Image-guided surgery for anal fistula in a 0.5T interventional MRI unit

PURPOSE: To determine whether MR-guided anorectal surgery is feasible, and to develop techniques for MR-guided anal fistula surgery. MATERIALS AND METHODS: Six patients with pilonidal sinus (PNS), and 21 with suspected anal fistulae were operated on in the GE Signa SPIO 0.5T interventional MRI unit. Procedures were performed with magnet-safe Lockhart-Mummery fistula probes. Preprocedural and intra-operative MRI (IOMRI) techniques were used to identify the extent of the fistula tracts and septic foci, and to ensure the adequacy of the surgical procedure. RESULTS: IOMRI demonstrated the PNS lesions and the adequacy of excision. Imaging failed to demonstrate a fistula in two patients, as confirmed by surgical examination. No images were obtained in one patient due to his size (weight in excess of 100 kg). In 18 patients a fistula tract or abscess was demonstrated and IOMRI was used to assess the adequacy of the surgical procedure. In three patients this demonstrated incomplete drainage of septic foci, which was not obvious on inspection of the surgical field. We believe that in these patients IOMRI prevented an incomplete procedure and the potential requirement for a second operation. Further surgery was performed to rectify this situation. The fistula tract was laid open in 13 patients, and a Seton drain was inserted in five. CONCLUSION: MRI-guided surgery for anal fistula is feasible. IOMRI demonstrates the exact anatomy of the tracts and abscesses, and confirms that all have been adequately treated. We believe it may become particularly useful in surgery for recurrent and complex anal fistulae, and may lead to fewer recurrences.