females were referred to one-stage fistulotomy. After surgery, the fibrosis (muscles divided) and residual muscles were measured and compared with the pre-operative. RESULTS: A total of 73 patients was included. The indication for the LIFT was significantly higher in females (47%), one-stage fistulotomy was significantly higher in the males (46%) and similar in seton placement. The minor postoperative incontinence was identified in 31% of patients underwent sphincter divided and were similar in both genders. The 3D-AUS identified seven failed cases. CONCLUSION: The 3D ultrasound was shown to be an effective method in the preoperative assessment of anal fistulas by quantifying the length of muscle to be divided, as the results were similar at the post-operative, providing a safe treatment approach according to the gender and percentage of muscle involvement. Additionally, 3D ultrasound successfully identified the healing tissue and the type of failure or recurrence.

RESUMO CONTEXTO: Não há dados definitivos quanto a níveis diferentes na secção do complexo esfincteriano e o efeito na função do canal anal no tratamento das fístulas anais. OBJETIVO: Avaliar a aplicação do ultrassom anorretal tridimensional no diagnóstico da fístula anal, quantificando o comprimento da musculatura que será seccionada, selecionando pacientes para diferente abordagens e identificando cicatrização e recorrência após tratamento. MÉTODOS: Um estudo prospectivo incluindo paciente portadores de fístula anal criptoglandular, tipo trans-esfinctérica avaliados pelo escore de incontinência fecal, ultrassom anorretal 3D e manometria anorretal antes e após a cirurgia. De acordo com os dados do ultrassom, pacientes do sexo masculino com envolvimento ≥50% do esfíncter externo anterior ou esfíncter externo+puborretal e do sexo feminino com envolvimento ≥40% foram referidos para cirurgia de ligadura do trajeto no espaço inter-esfinctérico (LIFT) ou colocação do sedenho. Aqueles com envolvimento <50% em homens e <40% mulheres foram indicados para fistulotomia em um tempo. Após a cirurgia, a musculatura secccionada (fibrose) e o músculo residual foram medidos e comparados no pós-operatório. RESULTADOS: Um total de 73 pacientes foi incluído. A indicação para LIFT foi significativamente maior em mulheres (47%) e a fistulotomia em homens (46%) e o sedenho similar em ambos os sexos. Sintomas de incontinência leve foi identificado em 31% dos submetidos à cirurgia com divisão de esfíncter e similar em ambos os sexos. O ultrassom identificou sete casos que não cicatrizaram. CONCLUSÃO: O ultrassom anorretal tridimensional demonstrou ser um método efetivo na avaliação da fístula anal, quantificando o comprimento do esfíncter a ser dividido, como demonstrado no resultado pós-operatório, fornecendo um tratamento seguro de acordo com sexo e percentual de músculo envolvido. Adicionalmente, identifica o tecido cicatrizado, tipo de recorrência e a falha no tratamento.

Tratamiento de fístula anal compleja asistida por video. Resultados a largo plazo / Treatment of complex anal fistula assisted by video. Long term results

Introducción: El tratamiento de las fístulas perianales sigue en la actualidad siendo controvertido, ya que aún no existe una técnica con baja tasa de recidiva, baja morbilidad y escasa o nula alteración de la continencia. Dentro de las técnicas "sphincter sparing", el tratamiento video asistido del trayecto fistuloso (VAAFT) aparece como una técnica con resultados promisorios. Objetivos: Evaluar la experiencia de 25 pacientes con fístulas perianales tratados con VAAFT. Materiales y Métodos: Estudio retrospectivo observacional. Pacientes portadores de fístulas criptoglandulares. Anatómicamente 15 eran transesfintéricas altas, 3 transesfintericas bajas y 7 interesfintéricas altas. Todos los pacientes tenían trayectos crónicos (más de un año de evolución). 20 pacientes ya tenían realizadas cirugías previas de su fístula, todos con sedal cortante. Cuatro de estos pacientes presentaban incontinencia a gases. Resultados: Entre Mayo 2016 y Abril 2018, se operaron 25 pacientes, 20 del sexo masculino y 5 del sexo femenino. A todos ellos se les realizó en el preoperatorio ecografía endoanal con traductor de 360° y manometría ano-rectal. A todos se les realizó interrogatorio sobre el estado de su continencia. En todos los pacientes se realizó el procedimiento según técnica descripta por Meinero con alguna modificación. En 3 pacientes no se logró identificar el orificio interno. En 4 pacientes el cierre del mismo se hizo con surget de PDS, en 3 se realizó algún tipo de colgajo (mucoso, locking flap) y en 15 pacientes se utilizó suturas mecánicas lineales de 45 mm. En 3 pacientes se agregó al VAAFT procedimiento LIFT. Tres pacientes tuvieron recidiva y 5 recurrencia. Se tomó como recurrencia a la supuración por orificio externo y/o ano más allá del cuarto mes posoperatorio, mientras que se clasificó como recidiva a aquellos pacientes que tuvieron más de seis meses sin supuración luego del cierre del orificio externo y posteriormente volvieron a supurar. No se perdió ningún paciente en el seguimiento postoperatorio. No se identificaron alteraciones de la continencia posteriores al tratamiento ni empeoramiento de aquellos que tenían incontinencia a gases. Las complicaciones fueron 4 abscesos en la zona del trayecto fistuloso que drenaron espontáneamente y 1 edema perineal por infiltración con glicina por ruptura del trayecto fístuloso. Conclusión: El procedimiento VAAFT demostró ser una técnica segura con las ventajas de ser mínimamente invasiva y la única bajo visión directa. (AU)

Introduction: The treatment of perianal fistulas is still controversial. Actually, there is no surgical technique with low recurrence rate, low morbidity and no alteration of continence. Between the "sphincter sparing techniques", the Video-assisted anal fistula treatment (VAAFT) appears as a technique with promising results. Objectives: Evaluate the experience of 25 patients with perianal fistulas treated with VAAFT. Methods: observational retrospective study. Patients with cryptoglandular fistulas. Anatomically 15 were high transphincteric fistulas, 3 low transphincteric fistulas and seven high intersphincteric. 20 of them had previous surgeries with cutting seton. Results: Between May 2016 and April 2018, 25 patients with fistula -in-ano were operated with VAAFT, 20 male and 5 female. Everyone underwent 360° endorectal ultrasound and rectal manometry before the procedure, wich was performed according to the technique describe by Meinero with some modifications. The closure of the internal orifice was performed with PDS surget in 4 cases, whereas 3 patients needed a mucosal advance flap and in 15 cases a 45 mm stapler was used. In 3 patients the internal orifice was not identified. The follow-up was for 2 years. The complications were four abscesses in the area of the fistulous tract, that drained spontaneously and one perineal edema due to infiltration with glycine due to rupture of the fistulous tract. Conclusion: The VAAFT procedure proved to be a safe technique with the advantages of the minimally-invasive techniques. Besides is the only technique under direct vision. (AU)

Fistulización a recto de un teratoma quístico maduro, una rara complicación / Rectal fistulization of a mature cystic teratoma, a rare complication

RESUMEN Los teratomas quísticos maduros son los tumores ováricos más frecuentes. La fistulización de estos a órganos vecinos (colon, intestino delgado y vejiga) es una complicación que cuando se presenta nos obliga a descartar un proceso infiltrativo. Tanto la malignización como la formación de fistulas son complicaciones excepcionales. Está descrito en la bibliografía la malignización como mecanismo de formación de dichas fistulas. Este hecho nos suele obligar a llevar a cabo intervenciones agresivas, como exenteraciones pélvicas anteriores y posteriores. Sin embargo, una revisión de los casos publicados (18) muestra que sólo el 22 % de las fistulas son resultado de una malignización de dicho teratoma. Presentamos una paciente con un teratoma quístico maduro que fistulizó a recto y su manejo en nuestro servicio. Precis: La fistulización a órganos vecinos de un teratoma es una complicación excepcional que requiere un diagnóstico preciso puesto que no siempre es secundaria a neoplasia.

ABSTRACT Mature cystic teratomas are the most common ovarian tumors. The fistulization of these teratomas to adjacent organs (colon, small intestine and bladder) is a complication that when it occurs forces us to rule out an infiltrative process. Together with malignancy, the fistula is a rare complication. Literature describes malignancy as a mechanism for the formation of these fistulas. This event usually forces us to carry out aggressive interventions, such as anterior and posterior pelvic exenterations. However, the case records of 18 patients report that only 22 % of fistulas are produced by malignant teratoma. The following case study presents a mature cystic teratoma that fistulated the rectum and its management in our service.

Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn / Usefulness of endoscopic ultrasound for perianal fistula in Crohn's disease

RESUMO Objetivo: determinar o papel da ultrassonografia endoscópica (UE) em relação à ressonância magnética nuclear (RMN) e ao exame sob anestesia (ESA) no manejo de pacientes com doença de Crohn fistulizante perianal. Métodos: estudo observacional transversal com pacientes com doença de Crohn perianal, avaliados em um centro terciário de Curitiba, Paraná, Brasil, de fevereiro de 2016 a março de 2017. Todos os pacientes foram submetidos à UE, RMN e ESA. O grau de concordância entre os três métodos foi avaliado através da obtenção do coeficiente de Kappa. Um valor de Kappa de 0,7 ou maior indicou boa concordância. O teste não paramétrico de Friedman foi utilizado para comparar o número de trajetos fistulosos detectados em cada modalidade. Considerou-se o nível de significância estatística como p<0,05. Resultados: vinte pacientes foram incluídos. Houve concordância entre os três exames em 11 pacientes. O nível de concordância de Kappa entre os três exames foi 0,53 (moderado) (p<0,001). Não houve diferença estatisticamente significativa em relação ao número de trajetos fistulosos detectados nos três exames (p=0,641). Houve falha na identificação de um trajeto fistuloso em três pacientes com a UE, em três pacientes com a RMN e em dois pacientes com o ESA. Conclusão: a UE foi comparável à RMN e ao ESA para avaliação da doença de Crohn fistulizante perianal, e pode ser considerada um exame válido para investigação pré-operatória desses pacientes.

ABSTRACT Objective: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease. Methods: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05. Results: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two. Conclusion: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

Imperforate Anus: Determination of Type Using Transperineal Ultrasonography

OBJECTIVE: This study was designed to assess the usefulness of transperineal ultrasonography (US) for the determination of imperforate anus (IA) type. MATERIALS AND METHODS:From January 2000 to December 2004, 46 of 193 patients with an IA underwent transperineal US prior to corrective surgery. Sonographic findings were reviewed to identify the presence of internal fistulas and to determine "distal rectal pouch to perineum (P-P)" distances. IA types were determined based on the sonographic findings, and the diagnostic accuracy of transperineal US was evaluated based on surgical findings. RESULTS: Of the 46 patients, 17 patients were surgically confirmed as having a high-type IA, three patients were confirmed as having an intermediate-type IA and 26 patients were confirmed as having a low-type IA. The IA type was correctly diagnosed by the use of transperineal US in 39 of the 46 patients (85%). In 14 of the 17 patients with a high-type IA, internal fistulas were correctly identified. All cases with a P-P distance > 16 mm were high-type IAs and all cases with a P-P distance < 5 mm were low-type IAs. CONCLUSION: Transperineal US is a good diagnostic modality for the identification of internal fistulas in cases of high-type IA and for defining the IA level.

Caracterización de fistulas anorrectales mediante resonancia magnética de alta resolución: revisión pictográfica / Characterization of anorectal fistulas by high-resolution magnetic resonance imaging: pictographic review

The goal of this pictorial review is the evaluation of perianal fistulas by means of magnetic resonance imaging. This technique has been shown to demonstrate accurately the anatomy of the perianal region. Our MRI protocol is simple and easy to standardize. We use the classification of St James University Hospital which employs simple anatomic discriminators identifiable on axial and coronal planes. Several examples are shown with emphasis in the importance of this classification.

El objetivo de esta revisión pictográfica es la evaluación de las fístulas anorrectales mediante resonancia magnética. Esta técnica ha demostrado ser altamente confiable para estudiar la anatomía de la región perianal. Nuestro protocolo de estudio es simple y fácil de estandarizar. Usamos la clasificación del Hospital de la Universidad de Saint James (Inglaterra) que enfatiza la relación de la fístula con el esfínter externo y su importancia en la continencia anal.

Comparison between anal endosonography and digital examination of anal fisulae and suppuration

Anal endosonography is a new, potentially promising technique for localizing fistulae track and associated abscess in the perianal region. A prospective trial was done comparing the accuracy of digital examination and anal endosonography in defining the anatomy of anal fistulae and anal suppuration. Before surgical interference, 50 patients were assessed clinically and anal endosonography was done for them. These findings were compared with operative findings