Evaluation of Complex Anal Fistula - EUA, EUAS OR MRI?
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Evaluation of Complex Anal Fistula - EUA, EUAS OR MRI?

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Evaluation of Complex Anal Fistula - EUA, EUAS OR MRI? Presentation Transcript

  • 1. EVALUATION OF COMPLEX ANAL FISTULA – EUA, EAUS OR MRI? Andrew Luck Northern Adelaide Colorectal Unit Lyell McEwin Hospital
  • 2. ANAL FISTULA
    • Fistula – “an abnormal track that connects two epithelialised surfaces”
    • Anal fistula – perianal skin to anal canal
      • Secondary extensions
      • Associated abscess formation
      • Involvement of anal sphincters
      • Perianal Crohn’s disease .
      • Can imaging (pre-op or intra-op) help the surgeon?
  • 3. CLASSIFICATION
    • A Subcutaneous
    • B Intersphincteric
    • C Trans-sphincteric
    • D Supra-sphincteric
    • E Extra-sphincteric
  • 4. ANAL FISTULA
    • PRINCIPLES OF MANAGEMENT
    • Control sepsis
    • Eliminate fistula
    • Preserve faecal continence
  • 5. ANAL FISTULA
    • CONTROL SEPSIS
    • Identify and drain abscesses
      • Horseshoe extensions
        • Abscess either side of midline
    • Drain high fistula – loose Seton
    • Lay open low fistula
    • Identify and control secondary tracts
  • 6. ANAL FISTULA
    • CONTROL SEPSIS
    • Need to know
      • Classification of fistula
      • Presence or absence of abscesses
        • Number and location
      • Presence or absence of secondary tracts
        • Number and location
    • What can imaging offer?
  • 7. ANAL FISTULA
    • ELIMINATE FISTULA
    • Lay open (or cutting Seton)
      • Subcutaneous, inter-sphincteric, low trans-sphincteric
    • Close fistula
      • Entire fistula
        • Anal fistula plug
        • Fibrin glue
      • Internal opening
        • Mucosal Advancement Flap
      • Disconnect fistula
        • LIFT procedure
  • 8. ANAL FISTULA
    • ELIMINATE FISTULA
    • Need to know
      • Classification of fistula
      • Course of tract from external to internal opening
      • Location of internal opening
    • What can imaging offer?
  • 9. ANAL FISTULA
    • PRESERVE CONTINENCE
    • Divide minimal sphincter
      • Internal
      • External
    • Divide NO sphincter in certain situations
      • Anteriorly in female
      • Sphincter defect already present
      • Incontinence already present
      • Crohn’s disease
    • Control sepsis
  • 10. ANAL FISTULA
    • PRESERVE CONTINENCE
    • Need to know
      • Classification of fistula
      • Course of tract from external to internal opening
      • Location of internal opening
      • Presence or absence of abscesses
        • Number and location
      • Presence or absence of secondary tracts
        • Number and location
  • 11. WHAT CAN IMAGING OFFER?
    • Pre-operative imaging
      • Magnetic resonance imaging
      • Endo-anal ultrasound
    • Intra-operative imaging
      • Endo-anal ultrasound
        • With hydrogen peroxide
    • Examples
    • Literature
    • What do I do?
  • 12.  
  • 13. EAUS – INTERSPHINCTERIC POSTERIOR ABSCESS
  • 14. EAUS – TRANS-SPHINCTERIC FISTULA AT 7 O’CLOCK
  • 15. EAUS – HORSESHOE ABSCESS
  • 16. EAUS WITH PEROXIDE
  • 17. EAUS WITH PEROXIDE
  • 18. EAUS WITH PEROXIDE
  • 19. EAUS WITH PEROXIDE
  • 20. EAUS WITH PEROXIDE
  • 21. EAUS WITH PEROXIDE
  • 22. MRI – TRANS-SPHINCTERIC FISTULA WITH SETON
  • 23. MRI – MULTIPLE TRACTS
  • 24. MRI – MULTIPLE TRACTS
  • 25. MRI – MULTIPLE TRACTS
  • 26. MRI – SUPRALEVATOR COLLECTION
  • 27. MRI – SUPRALEVATOR COLLECTION
  • 28. MRI – SUPRALEVATOR COLLECTION
  • 29. MRI – SUPRALEVATOR COLLECTION
  • 30. LITERATURE
    • Several studies compared preop imaging to preop clinical examination
    • Sahni et al (Abdominal imaging 2008)
      • Sensitivity of preop assessment in differentiating complex fistula from simple disease
        • Clinical examination 0.75 (0.65-0.86)
        • EAUS 0.92 (0.85-0.99)
        • MRI 0.97 (0.92-1.00)
  • 31. BUCHANAN ET AL (RADIOLOGY 2004) Clinical exam (%) EAUS (%) MRI (%) P value Primary tracts 61 81 90 <0.001 Abscesses 33 75 85 <0.001 Horseshoes 44 56 94 0.003 Internal opening 78 91 97 <0.001
  • 32. BUCHANAN ET AL (RADIOLOGY 2004)
    • Clinical exam did not include probes
    • EAUS did not include peroxide
    • Gold standard – EUA!!
      • EUA modified by MRI findings if there was disagreement
        • “ our hospital ethical committee decreed that there was overwhelming evidence that the MR images had to be available in the operating room and that non-disclosure was unethical”
  • 33. DOES IT HELP THE SURGEON?
    • Tinley et al (Colorectal disease 2006)
      • Intraoperative EAUS affected surgical management in 9/17 (53%) of cases
      • Mainly assessment of amount of EAS above fistula
    • Buchanan et al (BJS 2003)
      • Pre op MRI altered management in 3/30 (10%) of patients with primary fistulous disease
      • Identification of internal opening
  • 34. DOES IT HELP THE SURGEON?
    • Buchanan et al (Lancet 2002)
      • MRI in 71 patients with recurrent fistulas
        • Surgery and MRI agreed in 40/71(56%)
          • 5/40 (13%) recurrence rate
        • Surgery and MRI disagreed in 31/71 (44%)
          • 16/31 (52%) recurrence rate
          • ALL 16 recurrences at site predicted by MRI
        • Recurrence when surgeon followed MRI = 4/25 (16%)
        • Recurrence when surgeon ignored MRI = 8/14 ( 52%)
          • p=0.008
  • 35. DOES IT HELP THE SURGEON?
    • Beets-Tan et al (Radiology 2001)
      • Preop MRI in 56 patients
        • ‘ Important additional information’ in 12/56 (21%) patients
          • Primary fistula 2/24 (8%)
          • Recurrent fistula 4/17 (24%)
          • Crohn’s fistula 6/15 (40%)
      • MRI interobserver agreement 0.65 (fistula classification) to 0.93 (abscess)
      • MRI intraobserver agreement 0.75 (fistula classification) to 1.00 (horseshoe fistula)
  • 36. WHAT DO I DO?
    • Principles
      • Control sepsis
      • Eliminate fistula
      • Preserve continence
      • Do not cause undue pain
        • Delay in definitive treatment
        • Unnecessary pre op investigations eg EAUS with obvious abscess
      • Perform EAUS personally
      • Know, trust and collaborate with MRI radiologist
  • 37. WHAT DO I DO?
    • History
      • Level of pain
      • Past history of anal fistula or abscess
      • Crohn’s disease
      • PH anal surgery
    • Examination
      • Inspection
        • Cellulitis, abscess, external opening, Crohn’s
      • PR
        • Tenderness, masses, abscess, internal opening, tract
  • 38. WHAT DO I DO?
    • If severe pain and/or obvious abscess
      • EUA +/- EAUS as soon as possible
        • Drain abscess
        • GENTLE probe for fistula
          • Lay open if safe
          • Loose Seton if not sure
    • If primary and most likely simple fistula
      • EUA +/- EAUS
        • Low simple fistula – lay open
        • High fistula – loose Seton
          • Post op MRI to plan next procedure
        • Complex fistula – loose Seton(s) +/- Malecot catheter(s)
          • Post op MRI to plan next procedure
  • 39. WHAT DO I DO?
    • Recurrent fistula
    • Complex disease on initial examination
    • Crohn’s disease
    • Pre op MRI
      • Discuss images with trusted radiologist
    • Review options with patient
    • EUA +/- EAUS
      • Definitive surgical management