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PLACE DE L'IRM POUR EXPLORER LES PATHOLOGIES ANORECTALES. L'imagerie par résonance magnétique (IRM) est l'un des examens d'imagerie les plus utiles à l'exploration des pathologies ano rectales. Elle est complémentaire de l'examen clinique et de l'endo scopie. Elle permet de fournir des données indispensables à une prise en charge optimale du patient par le proctologue, le chirurgien ou l'oncologue en fonction de la nature de l'atteinte anale ou rectale. Il est nécessaire de respecter les différentes indications de cet examen, qui ont été bien définies pour chaque pathologie par les différentes sociétés savantes. Le protocole de l'IRM varie en fonction de la zone explorée et de la pathologie suspectée. C'est pourquoi il est indispensable de fournir au radiologue les informations nécessaires telles que la suspicion diagnostique, les données cliniques, ainsi que les résultats des examens complémentaires déjà réalisés. Les indications les plus fréquentes de l'IRM en proctologie sont les tumeurs anales et rectales. L'IRM permet le bilan initial de l'extension locorégionale de la tumeur ainsi que le suivi oncologique précoce et tardif grâce à l'étude comparative des examens de surveillance par rapport au bilan initial. L'IRM est indispensable pour l'exploration des suppurations anopérinéales complexes, en particulier liées à la maladie de Crohn. Elle permet la réalisation du bilan lésionnel initial ainsi que le contrôle post-drainage. En cas de suspicion de maladie de Verneuil ou de sinus pilonidal infecté, l'IRM participe à l'orientation vers le diagnostic étiologique. La déféco-IRM est une variante particulière de l'IRM pelvienne et périnéale. Elle fait partie du bilan des dysfonctions du plancher pelvien, car elle permet l'étude du comportement des différents organes pelviens au cours des efforts de poussée et de défécation. Les fissures anales et les thromboses hémorroïdaires sont les causes les plus fréquentes de douleurs anales. Leur diagnostic est purement clinique. En cas d'examen proctologique normal, l'IRM sert à chercher une autre cause à ces douleurs., Competing Interests: C. Touloupas et I. Boulay-Coletta et M. Zins déclarent n’avoir aucun lien d’intérêts. M. A. Haouari déclare des interventions ponctuelles pour Takeda. N. Fathallah déclare des interventions ponctuelles pour THD, Takeda, AbbVie, Amgen, Tillotts, La Roche-Posay, Sandoz, Viatris. L. Spindler déclare des interventions ponctuelles pour Biolitec et Takeda. V. de Parades déclare des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts.

Pilonidal Disease: THE REVOLUTION IN MINIMALLY INVASIVE SURGERY. Pilonidal disease is a common suppurative condition and affects 0.7% of the population. Surgical excision is the standard treatment. In France, the most common procedure is lay-open excision with healing by secondary intention. This procedure has low recurrence rates, but involves daily nursing care, long healing time and long period of sick-leave. Excision and primary repair or flap-based procedures are good alternatives to reduce these negative aspects but they expose to higher recurrence rates than excision with healing by secondary intention. The goal of minimally invasive techniques is to eradicate the suppuration, obtain healing as quick as possible, and limit the morbidity as much as possible. Old minimally invasive approaches such as phenolization or pit-picking are associated with low morbidity but with higher recurrence rates. Currently, new minimally invasive techniques are being developed. Endoscopic and laser treatment of pilonidal disease have shown promising results, with failure rates of less than 10% at 1 year, few complications and low morbidity. Complications are rare and minor. However, these interesting results need to be confirmed by better quality studies with longer follow-up., Competing Interests: L. Spindler déclare des interventions ponctuelles pour Biolitec. V. de Parades déclare des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts. N. Fathallah déclare des interventions ponctuelles pour les entreprises AbbVie, Viatris, Tillotts, Sandoz, Amgen, Biolitec et F Care Systems, et des liens durables avec l’entreprise Takeda. M. Draullette déclare n’avoir aucun lien d’intérêts.

Competing Interests: V. de Parades déclare avoir participé à des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts.

Anal Fistulas: SPARING THE SPHINCTER. Fistulotomy is the most used treatment for anal fistula. It is very effective with a cure rate of over 95% but carries a risk of incontinence. This has led to the development of various sphincter sparing techniques. The injection of biological glue or paste and the insertion of a plug have disappointing results and are expensive. The rectal advancement flap is still practised because of its cure rate of around 75% but it may result in some incontinence. Intersphincteric ligation of the fistula track and laser treatment are widely practised in France with cure rates between 60 and 70%. Video-assisted anal fistula treatment as well as injections of adipose tissue, stromal vascular fraction, platelet-enriched plasma and/or mesenchymal stem cells are emerging techniques for which even better results are expected., Competing Interests: V. de Parades déclare avoir participé à des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts. N. Fathallah déclare des interventions ponctuelles pour les entreprises AbbVie, Viatris, Tillotts, Sandoz, Amgen, Biolitec et F Care Systems, et des liens durables avec l’entreprise Takeda. L. Spindler, A. Barré et E. Pommaret déclarent avoir participé à des interventions ponctuelles pour Biolitec. A.-M. Haouari et P. Benfredj déclarent n’avoir aucun lien d’intérêts.

Competing Interests: V. de Parades déclare avoir participé à des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts. M. Aubert déclare n’avoir aucun lien d'intérêts.

MANAGEMENT OF SECONDARY LESIONS IN ANO-PERINEAL CROHN'S DISEASE. Anoperineal involvement in Crohn's disease is common and affects around 1/3 of patients during their disease. It constitutes a pejorative factor with an increased risk of permanent colostomy and proctectomy and is associated with a major deterioration in quality of life. Secondary anal lesions in Crohn's disease are fistulas and abscesses. They are difficult to treat and often recurrent. A multidisciplinary medico-surgical management in several stages is essential. The classic sequence is based on a first phase of drainage of fistulas and abscesses, a second phase of medical treatment based primarily on anti-TNF alpha and finally a third phase of surgical closure of the fistula tract(s). Conventional closure techniques such as biologic glue, plug, advancement flap and intersphincteric ligation of the fistula tract have limited effectiveness, are not always feasible, require technical skills and some have an impact on anal continence. In recent years, we have witnessed a real enthusiasm generated by the arrival of cell therapy. This has not spared proctology since adipose-derived allogeneic mesenchymal stem cells have had Marketing Authorisation and have been reimbursed in France since 2020 in the treatment of complex anal fistulas in Crohn's disease after failure of at least one biologic therapy. This new treatment offers an additional alternative in patients often in a situation of therapeutic impasse. Preliminary results in real life are satisfactory with a good safety profile. However, it will be necessary to confirm these results in the longer term and to work to determine the profile of the patients who could benefit the most from this expensive therapy., Competing Interests: N. Fathallah déclare des interventions ponctuelles pour les entreprises AbbVie, Viatris, Tillotts, Sandoz, Amgen, Biolitec et F Care Systems, et des liens durables avec l’entreprise Takeda. A. Alam déclare des interventions ponctuelles pour l’entreprise Biolitec. L. Kassouri déclare n’avoir aucun lien d’intérêts. A. Barré déclare des interventions ponctuelles pour les entreprises Takeda, Amgen, Tillotts. L. Spindler déclare des interventions ponctuelles pour Biolitec V. de Parades déclare des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts.

Anal fissure. Anal fissure is a painful proctological disease that most often affects young patients equally in both sexes. It significantly worsens the quality of life and requires rapid care. The anal fissure is most often located in the posterior anal commissure and frequently surmounted by a skin tag which can hide it and wrongly carry the diagnosis of hemorrhoids. Differential diagnoses such as carcinoma, Crohn's disease, sexually transmitted infection, etc. should be mentioned in case of atypical presentation. Its pathophysiology remains controversial, but in most cases, it results from the trauma of the passage of hard stools on an hypertonic anus. Medical treatment can cure just over half of patients. Surgery is reserved for failures of medical treatment and hyperalgesic fissure. In France, fissurectomy is the most commonly performed procedure while on the other side of the Channel or the Atlantic, lateral internal sphincterotomy is considered as the reference technique., Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts

Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

Management of anorectal bleeding. Anorectal bleeding is a common reason for consultation in general medical practice. The ano-rectal origin is suspected on the characteristics of the bleeding which is often scant and bright red color. Medical history and clinical examination alone are often sufficient to make a diagnosis, since the main causes are hemorrhoids and anal fissure. On the other hand, the estimated risk of anorectal tumours in patients with ano-rectal bleeding has been reported in about 10%. Colonoscopy is therefore necessary at the slightest diagnostic doubt and, anyway, in all patients aged over 45 years., Competing Interests: Les auteurs déclarent n'avoir aucun lien d'intérêts.

Competing Interests: V. de Parades déclare n'avoir aucun lien d'intérêts.

In theory, the first appointment for an anorectal problem is an easy consultation. Indeed, questioning the patient usually provides a suspicion of the diagnosis and the clinical examination is all the easier because the affected area is very accessible allowing immediate examination of the anatomical and clinical features. In addition therapeutic measures can be taken straight away in most cases. However conducting this consultation can be difficult in practice, particularly because of a taboo about the anal region. It is better, therefore, to observe a few rules for smoothly managing the different stages of this consultation.

Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis. Characteristically they have an endoanal primary opening, a fistula track and an abscess and/or an external purulent opening. Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia. Treating the fistula track occurs afterwards and aims to dry up the purulent discharge and avoid recurrence of the abscess by means of surgical fistulotomy. These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence. This explains the increasing interest in sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue.