© Borgis - Postępy Nauk Medycznych 8/2013, s. 543-547
*Aneta Obcowska1, Małgorzata Kołodziejczak2, Iwona Sudoł-Szopińska2, 3, 4
Przydatność przedoperacyjnego badania endosonograficznego w różnicowaniu przetok odbytu niskich z wysokimi
The usefulness of preoperative endosonographic differentiation of low and high anal fistula
1Department of General Surgery, Vascular Surgery Unit, Praski Hospital, Warsaw
Head of Department: Rafał Górewicz, MD, PhD
2Department of General Surgery, Proctology Unit, Solec Hospital, Warsaw
Head of Department: Jacek Bierca, MD, PhD
Head of Unit: Małgorzata Kołodziejczak, MD, PhD
3Department of Radiology, Institute of Rheumatology, Warsaw
Head of Department: prof. Iwona Sudoł-Szopińska, MD, PhD
4Department of Diagnostic Imaging, II Medicine Faculty, Medical University, Warsaw
Head of Department: prof. Wiesław Jakubowski, MD, PhD
Streszczenie
Wstęp. Przedoperacyjne określenie wysokości przetoki ma duże znaczenie w wyborze sposobu leczenia oraz ocenie ryzyka pooperacyjnej inkontynencji. Ze zwiększonym ryzykiem wystąpienia tego powikłania wiąże się leczenie wysokich przetok przezzwieraczowych i międzyzwieraczowych, przetok nadzwieraczowych, rozgałęzionych, w tym podkowiastych, oraz przetok przednich u kobiet.
Cel. Celem pracy było określenie czułości i swoistości badania endosonograficznego (ang. endoanal ultrasound – EUS) w ocenie typu kanału pierwotnego oraz wysokości przetoki odbytu.
Materiał i metody. Materiał stanowiła grupa 424 pacjentów, w tym 132 kobiet i 292 mężczyzn w średnim wieku 45,8 lat, zoperowanych z powodu przetoki odbytu w okresie od 1 grudnia 2008 do 8 kwietnia 2011 roku. Przeprowadzono retrospektywną analizę danych z 424 przedoperacyjnych badań EUS oraz protokołów operacyjnych u tych samych pacjentów. Sprawdzono zgodność oceny przetok pod względem typu kanału pierwotnego oraz jego wysokości.
Wyniki. W EUS stwierdzono 63,1% przetok niskich i 36,9% wysokich, zaś śródoperacyjnie odpowiednio 57,6 i 42,2% przetok (w 0,2% przypadków stwierdzono przetokę mnogą). Zgodność EUS ze stanem śródoperacyjnym w ocenie wysokości przetoki uzyskano w 344 przypadkach (84,3%). Czułość i swoistość tej metody w ocenie wysokości przetok wyniosły odpowiednio 75 i 91%.
Wnioski. Badanie EUS jest dobrym badaniem dodatkowym do określania wysokości przetoki, niezależnie od jej typu. Czułość i swoistość metody w ocenie wysokości przetok wynosi odpowiednio 75 i 91%.
Summary
Introduction. Preoperative determination of the fistula is of great importance in the selection of treatment and the risk of postoperative incontinence. High transsphincteric and intersphincteric fistulas, suprasphincteric fistulas, branching ones, including horseshoe ones and front fistulas in women are associated with an increased risk of complications related to treatment.
Aim. The aim of this study was to determine the sensitivity and specificity of endosonographic examinations (EUS – endoanal ultrasound) to determine the type of the original canal and the location of anal fistula.
Material and methods. The material was a group of 424 patients, including 132 women and 292 men with a mean age of 45.8 years, operated because of anal fistula in the period from 1 December 2008 to 8 April 2011. A retrospective study of 424 preoperative EUS examinations and operational protocols in the same patients was conducted. The compatibility of the assessment of fistulas in terms of type of canal and its original location was verified.
Results. In EUS examinations 63.1% low fistulas and 36.9% high fistulas were determined, and intraoperatively, respectively 57.6 and 42.2% of fistulas (in 0.2% of cases plural fistula was determined). EUS compliance with the state of the intraoperative assessment of the fistula was obtained in 344 cases (84.3%). The sensitivity and specificity of this method in the evaluation of fistulas were respectively 75 and 91%.
Conclusions. EUS is a good additional examination for the determination of the fistula location, regardless of its type. The sensitivity and specificity of the method in the assessment of fistula is respectively 75 and 91%.
Introduction
Anal fistula is described has been described in the medical literature for more than 2.5 thousand years.
To date, the disease has gone through a number of pathophysiological theories, classifications and a series of proposed treatments. The treatment of anal fistula is often problematic and leaves the surgeon with a choice between the courageous operational procedure with a lower risk of disease recurrence with simultaneous increased risk of postoperative incontinence (urinary and bowel gas) and cautious procedure, giving more relapses, but less complications of incontinence. The recurrence rate quoted in the literature depends on, among other things, the type of operation performed, and in the case of fistulotomy eq3uals 0-11% (1, 2), using the surgical technique of a displaced muscle flap 1.5-4.6% (3, 4), anodermal flap-plastry 0-3% (5-10), the Hippocratic operation method 4-39% (2, 11-13). Leaving the internal opening and insufficient expertise of a surgeon are also factors increasing the risk of reoccurrence (1).
The most serious postoperative complication is urinary incontinence due to sphincter damage. The first scale to evaluate the severity of fecal and gas incontinence was developed by Parks and Browning (14). The currently most commonly used classifications are the ones of Wexner or Vaizeya (15, 16). The risk of incontinence and anal fistula after the operation is 0 to 25% (urinary incontinence), and even up to 60% (periodic dirty linen) (1, 6, 17, 18). High fistulas, apart from the branching ones (including horseshoe ones), front fistulas in women, recurrent fistulas, also formed after irradiation, and in the course of Crohn’s disease are known as the so-called “complex” fistulas (19).
Their operation is associated with increased rates of postoperative incontinence. Some authors believe that another risk factor for incontinence are more previous incision and drainage of anus abscess (20). In centers specializing in colorectal surgery postoperative complication rate is much lower than in the general chirurgic branches.
The determination of a fistula location is essential for the proper planning of the operation and evaluating the risk of complications. The canal is described as high when it covers more than 30% of the length of the anal external sphincter muscle (21) (fig. 1, 2).
Fig. 1. Back high transsphincteric fistula.
Fig. 2. Back high horseshoe intrasphincteric fistula.
Aim
The aim of this study was to determine the sensitivity and specificity of endosonography examinations (EUS – endoanal ultrasound) to determine the type and height of the original canal of anal fistula.
Material and methods
The material was a group of 424 patients, including 132 women and 292 men, aged between 17 and 83 years (mean 45.8 years), operated because of anal fistula in the period from 1 December 2008 to 8 April 2011. The analysis does not include vaginal-rectal fistulas, fistula arising in the course of Crohn’s disease, tuberculosis, actinomycosis, cancer, against the presence of a foreign structure, and after irradiation of the anal area. The study included only patients scheduled for elective surgery, except of emergency cases operated because of concomitant anal abscess.
A retrospective comparative analysis of data from 424 EUS examinations and operational protocols in the same patients was conducted.
All EUS examinations were performed by a single, experienced radiologist with Profocus Ultraview 2202-7 apparatus with endorectal 3D mechanical head, with a frequency of 16 MHz. The examination was performed in the Sims position, without bowel preparation. Transrectal probe was coated with ultrasound gel, and a latex sheath, which was also applied to the gel. The type of fistula was determined, the height, the location of the internal opening, the presence of any branches, morphological condition of sphincters. A similar analysis was conducted during the operation. Parks classification was used in the assessment (22). Fistulas were included in the group of high ones when covered more than 1/3 the length of the external anal sphincter muscle.
Concordance between the preoperative assessment of anal fistula in study EUS for the entire group was determined, as well as for different types of original canals. The sensitivity and specificity of EUS in these groups were calculated. For the calculations, the χ2 of Pearson independence test was used.
Results
In the EUS examination the following were diagnosed: 100 intersphincteric fistulas (23.6%), 266 transsphincteric fistulas (62.8%), 45 suprasphincteric fistulas (10.6%), 9 extrasphincteric fistulas (2.1%) and 4 unusual (submucosal) ones (0.9%). Intraoperatively following were diagnosed, respectively, 67 (15.8%) intersphincteric fistulas, 265 (62.5%) transsphincteric fistulas, 74 (17.5%) suprasphincteric fistulas, 17 (4.0%) extrasphincteric fistulas, 1 (0.2%) unusual fistula (submucosal).
For the entire group conformity assessment primary channel type was found in 312 cases (73.6%).
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