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Importance of Magnetic Resonance Imaging in diagnosis, classification and evaluation of perianal fistula

Year 2017, Volume: 2 Issue: 1, 1 - 5, 16.04.2017
https://doi.org/10.25000/acem.298536

Abstract

Aim: Magnetic resonance imaging (MRI) is a non-invasive and high reliability procedure for evaluation of perianal area. In this study, our purpose is to present preoperative MRI findings and classification with images in diagnosed perianal fistula patients.

Methods: Contrast enhanced (CE) conventional MRI images, diffusion weighted MRI images and demographics of 57 patients were retrospectively evaluated. Perianal fistula classification is based on St James University Hospital (SJUH) classification system. 

Results: 57 patients (44 men and 13 women, average of 18 to 72 years, average age of 45.7 year) were included in this study. Most of the patients had symptoms of rectal pain and discharge. Some patients had additional complaints like rectal itching, swelling and erythema. 37 patients had grade 1, nine patients had grade 2, four patients had grade 3, five patients had grade 4 and two patients had grade 5 fistula. Fistula opening positions into anal canal were 6 o'clock in 21 patients, 7 o'clock in 10 patients. Fistula tract, its opening position into anal canal, presence of abscess and its relationship with sphincters or neighboring anatomical structures were clearly appreciated with conventional and diffusion weighted MRI in all patients.

Conclusion: Perianal fistula is the abnormal connection between anal canal and perinea. It is usually a complication of anorectal abscess. It could occur secondary to inflammatory processes like Crohn's disease, tuberculosis or malignancy. Surgery is considered as the primary treatment. Recurrence due to surgical inadequacy is common. Recurrence rates could be minimized with a good knowledge of MRI findings and well informing the surgeon.

References

  • 1. Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 2000; 20:623-635
  • 2. Parks AG, Gordon PH, Hardcastle JD. A classifica¬tion of fistula-in-ano. Br J Surg 1976;63(1):1–12.
  • 3. Seow-Choen, Phillips RK. Insights gained from the management of problematical anal fistulae at St. Mark’s Hospital, 1984-88. Br J Surg 1991;78(5): 539–541.
  • 4. de Miguel Criado J, del Salto LG, Rivas PF, et al. MR imaging evaluation of perianal fistulas: spectrum of imaging features. Radiographics 2012; 32:175-194
  • 5. Sainio P. Fistula-in-ano in a defi ned population. Incidence and epidemiological aspects. Ann Chir Gynaecol 1984;73: 219–24.
  • 6. Beckingham IJ, Spencer JA, Ward J, Dyke GW, Adams C, Ambrose NS. Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano. Br J Surg 1996;83(10):1396–1398.
  • 7. Barth MM, Smith MP, Pedrosa I, Lenkinski RE, Rofsky NM. Body MR imaging at 3.0 T: under¬standing the opportunities and challenges. Ra¬dioGraphics 2007;27(5):1445–1462; discussion 1462–1464.
  • 8. Chang KJ, Kamel IR, Macura KJ, Bluemke DA. 3.0-T MR imaging of the abdomen: comparison with 1.5 T. RadioGraphics 2008;28(7):1983–1998.
  • 9. Goodsall DH, Miles WE. Diseases of the anus and rectum. London, England: Longmans, Green, 1900.
  • 10. Eisenhammer S. A new approach to the anorectal fistulous abscess based on the high intermuscular le¬sion. Surg Gynecol Obstet 1958;106(5):595–599.
  • 11. Chapple KS, Spencer JA, Windsor AC, Wilson D, Ward J, Ambrose NS. Prognostic value of magnetic resonance imaging in the management of fistula-in-ano. Dis Colon Rectum 2000;43(4):511–516.
  • 12. Halligan S. Imaging fistula-in-ano. Clin Radiol 1998; 53:85–95.
  • 13. Buchanan G, Halligan S, Williams A, et al. Effect of MRI on clinical outcome of recurrent fistula-in-ano. Lancet 2002; 360: 1661-2.
  • 14. Buchanan GN, Halligan S, Williams AB, et al. Magnetic resonance imaging for primary fistula in ano. Br J Surg 2003; 90: 877-81.
  • 15. Kuijpers HC, Schulpen T. Fistulography for fistula- in-ano: is it useful? Dis Colon Rectum 1985; 28: 103-4.
  • 16. Guillaumin E, Jeffrey RB Jr, Shea WJ, Asling CW, Goldberg HI. Perirectal inflammatory disease: CT findings. Radiology 1986; 161: 153-7.
  • 17. Liang C, Lu Y, Zhao B, Du Y, Wang C, Jiang W. Imaging of anal fistulas: comparison of computed tomographic fistulography and magnetic resonance imaging. Korean J Radiol 2014; 15: 712-23.
  • 18. Law PJ, Bartram CI. Anal endosonography: tech¬nique and normal anatomy. Gastrointest Radiol 1989;14(4):349–353.
  • 19. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonography, and MR imaging in preopera¬tive assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004; 233(3):674–681.
  • 20. S. Halligan, J. Stoker Imaging of fistula in ano Radiology, 239 (2006), pp. 18–33

Perianal fistülün tanısında, sınıflandırılmasında ve değerlendirilmesinde Manyetik Rezonans Görüntüleme’nin önemi

Year 2017, Volume: 2 Issue: 1, 1 - 5, 16.04.2017
https://doi.org/10.25000/acem.298536

Abstract

Amaç:  Manyetik rezonans görüntüleme (MRG) perianal bölgenin değerlendirilmesinde yüksek güvenilirliğe sahip non-invaziv bir yöntemdir. Bu çalışmada, perianal fistül tanısı alan hastaların preoperatif MRG bulguları ve özellikle sınıflandırmanın görüntülerle birlikte sunulması amaçlandı. 

Yöntemler: Perianal fistül tanısı alan 57 hastanın demografik özellikleri ve kontrastlı konvansiyonel ve difüzyon MRG bulguları retrospektif olarak değerlendirildi.  Perianal fistül sınıflandırılması MRG bulgularını temel alan ‘St James Üniversite Hastanesi (SJUH) Sınıflaması’ referans alınarak yapıldı. 

Bulgular: Çalışmaya 57 hasta (44 erkek ve 13 kadın: yaş aralığı 18-72 yıl; ortalama yaş 45,7 yıl) dahil edildi. Hastaların büyük çoğunluğunun esas yakınması makatta ağrı ve akıntı idi. Bazı hastalar ek olarak makatta kaşıntı, şişlik ve kızarıklık semptomları da bildirdi. 37 hastada tip 1, dokuz hastada tip 2, dört hastada tip 3, beş hastada tip 4, iki hastada ise tip 5 fistül saptandı. Anal kanala açılım yerleri 21 hastada saat 6, 10 hastada saat 7 olarak saptandı. Konvansiyonel ve difüzyon MRG ile fistül traktı, apse varlığı, rektuma açılım yeri, sfinkterle veya komşu anatomik yapılarla ilişkisi tüm hastalarda net olarak değerlendirildi. 

Sonuç: Anal kanal ve perine derisi arasında meydana gelen anormal bağlantı perianal fistül olarak adlandırılmaktadır. Genellikle tekrarlayan anorektal apselerin komplikasyonudur. Crohn, tüberküloz, malignite gibi inflamatuar süreçlere sekonder de gelişebilir. Tedavide esas yöntem cerrahidir. Cerrahi yetersizliğine bağlı rekürrens oldukça sıktır. MRG bulgularının iyi bilinmesi ve cerrahın iyi yönlendirilmesi ile rekürrens oranı en aza indirgenebilmektedir.

References

  • 1. Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 2000; 20:623-635
  • 2. Parks AG, Gordon PH, Hardcastle JD. A classifica¬tion of fistula-in-ano. Br J Surg 1976;63(1):1–12.
  • 3. Seow-Choen, Phillips RK. Insights gained from the management of problematical anal fistulae at St. Mark’s Hospital, 1984-88. Br J Surg 1991;78(5): 539–541.
  • 4. de Miguel Criado J, del Salto LG, Rivas PF, et al. MR imaging evaluation of perianal fistulas: spectrum of imaging features. Radiographics 2012; 32:175-194
  • 5. Sainio P. Fistula-in-ano in a defi ned population. Incidence and epidemiological aspects. Ann Chir Gynaecol 1984;73: 219–24.
  • 6. Beckingham IJ, Spencer JA, Ward J, Dyke GW, Adams C, Ambrose NS. Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano. Br J Surg 1996;83(10):1396–1398.
  • 7. Barth MM, Smith MP, Pedrosa I, Lenkinski RE, Rofsky NM. Body MR imaging at 3.0 T: under¬standing the opportunities and challenges. Ra¬dioGraphics 2007;27(5):1445–1462; discussion 1462–1464.
  • 8. Chang KJ, Kamel IR, Macura KJ, Bluemke DA. 3.0-T MR imaging of the abdomen: comparison with 1.5 T. RadioGraphics 2008;28(7):1983–1998.
  • 9. Goodsall DH, Miles WE. Diseases of the anus and rectum. London, England: Longmans, Green, 1900.
  • 10. Eisenhammer S. A new approach to the anorectal fistulous abscess based on the high intermuscular le¬sion. Surg Gynecol Obstet 1958;106(5):595–599.
  • 11. Chapple KS, Spencer JA, Windsor AC, Wilson D, Ward J, Ambrose NS. Prognostic value of magnetic resonance imaging in the management of fistula-in-ano. Dis Colon Rectum 2000;43(4):511–516.
  • 12. Halligan S. Imaging fistula-in-ano. Clin Radiol 1998; 53:85–95.
  • 13. Buchanan G, Halligan S, Williams A, et al. Effect of MRI on clinical outcome of recurrent fistula-in-ano. Lancet 2002; 360: 1661-2.
  • 14. Buchanan GN, Halligan S, Williams AB, et al. Magnetic resonance imaging for primary fistula in ano. Br J Surg 2003; 90: 877-81.
  • 15. Kuijpers HC, Schulpen T. Fistulography for fistula- in-ano: is it useful? Dis Colon Rectum 1985; 28: 103-4.
  • 16. Guillaumin E, Jeffrey RB Jr, Shea WJ, Asling CW, Goldberg HI. Perirectal inflammatory disease: CT findings. Radiology 1986; 161: 153-7.
  • 17. Liang C, Lu Y, Zhao B, Du Y, Wang C, Jiang W. Imaging of anal fistulas: comparison of computed tomographic fistulography and magnetic resonance imaging. Korean J Radiol 2014; 15: 712-23.
  • 18. Law PJ, Bartram CI. Anal endosonography: tech¬nique and normal anatomy. Gastrointest Radiol 1989;14(4):349–353.
  • 19. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonography, and MR imaging in preopera¬tive assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004; 233(3):674–681.
  • 20. S. Halligan, J. Stoker Imaging of fistula in ano Radiology, 239 (2006), pp. 18–33
There are 20 citations in total.

Details

Subjects Surgery, Clinical Sciences, ​Internal Diseases
Journal Section Original Research
Authors

Mustafa Koplay

Mesut Sivri This is me

Alaaddin Nayman

Hakan Cebeci

İbrahim Guler This is me

Emine Uysal This is me

Yahya Paksoy

Publication Date April 16, 2017
Published in Issue Year 2017 Volume: 2 Issue: 1

Cite

Vancouver Koplay M, Sivri M, Nayman A, Cebeci H, Guler İ, Uysal E, Paksoy Y. Importance of Magnetic Resonance Imaging in diagnosis, classification and evaluation of perianal fistula. Arch Clin Exp Med. 2017;2(1):1-5.