Perianal fistula mapping at 3 T: volumetric versus conventional MRI sequences.

AIM: To evaluate volumetric contrast-enhanced three-dimensional T1-weighted (CE 3D T1) turbo spin-echo (TSE) with variable flip angle (SPACE), CE 3D T1 volumetric interpolated breath-hold examination (VIBE) sequences with conventional CE-two-dimensional (2D)-T1 and 2D-T2-weighted imaging (WI) sequences in assessing perianal fistulas. METHODS AND MATERIALS: Twenty-three patients with perianal fistula were included in this prospective study and underwent pelvic magnetic resonance imaging (MRI) at 3 T including fat-supressed CE 3D T1 SPACE, CE 3D T1 VIBE, axial and coronal 2D-T1WI together with 2D-T2WI sequences in the axial and coronal planes. Acquisition times were recorded. Performance of each sequence was evaluated in terms of image quality, presence of artefacts, lesion conspicuity, fistula type, presence of abscess, visibility of internal orifice, and number of internal orifices. Results were compared with post-surgical findings defined as the reference standard. RESULTS: Both CE 3D T1 VIBE and CE 3D T1 SPACE were the best sequences to determine fistula type and in terms of image quality, artefacts, and determining locations of internal orifices. The number of internal orifices was detected correctly in 23 (100%) patients for CE 3D T1 SPACE and CE 3D T1 VIBE sequences, in 17 (73.9%) patients on CE-T1WI, and in seven (30.4%) patients on 2D-T2WI. Lesion conspicuity was higher for CE 3D T1 SPACE and CE 3D T1 VIBE sequences compared to the 2D sequences (p<0.05). The overall acquisition time for each 3D sequence was shorter compared to the 2D sequences combined. CONCLUSION: CE 3D T1 SPACE and CE 3D T1 VIBE sequences may outperform conventional 2D sequences in the evaluation of perianal fistulas in terms of visibility and number of internal orifices with a shorter scanning time.

Hybrid seton for the treatment of high anal fistulas: results of 128 consecutive patients.

BACKGROUND: The aim of this study was to evaluate our experience in managing high anal fistulas with a simple modification of the cutting seton. METHODS: We performed a retrospective review of standardized patient charts and of prospectively collected scores and questionnaires. Surgical outcomes of 128 consecutive, well-documented patients with high anal fistulas, including anterior transsphincteric fistulas in females, treated using a hybrid seton, were analyzed. RESULTS: No significant complications occurred. The mean postoperative pain scores on a visual analog scale were 3.23 and 0.61, on days 1 and 7, respectively. Complete healing was achieved in 67 cases (52.3 %) at 1 month and in all cases (100 %) at 3 months. Recurrent fistula was noted in 2 patients (1.5 %) at 6 and 12 months. The mean postoperative incontinence scores at 3 and 12 months did not differ significantly from the preoperative score (p = 0.061, Wilcoxon's test). The depression, life style, and embarrassment item scores of the fecal incontinence quality of life index improved significantly after surgical treatment. CONCLUSIONS: The results of this series suggest that the hybrid seton might be a valid alternative for the treatment of high anal fistulas, eliminating the need for postoperative adjustments. The slow and stable cutting of the sphincter seems to have a positive effect on the maintenance of continence. The successful outcome is associated with significant improvement in quality of life.

Treatment for horseshoe fistula with the modified Hanley procedure using a hybrid seton: results of 21 cases.

BACKGROUND: The aim of the present study was to document our recent experience in managing horseshoe fistula of cryptoglandular origin with a modification of the Hanley procedure using a hybrid elastic one-stage cutting seton. METHODS: Surgical outcomes of the modified Hanley procedure for horseshoe fistulae using a seton from 2004 through 2010 were analyzed. The seton fashioned from a surgical glove was tied around the sphincter under less tension than a traditional cutting seton, hence the definition of "hybrid seton". In addition to excision of the superficial segments of the lateral tracts, deeper extensions into the ischiorectal spaces were curetted, and Penrose drains were placed. RESULTS: All of the patients were discharged on the first postoperative day. None required readmission or needed narcotic analgesics after discharge. Complete healing was achieved in all 21 cases at 8.0 ± 3.22 weeks postoperatively. Patients were able to return to regular work activity in 3.5 ± 1 weeks. The postoperative Cleveland Clinic Incontinence Score did not differ significantly from the preoperative score (p = 0.317, Wilcoxon's test). Recurrent fistula was noted in a single patient (4.8 %) after a mean follow-up of 20.9-months. CONCLUSIONS: The use of the hybrid elastic seton is a useful and safe additional modification for the treatment of horseshoe fistulae with the Hanley technique.

Retrorectal hemangiopericytoma: a case report.

Hemangiopericytoma is a rare, vascular soft tissue tumour originating from the pericytes, the contractile cells that surround capillaries. A case of retrorectal hemangiopericytoma in a 49-year-old woman is reported. With a posterior sagittal approach, the tumour was completely removed. Pathological examination, including immunohistological stains, was consistent with a hemangiopericytoma. A step-by-step approach to a retrorectal tumour is exemplified, and a very rare pathological entity is added to the spectrum of retrorectal masses.

Intradermal methylene blue injection for the treatment of intractable idiopathic pruritus ani: results of 30 cases.

Some cases of idiopathic pruritus anu may be refractory to treatment with dietary and hygienic instructions and short-term topical medications. In this study, we documented our technique and results with methylene blue injection in a large series of patients with intractable idiopathic pruritus ani. The results of 30 adult patients with well-documented intractable idiopathic pruritus ani who were treated with intradermal methylene blue injection are reported. No antibiotic prophylaxis, anesthesia or sedation was used. A total of 15 ml of a 1% methylene blue solution was injected intracutaneously and subcutaneously in the affected perianal area. A second injection (rescue treatment) was offered one month later to patients who declared partial response, and follow-up was restarted. One month after injection, 24 patients (80%) were symptom-free, 5 declared partial remissions, and one patient still had the same degree of pruritus ani. Five patients with partial remission underwent a second methylene blue injection, which provided complete relief in four. Therefore, the early response rate was 80% with single injection and 93.3% (28 of 30) with the rescue treatment. At six months, three recurrences were noted, indicating to a success rate of 83.3% (25 of 30). At 12 months after treatment, 23 patients (76.7%) were symptom free. This study has shown that intradermal methylene blue injection is a safe, simple, fast and efficient method of treating intractable idiopathic pruritus ani.

Modified Limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery.

BACKGROUND: The present study analyses the results of wide excision with primary closure (PC), wide excision with classical Limberg flap reconstruction (LF) and wide excision with modified Limberg flap reconstruction (MLF) in the surgical treatment of sacrococcygeal pilonidal disease. METHODS: One hundred and sixty-two well-documented patients who were operated on for pilonidal disease and followed for more than 1 year were analysed retrospectively. Group 1 was composed of patients with excision plus PC (n = 78) while group 2 included those with excision plus a LF reconstruction (n = 40), and group 3 included those with excision plus a MLF reconstruction (n = 44). RESULTS: There were no significant differences among the three groups with respect to age, sex distribution, frequency of recurrent disease, or follow-up periods (P > 0.05 for all comparisons). Significant disadvantages regarding postoperative infection rate, mobilization time, discharge from hospital, and time off work were noted for primary closure, compared with both LF and MLF reconstructions. Following a median follow-up period of 4.2 years, 14 recurrences (17.9%) developed in the PC group, three (7.5%) in the LF group, and none (0%) in the MLF group. The zero recurrence rate in the MLF group was significantly lower than that in the PC group (P = 0.003). On the other hand, the recurrence rate in the LF was not found to differ significantly from that in the PC group (P = 0.126). Comparing the LF and MLF groups, none of the surgical end points reached a statistically significant difference (P > 0.05 for all comparisons). CONCLUSIONS: For the surgical treatment of sacrococcygeal pilonidal disease, excision plus a classical or modified Limberg flap reconstruction proved to be superior to excision plus primary closure in terms of infection, mobilization time, discharge from hospital and time off work. Additionally, MLF reconstruction resulted in a statistically lower recurrence rate when compared with PC.

Elastic one-stage cutting seton for the treatment of high anal fistulas: preliminary results.

BACKGROUND: The management of high and complicated anal fistulas remains a therapeutic challenge, and the oldest and theoretically the simplest technique is to use a seton. In this article, we document our recent experience in managing high anal fistulas with a simple modification of the cutting seton. PATIENTS AND METHODS: Surgical outcomes of patients treated by the elastic cutting seton for anal fistulas that involved more than half of the sphincter muscles or for anterior trans-sphincteric fistulas in female patients were analyzed. The elastic seton, which was created by cutting a thin (2-3 mm) circular strip from a surgical glove, including its thicker sleeve, was inserted through the remaining tract in a double-strand fashion, and then tied on the sphincter with two knots in a slightly tight manner. RESULTS: Complete healing was achieved in 9 cases (45%) at 1 month and in all cases (100%) at 3 months postoperatively. Recurrent fistula was noted in a single patient (5%) at 8 months. Worsening of preoperative continence was noted in 4 patients (20%). However, the postoperative incontinence score (0.70+/-1.22) did not differ significantly from the preoperative score (0.41+/-0.41; p=0.059, Wilcoxon's test). CONCLUSIONS: The preliminary results of this series suggest that the elastic cutting seton may be a valid alternative for the treatment of high anal fistulas. The possible positive contribution of the slow and stable cutting of the sphincter on the maintenance of continence is further supported. An important practical disadvantage of the conventional seton treatment, namely the need for postoperative adjustments, is also eliminated.