Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.
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Purpose Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing.
Methods In patients operated for cryptoglandular anal fistulas, magnetic resonance imaging was performed preoperatively and at 3 months postoperatively to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system.
Results Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2±12.4 years; 46 men) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (32.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting nonhealing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%).
Conclusion GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting nonhealing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.
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Recent Advances in the Understanding and Management of Anal Fistula from India Vipul D. Yagnik, Sandeep Kumar, Anshul Thakur, Kaushik Bhattacharya, Sushil Dawka, Pankaj Garg Indian Journal of Surgery.2024; 86(6): 1105. CrossRef
Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas Pankaj Garg, Laxmikant Ladukar, Vipul Yagnik, Kaushik Bhattacharya, Gurleen Kaur Clinical and Experimental Gastroenterology.2024; Volume 17: 97. CrossRef
Recent advances in the diagnosis and treatment of complex anal fistula Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak Annals of Coloproctology.2024; 40(4): 321. CrossRef
Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review Alireza Teymouri, Amir Keshvari, Ali Ashjaei, Seyed Mohsen Ahmadi Tafti, Faeze Salahshour, Faezeh Khorasanizadeh, Amirhosein Naseri Health Science Reports.2023;[Epub] CrossRef
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Purpose Retrorectal tumors (RTs) are rare tumors that arise in the space between the mesorectum and the pelvic wall and often originate in embryonic tissues. The primary treatment for these tumors is complete excision surgery, and choosing the best surgical approach is very important.
Methods In this study, we retrospectively collected the data of 15 patients with RTs who underwent surgery in Imam Khomeini Hospital (Tehran, Iran) for 12 years to share our experiences of patients’ treatment and compare different surgical approaches.
Results A total of 5 tumors were malignant, 10 were benign, and most of the tumors were congenital. Malignant tumors were seen in older patients. Three surgical procedures were performed on patients. Three patients underwent abdominal approach surgery, and 8 patients underwent posterior surgery. A combined surgical approach was performed on 4 patients. Two patients underwent laparoscopic surgery. The abdominal approach had the least long-term complication, and the combined approach had the most complications; laparoscopic surgery reduced the length of hospital stay and complications after surgery.
Conclusion A multidisciplinary team collaboration using magnetic resonance imaging details is necessary to determine a surgical treatment approach. It could reduce the need for a preoperative biopsy. However, every approach has its advantages and disadvantages, and individualized treatment is the key.
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Purpose According to recent studies, magnetic resonance imaging (MRI) assessment of complex fistulas provides a significant benefit compared to fistulography, computed tomography, and ultrasonography. The aim of this study was to describe the accuracy of MRI and the importance of identifying puborectalis muscle involvement on MRI in patients with complex fistula.
Methods All patients who were clinically diagnosed with ‘complex’ or showed multiple fistula tracts underwent fistula MRI. Eligible patients were consecutive patients who underwent fistula MRI between September 2018 and September 2019 at our hospital.
Results A total of 83 patients (74 males, 9 females; 116 tracts) were included in this study. The sensitivity and specificity of MRI in diagnosing fistula tracts were 94.8% and 98.2%, respectively. The sensitivity and specificity in identifying internal opening were 93.9% and 97.3%, respectively. Of the 35 patients with puborectalis muscle involvement in the MRI, 31 images of suprasphincteric-type patients on the Park’s classification were classified. The patients of puborectalis involvement were divided into 2 groups according to the surgical procedure that was performed. There were 12 sphincter-saving procedures and 19 sphincter division procedures performed. Recurrence was seen in 2 patients in the sphincter-saving procedure group, while no case was seen in the sphincter division procedure group. Five complications were found in the sphincter division procedure group, of which 2 reported incontinence.
Conclusion Fistula MRI is a highly accurate examination for evaluating complex fistulas, and the puborectalis muscle involvement findings are very important for diagnosis and treatment.
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Purpose The response to neoadjuvant chemoradiotherapy (CRT) for rectal cancer can be assessed using digital rectal examination, endoscopy and magnetic resonance imaging (MRI). Precise assessment of clinical complete response (CR) after CRT is essential when deciding between optimizing surgery or organ-preserving treatment. The objectives of this study were to correlate the CR finding in endoscopy and MRI with pathologic CR and to determine the appropriate approach for combining endoscopy and MRI to predict the pathologic CR in patients with rectal cancer after neoadjuvant CRT.
Methods This retrospective cohort study included 102 patients with rectal cancer who underwent endoscopy and MRI at 2–4 weeks after CRT. We assigned a confidence level (1–4) for the endoscopic and MRI assessments. Accuracy, sensitivity, and specificity were analyzed based on the endoscopy, MRI, and combination method findings. Diagnostic modalities were compared using the likelihood ratios.
Results Of 102 patients, 17 (16.7%) had a CR. The accuracy, sensitivity, and specificity for the prediction CR of endoscopy with biopsy were 85.3%, 52.9%, and 91.8%, while those of MRI were 91.2%, 70.6%, and 95.3%, and those of combined endoscopy and MRI were 89.2%, 52.9%, and 96.5%, respectively. No significant differences were noted in the sensitivity and specificity of any each modality. The prediction rate for CR of the combination method was 92.6% after the posttest probability test.
Conclusion Our study demonstrated that combining the interpretation of endoscopy with biopsy and MRI could provide a good prediction rate for CR in patients with rectal cancer after CRT.
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Purpose Although the height of a rectal tumor above the anal verge (tumor height) partly determines the treatment strategy, no practical standard exists for reporting this. We aimed to demonstrate the differences in tumor height according to the diagnostic modality used for its measurement.
Methods We identified 100 patients with rectal cancers located within 15 cm of the anal verge who had recorded tumor heights measured by using magnetic resonance imaging (MRI), colonoscopy, and digital rectal examination (DRE). Tumor height measured by using MRI was compared with those measured by using DRE and colonoscopy to assess reporting inconsistencies. Factors associated with differences in tumor height among the modalities were also evaluated.
Results The mean tumor heights were 77.8 ± 3.3, 52.9 ± 2.3, and 68.9 ± 3.1 mm when measured by using MRI, DRE, and colonoscopy, respectively (P < 0.001). Agreement among the 3 modalities in terms of tumor sublocation within the rectum was found in only 39% of the patients. In the univariate and the multivariate analyses, clinical stage showed a possible association with concordance among modalities, but age, sex, and luminal location of the tumor were not associated with differences among modalities.
Conclusion The heights of rectal cancer differed according to the diagnostic modality. Tumor height has implications for rectal cancer’s surgical planning and for interpreting comparative studies. Hence, a consensus is needed for measuring and reporting tumor height.
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PURPOSE Recently, magnetic resonance imaging (MRI) has become the preferred diagnostic tool for preoperative assessment of TNM staging and circumferential resection margin (CRM) in patients with rectal cancer. The aim of this study is to evaluate the accuracy of preoperative MR imaging in the prediction of T, N stage and CRM compared with pathologic results on whole- mount sections. METHODS Thirty-five consecutive patients with rectal cancer were enrolled between Dec. 2005 and Apr. 2006. 1.5-T MR imaging, was performed, and pathologic results were investigated on whole-mount sections. The agreement between MR imaging and pathologic examination for the assessment of T, N stage and status of CRM were analyzed using kappa statistics. RESULTS The accuracy of MR imaging compared with pathologic assessment of T stage was 82.9% (kappa=0.56), and that of N stage was 74.3% (kappa= 0.31). Of the MR imaging planes, the oblique axial plane showed the most accurate prediction of CRM, regardless of tumor position within the circumference of the rectum. The accuracy of MR imaging in the oblique axial plane for predicting the CRM was 81.0% (kappa=0.62) in anterior and posterior rectal tumors and 71.4% (kappa=0.43) in laterally located rectal tumors. With a different CRM criteria for the measured distance in MR imaging, the accuracy of the 2-mm CRM criterion was 77.1% (kappa=0.53). CONCLUSIONS MR imaging in predicting T stage showed fair agreement according to kappa statistics. Of the MR imaging planes, the oblique axial plane provided the most accurate CRM information compared with pathologic examination. The actual measured distance of the CRM in MR imaging can be applied to the pathologic CRM.