Accuracy prediction of Goodsall's rule for anal fistulas of crypotogladular origin, is still standing?

Background: Treatment of anal fistulas is still a challenging task because of high recurrence and risk of incontinence. Identification of internal fistula opening is paramount for successful treatment. Goodsall's rule is commonly used to predict the course of fistula and internal opening. However, its accuracy has been questioned by many investigators and its role became a controversial topic. Method: This is a case series prospective study in which 320 consecutive patients with anal fistula with Mean age 48.9± 6 years ages (ranges from 16 to 64 years) and mean body mass index 24.8± 5.5 average 18.5-30.6) were enroled. Goodsall's rule was applied to all fistulas according to the site of external fistula opening. Location of internal fistula opening as suggested by Goodsall's rule then compared to the exact location of internal opening identified by perineal or pelvic MRI and intraoperative findings. to assess the accuracy and positive predictive value of the Goodsall's rule in predicting the internal opening of the tract. Results: The overall accuracy rate, positive predictive value (PPV), sensitivity and specificity of Goodsall's rule in this study were 74.75%, 77.1, 74.5, and 72.05, respectively. The accuracy in predicting the internal fistula opening was 52.4% in anterior tracts and 73% in posterior tracts. Goodsall's rule was found to be more accurate in posterior fistulas than anterior fistulas and in short superficial fistulas rather than in long and high fistulas. Conclusion: Goodsall's rule was accurate in 74.75% of anal fistulas. It was more accurate for posterior long fistulas and anterior short and superficial fistulas. Patients with long (>3 cm) anterior fistulas defied Goodsall's rule when they found to have fistulas tracking to a midline anterior origin. Further, short posterior fistulas were found to open more commonly in a direct radial course rather to midline posteriorly.

Preoperative magnetic resonance imaging of anal fistulas with scrotal extension: a retrospective study.

Introduction: This study aimed to elucidate the magnetic resonance (MR) characteristics of anal fistulas extending to the scrotum, and the applicable rules, and to correlate MR features with surgical findings. Methods: We conducted a retrospective study in 150 consecutive patients with anal fistulas extending into the scrotum, who were diagnosed and underwent surgery at University Medical Center Ho Chi Minh City between January 2017 and April 2022. MR findings were evaluated and compared with surgical findings using Cohens kappa coefficient (k) with a 95% confidence interval. Results: 150 patients (mean age 37.6 ± 10.9 years) with 166 fistulas, including 150 anal fistulas with scrotal extension. Most fistulas were low transsphincteric (80.0%, 120/150 patients). There was a strong agreement for primary tract classification and detecting the location of internal openings between MRI and surgical findings with k = 0.83 (0.780.87) and k = 0.89 (0.85 0.93) (p<0.001), respectively. There is a significant correlation between the location of internal openings and the type of fistula (p<0.05). Low transsphincteric fistulas were predominant in the anterior group (103/122 patients vs. 10/19 patients), while in the posterior group, it was more common in the high transsphincteric fistulas (7/19 patients vs. 14/122 patients), and the intersphincteric fistulas (1/19 patients vs. 5/122 patients); and the suprasphincteric fistulas were only seen in the posterior group (1 patient). Conclusion: Anal fistulas with scrotal extension are exceptions to Goodsalls rule. Albeit long-tract fistulas, most are low transsphincteric and have anterior internal openings.

Three-dimensional endoanal ultrasound to assess the validity of Goodsall's Rule and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening.

BACKGROUND: Correct identification of the internal opening is essential in the management of perianal fistulae. The aim of this study was to assess the validity of Goodsall's Law and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening using 3-dimensional endoanal ultrasound. METHODS: An observational study including patients diagnosed with fistula-in-ano, at our institution from January 2006 to December 2020 was performed. Location and distance from the anal verge of the external opening, internal opening, and the path of the fistulous tract were recorded during physical examination and endoanal ultrasound. Goodsall's and Midline rules were applied to all fistulae according to the location of the external opening. The location of the internal opening as predicted by either rule was then compared to the real location of the internal opening identified during endoanal ultrasound examination. RESULTS: Nine hundred and nine patients [657 (72.3%) males, mean age 50.78 (49.84-51.72) years] were included. 665 (73.2%) of fistulae were transsphinteric. Concordance between predicted internal opening site and the true internal opening location was 0.601 (good match) for Goodsall's rule, and 0.416 (moderate match) for the Midline rule. Goodsall's rule proved to be more predictive in the anterior plane (p < 0.001). Both rules were more likely to make a correct diagnosis in posterior fistulae located 4.5-7.5 mm from the anal verge. CONCLUSIONS: Both Midline and Goodsall's rules are highly predictive of the course of fistula tracts located in the posterior plane, and are lower for anterior located fistulae, female patients and when the external opening is located further from the anal verge.

It is time to retire Goodsall's Rule: the Midline Rule is a more accurate predictor of the true and natural course of anal fistulas.

BACKGROUND: On May 6, 1887 at a meeting of the West London Medico-Chirurgical Society, original observations attributed to D. H. Goodsall described an association between the secondary (external) sinus opening and the location of the primary (internal) opening of an anal fistula: posterior external sinuses had a midline origin and anterior external sinuses took a straight path to their internal origin-eponymously known as Goodsall's Rule. However, over the last century, published reports support the midline as the primary (internal) origin of all anal fistulas, thus challenging the predictive accuracy of Goodsall's Rule and prompting this expansive review. METHODS: A literature search was performed for studies describing the relationship between the secondary (external) opening and the primary (internal) opening of anal fistulas, including recent reports of the positive predictive value (PPV) of Goodsall's Rule. The studies were evaluated to determine the validity of Goodsall's observations. RESULTS: The midline was the dominant, primary (internal) opening site of all anal fistulas with up to 95% accuracy. Goodsall's Rule was inaccurate when applied to anal fistulas with an anterior off-midline external sinus opening which tend to mirror posterior off-midline external sinuses and curve to a midline origin, rather than take a straight course to a primary (internal) opening, as predicted by Goodsall. Use of the Midline Rule had superior predictive accuracy, reflected in an increase in overall PPV of the location of the primary (internal) origin from 49% using Goodsall's Rule to 71% using the Midline Rule (57-62% for men, 31-90% for women). CONCLUSIONS: Goodsall's Rule falls short in predicting the natural course of anal fistulas with an anterior off-midline external sinus opening, especially for women. Given the increased risk of fecal incontinence related to surgical intervention for anterior-based anal fistulas, especially in women, dependence on Goodsall's Rule to guide the surgeon may result in "disastrous consequences". The preponderance of evidence over the last century favors the Midline Rule as a more accurate predictor of the true and natural course of anal fistulas, regardless of the location of the external sinus opening.

Anatomical characteristics of anal fistula evaluated by three-dimensional anorectal ultrasonography: is there a correlation with Goodsall's theory? / Características anatômicas da fístula anal avaliadas por Ultrassonografia Anorretal Tridimensional: Há correlação com a teoria de Goodsall?

Purpose: We aimed to correlate the course of the anal fistula tract (T), location of the external opening (EO) and internal opening (IO) in anterior (A) and posterior (P) circumference using 3D-US according to Goodsall's rule. Methods: 151 patients with primary ptoglandular Transsphincteric fistulas were examined with 3D-US and compared with surgical finding. The type of the T (straight or curved), EO and IO were identified and divided into 3 Groups: GI: EO and IO are located in a position; GII: EO and IO are located in P position and GIII: OE and OI are located in the opposite position. The findings were correlated with Goodsall's rule. Results: 74/151(49%) were included in GI, of them, 41 (55%) were male (33/44% had straight tract and 8/11% curved) and 33 (45%) female (15/20%-straight and 18/25%-curved). GII included 68 (45%), of them, 50 (74%) were male (39/57%-straight and 11/15%-curved) and 18 (26%) female (14/20%-straight and 04/8%-curved). GIII = 9 (6%) and all of them had curved tract. The overall concordance between 3D-US and surgical finding was 98% for tract and 96% for IO. Conclusion: The 3D-US findings correlate with the Goodsall's rule in transsphincteric fistulas located in the anterior circumference straight type, in male, while in females the distribution of curved and straight paths is similar. In the posterior circumference no correlation was observed in both the sexes. .

Objetivo: Correlacionar o trajeto (T) da fístula anal, localização do orifício externo (OE) e orifício interno (OI) na hemicircunferência anterior (HCA) e posterior (HCP), utilizando 3D-US, com a lei de Goodsall. Método: 151 pacientes com fístulas transesfinctéricas criptoglangulares foram examinados com US-3D correlacionando com os achados cirúrgicos. Identificou-se o tipo de T (retilíneo ou curvo), OE e OI e distribuiu-se os pacientes em 3 grupos: GI:OE e OI localizados em HCA; GII:OE e OI localizados em HCP e GIII:OE e OI em posiç ões opostas. Os achados foram correlacionados com a lei de Goodsall. Resultados: 74/151(49%) incluídos no GI, destes, 41(55%) homens(33/44% com trajeto retilíneo e 8/11% curvo) e 33(45%) mulheres(15/20%-retilíneo e 18/25%-curvo). No GII incluídos 68(45%), destes, 50(74%) homens(39/57%-retilíneo e 11/15%-curvo) e 18(26%) mulheres(14/20%-retilíneo e 04/8%-curvo). GIII = 9(6%) todos os trajetos curvos. A concordância entre o US-3D e os achados cirúrgicos foi de 98% para trajetos e 96% para o OI. Conclusão: Os achados ultrassonográficos permitiram correlacionar fístulas transesfinctéricas com trajetos retilíneos localizadas na hemicircunferência anterior, em homens, enquanto em mulheres a distribuição dos trajetos em curvo e retilíneo foram similares. Na hemicircunferência posterior não houve correlação em ambos os sexos. .

Management of rare, low anal anterior fistula exception to Goodsall's rule with Ksarasutra.

Anal fistula (bhagandara) is a chronic inflammatory condition, a tubular structure opening in the ano-rectal canal at one end and surface of perineum/peri-anal skin on the other end. Typically, fistula has two openings, one internal and other external associated with chronic on/off pus discharge on/off pain, pruritis and sometimes passing of stool from external opening. This affects predominantly male patients due to various etiologies viz., repeated peri-anal infections, Crohn's disease, HIV infection, etc., Complex and atypical variety is encountered in very few patients, which require special treatment for cure. The condition poses difficulty for a surgeon in treating due to issues like patient hesitation, trouble in preparing ksarasutra, natural and routine infection with urine, stool etc., and dearth of surgical experts and technique. We would like to report a complex and atypical, single case of anterior, low anal fistula with tract reaching to median raphe of scrotum, which was managed successfully by limited application of ksarasutra.

"Ley de Goodsall", ¿Mito o Realidad? / Law on Goodsall. Myth or reality?

Introducción: a fines del siglo XIX, en su libro “Rectum and Annus Diseases” David Goodsall afirmaba: “Las fístulas pueden ser descriptas como anteriores o posteriores en relación a una línea coronal trazada a través del ano. Las anteriores tendrán un trayecto radiado hacia el canal anal, las posteriores describen un trayecto curvo hacia la línea media posterior”.(1-3) Cien años después, el perfeccionamiento de técnicas de diagnóstico por imágenes nos permite poner a prueba el postulado de Goodsall a más de un siglo de emitido, para establecer si su afirmación puede contribuir o no, a la determinación de trayectos fistulosos y por ende, mejorar las tasas de éxito en la terapéutica quirúrgica. Objetivo: analizar resultados de ecografías endoanales 360º en fístulas perianales, estableciendo si sus trayectos cumplen o no, el postulado enunciado por Goodsall. Diseño: estudio retrospectivo, descriptivo, observacional. Materiales y métodos: análisis retrospectivo de 285 ecografías de fístulas perianales realizadas desde 2004 al 2012. Se analizaron edad, sexo, clasificación de Parks,(4-5) orificios internos, externos, trayectos principales y accesorios, cavidad intermedia y complejidad. Se consideraron fístulas simples los tractos interesfintéricos y transesfinterianos bajos; como complejas las recidivas, los tractos transesfinterianos altos, supraesfinterianos y extraesfinterianos. Criterios de inclusión: fístulas de origen criptoglandular. Criterios de exclusión: fístulas subcutáneas, inflamatorias, malignas, específicas y/o por trauma. Resultados: se excluyeron 17 estudios. La serie se basó en 268 ecografías; 193 (72,01%) transesfinterianas, 70 (26,12%) interesfinterianas, 4 (1,49%) supraesfinterianas y 1 (0,37%) extraesfinteriana. 234 (87,76%) se correspondieron con la regla, siendo un 81,62% de los mismos fístulas simples y 18,37% complejas. De los 34 (12,68%) que no lo hicieron, un 58,82% fueron fístulas simples y 41,17%, complejas... (TRUNCADO).

Background: late in the nineteenth century, in “Rectum and Annus Diseases” David Goodsall stated that “Fistulas can be described as anterior or posterior related to a line drawn in the coronal plane across the anus, the so called transverse anal line. Anterior fistulas will have a direct tract into the canal anal. Posterior fistulas will have a curved tract with their internal opening lying in the posterior midline of the anal canal (1)”. Development of new imaging techniques allows us to verify whether Goodsall´s statement is true. Hundreds of years passed until we are able to check if his rule can really contribute to fistulae tracts determination, therefore improving chances of success in surgical approaches or not. Objective: analyzing endoanal ultrasonography (US) results performed in anal fistulae and determine if they follow Goodsall´s statement. Design: descriptive, observational, retrospective study. Material and methods: a retrospective study of 285 endoanal US performed from 2004 to 2012. Age, gender, Parks´s classification, internal and external orifice, main and secondary tracts, mid cavity, and complexity were analyzed. Interesphincteric and low transesphincteric tracts were considered single fistulas whereas high transsphincteric, suprasphincteric, extrasphincteric and recurrent tracts were considered to be complex fistulas. Inclusion criteria: fistulas arising in infected anal crypts. Exclusion criteria: subcutaneous, malignant, specifics, traumatic or inflammatory tracts. Results: 17 studies were excluded. Research was based in 268 studies. 193 (72,01%) transsphincteric, 70 (26,12%) interessphincteric, 4 (1,49%) suprasphincteric and 1 (0,37%) extrasphincteric fistulas. 234 (87,76%) studies followed the postulate, 81,62% of them were single fistulas and 18,37%, complex tracts. However, there were 34 (12,68%) studies that did not satisfy expectancy, 58,82% of them were single fistulas while 41,17% were complex... (TRUNCADO).

The utility of Goodsall's rule among Filipino patients with anal fistula

This prospective cross-sectional study was conducted to determine the accuracy of Goodsall's rule in predicting the location of the internal opening of an anal fistula based on the location of the external opening among Filipino patients and the clinical factors that significantly influenced the accuracy of Goodsall's rule. From January 15, 1997 to April 15, 1998, 102 adult patients were analyzed by age, gender, fistula type, previous fistula surgery, symptom duration, location of the external opening, type of fistulous tract and distance of external opening from the anal verge. Overall, in 79 patients (77.5%), the locations of the internal opening were accurately localized according to Goodsall's rule. Univariate analysis showed that only the location of the external opening (posterior vs. anterior) and the distance of the external opening from the anal verge ((3 cm vs.> 3 cm) demonstrated a significant correlation with Goodsall's rule. Multivariate logistic regression analysis further demonstrated that anteriorly located external openings and distance of the opening greater than 3 cm from the anal verge were unlikely to comply with Goodsall's rule (odds ratio=0.008). Only 2 of 14 patients (14.3%) with anterior external openings greater than 3 cm from the anal verge had fistulous tracts which followed this rule. Thus, surgeons are advised to exercise caution during the surgical evaluation and treatment of anal fistula with these characteristics.