Accuracy of hydrogen peroxide-enhanced ultrasound in the identification of internal openings of anal fistulas

Objective This prospective study was designed to assess the accuracy of hydrogen peroxide‐enhanced ultrasound in the identification of internal openings of anal fistulas, with surgical findings as the golden standard. Patients and methods A total of 143 consecutive patients (102 men; mean age, 45 years) with fistula‐in‐ano were assessed by hydrogen peroxide‐enhanced ultrasound before surgery involving one radiologist. Ultrasound was performed using a B & K Diagnostic Ultrasound System^? with a 10‐MHz rotating endoprobe. Hydrogen peroxide (3%) was infused into the fistula. All operations were perfomed by the same surgeon who was unaware of results of anal endosonography. Results In 128 (89.5%) patients, an internal opening was identified at surgery. Correct identification of an internal opening endosonographically was recorded in 80 (62.5%) patients. The internal opening was correctly identified by ultrasound in 32% (8/25) of patients with intersphincteric fistulas, in 77% (70/91) with transsphincteric fistulas, and in 17% (2/12) with suprasphincteric fistulas. Conclusion The accuracy of hydrogen peroxide‐enhanced anal endosonography for the identification of internal openings was still insufficient to justify pre‐operative endosonography as a diagnostic method for routine use in patients with fistula‐in‐ano.     

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.     

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.     

MR Imaging of Fistula in Ano: Indications and Contribution to Surgical Assessment

Background : Magnetic Resonance Imaging (MRI) is the imaging modality of choice for fistula in ano. The purpose of this study was to analyse the use of MRI, and to assess its contribution towards the assessment of this sometimes difficult condition.

Methods : A retrospective analysis of all patients with fistula in ano between January 2003 and December 2007 was performed, focussing on those who had MRI assessment. The primary pathology, indication for MRI and the contribution of this investigation to assessment of fistula in ano were analysed.

Results : MRI was performed in 40 patients. The primary pathologies included: perianal sepsis in 20 (50%), Crohn’s disease in 11 (27.5%), primary fistula in ano in 6 (15%) and others in 3 (7.5%) patients. Indications for MRI were to assess the fistula anatomy in 17 (42.5%), to assess a clinically suspected fistula in 12 (30%), to assess a complex fistula found at Examination Under Anaesthesia (EUA) in 6 (15%) and to exclude a fistula in 5 (12.5%). MRI was considered helpful in 34 (85%) of all cases. MRI established the fistula anatomy and guided further surgery in 47.1%, correlated with EUA findings in 38.2% and excluded a suspected fistula in 14.7% of these.

Conclusions : This study further supports the benefit of using MRI to assess fistula in ano. When used in selected patients, it was of benefit in 85% of cases, by establishing fistula anatomy and guiding further surgery, correlating EUA findings or excluding a clinically suspected fistula.     

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.     

Magnetic resonance imaging for primary fistula in ano

BACKGROUND: This was a prospective study designed to determine the therapeutic impact of magnetic resonance imaging (MRI) in primary fistula in ano, and to assess its effect on outcome. METHODS: Thirty patients with suspected primary fistula in ano underwent preoperative MRI, and the findings were revealed during surgery following examination under anaesthesia (EUA). Any effect on operative approach was noted. Outcome was assessed at a median of 12 months. RESULTS: Two patients had sinuses, one had no sepsis and 27 had fistulas: five superficial, seven intersphincteric, 14 trans-sphincteric and one suprasphincteric. MRI and EUA agreed in 15 patients and MRI findings altered the surgical approach in a further three (10 per cent); two of the latter patients were believed to have a sinus at EUA, which MRI correctly identified as a fistula, allowing definitive treatment. The therapeutic impact of MRI was therefore 10 per cent. Persisting disagreement between MRI and EUA in 12 patients mostly related to minor discrepancies in classification. Only one patient required further unplanned surgery, which was for skin-bridging rather than any new sepsis. CONCLUSION: In experienced hands, MRI has a therapeutic impact of 10 per cent for primary fistula in ano, precipitating surgery that is likely to reduce recurrence in a small, but important, proportion of patients.     

VIDEO-ASSISTED ANAL FISTULA TREATMENT: TECHNICAL CONSIDERATIONS AND PRELIMINARY RESULTS OF THE FIRST BRAZILIAN EXPERIENCE

Backgroung

Anorectal fistula represents an epithelized communication path of infectious origin between the rectum or anal canal and the perianal region. The association of endoscopic surgery with the minimally invasive approach led to the development of the video-assisted anal fistula treatment.

Aim

To describe the technique and initial experience with the technique video-assisted for anal fistula treatment.

Technique

A Karl Storz video equipment was used. Main steps included the visualization of the fistula tract using the fistuloscope, the correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening which can be accomplished through firing a stapler, cutaneous-mucosal flap, or direct closure using suture.

Results

The mean distance between the anal verge and the external anal orifice was 5.5 cm. Mean operative time was 31.75 min. In all cases, the internal fistula opening could be identified after complete fistuloscopy. In all cases, internal fistula opening was closed using full-thickness suture. There were no intraoperative or postoperative complications. After a 5-month follow-up, recurrence was observed in one (12.5%) patient.

Conclusion

Video-assisted anal fistula treatment is feasible, reproducible, and safe. It enables direct visualization of the fistula tract, internal opening and secondary paths.     

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。     

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.     

Anal fistulotomy between Skylla and Charybdis

Objective This study was undertaken to assess the results of anal fistulotomy on faecal continence, recurrence and satisfaction. Methods We reviewed the records of 60 patients who underwent anal fistulotomy between 1997 and 2000. Follow‐up was by a questionnaire with 46 (77%) patients responding. Mean follow‐up was 1–4 years. Fistulas were intersphincteric in 12 patients and transsphincteric in 34 patients. Operative procedure consisted of fistulotomy. Results Of 11 patients with high fistula, 9 (82%) had impaired continence; Of 17 patients with midanal fistula, 4 (24%) suffered impaired continence. Eighteen patients had a low fistula and 8 (44%) developed impaired continence. In the whole group 50% had suffered faecal incontinence. There were no recurrences and there was satisfaction with the situation in 87% of patients. Conclusions Fistulotomy for primary fistula in ano in this retrospective study with a follow‐up up to 4 years was associated with no recurrences. Eighty‐two percent of patients with a high anal opening have impaired faecal continence, nevertheless patients' satisfaction is high.     

High ligation of the fistula track by lateral approach: a modified sphincter‐saving technique for advanced anal fistulas

Aim Ligation of the intersphincteric fistula track is a novel surgical procedure with the advantage of avoiding anal incontinence. We conducted a preliminary investigation of a modified technique for complicated trans‐sphincteric anal fistula by high ligation of the track using a lateral approach. Method From June 2010 to May 2011, 10 patients received high ligation of the fistula track using a lateral approach. Patients selected for the procedure had a mature trans‐sphincteric type of anal fistula that involved a significant amount of the external sphincter. Patients with early fistulous abscess or with a history of previous anal surgery were excluded. The surgical technique involved making an incision from the external opening and extending this towards the direction of the internal opening, dissection of the fistula from the underlying soft tissue, high ligation above the internal sphincter and removal of the distal part of the fistula track for pathological examination. Results Of the 10 patients, eight were men and the mean ± SD age was 40.5 ± 7.23 years. The median (range) duration of follow‐up was 7 (6–10) months. In all patients, the wound was completely healed by the sixth postoperative week. Two cases of recurrence were noted later and were successfully managed by traditional fistulotomy. Conclusion High‐ligation surgery of the fistula track for trans‐sphincteric anal fistula, aimed at total anal sphincter preservation, has shown encouraging early results. Long‐term follow‐up and randomized controlled trials are necessary.     

高场磁共振成像在肛瘘诊断中的应用价值

为探讨1．5T高场磁共振成像（MRI）在肛瘘诊断中的应用价值,对31例临床诊断为肛瘘的患者术前应用1．5T高场磁共振体部相控阵列线圈进行轴位、矢状位、冠状位的多种序列的检查。结果发现,MRI诊断结果与手术诊断结果完全一致,吻合率达到100％。其中经括约肌肛瘘9例,括约肌间肛瘘16例,括约肌外肛瘘1例,括约肌上肛瘘5例。单纯性肛瘘11例,复杂性肛瘘20例。MRI对瘘管显示的敏感度为100％;对脓肿显示的敏感度为100％;内口有2例为假阴性,对内口显示的敏感度为93．5％。结果表明,应用1．5T高场MRI能准确定位肛瘘的内口、瘘管的走向及其与肛管直肠括约肌之间的关系,具有重要的临床实用和推广价值。     

一期根治术与单纯切开引流术治疗肛周脓肿的疗效对比观察

为比较一期根治术与单纯切开引流术治疗肛周脓肿的临床疗效,回顾2010年5月至2012年7月于我院行一期根治术或单纯切开引流术治疗的162例肛周脓肿患者资料,其中行一期根治术治疗106例（观察组）,行单纯切开引流术治疗56例（对照组）,并对两种术式的治疗效果进行对比分析。结果显示,术后随访1～2年,观察组治愈101例（95．28％）,发生肛瘘5例（4．72％）;对照组治愈19例（33．93％）,发生肛瘘37例（66．07％）。观察组肛瘘发生率明显低于对照组,差异有显著统计学意义,P＜O．01。术后随访和二次手术术中探查发现,观察组术后发生肛瘘主要是由于内口定位不准确所致。结果表明,一期根治术治疗肛周脓肿对防止术后形成肛瘘有较明显的效果,对内口定位清楚的肛周脓肿患者采用一期根治术是比较理想的选择。     

Simple clinical examination predicts complexity of perianal fistula

OBJECTIVE: To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment. PATIENTS AND METHODS: One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test. RESULTS: The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule. CONCLUSION: Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.     

Clinical Correlation and MRI Finding in the Management of Fistula in Ano

Fistula is considered to be any abnormal passage which connects two epithelial surfaces. Parks fistula classification demonstrates the biggest practical significance and divides fistulae into inter-sphincteric, trans-sphincteric, supra-sphincteric, and extra-sphincteric. Diagnostic method options are retrograde (RTG) fistulography, computed tomography (CT) fistulography, and magnetic resonance imaging (MRI) of pelvic organs. The purpose of the study is to correlate clinical examination and operative findings with the findings of MRI and to draw efficacy of MRI as a preoperative diagnostic tool in the management of fistula in ano. This study was performed at the Surgery Department and MRI unit of the Radiology Department of JLNH and RC, Bhilai, from January 2014 to July 2015. Patients with perianal fistulae were included in our prospective study. All patients underwent high-spatial resolution MR imaging. MR imaging findings were correlated with the intraoperative surgical finding. MR imaging shows 7 fistulous patients with side branching and 16 with abscess cavity which was 100% intraoperatively correlated. Fifty-six patients out of 60 completely correlated with MRI for primary track which was clinically significant. MRI had 96% sensitivity and 100% specificity for primary tract and internal opening and 100% sensitivity and specificity for abscess and multiple tracks. MRI is useful in successful treatment of perianal fistulae by providing more accurate anatomical information about the amount of sphincter above the track and the position and level of the internal opening, thereby increasing the likelihood of successful surgical treatment. So, MRI is the very important preoperative investigation tool for fistula in ano.     

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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。     

磁共振成像在复发性肛瘘中的应用价值

为探讨磁共振成像（magneticresonanceimaging,MRI）在复发性肛瘘中的应用价值,回顾40例复发性肛瘘患者的MRI表现,总结分析其内口位置特点、瘘管走行形态以及肛提肌侵犯范围等。MRI采用Philips1．5T超导型磁共振扫描机,软体线圈,检查体位为仰卧位。采用横断：TIWI自旋回波（SE）序列,T2WI快速自旋回波（FSE）序列,T2WI脂肪抑制（FAT—SAT）序列。冠状及斜冠状位：T2WIFSE序列。层厚5ram,间隔lmm。结果显示,40例复发性肛瘘患者均为高位肛瘘,手术证实均存在内口,其中38例术中所见与MRI表现一致,该38例患者内口均位于肛窦附近（32例存在1个内口,6例存在2个内口）;另2例MRI检查各序列及断面均未显示内口。瘘管长度7．0～16．0cm（其中走行平直23例,走行迂曲17例）;瘘管宽度0．8～3．0cm。瘘管走行于肌间者32例,走行于肛提肌内者8例。本组患者瘘管壁均不规则,其厚度为0．3～1．0cm。瘘管存在支管者11例;内盲瘘1例。瘘管仅侵犯耻骨直肠肌者4例,仅侵犯髂骨尾骨肌者9例,耻骨直肠肌及髂骨尾骨肌同时受侵27例;并发瘘管组织癌变1例。结果表明,MRI能准确显示内口的位置、瘘管走行及肛提肌受侵范围、程度,在复发性肛瘘术前检查中具有重要作用。     

Reprint to: Fistulotomy

Anal fistulotomy, the unroofing of the entire tract from the external to the internal opening, is the most effective and simple treatment for most patients with anal fistula. However, anal fistulotomy carries a risk of fecal incontinence that is related to the loss of sphincter function and the deformity of the anal canal that results from dividing the tissue encircled by the fistula. The main treatment challenge is how to select patients who will be cured of their fistula without developing postoperative fecal incontinence. The decision should be individualized according to the proportion of the muscle involved, the location of the tract, the patient's sex, history of previous anal surgery, continence, and finally, but not less importantly, the surgeon's experience.     

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.     

Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule

OBJECTIVE: To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge. SUMMARY BACKGROUND DATA: Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection. METHODS: From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy. RESULTS: Ninety-two patients with a tumor at 3 (range 1.5-4.5) cm from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2% and the 5-year overall and disease-free survival were 81% and 70%, respectively. CONCLUSIONS: The technique of intersphincteric resection permits us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. Tumor distance from the anal verge is no longer a limit for sphincter-saving resection.