Role of Magnetic Resonance Imaging Fistulography in Preoperative Evaluation of Perianal Fistulas

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1 Originl Article Print ISSN: Online ISSN: X DOI: /ijss/2017/446 Role of Mgnetic Resonnce Imging Fistulogrphy in Preopertive Evlution of Perinl Fistuls Sushil Kumr K Kle 1, Prteek Singh 2, Atul T Tyde 3, Surh Ptil 4, Atul Dhok 4 1 Professor, Deprtment of Rdiodignosis, Mhtm Gndhi Institute of Medicl Sciences, Sevgrm, Wrdh, Mhrshtr, Indi, 2 Post-grdute Student, Deprtment of Rdiodignosis, Mhtm Gndhi Institute of Medicl Sciences, Sevgrm, Wrdh, Mhrshtr, Indi, 3 Professor nd Hed, Deprtment of Rdiodignosis, Mhtm Gndhi Institute of Medicl Sciences, Sevgrm, Wrdh, Mhrshtr, Indi, 4 Assistnt Professor, Deprtment of Rdiodignosis, Mhtm Gndhi Institute of Medicl Sciences, Sevgrm, Wrdh, Mhrshtr, Indi Astrct Introduction: As per definition, perinl fistul is ny norml pssge connecting two epithelil surfces of nl cnl nd the skin of the perineum. Ojective: The ojective of this study is to study the vrious types of perinl fistuls, delineting the primry trck nd complictions of perinl fistul with mgnetic resonnce imging (MRI) nd evlute the ccurcy of MRI in the pre-opertive clssifiction. Mterils nd Methods: A retrospective study included 44 ptients referred for MRI y 1.5T Mgnetom Avnto MRI unit (Siemens Medicl Systems) with clinicl suspicion of perinl fistule etween Jnury 2016 nd July 2017, for evlution of the extent of disese. Out of these 26 ptients underwent surgery in our hospitl nd were included in the study. Imging ws performed with multiplnr T1-weighted (T1W), T2-weighted (T2W), nd proton density ft sturtion (PDFS) sequences. Fistuls were clssified ccording to St. Jmes s University Hospitl MRI sed clssifiction system (which correltes the Prks surgicl clssifiction to ntomic MRI findings) into five grdes. Then, the interreltion etween surgicl nd MRI findings ws sttisticlly nlyzed. Results: A totl of 26 ptients were studied, MRI reveled fistule in 21 (80.7%) ptients while 5 (19.2%) ptients hd only perinl sinuses. Out of totl 21 fistule seen, 10 (47.6%) were intersphincteric, 9 (42.8%) were trnssphincteric, nd 2 (9.5%) were suprsphincteric. No extrsphincteric fistul noted. Out of these fistule, 14 (66.6%) were simple, wheres 7 (33.3%) showed ssocited scess formtion, inflmmtion, nd rnching course. Sttisticl prmeters showed tht MRI hs sensitivity of 100% nd specificity of 83.3% in determining type nd extent of perinl fistul. Conclusion: MRI is relile noninvsive dignostic modlity for pre-opertive ssessment of perinl fistule nd guide for surgicl plnning y giving correct ssessment of the extent of disese, therey reducing the chnces of recurrence. Key words: Intersphincteric, Mgnetic resonnce imging, Perinl fistul, Suprsphincteric, Trnssphincteric INTRODUCTION As per definition, perinl fistul is ny norml pssge connecting two epithelil surfces of nl cnl nd the skin of the perineum. 1 They re thought to e result of nl glnd ostruction, with secondry scess formtion nd externl rupture of the scess. 2 Anl fistule hve een known ever since the times of Hypocrtes nd hve een descried through centuries. In Access this rticle online Month of Sumission : Month of Peer Review : Month of Acceptnce : Month of Pulishing : , Frederick Slmon performed successful opertion in London on the writer Chrles Dickens. Goodsll descries the fistulous pssge in detils, nd Prks Clssifiction shows the most prcticl significnce until nowdys. The incidence of perinl fistul rnges from pproximtely 1 to 2 per 10,000 individuls with n pproximte 2:1 mle to femle predominnce. 1 The most common presenting symptom is dischrge, discomfort, nd fever ut locl pin due to inflmmtion is lso common. 3 However, fistuls my e completely symptomtic. 4 Tretment of this condition includes surgicl explortion nd removl of the fistulous trck. 5 However, in 25-30% of cses, the condition hs tendency to recur. 5,6 This is most often ecuse surgicl explortion cn esily miss secondry trcks nd scesses, resulting in recurrent infection requiring re-explortion. Surgeons hve trditionlly used Corresponding Author: Dr. Prteek Singh, Deprtment of Rdiodignosis, Mhtm Gndhi Institute of Medicl Sciences, Sevgrm, Wrdh , Mhrshtr, Indi. Phone: E-mil: drprteek@gmil.com 25 Interntionl Journl of Scientific Study Septemer 2017 Vol 5 Issue 6

2 Kle, et l.: Role of MRI Fistulogrphy in Preopertive Evlution of Perinl Fistuls digitl rectl exmintion nd exmintion under nesthesi to detect the fistulous trck nd their internl opening. However, this method fils to identify complex fistuls nd their rnches, leding to wrong clssifiction nd incomplete tretment. 6,7 Conventionl fistulogrms hs two min disdvntges: First, the primry trck nd its extensions do not fill with contrst if they re plugged with pus or deris nd, second, the sphincter muscle ntomy is not imged; hence, the reltion etween the trck, the internl/externl sphincter, nd the levtor ni muscle is not reveled. 6 Trnsrectl ultrsound etter depicts fistule nd their reltion to the nl sphincter muscles. The opertor dependence, limited field of view nd sence of coronl plne of imging; however, re its disdvntges. 6 Computed tomogrphy (CT) fistulogrphy is limited y the fct tht ttenution vlues of the fistul trck, the res of firosis, nd sphincter muscles re similr to ech other. 6 Reserches hve shown tht techniques used for imging perinl fistuls including fistulogrphy, nl endosonogrphy, nd CT, hve proved no etter thn clinicl exmintion nd re uncomfortle to the ptient on one hnd nd or lck the ility to demonstrte secondry trcks nd reltionship of the fistulous trcks with the sphincter complex. 6-8 The following items were ssessed for ech of the used MRI sequences: The type of the fistul, loction of the internl opening, the presence or sence of sinus trcks, scesses nd horseshoe component s well s coexisting inflmmtion. The type of the fistul ws evluted ccording to the St. Jmes s University Hospitl MRI clssifiction system (Tle 2) 9 which correltes Prks surgicl clssifiction 10 to ntomicl MRI findings in the xil nd coronl plnes (Tle 3 nd Figure 1). The loction of the internl opening ws identified on xil imges using the nl clock with the 12 o clock position locted nterior nd the 6 o clock position locted posterior (Figure 2). 11 A fistul with trck medil to the levtor plte or puorectlis muscle is suprlevtor, while fistul lterl to these muscles is infrlevtor. Complicted primry trcks with secondry trcks, extensions or scesses were defined y their ntomicl loction: Ischio-nl, intersphincteric, or suprlevtor nd they were considered horseshoe if crossing the midline to the contrlterl side. 12 Fistulous trcks were differentited from scesses using the criteri of Lnido et l. 13 in which fistuls were defined s eing MATERIALS AND METHODS Totlly, 44 ptients with clinicl suspicion of perinl fistule were referred to the Rdiology Deprtment of tertiry cre rurl hospitl from Jnury 2016 nd July Out of these 26 ptients underwent surgery in our hospitl nd were evluted retrospectively. Mgnetic resonnce imging (MRI) imging ws done with 1.5T Mgnetom Avnto MRI unit (Siemens Medicl Systems) with prmeters nd protocol descried in Tle 1, using phsed rry ody coil. There ws no specil ptient preprtion. MRI fistulogrm ws performed with instilltion of contrst (gdolinium) or sline through the externl opening. Figure 1: Prks clssifiction. Drwing of the nl cnl in the coronl plne shows the Prks clssifiction of perinl fistuls. A = Intersphincteric, B = Trnssphincteric, C = Suprsphinc-teric, D = Extrsphincteric. The externl sphincter is the keystone of the Prks clssifiction Tle 1: Protocols nd prmeters used for MRI fistulogrphy Imging plne Non contrst scn MRI sequences Non contrst ft suppressed scn T1W FSE T2W FSE FS T1W FSE FS T2W FSE Axil nd coronl Sggitl, xil nd coronl Axil nd coronl Sggitl, xil nd coronl TR/TE (ms) 450/ / / /110 FOV (cm) Section thickness Intersection gp (mm) Mtrix MRI: Mgnetic resonnce imging, T1W: T1 weighted, T2W: T2 weighted, FS: Ft suppression, FOV: Field of view, FSE: Fst spin echo Interntionl Journl of Scientific Study Septemer 2017 Vol 5 Issue 6 26

3 Kle, et l.: Role of MRI Fistulogrphy in Preopertive Evlution of Perinl Fistuls Tle 2: MRI grding of no rectl fistul 9 Grde Description 1 Simple liner inter sphinctric fistul 2 Inter sphincteric fistul with inter sphincteric scess or secondry fistulous trck 3 Trns sphincteric fistul 4 Trns sphincteric fistul with scess or secondry trck within the ischionl or ischiorectl foss 5 Suprlevtor nd trnslevtor disese MRI: Mgnetic resonnce imging Tle 3: Prks clssifiction of no rectl fistul 10 Fistul type Inter sphincteric Trns sphincteric Supr sphincteric Extr sphincteric Quoted from Crido et l. 9 Description Confined to inter sphincteric plne, does not cross externl sphincter or levtor muscles Trck psses rdilly through externl sphincter Trck psses upwrd within inter sphincteric plne over puorectlis muscles nd descends through levtor muscles to the ischiorectl foss Course is completely outside externl sphincter Tle 4: MRI findings compred to surgicl findings Anormlity clssifictions MRI findings Surgicl findings Primry trck Intersphincteric 10 9 Trnssphincteric 9 9 Suprsphincteric 2 2 Extrsphincteric 0 0 Fistul detection totl Sinus trck 5 6 Totl (fistul+sinus) Ascess 6 6 Horseshoe fistul 3 3 MRI: Mgnetic resonnce imging Tle 5: Accurcy of MRI for detection of primry trck, scess, horseshoe fistul, nd internl opening MRI finding Sensitivity Specificity PPV NPV Primry trck 100 (20/20) 83.3 (5/6) 95.2 (20/21) 19.2 (5/26) Fistul 83.3 (5/6) 100 (20/20) 100 (5/5) 95.2 (20/21) Ascess 100 (6/6) 100 (6/6) 100 (6/6) 100 (6/6) Horseshoe fistul 100 (3/3) 100 (3/3) 100 (3/3) 100 (3/3) MRI: Mgnetic resonnce imging, PPV: Positive predictive vlue, NPV: Negtive predictive vlue Tle 6 : Comprison of sensitivity nd specificity of our study with interntionl literture Study Sensitivity Specificity Beckinghm et l % 100% Regin et l % 86% Our study 100% 83.3% Figure 2: Anl clock. Axil T2-weighted mgnetic resonnce imge of the mle perineum shows the nl clock digrm used to correctly locte nl fistuls with respect to the nl cnl. AP = Anterior perineum, L = left spect of the nl cnl, NC = Ntl cleft, R = Right spect of the nl cnl fluid fluid tuulr structures with dimeter smller thn 10 mm nd scesses were lrger thn 10 mm. Air pockets within the fluid collection lso suggested the presence of n scess. MRI findings were then correlted with the opertive findings. Surgicl findings were ccepted s the gold stndrd nd were recorded independently y the surgeon. RESULTS Out of the 26 ptients included in the study group with ge rnging from 20 to 67 yers. MRI reveled fistule in 21 (80.7%; 17 mles nd 4 femles) ptients while 5 (19.2%; 3 mles nd 2 femles) ptients hd only perinl sinuses. Out of totl 21 fistule seen, 10 (47.6%) were intersphincteric, 9 (42.8%) were trnssphincteric, nd 2 (9.5%) were suprsphincteric. No extrsphincteric fistul noted (Grph 1). Out of these fistule, 14 (66.6%) were simple, wheres 7 (33.3%) showed ssocited scess formtion, inflmmtion, nd rnching course. Grde 1 ws the most frequent (47.6%) type of norectl fistul. The most common loction of the internl opening of the fistul ws t 6 o clock position. The MRI findings were in ccordnce with surgicl findings in 25 out of 26 ptients regrding type nd extent of fistulin-no. One intersphincteric fistul misdignosed on MRI proved to e sinus (Tle 4). Sttisticl prmeters showed tht MRI hs sensitivity of 100% nd specificity of 83.3% in determining type nd extent of perinl fistul (Tle 5). 27 Interntionl Journl of Scientific Study Septemer 2017 Vol 5 Issue 6

4 Kle, et l.: Role of MRI Fistulogrphy in Preopertive Evlution of Perinl Fistuls Figure 3: ( nd ) T2-weighted FS xil nd coronl: Inter-sphincteric fistul in no with externl opening t 7 o clock position in right uttock nd internl opening t 11 o clock position of nl cnl Figure 6: T1-weighted post-contrst xil nd coronl: Trnssphincteric Y shped recto-cutneous fistul with externl opening t 7 o clock position with right ischiorectl nd glutel scess formtion s descried ove Figure 4: ( nd ) T1-weighed xil nd coronl: Trnssphincteric fistul in no with externl opening t 5 o clock position in left uttock nd internl opening t 3 o clock position of nl cnl on the left side Figure 5: T2-weighted ft suppression xil nd coronl: Suprsphinteric fistul in right uttock with externl opening t 7 o clock position nd internl opening t 6 o clock position DISCUSSION This is retrospective comprtive study etween surgery nd preopertive MRI, iming to precisely evlute the vlue of preopertive MRI exmintion. Until recently, imging hd very little role to ply in the preopertive evlution of perinl fistuls. The dvent of MRI with its excellent soft tissue contrst nd multiplnr cpilities mkes it n idel choice in the preopertive ssessment of perinl fistuls. A detiled ssessment of the ntomic reltionship etween the fistul nd the nl sphincter complex llows surgeons to choose the est surgicl tretment thus significntly reducing recurrence of the disese or possile secondry effects of surgery, such s fecl incontinence.9,14,15 Figure 7: T2-weighted ft suppression xil nd coronl: Perinl sinus trck with externl opening t 7 o clock position in right uttock with horseshoe shped scess involving ilterl ischiorectl foss Grph 1: Mgnetic resonnce imging findings The results of our study indicte tht MRI is highly ccurte for determining the type nd extent of perinl fistule. Sensitivity of 90% nd specificity of 100% seen in our study is comprle to interntionl literture Tles 6. MRI Appernce T1-weighted (T1W) imges give n excellent ntomic overview of the sphincter complex, levtor plte, nd ischiorectl foss. Fistulous trcks, inflmmtion, nd scesses pper s res of low to intermedite signl intensity on T1W imging. T2-weighted (T2W) imges provide good contrst etween the high signl intensity fluid in the trck nd the low signl firous wll of the fistul nd llow dequte differentition of the oundries of the internl nd externl nl sphincters. Active fistulous trcks nd extensions hve high signl intensity on T2W imges, while the sphincters hve low Interntionl Journl of Scientific Study Septemer 2017 Vol 5 Issue 6 28

5 Kle, et l.: Role of MRI Fistulogrphy in Preopertive Evlution of Perinl Fistuls signl intensity. Chronic fistulous trcks or scrs pper hypointense on oth T1W nd T2W imges. Ascesses pper hyperintense on T2W imges due to the presence of pus nd fluid in the center. Gdolinium-enhnced T1W imges re useful to differentite fluid-filled trck from n re of inflmmtion. The trck wll enhnces, wheres the centrl portion is hypointense. Ascesses re lso very well depicted on post-gdolinium imges. 16 The exct loction of the primry trck (ischionl or intersphincteric) is most esily visulized on xil imges; the presence of disruption of the externl nl sphincter differentites trnssphincteric fistul from n intersphincteric one. The internl opening of the fistul is lso est seen in this plne. As mentioned erlier, coronl imges depict the levtor plne, therey llowing differentition of suprlevtor from infrlevtor infection. In our experience, xil T2W ft-suppressed imges were the most useful for locting the fistulous trck (Figure 3-7). CONCLUSION Our study supports tht, MR fistulogrphy precisely demonstrte the ntomy of the perinl region, show the nl sphincter complex nd clerly identify the reltionship of fistuls to the pelvic diphrgm nd ischiorectl foss which hs importnt implictions for surgicl mngement nd outcome. Pre-opertive MRI cn help recognize the unidentified infection, ccurte in the detection of the secondry extension nd scess formtion nd mrkedly decresing the incidence of recurrence nd llowing side effects such s fecl incontinence to e voided. REFERENCES 1. Sinio P. Fistul-in-no in defined popultion. Incidence nd epidemiologicl spects. Ann Chir Gynecol 1984;73: Bhy AK, Kumr N. MRI with MR fistulogrm for perinl fistul: A successful comintion. Clin Gstrointest Mgnetom 2007;1: Lluger J, Plmer J, Pérez C, Monill J, Rié J, Moreno A. The norml nd pthologic ischiorectl foss t CT nd MR imging. Rdiogrphics 1998;18: Prctice prmeters for tretment of fistul-in-no - Supporting documenttion. The stndrds prctice tsk force. The Americn Society of Colon nd Rectl Surgeons. Dis Colon Rectum 1996;39: Buchn R, Grce RH. Anorectl suppurtion: The results of tretment nd the fctors influencing the recurrence rte. Br J Surg 1973;60: Hllign S, Stoker J. Imging of fistul in no. Rdiology 2006;239: Buchnn GN, Hllign S, Brtrm CI, Willims AB, Trroni D, Cohen CR. Clinicl exmintion, endosonogrphy, nd MR imging in preopertive ssessment of fistul in no: Comprison with outcome-sed reference stndrd. Rdiology 2004;233: Morris J, Spencer JA, Amrose NS. MR imging clssifiction of perinl fistuls nd its implictions for ptient mngement. Rdiogrphics 2000;20:623-35; discussion De Miguel Crido J, del Slto LG, Rivs PF, del Hoyo LF, Velsco LG, de ls Vcs MI, et l. MR imging evlution of perinl fistuls: Spectrum of imging fetures. RdioGrphics 2012;32: Prks AG, Gordon PH, Hrdcstle JD. A clssifiction of fistulin-no. Br J Surg 1976;63: Michlopoulos A, Ppdopoulos V, Tziris N, Apostolidis S. Perinl fistuls. Tech Coloproctol 2010;14:S George U, Shot A, Rthore S. MRI in evlution of perinl fistul. J Med Imging Rdit Oncol 2011;55: Lnido M, Mkowiec F, Dmmnn F, Jehle EC, Clussen CD, Strlinger M. Perinl complictions of Crohn s disese: MR imging findings. Eur Rdiol 1997;7: Beckinghm IJ, Spencer JA, Wrd J, Dyke GW, Adms C, Amrose NS. Prospective evlution of dynmic contrst enhnced mgnetic resonnce imging in the evlution of fistul in no. Br J Surg 1996;83: Buchnn G, Hllign S, Willims A, Cohen CR, Trroni D, Phillips RK, et l. Effect of MRI on clinicl outcome of recurrent fistul-in-no. Lncet 2002;360: Spencer JA, Wrd J, Beckinghm IJ, Adms C, Amrose NS. Dynmic contrst-enhnced MR imging of perinl fistuls. Am J Roentgenol 1996;167: Beets-Tn RG, Beets GL, vn der Hoop AG, Kessels AG, Vliegen RF, Beten CG, et l. Preopertive MR imging of nl fistuls: Does it relly help the surgeon? Rdiology 2001;218: How to cite this rticle: Kle SKK, Singh P, Tyde AT, Ptil S, Dhok A. Role of Mgnetic Resonnce Imging Fistulogrphy in Preopertive Evlution of Perinl Fistuls. Int J Sci Stud 2017;5(6): Source of Support: Nil, Conflict of Interest: None declred. 29 Interntionl Journl of Scientific Study Septemer 2017 Vol 5 Issue 6

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