Comparison of hydrogen peroxide instillation with Goodsall's rule for fistula-in-ano

Background : Identification of the internal opening is an essential step in the management of fistula‐in‐ano. The predictive accuracy of Goodsall’s rule is compared with instillation of hydrogen peroxide for fistulas‐in‐ano. Methods : Thirty‐five patients (32 male, three female; median age 42 years; range: 6 months–70 years) were studied. Hydrogen peroxide solution was injected into the external opening of the fistula track and effervescence was observed at the internal opening within the anal canal. A fistula track was either excised or incised. Setons were placed within high fistulas. Results : There were 24 simple fistulas, compared to 11 complex fistulas (horseshoe, n = 4; abscess, n = 4). Eighteen external openings were anterior and 17 were posterior. Thirty‐four of 35 (97%) internal openings were identified. Only 20 internal openings were in accordance with Goodsall’s rule (positive predictive value: 59%). Predictive accuracy was greater for anterior external openings (13 of 18 (72%)) versus posterior external openings (six of 17 (41%); P = 0.016). For recurrent fistulas, seven of 17 fistula tracks had an internal opening in accordance with Goodsall’s rule, resulting in a positive predictive value of 41%. (Positive predictive value: anterior 67%vs posterior 12.5%; P = 0.0009.) Conclusion : The overall predictive accuracy of Goodsall’s rule was poor chiefly because of poor predictive accuracy in posterior and recurrent fistulas. The use of Goodsall’s rule alone in decision‐making before surgical intervention is not recommended.     

Pre-operative assessment of anal fistulas using endoanal ultrasound

Objective To study the accuracy of endoanal ultrasound in pre‐operative assessment of cryptoglandular anal fistulas, with respect to the site of the internal opening, type and depth of the fistula tract. Patients and methods A consecutive series of 151 patients with anal sepsis underwent pre‐operative endoanal ultrasound assessment of a suspected anal fistula. Hydrogen peroxide was used to define the tract when there was doubt as to the course of the fistula. All patients subsequently had surgical exploration under anaesthesia, irrespective of findings at sonography. The site of the internal opening, depth and type of fistula were recorded at surgery, and concordance with the ultrasound was assessed. Results One hundred and forty‐five patients were subsequently shown to have a fistula at surgical exploration. Type of fistula: Two thirds were transsphincteric (63%) and one third were inter sphincteric (32%), with a few submucosal, and supra sphincteric fistulas. Ultrasound correctly predicted surgical findings in 82% of patients (124/151). Concordance was highest for transsphincteric fistulas (87%). Internal opening: Accuracy of predicting the site of the internal opening was 93% (140/151). The commonest site for the internal opening was the midline posteriorly (49%), followed by the midline anteriorly (25%), the rest lay laterally. Fistula depth: Ultrasound and surgical assessment of the depth of fistulas was concordant in 120 of 145 patients (83%). Conclusions Endoanal ultrasound has a high accuracy of predicting the site of internal opening of an anal fistula. Endoanal ultrasound is able to assess the type and depth of a fistula. This information is useful for pre‐operative planning of fistula treatment.     

Anography: a technique for determining the location of the internal opening in perianal fistula

Aim Anography is a radiological investigation for fistula‐in‐ano that identifies the primary fistula track through the internal opening. The efficacy of anography as a radiological method of identifying the location of the internal opening was investigated. Method A retrospective study of 50 patients with a clinical diagnosis of fistula‐in‐ano of criptoglandular aetiology was performed. During anography, the location of the internal opening was recorded with respect to the quadrant of anal canal and distance from the anal verge. These data were compared with the findings during examination under anaesthesia (EUA), which was used as the gold standard for the identification of the internal opening. Results The sensitivity of anography for identifying a patent internal opening was 91% and specificity 100%. There was complete agreement between anography reports and findings at EUA regarding the quadrant of anal canal in which the internal opening was located. In more than 90% of patients, the internal opening was found at EUA within 1 cm from the site described on anography. Conclusion Anography is an accurate test for predicting the exact quadrant of the anal canal in which the internal opening is located, as well as the distance of the internal opening from the anal verge. This inexpensive and simple radiological investigation should be the test of first choice in the evaluation of patients with fistula‐in‐ano when difficulty is anticipated in identifying the internal opening.     

�����ھ����������ڿ����ϵĸ�������ϼ�ֵ

目的 了解经肛门超声内镜检查对内口已经愈合的肛瘘病人内口部位的诊断价值。方法 对临床常规手术未能发现肛瘘内口的12例病人进行超声内镜检查,并进行手术治疗。分析经肛门超声内镜检查对内口已经愈合的肛瘘病人内口部位的诊断价值和超声影像学特点,并与其它常规检查方法比较。结果 内镜超声检查在12例病 人均发现已经愈合的内口的准确位置,准确性优于Goodsall规律、肛门直肠肛门指诊、窦道造影或美蓝注射以及窦道探针探查。结论 经肛瘘外口位置注射美蓝,可方便手术医师快速定位内口。经肛门超声内镜检查是定位已经愈合的肛瘘内口的准确、快速、简单、耐受性好的检查手段。在超声内镜发现内口后,经内镜在内口位置注射美蓝,可方便手术医师快速定位内口。     

Comparación de la ecografía endoanal contrastada con la cirugía en el diagnóstico de las fístulas endoanales

Purpose

To evaluate the usefulness of hydrogen peroxide-enhanced ultrasound (H₂O₂) in the preoperative assessment of perianal fistulas and to compare these results with unenhanced ultrasound findings.

Methods

All patients with surgically confirmed perianal fistula who underwent preoperative enhanced and unenhanced ultrasound were included. We compared enhanced and unenhanced ultrasound findings with surgical results (χ² and McNemar tests).

Results

A total of 44 surgically treated patients were analysed. Hydrogen peroxide-enhanced ultrasound correctly identified primary fistula tracks in 34 patients (sensitivity of 77%), 100% of abscesses and the internal opening in 29 out of 37 identified with surgery (sensitivity of 78% and specificity of 70%). The use of hydrogen peroxide provided additional information to the ultrasound performed without the use of contrast enhancement in 32 of the 44 patients (73%). H₂O₂ increased the number of fistula tracts correctly detected (77% vs 45%; p<0.003), particularly suprasphincteric fistulas, as well as internal openings (78% vs 22%; p<0.001) and secondary tracks (70% vs 0%). Additional detection of fistula tracks after H₂O₂ injection was higher in patients with previous surgery (68% vs 35%; p<0.05).

Conclusions

Hydrogen peroxide-enhanced ultrasound shows good agreement compared with surgical findings in the assessment of perianal fistulas. H₂O₂ improves conventional ultrasound results, increasing the detection of fistula tracks and internal openings, and also providing additional information, particularly in previously operated patients.     

术前三维肛管直肠腔内超声检查对肛瘘的应用价值

目的：探讨三维肛管直肠腔内超声（3D-EAUS）检查在肛瘘术前评估中的应用价值。方法前瞻性纳入2012年3月至2013年3月第二炮兵总医院结直肠肛门外科连续收治的诊断明确、拟行手术的100例肛瘘患者,采用计算机产生随机号的方法随机分为超声组和对照组,每组各50例。超声组术前采用3D-EAUS检查,对照组术前常规检查、采用指诊或探针探查,比较两组肛瘘内口定位、肛瘘分型及是否存在分支瘘管的准确率。结果与对照组比较,超声组的内口定位准确率较高,超声组和对照组分别为96．0％（48／50）和82．0％（41／50）（P＝0．02）。超声组与对照组对复杂性肛瘘的诊断分别为96．7％（29／30）比74．1％（20／27）（P＝0．021）;对肛瘘分型的诊断分别为96．0％（48／50）比78％（39／50）（P＝0．01）;对是否存在分支瘘管的诊断分别为94．0％（47／50）比84．0％（42／50）（P＝0．025）。但对于简单性肛瘘,两组内口定位准确率相当[95．0％（19／20）比91．3％（21／23）, P＝1．000]。结论三维肛管直肠腔内超声在内口定位、瘘管分型及分支瘘管的诊断方面具有较高的应用价值,尤其对复杂性肛瘘患者,值得在临床推广。     

��ά�س�����ɨ����������Ӱ��λ��ϸ����ٴ��о�

??Three-dimensional endoanal ultrasound for the locational diagnosis of anal fistula: a preliminary application study BEI Shao-sheng??DING Ke, WANG Jian-xin, et al??Department of Anorectal Surgy??the Second Hospital of Shandong University??Jinan 250033??China Corresponding author??DING Ke??E-mail??dingke@163.com Abstract Objective To evaluate the effectiveness and applied value of three-dimensional (3D)-Endoanal ultrasound combined with hydrogen peroxide angiography for the locational diagnosis of anal fistula. Methods 3D-endoanal ultrasound examination was performed in 17 patients with clinically suspected anal fistulas between November 2008 and January 2009 at the Second Hospital of Shandong University and results were compared with surgical findings. Results Seventeen patients were confirmed by 3D-endoanal ultrasound examination. Nine patients had simple fistulas. Eight patients had complex fistulas. At the same time 7 patients had low located fistulas, and 10 patients had high located fistulas including 8 patients with trsphincter fistulas, 1 patient with inter sphincter fistula and 1 patient with extra-sphincter fistula. All patients were confirmed by operation. But on surgery’s professional examination 1 case with high located fistulas was remisdiagnosed as low located fistulas.3D-Endoanal ultrasound had a accuracy of 90.9%. The 3D shape and track of fistula could be well shown the site of anal fistula and its relationship with the phincter complex and the levator animuscle. Conclusion 3D-Endoanal ultrasound examination combined with fistulography is a very effective and reliable method for the locational diagnosis of anal fistula.     

How the location of the internal opening of anal fistulas affect the treatment results of primary transsphincteric fistulas

Purpose  

The purpose of this study was to assess the influence of identification of the location of the internal opening of anal fistula on the recurrence rate after surgical treatment in patients with primary transsphincteric anal fistulas. The influence of preoperative rectal ultrasound on the treatment results was studied.     

Usefulness of anal endosonography in the assessment of fistula-in-ano

AIM: The purpose of the present study was to define the diagnostic value of anal endosonography in the diagnostic work-up of fistula-in-ano. METHODS: A retrospective study was carried out on 191 consecutive patients (m: 121; f: 70; mean age: 44.0 +/- 12.5 years; range: 0.5-77 years) who were diagnosed to suffer from fistula-in-ano by performing anal endosonography in an outpatient setting. All images were obtained with a Combison 310A ultrasound scanner (Kretz GmbH, Zipf, Osterreich) and 5-Mhz and 7.5-MHz transducer. 131 patients underwent surgery. According to the endosonographic findings fistulas were classified as transsphincteric in 44 %, intersphincteric in 22 %, subanodermal in 16 %, anovaginal in 8 %, suprasphincteric in 5 %, extrasphincteric in 1 % and others in 4 %. RESULTS: In 125 patients (95 %) the preoperative diagnosis was confirmed intraoperatively. This cohort included 12 patients with a complex fistula system. In only 6 patients the preoperative ultrasound finding was misinterpreted. CONCLUSION: In conclusion this study has shown that anal endosonography is a useful and reliable tool in the preoperative evaluation of uncomplicated and complicated anorectal fistulas.     

肛瘘MRI术前诊断价值与术中结果对照分析

【摘要】〓目的〓探讨术前磁共振(MRI)检查对肛瘘的定位、分型的临床指导意义。方法〓50例肛瘘患者行MRI检查,根据MRI所见,定位瘘道位置,依据窦道与肛门内外括约肌关系进行分型,并与术中所见结果相对照。结果〓手术证实50例患者中,30例为单纯性肛瘘,20例为复杂性肛瘘。括约肌间型20例,经括约肌型12例,括约肌上型6例,括约肌外型3例,表浅型9例。原发性瘘管72个,内口78个,外口77个,肛周脓肿17个。MRI诊断原发瘘管、内口、肛周脓肿的灵敏度分别为93.1%、96.2%、100%,特异度分别为91.5%、97.5%、91.3%。结论〓MRI可准确地判断肛瘘的分型、瘘管数量、走行、支管、内口的位置及有无肛周脓肿形成,为临床手术治疗提供重要指导信息。     

Fibrin glue in perianal fistulas--a pilot study.

BACKGROUND AND AIMS: Anal fistula surgery is associated with considerable morbidity, mainly related to anal incontinence. As promising results of the use of fibrin glue in the treatment of complex anal fistulas were recently shown, we planned to do a randomized trial comparing the use of fibrin glue and surgery in the treatment of perianal fistulas. There were no reports of the use of fibrin glue in the management of previously untreated anal fistulas. MATERIAL AND METHODS: Prior to the planned study a pretrial pilot series of 10 patients with different perianal fistulas were treated. Informed consent was obtained from every patient. Under spinal anesthesia, the fistula track was identified and brushed to remove granulous tissue, then washed with hydrogen peroxide and thereafter filled with fibrin glue. RESULTS: We performed fibrin gluing on 10 patients with perianal fistulas of different etiology and type. The gluing was done once to 7 patients, twice to 2 and three times to one patient. In all but one patient the fistula and symptoms recurred after only one month. One patient with a low trans-sphincteric fistula of which the internal opening was not found, was symptom-free for 6 months. At the one-month follow-up visit the external opening of the fistula was almost unidentifiable, suggesting that the fistula had healed. However, due to recurrence fistulotomy was performed after 6 months. CONCLUSIONS: Fistulas around the anus, with or without associated inflammatory bowel disease, do not seem to heal after fibrin gluing.     

�������CT�ڸ�����λ����е�Ӧ��̽��

目的探讨多层螺旋CT(MSCT)平扫、增强并结合瘘管造影对肛瘘进行定位诊断的临床应用价值。方法2004年7月至2006年5月间温州医学院附属第一医院对32例临床疑诊为肛瘘的病人使用16层螺旋CT扫描和瘘管造影。原始图像采用多平面重建(MPR)和容积重建(VR)技术进行三维重建,后处理图像由放射科专业医生完成。将术前获取的影像学资料与显微肛瘘手术和随访结果进行比较。结果MSCT上4例未发现肛瘘,5例为单纯性肛瘘,23例为复杂性肛瘘,均经过手术证实,肛肠专科检查将8例复杂性肛瘘误诊为单纯性肛瘘。MSCT上低位肛瘘6例,高位肛瘘22例,均经过手术证实,其中肛肠专科检查将8例高位肛瘘误诊为低位肛瘘,MSCT上3例括约肌外瘘误诊为括约肌上瘘。MSCT对术前内口、支管、脓腔评价的准确率分别为62.1%、89.3%、100.0%。MSCT后处理重建技术中,MPR包括曲面重建(CPR)可清晰显示瘘管的具体位置及其与肛管内外括约肌、肛提肌的关系,VR能三维再现瘘管的形态和走行特点。结论MSCT平扫、增强并结合瘘管造影是一种有效而可靠的对肛瘘进行定位诊断的检查方法,可以为手术提供有效依据。     

复发性肛瘘的诊治(附45例报告)

目的：提高肛瘘的一次性治愈率．减少肛瘘术后复发率．分析肛瘘再手术的原因。方法：1998年10月-2003年10月收治曾在外医院行肛瘘手术后又复发肛瘘病例45例．用亚甲蓝和过氧化氢混合液作外口注射染色加探针寻找内口．切开瘘道清除腐朽坏死及瘢痕组织后．抗生素冲洗伤口后作一期缝合．内口切开引流或切开挂线引流。术后针对不同原因采用中西医结合治疗．外加中药薰洗、坐浴。结果：45例全部临床治愈．治愈率达100％。结论：肛瘘手术完全能一次治愈。关键在于治疗过程中应注意内口(原发感染灶)与合并症的正确处理。     

三维肛管直肠腔内超声在肛瘘诊治中的应用

目的 探讨三维肛管直肠腔内超声定位肛瘘内口、显示瘘管走行的价值.方法 2008年11月至2010年1月应用三维肛管直肠腔内超声检查肛瘘患者127例,在三维立体模块中根据声像图特征进行内口定位、瘘管走行追踪.结果 定位内口116例,准确率91.3%(116/127),其中112例患者内口开口于齿线处,4例发现内口于直肠壶腹;127例患者定位主管,准确率100%(127/127),其中经括约肌瘘75例,括约肌间瘘47例,括约肌上瘘2例,括约肌外瘘3例;定位支管37例,准确率100%(37/37).结论 应用三维肛管直肠腔内超声检查肛瘘,能够准确定位内口、显示瘘管走行,能为临床治疗方法的选择提供必要的诊断依据.     

The efficacy of anal fistula plug in fistula‐in‐ano: a systematic review

Aims To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula‐in‐ano especially the complex fistulas. Method The database of PUBMED, MEDLINE, SCOPUS, EMBASE and COCHRANE LIBRARY for the period 1995–2009 was searched. A systematic analysis was carried to evaluate the success rate of AFP procedure in fistula‐in‐ano. Results A total of 25 studies were extracted and 12 (n = 317) were finally included in the systematic review. The follow‐up period ranged from 3.5 to 12 months. The AFP procedure had a success rate (patient cure rate) ranging from 24% to 92%. In complex fistula‐in‐ano in prospective studies (8/12 studies), the success rate was 35–87%. The success rate in patients with Crohn’s disease was 29–86%. The success rate in the patients with single tracts was 44–93% and in patients with multiple tracts, success ranged from 20% to 71%. The abscess formation/sepsis rate was 4–29% (11/108) and the plug extrusion rate was 4–41% (42/232–19%). Conclusion Anal fistula plug procedure has a success rate ranging from 24% to 92% in different studies. In prospective studies of complex fistula‐in‐ano, there was a moderate success rate of 35–87%. As AFP is associated with low morbidity and sepsis, it appears to be a safe procedure. Further randomized controlled trials studying objective parameters of fistula healing are needed to substantiate these findings.     

多层螺旋CT联合瘘管造影对肛瘘的术前评价

目的探讨瘘管造影后多层螺旋CT(multi-slice computed tomography,MSCT)在肛瘘术前评价中的价值。方法术前对27例怀疑肛瘘的患者瘘管造影后行MSCT平扫及三维重建,其中13例行增强扫描,并与手术或随访结果对照。结果27例中手术证实肛瘘23例,4例临床随访为肛周感染破溃,MSCT诊断3例为单纯性肛瘘,20例为复杂性肛瘘,4例未发现肛瘘。MSCT正确分级:1级肛瘘3例,2级肛瘘18例,另2例3级肛瘘误诊为2级肛瘘。MSCT对内口及支管评价的敏感度、特异度、准确度、阳性预测值和阴性预测值分别为60.8%、85.7%、66.7%、93.3%、40.0%以及92%、100%、93.1%、100%和66.7%,对脓肿预测值则均为100%。MSCT三维重建能再现瘘管的形态和走行特点、瘘管与肛管内外括约肌和肛提肌的关系。结论MSCT联合瘘管造影是一种术前评价肛瘘的有效方法。     

Potential clinical implications of direction of a trans-sphincteric anal fistula track

BACKGROUND: The longitudinal direction of a trans-sphincteric anal fistula track through the anal sphincter complex may have implications regarding fistulotomy. METHODS: The angle of the track of trans-sphincteric fistulas relative to the longitudinal axis of the anal canal was measured before operation by means of magnetic resonance imaging (MRI) in 46 patients. This was compared with the findings at operation. RESULTS: The track passed cranially as well as laterally at an acute angle (less than 90 degrees ) in 23 patients while it passed either transversely or caudally at an obtuse angle (90 degrees or more) in the remaining 23. The internal opening was significantly higher in relation to the dentate line (above in eight patients, at the dentate line in 14 and below in one patient) when the track was acute than when it was obtuse (above in one, at the dentate line in 17 and below in five patients) (P = 0.004). The fistula track crossed the sphincter at a median angle of 35 degrees, 95 degrees and 132 degrees from internal openings sited above, at and below dentate line level respectively (P = 0.002). CONCLUSION: Fistula tracks passed cranially and laterally through the sphincter complex in half of these patients, and were most acutely angled on MRI when internal openings were situated above the dentate line. Preoperative MRI might alert surgeons to the potential hazard of fistulotomy being more extensive than anticipated from simple palpation of the level of the internal opening.     

A unique 3D endoanal ultrasound feature of perianal Crohn’s fistula: the ‘Crohn ultrasound fistula sign’

Aim Using a high‐resolution 3D endoanal ultrasound, we have observed that some perianal fistulas show a hypoechogenic fistula tract surrounded by a well‐defined hyperechogenic area with a thin hypoechogenic edge in patients with Crohn’s disease [‘Crohn’s Ultrasound Fistula Sign’ (CUFS)], unlike conventional fistula tracks. The study aimed to determine the prevalence of CUFS in a consecutive series of patients with anal fistula. Method Of 157 patients (median age 45, range 14–86 years, 100 males) with perianal fistula were examined with 3D endoanal ultrasound. All 3D volumes were stored and analysed retrospectively by two independent observers blinded to the clinical information of the patients. Results There were 29 patients with Crohn’s disease of whom 20 (69%) showed CUFS. CUFS was absent in 125 (98%) of 128 patients without Crohn’s disease. The positive and negative predictive value of CUFS for Crohn’s disease was 87% and 93%, respectively. The kappa value of the two independent observers was 0.77, indicating a substantial interobserver agreement. Conclusion This study provides a new 3D endoanal ultrasound criterion, CUFS, of perianal fistula in patients with Crohn’s disease. The sign can be used to discriminate a Crohn’s from other types of fistula, which may be useful in the management of patients with anal fistula.     

Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review

BACKGROUNDA complex anal fistula is a challenging disease to manage.AIMTo review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.METHODSAnal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores.RESULTSA total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug (n = 56), 50.3% in PERFACT (n = 175), 86% in TROPIS (n = 408), and 98.6% in fistulotomy (n = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, P = 0.057, not significant).CONCLUSIONFistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.     

Fistula-in-ano. Clinical features and long-term results of surgery in 199 adults

The clinical features and the long-term results of surgery for anal fistula were studied. Fistula distribution was subcutaneous (13%), intermuscular (14%), low anal (55%) or high anal (18%). There were no pelvirectal fistulas. The location was mostly posteriorly in the anus, except for the low anal fistulas, which were most frequent anteriorly. Follow-up examination was carried out on 199 patients, on average 9 years after fistula operation. The recurrence rate was 11% after laying open of fistula, with the highest rate (26%) in high anal fistula. The most common causes of recurrence were undetected internal opening and incomplete laying open of the fistulous tract proper. Most (91%) of the recurrences appeared within 18 months after surgery. Minor defects in anal control were found in 34% of the patients, and in 9% of controls matched for age and sex but with no anal surgery. Multiple operations for anal fistula, and also a gutter-shaped and a firm or hard scar in the anal canal adversely affected anal control. The amount of divided sphincter musculature did not influence the incidence of postoperative anal incontinence.