Puborectalis Muscle Involvement on Magnetic Resonance Imaging in Complex Fistula: A New Perspective on Diagnosis and Treatment

Abstract

Purpose: According to recent studies, magnetic resonance imaging (MRI) assessment of complex fistulas provides a significant benefit compared to fistulography, computed tomography, and ultrasonography. The aim of this study was to describe the accuracy of MRI and the importance of identifying puborectalis muscle involvement on MRI in patients with complex fistula.Methods: All patients who were clinically diagnosed with ‘complex’ or showed multiple fistula tracts underwent fistula MRI. Eligible patients were consecutive patients who underwent fistula MRI between September 2018 and September 2019 at our hospital.Results: A total of 83 patients (74 males, 9 females; 116 tracts) were included in this study. The sensitivity and specificity of MRI in diagnosing fistula tracts were 94.8% and 98.2%, respectively. The sensitivity and specificity in identifying internal opening were 93.9% and 97.3%, respectively. Of the 35 patients with puborectalis muscle involvement in the MRI, 31 images of suprasphincteric-type patients on the Park’s classification were classified. The patients of puborectalis involvement were divided into 2 groups according to the surgical procedure that was performed. There were 12 sphincter-saving procedures and 19 sphincter division procedures performed. Recurrence was seen in 2 patients in the sphincter-saving procedure group, while no case was seen in the sphincter division procedure group. Five complications were found in the sphincter division procedure group, of which 2 reported incontinence.Conclusion: Fistula MRI is a highly accurate examination for evaluating complex fistulas, and the puborectalis muscle involvement findings are very important for diagnosis and treatment.

Efficacy and safety of transanal opening of intersphincteric space in the treatment of high complex anal fistula: A meta‑analysis

“…HCAF is a refractory disease in colorectal anal surgery. The main reasons for this are difficulty in understanding the pathophysiology, risk of copracrasia and high recurrence rates (16)(17)(18). Since Eisenhammer (19) emphasized the importance of the inner sphincter plane in the pathogenesis and spread of the fistula in 1953, the role of the sphincter space in the pathogenesis of the anal fistula is gaining increasing recognition (20,21).…”

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

“…The EAS plays a major role in maintaining continence and risk of damage to the EAS is very high in these fistulas. Because this risk of incontinence is so high, these fistulas are extra concerning[ 4 , 5 , 25 ]. The most commonly performed procedure, fistulotomy, is contraindicated in these fistulas[ 25 ].…”