Search

ABSTRACT: Background: This study aimed to assess the correlation between preoperative magnetic resonance imaging (MRI) findings and intraoperative observations in patients diagnosed with anorectal fistulas and evaluate the diagnostic accuracy of MRI in identifying fistulous tracts, internal openings, and associated complications. Materials and Methods: A prospective study was conducted at Pt. JNM Medical College, Raipur, from April 2018 to September 2019, involving 30 patients diagnosed with anorectal fistulas. Preoperative MRI scans were performed for all patients, and findings were compared with intraoperative observations. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI in detecting internal openings, fistulous tracts, and abscesses were calculated. Results: Among the 30 patients, 26 were male (86.66%) and 4 were female (13.33%), with a mean age of 35.6 years. MRI identified 63.33% of cases as simple fistulas and 36.66% as complex fistulas. The internal opening was most commonly located at the 6 o'clock position (26.66%). MRI findings correlated with intraoperative findings in 86.66% of cases. The sensitivity of MRI was 100% for detecting simple tracts and 80% for detecting abscesses, with discrepancies observed in 13.33% of cases. Conclusion: MRI proved to be a valuable tool in the preoperative evaluation of anorectal fistulas, demonstrating high accuracy in identifying fistulous tracts and associated complications. However, in some cases, intraoperative findings differed from MRI, emphasizing the need for thorough surgical exploration. [ABSTRACT FROM AUTHOR]

Pankaj Garg,1,2 Vipul D Yagnik,3 Sushil Dawka,4 Baljit Kaur,5 Geetha R Menon6 1Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, Punjab, India; 2Department of Colorectal Surgery, Garg Fistula Research Institute Surgery, Panchkula, Haryana, India; 3Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India; 4Department of Surgery, SSR Medical College, Belle Rive, Mauritius; 5Department of Radiology, SSRD MRI Imaging Centre, Chandigarh, Haryana, India; 6National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, IndiaCorrespondence: Pankaj Garg, Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, Punjab, 140507, India, Fax +91 9501011000, Email drgargpankaj@yahoo.comBackground: Anal fistulas cause great uncertainty and anxiety in patients and surgeons alike. This is largely because of the inability to accurately confirm postoperative fistula healing, especially long-term healing. There is no scoring system available that can objectively assess cryptoglandular anal fistulas for postoperative healing and can also accurately predict long-term healing.Methods: Several parameters that could indicate anal fistula healing were assessed. Out of these, six parameters (four MRI-based and two clinical) were finalized, and a weighted score was given to each parameter. A novel scoring system (NSS) was developed. A minimum possible score (zero) indicated complete healing whereas the maximum weighted score (n = 20) indicated confirmed non-healing. Scoring was done with postoperative MRI (at least 3 months post-surgery), then compared with the actual healing status, and subsequently correlated with the final long-term clinical outcome.Results: The NSS was validated in 183 operated cryptoglandular fistula-in-ano patients over a 3-year period in whom 283 MRIs (preoperative plus postoperative) were performed. The postoperative follow-up was 12– 48 months (median-30 months). The NSS was found to have a very high positive predictive value (98.2%) and moderately high negative predictive value (83.7%) for long-term fistula healing. Additionally, its sensitivity and specificity in predicting healing were 93.9% and 94.7%, respectively.Conclusion: Thus, this new scoring system is highly accurate and would be a useful tool for surgeons and radiologists managing anal fistulas. By objectivizing the assessment of postoperative healing, it can both ease and streamline management. Moreover, reliable prediction of recurrence-free long-term healing will greatly allay the apprehensions associated with this dreaded disease.Keywords: anal fistula, MRI, postoperative, scoring system, internal opening, healing

Pankaj Garg,1,2 Baljit Kaur,3 Konica Singla,2 Geetha R Menon,4 Vipul D Yagnik5 1Department of Colorectal Surgery, Indus International Hospital, Mohali, India; 2Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India; 3Department of Radiology, SSRD Imaging Centre, Chandigarh, India; 4Department of Biostatistics, Indian Council of Medical Research, New Delhi, India; 5Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, IndiaCorrespondence: Pankaj GargGarg Fistula Research Institute (GFRI), H.no- 1042, Sector-15, Panchkula, Haryana, 134113, IndiaFax +91 9501522000Email drgargpankaj@yahoo.comPurpose: In some anal fistulas, the internal/primary opening cannot be located even after examination and assessment on MRI or transrectal ultrasound. The efficacy of a simple new protocol to manage such therapeutically challenging fistulas was tested.Patients and Methods: All anal fistula patients operated consecutively over 7 years were included in the study. A simple two-step protocol was followed for fistulas in which the internal opening was not locatable after clinical examination and MRI assessment. First, the MRI was reassessed. The site where the fistula was closest to the internal sphincter was noted. It was assumed that the internal-opening was located at that position and the fistula was treated accordingly. Second, in horseshoe anal fistulas with no apparent internal opening, it was assumed that the internal opening was located in the midline. Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. Incontinence was evaluated by objective incontinence scores (Vaizey scores).Results: A total of 757 patients were operated (median follow-up-33 months). Of these, 57 patients were excluded due to short or inadequate follow-up. In 154/700 (22%) patients, the internal opening could not be located while in 546/700 (78%), the internal opening was found. Both the groups were similar in all parameters. In the “internal-opening found” group, the fistula healed completely in 486/546 (89%) and in the ‘internal-opening not found group’, the fistula healed in 140/156 (90.9%) (p=1.01). The objective continence scores did not change significantly after surgery in both the groups.Conclusion: This new protocol seems effective as a high cure rate could be achieved in ‘internal-opening not found’ fistulas which was comparable to fistula healing in the ‘internal-opening found’ group.Keywords: anal fistula, internal opening, horseshoe, MRI, recurrence, fistula-in-ano

Background: Correct identification of the internal opening is essential in the management of perianal fistulae. The aim of this study was to assess the validity of Goodsall's Law and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening using 3-dimensional endoanal ultrasound. Methods: An observational study including patients diagnosed with fistula-in-ano, at our institution from January 2006 to December 2020 was performed. Location and distance from the anal verge of the external opening, internal opening, and the path of the fistulous tract were recorded during physical examination and endoanal ultrasound. Goodsall's and Midline rules were applied to all fistulae according to the location of the external opening. The location of the internal opening as predicted by either rule was then compared to the real location of the internal opening identified during endoanal ultrasound examination. Results: Nine hundred and nine patients [657 (72.3%) males, mean age 50.78 (49.84–51.72) years] were included. 665 (73.2%) of fistulae were transsphinteric. Concordance between predicted internal opening site and the true internal opening location was 0.601 (good match) for Goodsall's rule, and 0.416 (moderate match) for the Midline rule. Goodsall's rule proved to be more predictive in the anterior plane (p < 0.001). Both rules were more likely to make a correct diagnosis in posterior fistulae located 4.5–7.5 mm from the anal verge. Conclusions: Both Midline and Goodsall's rules are highly predictive of the course of fistula tracts located in the posterior plane, and are lower for anterior located fistulae, female patients and when the external opening is located further from the anal verge. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the rules for anal fistulas with scrotal extension, in particular, whether a high transsphincteric or suprasphincteric fistula, of which internal openings are usually located posteriorly, would extend into the scrotum. Methods: We retrospectively analyzed 446 consecutive male patients who underwent definitive anal fistula surgery. We compared fistulas with scrotal extension according to the location of the internal opening and divided them into anterior and posterior groups. Results: Forty-six (82.1%) of the 56 anal fistulas with scrotal extension had anterior internal openings. After excluding recurrent fistulas, 42 (87.5%) of the 48 anal fistulas with scrotal extension had anterior internal openings. The relative risk of scrotal extension in the anterior group was 14.22 times higher than that in the posterior group (95% CI: 7.43-27.21; p

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. [ABSTRACT FROM AUTHOR]