The combination of pelvic magnetic resonance imaging and tridimensional endoanal ultrasound in the preoperative assessment of perianal fistulas

Background: We designed a prospective study of diagnostic accuracy that compared pelvic MRI and 3D-EAUS versus pelvic MRI alone in the preoperative evaluation and postoperative outcomes of patients with perianal fistulas. Material and Methods: The sample size was 72 patients and was divided into two imaging groups. MRI alone was performed in the first group. Both MRI and 3D-EAUS were performed in parallel in the second group. Surgical exploration took place after two weeks and was the standard reference. Park’s classification, the presence of a concomitant abscess cavity or a secondary tract, and the location of the internal opening were recorded. All patients were re-evaluated for complete fistula healing and fecal incontinence (according to the Wexner scale) six months postoperatively. All the collected data were subjected to statistical analysis. Results: Group MRI included 36 patients with 42 fistulas. Group MRI + 3D-EAUS included 36 patients with 46 fistulas. The adjusted sensitivity and negative predictive value were 1.00 for most fistula types in the group of combined imaging. The adjusted specificity highly improved for intersphincteric fistulas, and slightly improved for extrasphincteric fistulas, in the same group. The adjusted balanced accuracy increased for all fistula types, except rectovaginal, which were better visualized only with MRI. The combination of imaging methods showed improved diagnostic accuracy only in the detection of a secondary tract. The healing rate at six months was 100%. Fecal incontinence at six months didn’t present a statistically significant difference between the two groups (Fisher's exact test p-value > 0.9). Patients with complex perianal fistulas had a statistically significant higher probability of undergoing a second surgery (x² test p-value = 0.019). Conclusions: The combination of pelvic MRI and 3D-EAUS showed increased metrics of diagnostic accuracy and should be used in the preoperative evaluation of all patients with perianal fistulas, especially those with complex types.Εισαγωγή: Σχεδιάσαμε μια προοπτική μελέτη διαγνωστικής ακρίβειας, η οποία συνέκρινε τον συνδυασμό της MRI ελάσσονος πυέλου – περινέου και του 3D-EAUS έναντι της MRI μόνης, όσον αφορά την προεγχειρητική διερεύνηση και τα μετεγχειρητικά αποτελέσματα ασθενών που αντιμετωπίστηκαν για περιεδρικά συρίγγια. Υλικό και Μέθοδοι: Το μέγεθος του δείγματος υπολογίστηκε σε 72 ασθενείς και χωρίστηκε σε δύο ομάδες απεικόνισης. Στην πρώτη ομάδα εφαρμόστηκε μόνο MRI ελάσσονος πυέλου – περινέου. Στη δεύτερη ομάδα διενεργήθηκε MRI ελάσσονος πυέλου – περινέου και 3D-EAUS, ενώ θεωρήθηκε ότι οι δύο απεικονίσεις συνδέονταν παράλληλα μεταξύ τους. Η χειρουργική διερεύνηση και θεραπεία των ασθενών έγινε 2 εβδομάδες αργότερα, και θεωρήθηκε η εξέταση αναφοράς (standard reference). Καταγράφηκαν η ταξινόμηση των περιεδρικών συριγγίων κατά Parks, η παρουσία συνοδού αποστηματικής κοιλότητας ή δευτερεύοντος συριγγώδους πόρου, καθώς και η θέση του έσω στομίου του συριγγίου. Όλοι οι ασθενείς επανεκτιμήθηκαν κλινικά τον 6ο μετεγχειρητικό μήνα, έπειτα από την οριστική χειρουργική θεραπεία της νόσου. Αξιολογήθηκαν και καταγράφηκαν η πλήρης επούλωση του χειρουργικού τραύματος και η ύπαρξη ακράτειας κοπράνων, σύμφωνα με την κλίμακα Wexner. Όλα τα συγκεντρωμένα δεδομένα υποβλήθηκαν στην κατάλληλη στατιστική ανάλυση και επεξεργασία. Αποτελέσματα: Η ομάδα MRI συμπεριέλαβε 36 ασθενείς με 42 συρίγγια. Η ομάδα MRI + 3D-EAUS είχε 36 ασθενείς με 46 συρίγγια. Η προσαρμοσμένη ευαισθησία και η προσαρμοσμένη αρνητική προγνωστική αξία είχαν τιμή 1.00 για τους περισσότερους τύπους περιεδρικών συριγγίων, στην ομάδα της συνδυασμένης απεικόνισης. Η προσαρμοσμένη ειδικότητα βελτιώθηκε σημαντικά για τα μεσοσφιγκτηριακά συρίγγια και ελάχιστα για τα εξωσφιγκτηριακά συρίγγια, στην ίδια ομάδα απεικόνισης. Η τιμή της προσαρμοσμένης ισορροπημένης ακρίβειας αυξήθηκε σε όλους τους τύπους περιεδρικών συριγγίων, εκτός από τα ορθοκολπικά συρίγγια, τα οποία φάνηκε πως απεικονίζονταν καλύτερα μόνο με την MRI. Ο συνδυασμός των απεικονιστικών μεθόδων είχε αυξημένη διαγνωστική ακρίβεια μόνο για τον εντοπισμό πιθανού δευτερεύοντος συριγγώδους πόρου. Το ποσοστό επούλωσης του χειρουργικού τραύματος στους 6 μήνες ήταν 100%. Η ακράτεια κοπράνων δεν παρουσίασε καμία στατιστικώς σημαντική διαφορά μεταξύ των δύο ομάδων απεικόνισης στου 6 μήνες (Fisher's exact test p-value > 0.9). Οι ασθενείς με σύνθετα περιεδρικά συρίγγια είχαν στατιστικώς σημαντικά μεγαλύτερη πιθανότητα να υποβληθούν σε επαναληπτικό χειρουργείο για την οριστική θεραπεία της νόσου τους (x² test p-value = 0.019). Συμπεράσματα: Ο συνδυασμός της MRI και του 3D-EAUS έδειξε αυξημένα μέτρα διαγνωστικής ακρίβειας και θα πρέπει να χρησιμοποιείται σε όλους τους ασθενείς με περιεδρικά συρίγγια, ειδικά σε αυτούς με σύνθετου τύπου

Inset Mapper: A software tool in Island cartography

Island cartography deals with special cartographic problems confronted in the portrayal of island regions and demands the use of specially developed software tools. One of the most commonly faced problems is the need of inset map creation for very small islands, and sometimes isolated ones, that must be displayed in the main map. This paper presents the methodology followed for the development of the Inset Mapper (IM) Software toolbox, describes the toolbox, and showcases its ability to create inset maps in Island regions. The IM software tool provides a useful cartographic tool for assisting the selection of the most appropriate position and scale of the inset map in an Island region

Pneumoscrotum as Complication of Blunt Thoracic Trauma: A Case Report

Introduction. Pneumoscrotum is a rare clinical entity. It presents with swollen scrotal sac and sometimes with palpable crepitus. It has many etiologies. One of them is due to blunt trauma of the thoracic cage, causing pneumothorax and/or pneumomediastinum. Case Presentation. We report the case of an 82-year-old male who was transferred to the Emergency Department with signs of respiratory distress after a blunt chest trauma. A CT scan was obtained, and bilateral pneumothoraces with four broken ribs were disclosed. Subcutaneous emphysema expanding from the eyelids to the scrotum was observed, and a chest tube was inserted on the right side with immediate improvement of the vital signs of the patient. Discussion. Pneumoscrotum has three major etiologies: (a) local introduction of air or infection from gas-producing bacteria, (b) pneumoperitoneum, and (c) air accumulation from lungs, mediastinum, or retroperitoneum. These sources account for most of the cases described in the literature. Treatment should be individualized, and surgical consultation should be obtained in all cases. Conclusion. Although pneumoscrotum itself is a benign entity, the process by which air accumulates in the scrotum must be clarified, and treatment must target the primary cause

Myxoma of the small intestine complicated by ileo-ileal intussusception: Report of an extremely rare case

AbstractINTRODUCTIONMyxomas of the small intestine are extremely rare types of primary bowel neoplasms. Their presence can trigger intestinal intussusception in the adults. We present the eighth case of intestinal myxoma reported in the English literature.PRESENTATION OF CASEOur patient is a 44-year-old Caucasian female who presented with clinical and imaging findings of intestinal intussusception. Laparotomy revealed ileo-ileal intussusception caused by an intramural mass of the middle-ileum which was resected. Histological and immunohistochemical studies pointed to the diagnosis of benign intestinal myxoma, while imaging studies of the heart excluded a synchronous cardiac myxoma. Twenty months after surgery she remains disease-free.DISCUSSIONThe myxoma is a benign, true neoplasm which resembles primitive mesenchyme. It occurs predominantly in the heart and is also found in several soft tissues and bones. Myxomas seem to grow at different rates of speed, they infiltrate adjacent structures and they do not metastasize, apart from cardiac variants. Intestinal myxomas share some clinical characteristics which are emphasized.CONCLUSIONMyxomas of the small intestine should be included in the differential diagnosis of ileal tumors in middle-aged women manifesting as intestinal intussusception. Treatment should include wide resection of the affected intestinal segment with primary anastomosis. A close follow-up control of the patients along with cardiac imaging evaluation is recommended postoperatively, in order to detect and treat any possible recurrence of the tumor or a synchronous cardiac myxoma

Extramammary Paget’s Disease of the Vulva: Report of Two Cases

Extramammary Paget’s disease is a rare condition, affecting 6.5% of all patients with Paget’s disease. The most common extramammary site is the vulvar area. Although diagnosis in some patients is difficult to set, early diagnosis is of high importance in order to detect the irreversible progression of the lesion early and prevent distant metastasis. An 89-year-old female and a 69-year-old female presented within three months with an eczematous lesion with leukoplakia in the vulva. The incisional biopsy of the skin revealed extramammary Paget’s disease. Both patients underwent a surgical wide local excision of the lesion and the specimens were sent for histopathological examination. Extramammary Paget’s disease has a high potential for distant malignancies and local recurrence, dictating that surgical excision is the most efficient treatment. The rareness of the condition and the diagnostic difficulties underline the need for early skin biopsy, which is the most efficient diagnostic tool

Giant Echinococcosis of the Liver with Suppuration: A Case Report and Review of the Literature

Purpose: Cystic echinococcosis (CE) is a common, complex parasitic disease that constitutes a major public health concern. CE demonstrates high endemicity in areas where dogs are used for herding or where animal husbandry practices involve close contact with livestock. It can clinically manifest with a variety of signs and symptoms, such as cholangitis, jaundice, pancreatitis, external biliary fistula, inferior vena cava obstruction, portal hypertension, and superinfection. The latter can notably be related to suppuration, either by rupture or bacteremia. The aim of this study is to report our 76-year-old patient who presented with a primarily infected giant-suppurated hydatid cyst of the liver and its surgical management. Methods: In this case, the diagnosis was based primarily on clinical presentation, computed tomography (CT) scan, and magnetic resonance imaging (MRI) of the patient’s abdomen. The surgical procedure of choice was the partial retaining of the pericystic membrane and drainage of the cystic contents (partial pericystectomy). Results: The surgical management and meticulous long-term follow-up of our patient produced a positive outcome without any post-operative complications

HPV-Induced Anal and Peri-Anal Neoplasia, a Surgeon’s Experience: 5-Year Case Series

Purpose: One of the most known sexually transmitted diseases is Condylomata acuminata (CA), a skin lesion occurring due to infection from Human Papilloma Virus (HPV). CA has a typical appearance of raised, skin-colored papules ranging in size from 1 mm to 5 mm. These lesions often form cauliflower-like plaques. Depending on the involved HPV-subtype (either high-risk or low-risk) and its malignant potential, these lesions are likely to lead to malignant transformation when specific HPV subtypes and other risk factors are present. Therefore, high clinical suspicion is required when examining the anal and perianal area. Methods: In this article, the authors aim to present the results of a five-year case series (2016–2021) of anal and perianal cases of CA. Results: A total of 35 patients were included in this study. Patients were categorized based on specific criteria, which included gender, sex preferences, and human immunodeficiency virus infection. All patients underwent proctoscopy and excision biopsies were obtained. Based on dysplasia grade patients were further categorized. The group of patients where high-dysplasia squamous cell carcinoma was present was initially treated with chemoradiotherapy. Abdominoperineal resection was necessary in five cases after local recurrence. Conclusions: CA remains a serious condition where several treatment options are available if detected early. Delay in diagnosis can lead to malignant transformation, often leaving abdominoperineal resection as the only option. Vaccination against HPV poses a key role in eliminating the transmission of the virus, and thus the prevalence of CA