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EVALUATION OF COMPLEX ANAL FISTULA – EUA, EAUS OR MRI? Andrew Luck Northern Adelaide Colorectal Unit Lyell McEwin Hospital
ANAL FISTULA <ul><li>Fistula – “an abnormal track that connects two epithelialised surfaces” </li></ul><ul><li>Anal fistul...
CLASSIFICATION <ul><li>A Subcutaneous </li></ul><ul><li>B Intersphincteric </li></ul><ul><li>C Trans-sphincteric </li></ul...
ANAL FISTULA  <ul><li>PRINCIPLES OF MANAGEMENT </li></ul><ul><li>Control sepsis </li></ul><ul><li>Eliminate fistula </li><...
ANAL FISTULA <ul><li>CONTROL SEPSIS </li></ul><ul><li>Identify and drain abscesses </li></ul><ul><ul><li>Horseshoe extensi...
ANAL FISTULA <ul><li>CONTROL SEPSIS </li></ul><ul><li>Need to know </li></ul><ul><ul><li>Classification of fistula </li></...
ANAL FISTULA <ul><li>ELIMINATE FISTULA </li></ul><ul><li>Lay open (or cutting Seton) </li></ul><ul><ul><li>Subcutaneous, i...
ANAL FISTULA <ul><li>ELIMINATE FISTULA </li></ul><ul><li>Need to know </li></ul><ul><ul><li>Classification of fistula </li...
ANAL FISTULA <ul><li>PRESERVE CONTINENCE </li></ul><ul><li>Divide minimal sphincter </li></ul><ul><ul><li>Internal  </li><...
ANAL FISTULA <ul><li>PRESERVE CONTINENCE </li></ul><ul><li>Need to know </li></ul><ul><ul><li>Classification of fistula </...
WHAT CAN IMAGING OFFER? <ul><li>Pre-operative imaging </li></ul><ul><ul><li>Magnetic resonance imaging </li></ul></ul><ul>...
 
EAUS – INTERSPHINCTERIC POSTERIOR ABSCESS
EAUS – TRANS-SPHINCTERIC FISTULA  AT 7 O’CLOCK
EAUS – HORSESHOE ABSCESS
EAUS WITH PEROXIDE
EAUS WITH PEROXIDE
EAUS WITH PEROXIDE
EAUS WITH PEROXIDE
EAUS WITH PEROXIDE
EAUS WITH PEROXIDE
MRI – TRANS-SPHINCTERIC FISTULA WITH SETON
MRI – MULTIPLE TRACTS
MRI – MULTIPLE TRACTS
MRI – MULTIPLE TRACTS
MRI – SUPRALEVATOR COLLECTION
MRI – SUPRALEVATOR COLLECTION
MRI – SUPRALEVATOR COLLECTION
MRI – SUPRALEVATOR COLLECTION
LITERATURE <ul><li>Several studies compared preop imaging to preop clinical examination </li></ul><ul><li>Sahni et al (Abd...
BUCHANAN ET AL (RADIOLOGY 2004) Clinical exam (%) EAUS (%) MRI (%) P value Primary tracts 61 81 90 <0.001 Abscesses 33 75 ...
BUCHANAN ET AL (RADIOLOGY 2004) <ul><li>Clinical exam did not include probes </li></ul><ul><li>EAUS did not include peroxi...
DOES IT HELP THE SURGEON? <ul><li>Tinley et al (Colorectal disease 2006) </li></ul><ul><ul><li>Intraoperative EAUS affecte...
DOES IT HELP THE SURGEON? <ul><li>Buchanan et al (Lancet 2002) </li></ul><ul><ul><li>MRI in 71 patients with recurrent fis...
DOES IT HELP THE SURGEON? <ul><li>Beets-Tan et al (Radiology 2001) </li></ul><ul><ul><li>Preop MRI in 56 patients </li></u...
WHAT DO I DO? <ul><li>Principles </li></ul><ul><ul><li>Control sepsis </li></ul></ul><ul><ul><li>Eliminate fistula </li></...
WHAT DO I DO? <ul><li>History </li></ul><ul><ul><li>Level of pain </li></ul></ul><ul><ul><li>Past history of anal fistula ...
WHAT DO I DO? <ul><li>If severe pain and/or obvious abscess </li></ul><ul><ul><li>EUA +/- EAUS as soon as possible </li></...
WHAT DO I DO? <ul><li>Recurrent fistula  </li></ul><ul><li>Complex disease on initial examination  </li></ul><ul><li>Crohn...
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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?

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

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