MRI of Recurrent Fistula-in-Ano: Is it Different from Treatment-Naive Fistula-in-Ano and How Does it Correlate with Anal Sphincter Morphology?
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SUBMITTER: Augustine A
PROVIDER: S-EPMC9968521 | biostudies-literature | 2022 Nov
REPOSITORIES: biostudies-literature
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Project description:Aim/backgroundThe commonly used fistula-in-ano classifications, Park or St. James's University hospital(SJUH), neither grade fistulas as per their severity nor guide regarding their management. A new classification(NC), published in 2017, proposed to classify fistulas as per their severity and also guided in its management. The early grades (NC grade I & II) were simple fistulas and were amenable to fistulotomy whereas higher grades (NC grade III-V) were complex fistulas and were not amenable to fistulotomy.MethodsLower grades of all the three classifications were classified as simple (Parks: I, SJUH:I-II, NC:I-II) whereas higher grades were classified as complex (Parks: II-IV, SJUH: III-V, NC: III-V) fistulas. Fistulotomy should be possible in simple fistulas but not in complex fistulas. This was analysed for all these classifications. The long-term follow-up of continence was done by an objective scoring system (Vaizey's scores).ResultsThe SJUH & Parks classifications categorized 504/828 fistulas as 'complex' which was quite inaccurate as 42.7%(215/504) of these fistulas were safely amenable to fistulotomy. On the other hand, the New classification (NC) classified 282/828 fistulas as 'complex' which was very accurate as 99% (279/282) of these were actually complex and were not amenable to fistulotomy. The change in the preoperative and the postoperative continence scores in the patients who underwent fistulotomy, as per these classifications, Parks & SJUH vs NC, was 0.064 ± 0.62 and 0.089 ± 0.85 respectively and was not significantly different(p = 0.80, Mann-Whitney U test).ConclusionsThe New classification(NC) seems better than the existing classifications for grading the disease as well as in guiding the management of the disease.
| S-EPMC7522535 | biostudies-literature
Project description:Video-assisted anal fistula treatment (VAAFT) may have a recurrence rate comparable to that of fistulectomy and sphincter repair (FSR) in the treatment of high anal fistula and with potential advantages in wound healing, functional outcome and quality of life. The aim and objectives of the study are to compare the outcome of VAAFT with that of FSR for high cryptoglandular anal fistula. This was a single-centre randomized controlled trial of adults with high anal fistula comparing FSR with VAAFT. Primary outcome was fistula recurrence. Secondary outcomes were results of anal manometry, quality of life and faecal continence. A power calculation of 33 patients in each arm (1 : 1) was based on recurrence in the FSR and VAAFT groups of 5 per cent and 30 per cent respectively. Follow-up at 6 months after surgery included physical examination, MRI, anal manometry, quality-of-life assessment (RAND SF 36 questionnaire) and faecal-continence assessment (Wexner score). The study was terminated early due to high recurrence rates in both groups. A total of 45 patients were included. Recurrence rates were 65 per cent for VAAFT and 27 per cent for FSR, with hazard ratio 4.18 (P = 0.016). Length of the fistula was a risk factor with an association with recurrence (hazard ratio 1.8, P = 0.020). There were significant differences in quality of life in favour of FSR and in anal manometry in favour of VAAFT with a significant improvement in Wexner score in both groups. FSR was associated with a lower recurrence rate than VAAFT in the management of complex anal fistulae in this single-centre study but the study was terminated early due to higher than predicted recurrence rate in both groups. NCT02585167 (http://www.clinicaltrials.org).
| S-EPMC8493008 | biostudies-literature
Project description:ObjectivesTo develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis.MethodsAn expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed.ResultsIn the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented.ConclusionThese expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis.Key points• Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis. • While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation. • In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions.
| S-EPMC7431441 | biostudies-literature
Project description:BackgroundTherapeutic principles of fistula-in-ano (FIA) are lacking evidence-based consensus on treatment options. Non-cutting, sphincter-sparing options have not been published for infancy and childhood FIA.Patients and methodsWe are presenting retrospective data on FIA treatment with non-cutting seton placement between 2011 and 2020. Data were collected based on medical records and complemented by patients' contact for follow-up analyses between November 2021 and October 2022. Data were analyzed regarding the outcome variables of recurrent FIA and recurrent perianal abscess. Furthermore, outcomes in different age groups were compared (<1/1.5-12 years of age).ResultsTreatment duration with non-cutting seton was at a median of 4.6 months and was not associated with recurrent FIA (p = 0.8893). Overall recurrence rate of FIA within an observation time of 9 months postsurgically was at 7% (n = 3/42) and was only seen in infancy, whereas recurrent perianal abscess was mainly observable in children (n = 2, p = 0.2132). Comparison of age groups revealed no significant differences. Of the 42 included patients, 37 responded in the follow-up analysis, resulting in a response rate of 88% with a median follow-up time of 4.9 years. Fecal incontinence was postsurgically only seen in two patients, who were diagnosed prior to surgery and symptoms remained unchanged.ConclusionsNon-cutting seton placement might be a promising option in the treatment of FIA in infancy and childhood. Perioperative settings like duration of placed seton and antibiotic treatment have to be discussed in further prospective, enlarged population-based studies.
| S-EPMC10126327 | biostudies-literature
Project description:The external anal sphincter (EAS) may be injured in 25-35% of women during the first and subsequent vaginal childbirths and is likely the most common cause of anal incontinence. Since its first description almost 300 years ago, the EAS was believed to be a circular or a "donut-shaped" structure. Using three-dimensional transperineal ultrasound imaging, MRI, diffusion tensor imaging, and muscle fiber tracking, we delineated various components of the EAS and their muscle fiber directions. These novel imaging techniques suggest "purse-string" morphology, with "EAS muscles" crossing contralaterally in the perineal body to the contralateral transverse perineal (TP) and bulbospongiosus (BS) muscles, thus attaching the EAS to the pubic rami. Spin-tag MRI demonstrated purse-string action of the EAS muscle. Electromyography of TP/BS and EAS muscles revealed their simultaneous contraction and relaxation. Lidocaine injection into the TP/BS muscle significantly reduced anal canal pressure. These studies support purse-string morphology of the EAS to constrict/close the anal canal opening. Our findings have implications for the effect of episiotomy on anal closure function and the currently used surgical technique (overlapping sphincteroplasty) for EAS reconstructive surgery to treat anal incontinence.
| S-EPMC3949029 | biostudies-literature
Project description:ObjectiveTo describe long-term quality of life (QOL) outcomes after rectourethral fistula (RUF) repair. RUF is a debilitating diagnosis and complex surgical dilemma with limited data regarding QOL after repair.MethodsPatients at a tertiary referral center undergoing transperineal RUF repair 1/2009-5/2016 were analyzed. Patients were contacted by telephone to assess QOL following repair. Descriptive analysis performed of short-term surgical data (success and complications) and long-term QOL data (novel questionnaire).ResultsTwenty one men underwent RUF surgery with 95% success after initial repair. Fifty two percent had a history of radiation and/or ablation. Four individuals (19%) experienced a Clavien-Dindo complication within 30 days, with 3 of those being grade III+. Fifteen had postoperative urinary incontinence, of whom 73% underwent artificial urinary sphincter placement. Three previously radiated individuals underwent subsequent urethral stricture surgery. At long-term follow-up (mean 45.6 ± 27.1 months), 53% reported perineal pain, 43% reported problems related to the gracilis flap, and 80% reported urinary incontinence (primarily occasional mild leakage). Twenty one percent were unable to do the things they wanted in their daily lives, while 80% reported that surgery positively impacted their life. None would have opted for complete urinary diversion.ConclusionRUF repair leads to patient satisfaction and improved QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to suitable radiated and nonradiated patients.
| S-EPMC6289716 | biostudies-literature
Project description:ObjectivesThe objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.Data sourcesA review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.Methods of study selectionObservational studies (cohort/case-control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.Tabulation, integration and resultsFrom the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42-4.01) or ventouse (OR 2.44, 95 % CI 1.83-3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24-2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06-2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1-1.35).ConclusionThe overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.
| S-EPMC4879153 | biostudies-literature
Project description:BackgroundLong-term results after obstetric anal sphincter injury (OASI) are poor. We aimed to improve the long-term outcome after OASI by lessening symptoms of anal incontinence.MethodsIn a prospective study at Malmö University Hospital, twenty-six women with at least grade 3B OASI were classified and sutured in a systematic way, including separate suturing of the internal and external sphincter muscles with monofilament absorbable sutures. The principal outcome assessed by answers given to six questions, was a difference in anal incontinence score, between the study group and two control groups (women with prior OASI [n = 180] and primiparous women delivered vaginally without a diagnose of OASI [n = 100]).ResultsAn anal incontinence score of zero (i.e., no symptoms) was found in 74% of the study group, 47% of the OASI control group, and 66% of the vaginal control group (p = 0.02 and 0.5, as compared to the study group).ConclusionsA modified suturing technique was followed by significant improved one-year symptoms of anal incontinence as compared to historical cases.
| S-EPMC2949785 | biostudies-literature
Project description:Background & aimsThe anal sphincters and puborectalis are imaged routinely with an endoanal magnetic resonance imaging (MRI) coil, which does not assess co-aptation of the anal canal at rest. By using a MRI torso coil, we identified a patulous anal canal in some patients with anorectal disorders. We aimed to evaluate the relationship between anal sphincter and puborectalis injury, a patulous anal canal, and anal pressures.MethodsWe performed a retrospective analysis of data from 119 patients who underwent MRI and manometry analysis of anal anatomy and pressures, respectively, from February 2011 through March 2013 at the Mayo Clinic. Anal pressures were determined by high-resolution manometry, anal sphincter and puborectalis injury was determined by endoanal MRI, and anal canal integrity was determined by torso MRI. Associations between manometric and anatomic parameters were evaluated with univariate and multivariate analyses.ResultsFecal incontinence (55 patients; 46%) and constipation (36 patients; 30%) were the main indications for testing; 49 patients (41%) had a patulous anal canal, which was associated with injury to more than 1 muscle (all P ≤ .001), and internal sphincter (P < .01), but not puborectalis (P = .09) or external sphincter (P = .06), injury. Internal (P < .01) and external sphincter injury (P = .02) and a patulous canal (P < .001), but not puborectalis injury, predicted anal resting pressure. A patulous anal canal was the only significant predictor (P < .01) of the anal squeeze pressure increment.ConclusionsPatients with anorectal disorders commonly have a patulous anal canal, which is associated with more severe anal injury and independently predicted anal resting pressure and squeeze pressure increment. It therefore is important to identify a patulous anal canal because it appears to be a marker of not only anal sphincter injury but disturbances beyond sphincter injury, such as damage to the anal cushions or anal denervation.
| S-EPMC4575824 | biostudies-literature
Project description:IntroductionIn a recent Cochrane review, the authors concluded that there is an urgent need for well-powered, well-conducted randomized controlled trials comparing various modes of treatment of fistula-in-ano. Ten randomized controlled trials were available for analyses: There were no significant differences in recurrence rates or incontinence rates in any of the studied comparisons. The following article reviews the studies available for treatment of fistula-in-ano with a fistula plug with special attention paid to the technique.Material and methodsPubMed, Medline, Embase, and the Cochrane medical database were searched up to July 2015. Sixty-four articles were relevant for this review.ResultsHealing rates of 50-60% can be expected for treatment of complex anal fistula with a fistula plug, with a plug-extrusion rate of 10-20%. Such results can be achieved not only with plugs made of porcine intestinal submucosa but also those made of other biological or synthetic bioabsorbable mesh materials. Important technical steps are firm suturing of the head of the plug in the primary opening and wide drainage of the secondary opening.DiscussionTreatment of a complex fistula-in-ano with a fistula plug is an option with a success rate of 50-60% with low complication rate. Further improvements in technique and better studies are needed.
| S-EPMC4607815 | biostudies-literature