Complex perirectal sepsis: clinical classification and imaging |
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Authors: | A P Zbar N C Armitage |
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Institution: | (1) University of the West Indies School of Clinical and Medicine Research, Queen Elizabeth Hospital, Martindales Road, St. Michael, Barbados;(2) Nottingham University Hospital, Nottingham, UK |
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Abstract: | Background The use of specialized imaging to
assess cryptogenic fistula-in-ano is selective, aimed at
delineation of the site of the internal fistula opening and
the relationship of the primary and secondary tracks and
collections to the main levator plate. Advanced imaging
also permits definition of the destructive effects of
perirectal sepsis (e.g. internal or external anal sphincter
damage, perineal body destruction and an ano- or rectovaginal
fistula), which may require secondary reconstructive
surgery.
Methods We performed a PubMed
search of outcomes for fistula management in the
English and non-English literature, and summarized
results regarding the accuracy of internal opening and
horseshoe detection as well as the operative correlation
for cryptogenic and non-cryptogenic fistula-in-ano using
endoanal ultrasound (EAUS) and magnetic resonance
(MR) imaging. Only literature defining these characteristics was included.
Results The advantages and limitations
of the main forms of imaging are discussed in this
review with emphasis on EAUS and endoanal or pelvic
phased-array MR fistulography. The new technique of
transperineal sonography is highlighted. A small but
important group of patients with complex fistula-in-ano
require specialized imaging. There are specific limitations
of endoanal ultrasound (EAUS) which necessitate
pelvic phased-array MR imaging. Initial work suggests
that EAUS may have a role in intraoperative use for
image-guided drainage of recurrent abscesses where
operative interpretation can be difficult. The coloproctologist
in a tertiary referral center must acquire the skills of
ultrasound performance in order to successfully treat fistulous
disease, suggesting a role for formal imaging
accreditation as part of coloproctological training.
Conclusion Future studies should determine both what
sequential imaging algorithms for imaging are cost-effective
as well as predictive of fistula cure. |
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Keywords: | Fistula-in-ano Endoanal ultrasound Magnetic resonance imaging Transperineal ultrasound Hydrogen peroxide Transcutaneous ultrasound Horseshoe fistula Perirectal sepsis Transsphincteric fistula Intersphincteric abscess |
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