Anal fistula at roof of ischiorectal fossa inside levator-ani muscle (RIFIL): a new highly complex anal fistula diagnosed on MRI

Garg, Pankaj; Dawka, Sushil; Yagnik, Vipul D; Kaur, Baljit; Menon, Geetha R

doi:10.1007/s00261-021-03261-y

Cited by 10 publications

(12 citation statements)

References 16 publications

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“…The three muscle layers in the sphincter-complex[ 9 ] are (1) Inner circular muscle layer of gut continues downwards in the anal sphincter complex as IAS; (2) Outer longitudinal muscle layer of gut continues downwards in the anal sphincter complex as CLM; and (3) Puborectalis component of levator ani muscle continues downwards in the anal sphincter complex as EAS (Figure 1 ). Conventionally, it was assumed that inside the sphincter-complex, there is only one space where the fistula extends and this space between the IAS and EAS was labelled as the ‘intersphincteric space’.…”

Section: Challenges In Managing These Fistulasmentioning

confidence: 99%

“…Conventionally, it was assumed that inside the sphincter-complex, there is only one space where the fistula extends and this space between the IAS and EAS was labelled as the ‘intersphincteric space’. However, with the availability of higher resolution magnetic resonance imaging (MRI) and increasing experience, it has been demonstrated that there are three potential spaces associated with in these muscle layers through which the fistula can extend[ 9 ].…”

Section: Challenges In Managing These Fistulasmentioning

confidence: 99%

“…The three potential spaces in the anal sphincter-complex are (1) Inner intersphincteric space (inner space): Between IAS and CLM; (2) Middle intersphincteric space (middle space): Between CLM and EAS (conventional intersphincteric space); and (3) Outer-sphincteric space (outer space): Between the lateral muscle fibers of EAS and its covering fascia[ 9 ] (Figure 1 ).…”

Section: Challenges In Managing These Fistulasmentioning

confidence: 99%

“…The fistulas traversing superiorly in (1) Inner intersphincteric space (inner space) between IAS and CLM inside the rectal wall to become a high intrarectal fistula as these fistulas are present between the muscle layers of the rectal wall[ 8 ]. At times, these are erroneously labelled as submucous fistula[ 8 ] (Figures 8 and 9 ); (2) Middle intersphincteric space (middle space) between CLM and EAS become a supralevator fistula (if it continues into the supralevator space) (Figures 2 and 3 ) or a suprasphincteric fistula (if pus extending superiorly in the middle space reaches up to the top of the EAS and then traverses through the junction between the EAS and puborectalis to enter the ischiorectal fossa[ 15 ]) (Figures 4 - 6 ); and (3) Outer-sphincteric space (outer space) between the EAS and its lateral fascia becomes a RIFIL fistula[ 9 ] (Figures 10 - 12 ).…”

Section: Challenges In Managing These Fistulasmentioning

confidence: 99%

“…The high-five anal fistulas include: (1) Supralevator ( Figures 2 and 3 ); (2) Suprasphincteric (Figures 4 - 6 ); (3) Extrasphincteric (Figure 7 ); (4) High intra-rectal (Figures 3 , 8 and 9 )[ 8 ]; and (5) RIFIL (Figures 10-12 )[ 9 ]. These fistulas are considered most dreaded because understanding their anatomy and pathophysiology, proper diagnosis, and successful safe treatment are quite challenging.…”

Section: Introductionmentioning

confidence: 99%

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Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Garg¹,

Yagnik²,

Dawka³

et al. 2022

WJG

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Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.

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Section: Challenges In Managing These Fistulasmentioning

confidence: 99%

Section: Challenges In Managing These Fistulasmentioning

confidence: 99%

Section: Challenges In Managing These Fistulasmentioning

confidence: 99%