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Madany AH, Murad AF, Kabbash MM, Ahmed HM. Magnetic resonance imaging in the workup of patients with perianal fistulas. Egypt J Radiol Nucl Med 2023. [DOI: 10.1186/s43055-023-00975-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Abstract
Background
Perianal sepsis and fistulas are common lesions. Fistula-in-ano is a tedious problem because of high recurrence rates and severe unexpected complications postoperatively. Many imaging modalities are used to evaluate this area. Magnetic resonance imaging (MRI) has been considered the gold standard procedure for perianal fistula assessment, i.e., it provides the surgeon with an accurate roadmap to select the best surgical approach, determines the extent of sphincter division, and estimates the risk of postoperative incontinence. We carried out a prospective diagnostic accuracy study involving 50 patients (mean age, 42.44 years) with perianal fistulas who underwent pelvic MRI with a 1.5 Tesla scanner using multiple sequences, including diffusion and post-contrast series that were either local or systemic. This study aimed to evaluate the diagnostic validity of pelvic MRI/MR fistulogram in perianal fistula assessment, identify perianal fistula-associated findings by MRI, and optimize the MRI technique with maximum technical safety.
Results
Intersphincteric fistulas were the most common type of perianal fistula observed based on Parks’ classification. Intersphincteric, trans-sphincteric, extrasphincteric, and suprasphincteric fistulas were found in 30 (60%), 12 (24%), 4 (8%), and 4 (8%) patients, respectively. According to St. James’ classification, 21 (42%), 9 (18%), 8 (16%), 4 (8%), and 8 (16%) patients had perianal fistula grades I, II, III, IV, and V, respectively. The combination of variable MR sequences and MR fistulogram increased the diagnostic validity of MRI examinations. Our results correlated with surgical results (reference standard) with perfect interobserver reliability.
Conclusions
Of all imaging modalities, MRI has become a prerequisite for a successful surgery of a perianal fistula. MRI can identify: (a) fistula morphological details, (b) the relationship between the fistulous tract and the anal sphincter, (c) fistula wound healing, (d) an active versus chronic scarred fistula, (e) postoperative stigmata, and (f) a perianal fistula from its mimics. MRI with variable sequences and MRI fistulogram are successful combinations that increase diagnostic efficiency with technical safety by avoiding both ionizing radiation and systemic gadolinium.
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van Gruting IM, Stankiewicz A, Thakar R, Santoro GA, IntHout J, Sultan AH. Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome. Cochrane Database Syst Rev 2021; 9:CD011482. [PMID: 34553773 PMCID: PMC8459393 DOI: 10.1002/14651858.cd011482.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. OBJECTIVES To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. SEARCH METHODS We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. SELECTION CRITERIA Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. MAIN RESULTS Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. AUTHORS' CONCLUSIONS In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
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Affiliation(s)
- Isabelle Ma van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, Netherlands
| | | | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
| | - Giulio A Santoro
- Section of Anal Physiology and Ultrasound, Department of Surgery, Regional Hospital, Treviso, Italy
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
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Abstract
Rectal prolapse is usually of benign etiology. Rarely, sigmoido-rectal
intussusception results from a malignant lead-point. We report the case of a
patient with a partially obstructing sigmoid cancer causing a full thickness
rectal prolapse requiring surgical intervention. An 82-year-old woman presented
with 1 week of rectal bleeding, fecal incontinence, and weight loss. Computed
tomography identified sigmoido-rectal intussusception. Colonoscopic biopsy
revealed high-grade dysplasia. Magnetic resonance imaging demonstrated a 6-cm
mass forming the lead point of the intussusceptum with epiploic appendages seen
within the rectal lumen. She underwent laparoscopic low anterior resection with
final pathology consistent with T2N0 adenocarcinoma, and recovered well. Among
adult patients with rectal prolapse, suspicion for underlying malignancy should
prompt a thorough investigation to inform the decision for resection, which may
be safely performed by minimally invasive techniques.
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Affiliation(s)
- Amanda C Filiberto
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Sanda A Tan
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Thomas E Read
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Atif Iqbal
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
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van Gruting IMA, Kluivers K, Sultan AH, De Bin R, Stankiewicz A, Blake H, Thakar R. Does 4D transperineal ultrasound have additional value over 2D transperineal ultrasound for diagnosing posterior pelvic floor disorders in women with obstructed defecation syndrome? Ultrasound Obstet Gynecol 2018; 52:784-791. [PMID: 29882224 DOI: 10.1002/uog.19105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 04/26/2018] [Accepted: 05/13/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To establish the diagnostic test accuracy of two-dimensional (2D) and four-dimensional (4D) transperineal ultrasound (TPUS) for diagnosis of posterior pelvic floor disorders in women with obstructed defecation syndrome (ODS), in order to assess if 4D ultrasound imaging provides additional value. METHODS This was a prospective cohort study of 121 consecutive women with ODS. Symptoms of ODS and pelvic organ prolapse on clinical examination were assessed using validated methods. All women underwent both 2D- and 4D-TPUS. Imaging analysis was performed by two blinded observers. Posterior pelvic floor disorders were dichotomized into presence or absence, according to predefined cut-off values. In the absence of a reference standard, a composite reference standard was created from a combination of results of evacuation proctography, magnetic resonance imaging and endovaginal ultrasound. Primary outcome measures were diagnostic test characteristics of 2D- and 4D-TPUS for rectocele, enterocele, intussusception and anismus. Secondary outcome measures were interobserver agreement, agreement between the two imaging techniques, and association of severity of ODS symptoms and degree of posterior vaginal wall prolapse with conditions observed on imaging. RESULTS For diagnosis of all four posterior pelvic floor disorders, there was no difference in sensitivity or specificity between 2D- and 4D-TPUS (P = 0.131-1.000). Good agreement between 2D- and 4D-TPUS was found for diagnosis of rectocele (κ = 0.675) and moderate agreement for diagnoses of enterocele, intussusception and anismus (κ = 0.465-0.545). There was no difference in rectocele depth measurements between the techniques (19.9 mm for 2D vs 19.0 mm for 4D, P = 0.802). Interobserver agreement was comparable for both techniques, although 2D-TPUS had excellent interobserver agreement for diagnosis of enterocele and rectocele depth measurements, while this was only moderate and good, respectively, for 4D-TPUS. Diagnoses of rectocele and enterocele on both 2D- and 4D-TPUS were significantly associated with degree of posterior vaginal wall prolapse on clinical examination (odds ratio (OR) = 1.89-2.72). The conditions observed using either imaging technique were not associated with severity of ODS symptoms (OR = 0.82-1.13). CONCLUSIONS There is no evidence of superiority of 4D ultrasound acquisition to dynamic 2D ultrasound acquisition for the diagnosis of posterior pelvic floor disorders. 2D- and 4D-TPUS could be used interchangeably to screen women with symptoms of ODS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I M A van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - K Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - R De Bin
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Stankiewicz
- Department of Radiology, Croydon University Hospital, Croydon, UK
| | - H Blake
- Department of Radiology, Croydon University Hospital, Croydon, UK
| | - R Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
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Carrington EV, Scott SM, Bharucha A, Mion F, Remes-Troche JM, Malcolm A, Heinrich H, Fox M, Rao SS. Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 2018; 15:309-323. [PMID: 29636555 PMCID: PMC6028941 DOI: 10.1038/nrgastro.2018.27] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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Affiliation(s)
- Emma V. Carrington
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - S. Mark Scott
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Adil Bharucha
- Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, MN, USA
| | - François Mion
- Exploration Fonctionnelle Digestive, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon I University and Inserm 1032 LabTAU, Lyon, France
| | - Jose M. Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México
| | - Allison Malcolm
- Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia
| | - Henriette Heinrich
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
- Clinic for Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Satish S. Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia
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van Gruting IMA, Stankiewicz A, Thakar R, IntHout J, Santoro GA, Sultan AH. Imaging modalities for the detection of posterior compartment disorders in women with obstructed defaecation syndrome. Hippokratia 2015. [DOI: 10.1002/14651858.cd011482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Isabelle MA van Gruting
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
| | - Aleksandra Stankiewicz
- Croydon University Hospital; Department of Radiology; 530 London Road Croydon UK CR7 7YE
| | - Ranee Thakar
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
| | - Joanna IntHout
- Radboud university medical center; Radboud Institute for Health Sciences; Geert Grooteplein noord 21; route 133 Nijmegen Netherlands 6500 HB
| | - Giulio A Santoro
- Regional Hospital; Section of Anal Physiology and Ultrasound, Department of Surgery; Piazzale Ospedale 1 Treviso Italy 31100
| | - Abdul H Sultan
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
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Reichert M, Schwandner T, Hecker A, Behnk A, Baumgart-Vogt E, Wagenlehner F, Padberg W. Surgical Approach for Repair of Rectovaginal Fistula by Modified Martius Flap. Geburtshilfe Frauenheilkd 2014; 74:923-927. [PMID: 25364031 DOI: 10.1055/s-0034-1383149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/08/2014] [Accepted: 09/15/2014] [Indexed: 12/19/2022] Open
Abstract
Rectovaginal fistulas (RVF) are rare but represent a challenge for both patients and surgeons. The most common cause of RVF is obstetric trauma, and treatment is based on fistula classification and localization of the fistula in relation to the vagina and rectum. Conventional therapy frequently fails, making surgery the most viable approach for fistula repair. One surgical procedure which offers adequate repair of lower and middle rectovaginal fistulas consists of interposition of a bulbocavernosus fat flap also called modified Martius flap. First described by Heinrich Martius in 1928, this approach has been continuously modified and adjusted over time and is used in the repair of various pelvic floor disorders. Overall success rates reported in the literature of the interposition of a Martius flap as an adjunct procedure in the surgical management of RVF are 65-100 %. We present a detailed description of the operation technique together with a discussion of the use of a dorsal-flapped modified Martius flap in the treatment of RVF.
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Affiliation(s)
- M Reichert
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen
| | - T Schwandner
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen
| | - A Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen
| | - A Behnk
- Department of Gynaecology and Obstetrics, University Hospital of Giessen, Giessen
| | | | - F Wagenlehner
- Department of Urology, University Hospital of Giessen, Giessen
| | - W Padberg
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen
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Oh JS, Koea JB. Radiation risks associated with serial imaging in colorectal cancer patients: Should we worry? World J Gastroenterol 2014; 20:100-109. [PMID: 24415862 PMCID: PMC3885998 DOI: 10.3748/wjg.v20.i1.100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/31/2013] [Accepted: 08/09/2013] [Indexed: 02/06/2023] Open
Abstract
To provide an overview of the radiation related cancer risk associated with multiple computed tomographic scans required for follow up in colorectal cancer patients. A literature search of the PubMed and Cochrane Library databases was carried out and limited to the last 10 years from December 2012. Inclusion criteria were studies where computed tomographic scans or radiation from other medical imaging modalities were used and the risks associated with ionizing radiation reported. Thirty-six studies were included for appraisal with no randomized controlled trials. Thirty-four of the thirty-six studies showed a positive association between medical imaging radiation and increased risk of cancer. The radiation dose absorbed and cancer risk was greater in children and young adults than in older patients. Most studies included in the review used a linear, no-threshold model to calculate cancer risks and this may not be applicable at low radiation doses. Many studies are retrospective and ensuring complete follow up on thousands of patients is difficult. There was a minor increased risk of cancer from ionizing radiation in medical imaging studies. The radiation risks of low dose exposure (< 50 milli-Sieverts) are uncertain. A clinically justified scan in the context of colorectal cancer is likely to provide more benefits than harm but current guidelines for patient follow up will need to be revised to accommodate a more aggressive approach to treating metastatic disease.
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Daabis N, El Shafey R, Zakaria Y, Elkhadrawy O. Magnetic resonance imaging evaluation of perianal fistula. The Egyptian Journal of Radiology and Nuclear Medicine 2013. [DOI: 10.1016/j.ejrnm.2013.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Abstract
The rectum and anus are two anatomically complex organs with diverse pathologies. This article reviews the basic anatomy of the rectum and anus. In addition, it addresses the current radiographic techniques used to evaluate these structures, specifically ultrasound, magnetic resonance imaging, and defecography.
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Affiliation(s)
- Patrick Solan
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
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Abstract
Barium studies are one of the best investigations for evaluating submucosal and extrinsic mass lesions. However, barium studies bring less money, are operator dependent and one of the more difficult investigations for radiologists to master. Economic factors have acted as powerful disincentives for performing gastrointestinal (GI) fluoroscopy in most radiology practices. In this pictorial essay, we discuss the role of conventional defecography in evaluating evacuatory disorders in the Indian population.
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Affiliation(s)
- Sheo Kumar
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M. German S3-Guideline: rectovaginal fistula. Ger Med Sci 2012; 10:Doc15. [PMID: 23255878 PMCID: PMC3525883 DOI: 10.3205/000166] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Indexed: 12/12/2022]
Abstract
Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. Methods: A systematic review of the literature was undertaken. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Strittmatter B, Lenhard B, Bader W, Geschwend J, Krammer H, Stange E. S3-Leitlinie: Rektovaginale Fisteln (ohne M. Crohn): AWMF-Registriernummer: 088/004. coloproctology 2012; 34:211-46. [DOI: 10.1007/s00053-012-0287-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Etienney I, de Parades V. Three-dimensional endoanal ultrasonography in daily proctological practice. Clin Res Hepatol Gastroenterol 2011; 35:260-70. [PMID: 21393087 DOI: 10.1016/j.clinre.2010.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 02/10/2010] [Accepted: 10/18/2010] [Indexed: 02/04/2023]
Abstract
Three-dimensional endoanal ultrasonography (3D-EAUS) provides unequalled quality in terms of the anatomical image of the anal canal and sphincter complex. In less than one minute it produces a three-dimensional "cube" that can be manipulated in all spatial dimensions, then archived. In just a few years it has become a new gold standard exploration in proctology. In addition to image quality, 3D-EAUS has the advantage of being easily and rapidly performed, well-tolerated and moderate in cost. For anal incontinence, 3D-EAUS contributes to the identification of sphincter defects. The anatomy of the sphincters can be evaluated spatially. Simple scoring systems with good reproducibility and readily applicable in routine practice can be used to evaluate the "damaged" sphincter volume. For the management of anoperineal suppurations, 3D-EAUS provides information on the fistulous track(s) and on potential collections. These data are crucial as the choice of treatment and its efficacy depend on accurate topographic assessment of the suppuration and the state of the sphincter apparatus.
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Affiliation(s)
- Isabelle Etienney
- Proctologie médico-interventionnelle, centre hospitalier Diaconesses-Croix-Saint-Simon, site Reuilly, 18, rue du Sergent-Bauchat, 75012 Paris, France.
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Heron DE, Andrade RS, Beriwal S, Smith RP. PET-CT in radiation oncology: the impact on diagnosis, treatment planning, and assessment of treatment response. Am J Clin Oncol 2008; 31:352-62. [PMID: 18845994 DOI: 10.1097/COC.0b013e318162f150] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To review the role of hybrid positron emission tomography (PET)-computed tomography (CT) systems in the design and management of cancer patients in the modern radiation oncology practice. PET is co-registered with CT and incorporated into a systematic approach to the staging, management, and assessment of response and surveillance of a variety of oncologic diagnoses. METHODS A review of the literature of functional imaging such as PET-CT in staging, treatment plan design, assessment of response and detection of recurrence for tumors involving the head and neck, lung, esophagus, rectum amongst others. RESULTS PET and PET-CT offer significant advantages which include more accurate staging which often results in management changes in roughly one-third of patients across a number of disease site. More accurate target definition may augment highly conformal radiation treatment plans using intensity-modulated radiation therapy and stereotactic radiosurgery and radiotherapy. CONCLUSION The emerging data appears to suggest the functional imaging may be a more useful tool to evaluate the therapeutic effect of treatment, detect early failures and prognosticate long-term outcome.
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Toyonaga T, Tanaka Y, Song JF, Katori R, Sogawa N, Kanyama H, Hatakeyama T, Matsushima M, Suzuki S, Mibu R, Tanaka M. Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula. Tech Coloproctol 2008; 12:217-23. [PMID: 18679573 DOI: 10.1007/s10151-008-0424-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 06/10/2008] [Indexed: 01/05/2023]
Abstract
BACKGROUND This study was undertaken to evaluate the accuracy of endoanal ultrasonography for preoperative assessment of anal fistula, with special reference to the difference between acute and chronic fistula. METHODS The subjects comprised 401 patients treated for acute or chronic anorectal sepsis of cryptoglandular origin during the period January through December 2005. All patients underwent physical examination and endoanal ultrasonography. Agreement between the physical and endosonographic findings and the definitive surgical findings were evaluated with special reference to classification of the primary tract and horseshoe extension and localization of the internal opening. The difference in accuracy of endosonographic assessment between acute and chronic fistula was also evaluated. RESULTS The accuracy of endoanal ultrasonography was significantly higher than that of physical examination in detecting the primary tract (88.8% vs. 85.0%, p=0.0287) and horseshoe extension (85.7% vs. 58.7%, p<0.0001) and in localizing the internal opening (85.5% vs. 69.1%, p<0.0001). Furthermore, localization of the internal opening by endosonography was significantly more accurate in chronic fistula than in acute fistula (89.5 % vs. 76.8%, p<0.0001), although the accuracy in detecting the primary tract and horseshoe extension was not significantly different. CONCLUSIONS Endoanal ultrasonography is reliable and useful for preoperative assessment of anal fistula, particularly for detecting horseshoe extension and localizing the internal opening. Endosonographic assessment provides clearer depiction of the internal opening during periods of quiescence than during the period of abscess formation. For patients with acute anorectal sepsis, initial surgical drainage and subsequent fistula surgery, rather than one-stage fistula surgery, may be advisable to avoid misidentification of the internal opening.
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Affiliation(s)
- T Toyonaga
- Matsushima Hospital Colo-Proctology Center, 19-11 Tobehoncho, Nishi-ku, Yokohama, Japan.
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Bader FG, Bouchard R, Lubienski A, Keller R, Mirow L, Czymek R, Habermann JK, Bruch HP, Roblick UJ. [Progress in diagnostics of anorectal disorders. Part II: radiology]. Chirurg 2008; 79:410-7. [PMID: 18418564 DOI: 10.1007/s00104-008-1544-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.
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Affiliation(s)
- F G Bader
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburgerallee 160, 23538 Lübeck
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Ros Mendoza LH, Sarría Octavio de Toledo L, Martínez Mombila E, Elías Pollina J. [Morphologic evaluation of fecal incontinence by magnetic resonance imaging in patients with corrected anal atresia]. An Pediatr (Barc) 2008; 68:232-8. [PMID: 18358133 DOI: 10.1157/13116702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To describe the findings obtained with magnetic resonance imaging (MRI) in patients with ano-rectal atresia, after treatment by posterior sagittal anorectoplasty (PSARP), who have fecal incontinence and to describe its usefulness in the evaluation of causes of incontinence. SUBJECT AND METHODS Twelve patients, 9 men and 3 women, with anorectal atresia were examined with 0.5T MRI after performing PSARP for imperforate anus. The study included T1-weighted, T2-weighted and proton-density, axial, sagittal and coronal planes. The location of descended neorectus and the degree of development of pelvic musculature were evaluated. RESULTS Normal development of anus levator muscles and sphincterian complex were observed in six patients, with correct situation of neorectus between anus levator muscles and sphincterian complex in five of them and eccentric in the other one. Diverse grades of striate muscular complex underdevelopment were showed in the other six cases, moderate grade in four of them and severe hypoplasia in the other two. Spinal and urogenital congenital anomalies were found in these patients. Sagittal and coronal T1-weighted MR images were the most useful planes in evaluating the relationship between anus levator muscles and sphincterian complex and axial T1-weighted MR images in the evaluation of the level of development of striated muscle complex in the evaluation of patients. CONCLUSIONS MRI is useful in the evaluation of patients with fecal incontinence after performing PSARP for anorectal atresia. Unsuitable neorectus position or striated muscle complex hypoplasia are causes of postoperative incontinence in these patients.
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Affiliation(s)
- L H Ros Mendoza
- Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, Spain.
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Dobben AC, Felt-bersma RJF, ten Kate FJW, Stoker J. Cross-Sectional Imaging of the Anal Sphincter in Fecal Incontinence. AJR Am J Roentgenol 2008; 190:671-82. [DOI: 10.2214/ajr.07.2920] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Sommer G, Schaefer AO, Baumann T, Ludwig UA, Fautz HP. Sliding multislice MRI for abdominal staging of patients with pelvic malignancies: A pilot study. J Magn Reson Imaging 2008; 27:666-72. [DOI: 10.1002/jmri.21279] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Donmez FY, Tunaci M, Yekeler E, Balik E, Tunaci A, Acunas G. Effect of using endorectal coil in preoperative staging of rectal carcinomas by pelvic MR imaging. Eur J Radiol 2007; 67:139-45. [PMID: 17720346 DOI: 10.1016/j.ejrad.2007.06.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 04/28/2007] [Accepted: 06/20/2007] [Indexed: 01/13/2023]
Abstract
PURPOSE To assess the accuracy of magnetic resonance imaging with pelvic phased-array and endorectal coils prospectively, and evaluate if endorectal coil provides any additional information to high resolution pelvic MR imaging in rectal carcinoma staging. MATERIALS AND METHODS Preoperative MRI of 25 patients with rectal carcinoma was performed with pelvic phased-array coil alone, and with both phased-array coil and endorectal coil placed. Staging was made by evaluating images obtained by using both coils prospectively, and correlated with histopathologic staging. The images were then assessed separately, and compared to each other retrospectively. RESULTS Two and 3 of the 5 histopathologically proved T1 tumors were staged correctly on MRI with pelvic phased-array coil alone and after the endorectal coil placement, respectively. Histopathologically identified five T2 tumors were staged correctly as T2 in 4 of the cases, 1 was understaged and 10 of 14 patients who had T3 tumor were staged as T3, 4 of them were understaged as T2 on both techniques. Specificity, sensitivity and accuracy rates for staging of T3 tumors were found as 71%, 100% and 84%, respectively, for each technique. Sensitivity and positive predictive value of N staging were both 88% on both techniques. CONCLUSION Pelvic MR imaging after the placement of endorectal coil in addition to the phase-array coil was not superior to the imaging with phased-array coil alone in T staging of rectal carcinomas and the latter achieved better visualization of the lymph nodes by means of larger field of view.
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Affiliation(s)
- Fuldem Yildirim Donmez
- Department of Radiology, Baskent University, Faculty of Medicine, 06490 Bahcelievler, Ankara, Turkey.
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Étienney I, de Parades V, Atienza P. Quel est l’apport des examens complémentaires dans la prise en charge d’une fistule anale? ACTA ACUST UNITED AC 2007; 1:78-85. [DOI: 10.1007/s11725-007-0025-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Schaefer O, Langer M. Detection of recurrent rectal cancer with CT, MRI and PET/CT. Eur Radiol 2007; 17:2044-54. [PMID: 17404742 DOI: 10.1007/s00330-007-0613-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 02/07/2007] [Accepted: 02/09/2007] [Indexed: 02/08/2023]
Abstract
Computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) all have the potential to directly visualize local and distant relapse of colorectal cancer (CRC). Nevertheless, the role of diagnostic imaging for routine follow-up of CRC patients remains controversial. Although MRI and PET have advantages over CT in the detection of local recurrence, until now only a few surveillance programs recommend the use of annual CT for routine follow-up. The objective of this review is to elucidate the current status of diagnostic imaging for the detection of recurrent rectal cancer based on the recent literature and our own experience. Furthermore, an insight into contemporary surveillance programs and an outlook concerning a novel technical approach to moving-table MRI at 1.5 Tesla for staging purposes are given.
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Affiliation(s)
- O Schaefer
- Department of Diagnostic Radiology, University Hospital Feiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany.
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Dobben AC, Terra MP, Slors JFM, Deutekom M, Gerhards MF, Beets-Tan RGH, Bossuyt PMM, Stoker J. External anal sphincter defects in patients with fecal incontinence: comparison of endoanal MR imaging and endoanal US. Radiology 2007; 242:463-71. [PMID: 17255418 DOI: 10.1148/radiol.2422051575] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To prospectively compare in a multicenter study the agreement between endoanal magnetic resonance (MR) imaging and endoanal ultrasonography (US) in depicting external anal sphincter (EAS) defects in patients with fecal incontinence. MATERIALS AND METHODS The study was approved by the medical ethics committee of all participating centers. A total of 237 consenting patients (214 women, 23 men; mean age, 58.6 years +/- 13 [standard deviation]) with fecal incontinence were examined from 13 different hospitals by using endoanal MR imaging and endoanal US. Patients with an anterior EAS defect depicted on endoanal MR images and/or endoanal US scans underwent anal sphincter repair. Surgical findings were used as the reference standard in the determination of anterior EAS defects. The Cohen kappa statistic and McNemar test were used to calculate agreement and differences between diagnostic techniques. RESULTS Agreement between endoanal MR imaging and endoanal US was fair for the depiction of sphincter defects (kappa = 0.24 [95% confidence interval: 0.12, 0.36]). At surgery, EAS defects were found in 31 (86%) of 36 patients. There was no significant difference between MR imaging and US in the depiction of sphincter defects (P = .23). Sensitivity and positive predictive value were 81% and 89%, respectively, for endoanal MR imaging and 90% and 85%, respectively, for endoanal US. CONCLUSION In the selection of patients for anal sphincter repair, both endoanal MR imaging and endoanal US are sensitive tools for preoperative assessment, and both techniques can be used to depict surgically repairable anterior EAS defects.
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Affiliation(s)
- Annette C Dobben
- Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Toyonaga T, Matsushima M, Tanaka Y, Shimojima Y, Matsumura N, Kannyama H, Nozawa M, Hatakeyama T, Suzuki K, Yanagita K, Tanaka M. Microbiological analysis and endoanal ultrasonography for diagnosis of anal fistula in acute anorectal sepsis. Int J Colorectal Dis 2007; 22:209-13. [PMID: 16601946 DOI: 10.1007/s00384-006-0121-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Treatment of anorectal sepsis requires prompt surgical drainage, but it is important to identify any associated anal fistula for preventing recurrence. We evaluated whether microbiological analysis and/or endoanal ultrasonography could be used to predict anal fistula in patients with acute anorectal sepsis. METHODS Five hundred fourteen consecutive patients with acute anorectal sepsis were studied. Clinical data, digital examination findings, endosonographic findings, and results of microbiological analysis were compared with definitive surgical findings of the presence or absence of anal fistula. RESULTS Anorectal abscess with anal fistula was found in 418 patients, and anorectal abscess without anal fistula was found in 96 patients. Microbiological examination showed that Escherichia coli, Bacteroides, Bacillus, and Klebsiella species were significantly more prevalent in patients with fistula (P<0.01), and coagulase-negative Staphylococci and Peptostreptococcus species were significantly more prevalent in patients without fistula (P<0.01). Results of endoanal ultrasonography were concordant with the definitive surgical diagnosis in 421 (94%) of 448 patients studied. CONCLUSION Acute anorectal sepsis due to colonization of "gut-derived" microorganisms rather than "skin-derived" organisms is more likely to be associated with anal fistula. When the microbiological analysis yields gut-derived bacteria, but no fistula has been found in the initial drainage operation, repeat examinations during a period of quiescence, including careful digital assessment and meticulous endosonography, are warranted to identify a potentially missed anal fistula.
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Affiliation(s)
- Takayuki Toyonaga
- Department of Surgery, Matsushima Hospital Colo-Proctology Center, Yokohama, Japan.
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Dench JE, Scott SM, Lunniss PJ, Dvorkin LS, Williams NS. Multimedia article. External pelvic rectal suspension (the express procedure) for internal rectal prolapse, with or without concomitant rectocele repair: a video demonstration. Dis Colon Rectum 2006; 49:1922-6. [PMID: 17053866 DOI: 10.1007/s10350-006-0719-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol), designed to correct internal rectal prolapse, with or without rectocele. INCLUSION CRITERIA severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol patch in the rectovaginal plane. RESULTS Short-term results for the "Express" are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography. CONCLUSIONS This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.
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Affiliation(s)
- Julia E Dench
- Centre for Academic Surgery, GI Physiology Unit, The Royal London Hospital, Whitechapel, London, United Kingdom
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Abstract
BACKGROUND Posterior vaginal wall prolapse is common in parous women and may be due to rectocele, enterocele or perineal hypermobility. Translabial ultrasound can be used to detect defects of the rectovaginal septum, that is, a 'true rectocele', potentially avoiding the need for defecation proctography. However, it is currently unknown whether specific sonographic appearances are associated with bowel symptoms. AIMS To correlate symptoms of bowel dysfunction and sonographic findings. METHODS In a prospective observational study, 505 women were seen during attendance at tertiary urogynaecological clinics and underwent a standardised interview, which included a set of questions regarding bowel function. They were assessed clinically and by translabial ultrasound, supine and after voiding. The presence of a rectocele was determined on maximal Valsalva. RESULTS Clinically, 314 women (64%) were found to have a rectocele. There were associations between clinical staging and ampullary descent on ultrasound (P < 0.001), the presence of a true rectocele (P < 0.001) and the depth of a defect (P < 0.001). Defects of the rectovaginal septum ('true rectocele') were identified in 54%. They were associated with symptoms of incomplete bowel emptying (P < 0.001) and digitation (P = 0.002), and less so with dyschezia (P = 0.01), faecal incontinence (P = 0.02) and chronic constipation (P = 0.04). CONCLUSIONS True rectoceles are found in more than half of women presenting with pelvic floor disorders. This finding correlates strongly with clinical prolapse grading--large clinical rectoceles are more likely to be caused by a fascial defect. Incomplete bowel emptying and digitation are significantly associated with such defects detected on ultrasound.
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Affiliation(s)
- Hans Peter Dietz
- Westerb Clinical School, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia.
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Titu LV, Breen DJ, Nicholson AA, Hartley J, Monson JRT. Is routine magnetic resonance imaging justified for the early detection of resectable liver metastases from colorectal cancer? Dis Colon Rectum 2006; 49:810-5. [PMID: 16741638 DOI: 10.1007/s10350-006-0537-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to determine whether routine follow-up by magnetic resonance imaging improves the detection of resectable liver metastases from colorectal cancer and patients' survival. METHODS Patients who underwent curative surgery for colorectal cancer were included in a program of liver surveillance by routine magnetic resonance imaging, in addition to the standard follow-up protocol consisting of clinical examination and biochemical tests. The median follow-up was 41 (interquartile range, 30-53) months, with a median magnetic resonance imaging surveillance period of 20 (interquartile range, 12-27) months. Cases were analyzed for mode of diagnosis, resectability, and overall survival. RESULTS Liver metastases were found in 37 (13 percent) of 293 patients studied. Magnetic resonance imaging diagnosed hepatic metastases with 84 percent sensitivity and 90 percent specificity. In 28 (76 percent) patients, carcinoembryonic antigen and/or liver function tests were abnormally elevated and 5 patients (14 percent) were symptomatic. Hepatic resection was possible in only nine patients (24 percent). Magnetic resonance imaging detected all resectable cases, whereas traditional follow-up would have missed three (33 percent) cases suitable for surgery. CONCLUSIONS Although magnetic resonance imaging surveillance increased the number of patients suitable for liver resection by 50 percent, these represented only 1 percent of the patients included in the study. Whether these results are enough to justify the allocation of expensive resources is controversial.
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Affiliation(s)
- Liviu V Titu
- Academic Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire, United Kingdom
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Dobben AC, Stoker J. Reply. AJR Am J Roentgenol 2006; 186:E20-E20. [DOI: 10.2214/ajr.06.5038.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Titu LV, Nicholson AA, Hartley JE, Breen DJ, Monson JRT. Routine follow-up by magnetic resonance imaging does not improve detection of resectable local recurrences from colorectal cancer. Ann Surg 2006; 243:348-52. [PMID: 16495699 PMCID: PMC1448927 DOI: 10.1097/01.sla.0000201454.20253.07] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine if routine follow-up by magnetic resonance imaging (MRI) improves the detection of resectable local recurrences from colorectal cancer. SUMMARY BACKGROUND DATA Surgical treatment offers the best prospect of survival for patients with recurrent colorectal cancer. Unfortunately, most cases are often diagnosed at an unresectable stage when traditional follow-up methods are used. The impact of MRI surveillance on the early diagnosis of local recurrences has yet to be ascertained. METHODS Patients who underwent curative surgery for rectal and left-sided colon tumors were included in a program of pelvic surveillance by routine MRI, in addition to the standard follow-up protocol. Cases were then analyzed for mode of diagnosis, resectability, and overall survival. RESULTS Pelvic recurrence was found in 30 (13%) of the 226 patients studied. MRI detected 26 of 30 (87%) and missed 4 of 30 (13%) cases with local recurrence. Of the latter, 3 were anastomotic recurrences. In 28 (14%) patients, local recurrence was suspected by an initial MR scan but cleared by subsequent MRI or CT-guided biopsy. Recurrent pelvic cancer was diagnosed by MRI with 87% sensitivity and 86% specificity. In 19 (63%) cases, CEA was abnormally elevated, and 9 patients (30%) were symptomatic. Surgical resection was possible in only 6 patients (20%). There was no difference between MRI and conventional follow-up tests in their ability to detect cases suitable for surgery. CONCLUSIONS Pelvic surveillance by MRI is not justified as part of the routine follow-up after a curative resection for colorectal cancer and should be reserved for selectively imaging patients with clinical, colonoscopic, and/or biochemical suspicion of recurrent disease.
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Affiliation(s)
- Liviu V Titu
- Academic Surgical Unit, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, UK
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Abstract
OBJECTIVE The purpose of this study was to determine the accuracy of synergic body coil MRI using SPIR technique without contrast, in the determination of fistula characteristics in patients with clinically positive signs. METHOD AND SUBJECTS This was a case-series prospective study including 29 consecutive patients with clinically suspected fistulas-in-ano. The standard synergic body coil was used and all patients had T2-weighted SPIR sequences. One radiologist, without prior knowledge of the clinical examination, analysed images and noted the presence of the fistula, its classification and the presence and number of any collections or extensions. The surgeon noted the MRI findings and looked for lesions suggested on MRI. The results of the MRI and surgical assessments were then compared. Results of surgical exploration while the surgeon was aware of MRI results were considered as the gold standard of surgical anatomy. RESULTS Twenty-three (79.31%) of 29 fistula tracks were seen on MRI which correctly determined the type of all fistulas. In the six cases where the fistula was not seen on MRI, five were low trans-sphincteric and one was rectovaginal. MRI identified 8 of 10 collections. CONCLUSION The synergic body coil MRI with SPIR sequencing without endoanal coils had a high accuracy in the diagnosis of high fistulas collections, complex fistulas and extensions.
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Affiliation(s)
- B Mahjoubi
- Department of Surgery, Iran University of Medical Sciences and Health Care Services, Tehran, Iran.
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Roach SC, Hulse PA, Moulding FJ, Wilson R, Carrington BM. Magnetic resonance imaging of anal cancer. Clin Radiol 2005; 60:1111-9. [PMID: 16179172 DOI: 10.1016/j.crad.2005.05.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 05/19/2005] [Accepted: 05/26/2005] [Indexed: 10/25/2022]
Abstract
AIM The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearances of primary and recurrent anal carcinoma, and to demonstrate the commonest patterns of local and distant disease spread. METHODS A retrospective review was performed of 27 cases of biopsy-proven anal carcinoma, where MRI was used for primary staging (9 patients) or suspected recurrence (18 patients). Two oncological radiologists reviewed the MR images, following a standardized approach. The size, extent and signal characteristics of the anal tumour were documented. Metastatic disease spread to lymph nodes, viscera and bone was recorded. In all, 7 patients with recurrent disease underwent surgery and subsequent histological correlation was performed. RESULTS Primary and recurrent tumours were of high signal intensity relative to skeletal muscle on T2-weighted images (T2WI), and of low to intermediate signal intensity on T1-weighted images (T1WI). Lymph node metastases were of similar signal intensity to the anal cancer. Recurrent tumours were more locally advanced than primary tumours and extended into adjacent organs and the pelvic skeleton. Recurrent lymph node disease involved perirectal, presacral and internal iliac nodes more commonly than did primary lymph node disease. CONCLUSION MRI can be useful in the primary staging of bulky tumours or of those with a long craniocaudal extent. MR has a role in the preoperative evaluation and surgical planning of cases of recurrent disease following radiotherapy.
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Affiliation(s)
- S C Roach
- Department of Diagnostic Radiology, Christie Hospital, Manchester, UK
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Abstract
OBJECTIVE Defecography may be useful in pre-operative assessment of patients with genital prolapse. Defecography is an invasive and embarrassing procedure for patients and little effort has been made to optimalise selection criteria for defecography. This study investigated whether discrimination of high and low probability of abnormal defecography is possible based on the quantified findings from patient history, pelvic examination and a validated questionnaire. DESIGN Prospective observational study. SETTING Three teaching hospitals in The Netherlands. POPULATION Eighty-two patients undergoing surgical correction of uterine prolapse Stages 2-4. METHODS A history and pelvic examination were obtained from all patients. A validated questionnaire was used to assess the presence of defecation and micturition symptoms. Using multivariate logistic regression analyses with receiver operating characteristic curves, a diagnostic model to predict the presence of an abnormal defecography was systematically constructed and validated. MAIN OUTCOME MEASURE Presence of abnormal finding at defecography. RESULTS The most important predictors for abnormal defecography were prolapse of the posterior vaginal wall, history of abdominal or pelvic surgery and the presence of constipation. With these variables, a prediction rule could be constructed which predicted the prevalence of an abnormal defecography (area under curve = 0.73; 95% CI 0.61-0.83). CONCLUSIONS This study shows that a diagnostic model based on findings obtained from a non-invasive workup can accurately predict the presence of an abnormal defecography. Such a model provides the possibility to tailor the request for defecography to the individual patient.
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Affiliation(s)
- Jan-Paul W R Roovers
- Department of Obstetrics and Gynecology, University Medical Center, Utrecht, The Netherlands
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Dobben AC, Wiersma TG, Janssen LWM, de Vos R, Terra MP, Baeten CG, Stoker J. Prospective Assessment of Interobserver Agreement for Defecography in Fecal Incontinence. AJR Am J Roentgenol 2005; 185:1166-72. [PMID: 16247127 DOI: 10.2214/ajr.04.1387] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The primary aim of our study was to determine the interobserver agreement of defecography in diagnosing enterocele, anterior rectocele, intussusception, and anismus in fecal-incontinent patients. The subsidiary aim was to evaluate the influence of level of experience on interpreting defecography. SUBJECTS AND METHODS Defecography was performed in 105 consecutive fecal-incontinent patients. Observers were classified by level of experience and their findings were compared with the findings of an expert radiologist. The quality of the expert radiologist's findings was evaluated by an intraobserver agreement procedure. RESULTS Intraobserver agreement was good to very good except for anismus: incomplete evacuation after 30 sec (kappa, 0.55) and puborectalis impression (kappa, 0.54). Interobserver agreement for enterocele and rectocele was good (kappa, 0.66 for both) and for intussusception, fair (kappa, 0.29). Interobserver agreement for anismus: incomplete evacuation after 30 sec was moderate (kappa, 0.47), and for anismus: puborectalis impression was fair (kappa, 0.24). Agreement in grading of enterocele and rectocele was good (kappa, 0.64 and 0.72, respectively) and for intussusception, fair (kappa, 0.39). Agreement separated by experience level was very good for rectocele (kappa, 0.83) and grading of rectoceles (kappa, 0.83) and moderate for intussusception (kappa, 0.44) at the most experienced level. For enterocele and grading, experience level did not influence the reproducibility. CONCLUSION Reproducibility for enterocele, anterior rectocele, and severity grading is good, but for intussusception is fair to moderate. For anismus, the diagnosis of incomplete evacuation after 30 sec is more reproducible than puborectalis impression. The level of experience seems to play a role in diagnosing anterior rectocele and its grading and in diagnosing intussusception.
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Affiliation(s)
- Annette C Dobben
- Department of Radiology, G1-228, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
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Gosselink MP, West RL, Kuipers EJ, Hansen BE, Schouten WR. Integrity of the anal sphincters after pouch-anal anastomosis: evaluation with three-dimensional endoanal ultrasonography. Dis Colon Rectum 2005; 48:1728-35. [PMID: 15981069 DOI: 10.1007/s10350-005-0113-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography. METHODS Patients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI). RESULTS Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores. CONCLUSION Handsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.
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West RL, Dwarkasing S, Briel JW, Hansen BE, Hussain SM, Schouten WR, Kuipers EJ. Can three-dimensional endoanal ultrasonography detect external anal sphincter atrophy? A comparison with endoanal magnetic resonance imaging. Int J Colorectal Dis 2005; 20:328-33. [PMID: 15666154 DOI: 10.1007/s00384-004-0693-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2004] [Indexed: 02/04/2023]
Abstract
PURPOSE Anal sphincter atrophy is associated with a poor clinical outcome of sphincter repair in patients with faecal incontinence. Preoperative assessment of the sphincters is therefore relevant. External anal sphincter (EAS) atrophy can be detected by endoanal magnetic resonance imaging (MRI), but not by conventional endoanal ultrasonography (EUS). Three-dimensional EUS allows multiplanar imaging of the anal sphincters and thus enables more reliable anal sphincter measurements. The aim of the present study was to establish whether 3D EUS measurements can be used to detect EAS atrophy. For this purpose 3D EUS measurements were compared with endoanal MRI measurements. METHODS Patients with symptoms of faecal incontinence underwent 3D EUS and endoanal MRI. Internal anal sphincter (IAS) and EAS defects were assessed on 3D EUS and endoanal MRI. EAS atrophy was determined on endoanal MRI. The following measurements were performed: EAS length, thickness and area. Furthermore, EAS volume was determined on 3D EUS and compared with EAS thickness and area measured on endoanal MRI. RESULTS Eighteen parous women (median age 56 years, range 32-80) with symptoms of faecal incontinence were included. Agreement between 3D EUS and endoanal MRI was 61% for IAS defects and 88% for EAS defects. EAS atrophy was seen in all patients on endoanal MRI. Correlation between the two methods for EAS thickness, length and area was poor. In addition, correlation was also poor for EAS volume determined on 3D EUS, and EAS thickness and area measured on endoanal MRI. CONCLUSION Three-dimensional EUS and endoanal MRI are comparable for detecting EAS defects. However, correlation between the two methods for EAS thickness, length and area is poor. This is also the case for EAS volume determined on 3D EUS and EAS thickness and area measured on endoanal MRI. Three-dimensional EUS can be used for detecting EAS defects, but no 3D EUS measurements are suitable parameters for assessing EAS atrophy.
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Affiliation(s)
- R L West
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, 3000 Rotterdam, The Netherlands.
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Kuo LJ, Chern MC, Tsou MH, Liu MC, Jian JJM, Chen CM, Chung YL, Fang WT. Interpretation of magnetic resonance imaging for locally advanced rectal carcinoma after preoperative chemoradiation therapy. Dis Colon Rectum 2005; 48:23-8. [PMID: 15690653 DOI: 10.1007/s10350-004-0787-5] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Neoadjuvant concomitant chemoradiotherapy has been used in cases of locally advanced rectal cancer to preserve sphincter function, decrease local recurrence, and improve survival. Preoperative staging is essential for planning and providing optimal therapy. The purpose of this study is to determine the accuracy of staging with magnetic resonance imaging and to define any factors that interfere in interpretation of images obtained after preoperative chemoradiation therapy. METHODS Thirty-six patients with biopsy-proven, locally advanced rectal cancer were treated with preoperative concomitant 5-fluorouracil-based chemotherapy and radiation, followed six to eight weeks later by radical surgery. Preoperative magnetic resonance images were reinterpreted by one radiologist and the results compared with histopathologic staging. RESULTS T-level downstaging occurred in 10 of 36 patients (28 percent), and N-level downstaging occurred in 29 of 36 patients (80 percent) after completion of chemoradiation therapy. Pathologic complete remission after chemoradiotherapy occurred in five patients (12 percent). Of the 36 patients, 17 (47 percent) were overstaged and 2 (6 percent) were understaged in T-level, whereas 10 patients (28 percent) were overstaged and 3 patients (8 percent) were understaged in N-level. The accuracy of magnetic resonance imaging for determining depth of wall invasion was 47 percent, with 64 percent accuracy for nodal staging. CONCLUSIONS Magnetic resonance imaging is commonly used in staging of pelvic malignancies because of its fine resolution, but chemoradiotherapy may decrease its accuracy. Thickening of the rectal wall after radiation by marked fibrosis, and peritumoral infiltration of inflammatory cells and vascular proliferation may contribute to overestimation of stage. By contrast, pathologic residual cancer beneath normal mural structure after chemoradiation therapy may result in understaging of rectal cancer.
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Affiliation(s)
- Li-Jen Kuo
- Division of Colorectal Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center Hospital, Taipei, Taiwan.
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Schaefer O, Oeksuez MO, Lohrmann C, Langer M. Differentiation of Anal Sphincters With High-Resolution Magnetic Resonance Imaging Using Contrast-Enhanced Fast Low-Angle Shot 3-Dimensional Sequences. J Comput Assist Tomogr 2004; 28:174-9. [PMID: 15091119 DOI: 10.1097/00004728-200403000-00004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The imaging of the anal apparatus is becoming more and more important in the management of patients who suffer from anorectal disease. The exact differentiation of the sphincter muscles is a major requirement for the detection of disorders of the anal canal. The purpose of this study was to evaluate a new magnetic resonance (MR) imaging protocol using contrast-enhanced, high-resolution, fast low-angle shot, 3-dimensional (3D) sequences and image subtraction regarding the visualization and differentiation of the internal and external sphincter muscles. METHODS High-resolution pelvic MR imaging (1.5 T) was performed in 85 patients (42 male, 43 female; age range: 12-81 years) with a phased-array body coil. For an anatomic overview of the pelvic region, a short tau inversion recovery sequence in the coronal plane was carried out, followed by a 3D, high-resolution, fat-saturated, T1-weighted, gradient echo sequence before and after intravenous administration of a contrast agent (gadobenic acid, 0.15 mmol/kg). To optimize the visualization of the sphincter muscles, subtraction of the unenhanced from the contrast-enhanced sequences was routinely performed. The signal intensities of the internal and external sphincter muscles were measured in the axial plane on the subtracted images. RESULTS The distribution of the mean signal intensities of the internal and external sphincter muscles as well as the difference between both revealed a normal deviation. The confidence interval on a 95% significance level ranged between 1.6941 and 1.9393, with a mean of 1.81. In the whole study group, the signal intensity of the internal sphincter muscle was significantly higher than that of the external sphincter, thus facilitating the identification and differentiation of the 2 components of the anal sphincter complex. CONCLUSION The presented MR imaging protocol is robust, provides a high image quality, and is well accepted by patients because of its noninvasiveness.
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Affiliation(s)
- Oliver Schaefer
- Department of Radiology, University Hospital of Freiburg, Freiburg, Germany.
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Abstract
Pre- and postoperative adjuvant treatments for locally advanced, operable (R0 resection) rectum carcinoma have led to improved results. In principle, according to the interdisciplinary consensus of the German Cancer Society, the recommended treatment for rectum carcinoma (T3/4; N0; M0; any T stage; N+; M0) is still postoperative adjuvant radiochemotherapy. In the meantime, however, based on the good results obtained from various clinical trials preoperative adjuvant treatment is favored internationally. Not only does this treatment scheme show a comparably better compliance of the patients but it also seems to be better tolerated. One treatment option for resectable T3 tumors immediately followed by surgery is the sole hypofractionated preoperative 3-4 field external beam radiotherapy. An additional benefit can be expected from protracted preoperative radiochemotherapy (single dose 2 Gy, total dose >40 Gy, chemotherapy based on 5-FU) followed by operation several weeks later. For T4 tumors with expected R1 or R2 resection, preoperative treatment is urgently recommended. A further aim in compliance with the surgical approach (R0 resection!) and multimodal treatment may be for individual cases the preservation of continence.
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Affiliation(s)
- F Zimmermann
- Klinik und Poliklinik für Strahlentherapie und Radiologische Onkologie, Klinikum rechts der Isar der Technischen Universität München
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Abstract
OBJECTIVE To assess the reliability of anal endosonography (AES) in the diagnosis of anal fistulae and abscesses. MATERIAL AND METHODS 86 patients with different types of anal fistulae and abscesses were prospectively examined with a 7.0 MHz transducer. Type of anal fistulae, differentiation between simple and complex tracts, and location of their internal openings were defined. In 66 cases with permeable external opening, hydrogen peroxide solution was introduced into the fistula tract. Reliability of AES was defined after surgical treatment of all cases. RESULTS 74 anal fistulae, including 43 transsphincteric, 11 intersphincteric, 6 suprasphincteric, 3 superficial, and 11 ano-vaginal were found on AES. 27 fistulae were complex, and 47 simple fistulae. In 10 patients a coexisting abscess was found; the remaining 12 abscesses were without any fistula. Surgery confirmed the type of anal fistula in 64 patients (86.5%), and location of internal openings in 60 cases (81.1%). All abscesses were confirmed. CONCLUSION AES showed high accuracy in diagnosing anal fistulae and abscesses.
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Affiliation(s)
- I Sudoł-Szopińska
- Department of Imaging Diagnostics, II Medical Faculty, Medical Academy Warsaw, Poland
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Abstract
In Europe, short-term radiotherapy is increasingly used in the primary management of rectal cancer. In the United States, postoperative chemoradiotherapy is the standard treatment of choice. The rationale and indications for radiotherapy and possible combinations with chemotherapy are discussed and an overview of all of the randomised trials containing radiotherapy as one randomisation arm is given. Three major indications for radiotherapy can be identified: the reduction of local recurrences in mobile rectal cancer, downstaging of the tumour in primary irresectable tumours and downsizing of low-lying tumours in attempts to more frequently perform a sphincter-saving procedure. For reduction of local recurrences, radiotherapy can be given either pre- or postoperatively, although preoperative therapy is more dose-efficient. Short-term preoperative radiotherapy reduces the number of recurrences and improves survival. Improved survival is also reported after postoperative radiotherapy in combination with chemotherapy, however, the relevance of the radiotherapy component is discussed. Although the debate about radiotherapy is still ongoing, we strongly believe that the results demonstrate that short-term preoperative radiotherapy is the treatment of choice for resectable rectal cancer.
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Affiliation(s)
- C A M Marijnen
- Department of Clinical Oncology, LUMC, Leiden, The Netherlands.
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Hiller L, Radley S, Mann CH, Radley SC, Begum G, Pretlove SJ, Salaman JH. Development and validation of a questionnaire for the assessment of bowel and lower urinary tract symptoms in women. BJOG 2002; 109:413-23. [PMID: 12013162 DOI: 10.1111/j.1471-0528.2002.01147.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To develop a simple but sensitive instrument to evaluate and document symptoms of both bowel and urinary dysfunction in women. DESIGN A 22-item questionnaire covering a range of bowel and urinary symptoms was developed and underwent rigorous psychometric testing. SETTING The gynaecology departments of three hospitals, a urogynaecology clinic, a functional bowel clinic and a general practice. POPULATION Six hundred and thirty women, comprising four groups: 1. women awaiting hysterectomy (n = 379), 2. women following hysterectomy (n = 45), 3. women referred with functional bowel and/or urinary symptoms (n = 65), 4. asymptomatic controls (n = 141). MAIN OUTCOME MEASURES The content, construct and criterion validity, internal consistency, reliability and responsiveness of the questionnaire were measured. RESULTS Peer and patient reports and missing data patterns supported face and content validity. Factor analysis showed a clinically relevant four-factor structure with low content replication able to distinguish between patient groups, indicating good internal structure. Comparison with clinical, anorectal physiological, videoproctographic, transit time and urodynamic test results provide provisional indication of criterion validity. Key domain question analysis and Cronbach's alphas showed internal consistency. Kappa values demonstrated good test-retest reliability and key question correlation over time proved responsiveness. CONCLUSIONS Our findings support the suitability, clinical validity, reliability and responsiveness of a simple questionnaire, which is sensitive to the constraints of clinical practice. The authors recommend its use in health care evaluation research assessing the effects of pelvic surgery and as a useful tool in comparing treatment efficacy.
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Affiliation(s)
- L Hiller
- Birmingham Clinical Trials Unit, Edgbaston, UK
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Abstract
Anal endosonography became a valuable imaging method for diagnosis of anal diseases because of its accessibility, relative simplicity of performance, and low cost. It is used most often to detect anal sphincter defects, to classify anal fistulas and perianal abscesses, and to stage anal tumors. This review presents a normal anatomy of the anal canal, examination technique, and normal endosonographic anatomy of anal sphincters. The endosonographic findings of anal sepsis, malignancy, trauma, abnormalities in Crohn disease, and ulcerative colitis, as well as the role for anal endosonography among other imaging modalities, are discussed.
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Sudoł-Szopińska I, Jakubowski W, Szczepkowski M. Contrast-enhanced endosonography for the diagnosis of anal and anovaginal fistulas. J Clin Ultrasound 2002; 30:145-150. [PMID: 11948570 DOI: 10.1002/jcu.10042] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
PURPOSE We assessed whether contrast-enhanced anal endosonography (AES) with hydrogen peroxide improves the identification of anal fistulas and their internal openings compared with non-contrast AES. METHODS The study group comprised 12 patients who had various types of anal fistulas with visible external openings. AES was performed before and about 15 seconds after injection of 1 ml of 3% hydrogen peroxide into the fistula tract through the external opening. RESULTS Both contrast and non-contrast AES revealed 7 transsphincteric, 2 intersphincteric, 1 suprasphincteric, and 2 anovaginal fistulas. Simple tracts were found in 8 cases and complex tracts in 4 cases on non-contrast AES. Contrast-enhanced AES revealed 9 simple and 3 complex fistulas. One fistula that appeared complex on the non-contrast study appeared simple after contrast agent administration. Contrast-enhanced AES demonstrated more internal openings than non-contrast AES did. Surgery confirmed 11 of the fistulas; an internal opening could not be located surgically for the other tract. CONCLUSIONS Contrast-enhanced AES appears to be superior to non-contrast AES in the preoperative assessment of anal and anovaginal fistulas and in demonstrating and locating their internal openings.
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Affiliation(s)
- Iwona Sudoł-Szopińska
- Imaging Diagnostics Department, II Medical Faculty, Medical Academy, Kondratowicza 8, 03-285 Warsaw, Poland
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Abstract
Radiation kills cancer cells by inducing various degrees of deoxyribonucleic acid fragmentation and disruption of intracellular membranes that lead to either immediate or delayed cell death. Although radiation can be effective in destroying cancer, its usefulness is limited by damage to normal tissues that surround the target tumour or those in the path of the radiation beam. The rectum and anus are damaged frequently during radiotherapy for abdominopelvic malignancy, including preresection therapy for rectal cancer. Such damage is often associated with lesions in the perineal skin, genitourinary tract, colon, and small intestine. Surgical intervention often is required for the most severe forms of these complications.
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Affiliation(s)
- E. D. Reis
- Department of Surgery, The Mount Sinai Medical Centre, New York, NY, USA
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De Parades V, Cuenod CA, Thomas C, Marteau P, Parisot C, Atienza P. L’imagerie dans la maladie de Crohn anopérinéale. ACTA ACUST UNITED AC 2000; 30:565-77. [DOI: 10.1007/bf03026173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Over 11 000 new cases of rectal cancer are reported in the UK each year. Recent technical advances have increased interest in local management of the disease. The introduction of screening for colorectal cancer will potentially lead to an increased number of early rectal cancers suitable for local curative treatment. In addition, as the proportion of elderly patients in the population rises, local methods of treatment of rectal cancer will become increasingly important in this group of patients with comorbid disease. A literature search was performed on Medline database for English language publications on local treatments of rectal carcinoma. Preoperative assessment, selection of patients, local therapeutic and palliative methods of treatment were evaluated. Local methods of treatment can be used for potentially curative operations for rectal cancer. Preoperative endoanal ultrasound appears to be the most useful investigation for determining depth of local invasion. Transanal endoscopic microsurgery has extended the boundaries of local surgery and permits access to the mid and upper rectum with results similar to those of conventional local techniques. Laser therapy and transanal resection provide the best form of palliation for more advanced rectal carcinomas.
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Affiliation(s)
- Cook
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
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