Identification of epithelialization in high transsphincteric fistulas

textabstractBackground At present, transanal advancement flap repair (TAFR) is the treatment of choice for transsphincteric fistulas passing through the upper and middle third of the external anal sphincter. It has been suggested that epithelialization of the fistula tract contributes to the failure of the treatment. The aim of this study was to assess the prevalence of epithelialization of the fistula tract and to study its effect on the outcome of TAFR and TAFR combined with ligation of the intersphincteric fistula tract (LIFT). Methods Forty-four patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Nine of these patients underwent a combined procedure of TAFR with LIFT. In all patients the fistula tract was excised from the external opening up to the outer border of the external anal sphincter. In patients undergoing TAFR combined with LIFT an additional central part of the intersphincteric fistula tract was excised. A total of 53 specimens were submitted. Histopathological examination of the specimens was carried out by a pathologist, blinded for clinical data. Results Epithelialization of the distal and intersphincteric fistula tract was observed in only 25 and 22% of fistulas, respectively. There was no difference in outcome between fistulas with or without epithelialization. Conclusions Epithelialization of high transsphincteric fistulas is rare and does not affect the outcome of TAFR and TAFR combined with LIFT

Treatment of Anal Fistulas With High Intersphincteric Extension

<p>BACKGROUND:</p><p>Intersphincteric fistulas with a high upward extension, up to or above the level of the puborectal muscle, in the intersphincteric plane are rare. Most of these fistulas have no external opening and they are frequently associated with a high intersphincteric and/or supralevator abscess. Division of a large amount of internal anal sphincter by extended fistulotomy has a potential risk of diminished fecal continence.</p><p>OBJECTIVE:</p><p>The aim of this study was to evaluate flap repair combined with drainage of associated abscesses in high intersphincteric fistulas.</p><p>DESIGN:</p><p>This study was performed as a retrospective review.</p><p>SETTINGS:</p><p>The study was conducted at the Division of Colon and Rectal Surgery, Erasmus MC, between March 1995 and February 2011.</p><p>PATIENTS:</p><p>Fourteen patients with a cryptoglandular fistula with high intersphincteric extension were included.</p><p>INTERVENTIONS:</p><p>Transanal advancement flap repair combined with intersphincteric and/or extrasphincteric drainage of associated abscesses was performed. Preoperatively, patients underwent endoanal MRI.</p><p>MAIN OUTCOME MEASURES:</p><p>Healing was defined as complete wound healing with absence of symptoms. Patients were followed up to assess the recurrence rate and Rockwood fecal continence score.</p><p>RESULTS:</p><p>In 1 patient the fistula was not associated with an abscess. In 10 patients the fistula tract ended in a high intersphincteric abscess. Three patients presented with a high intersphincteric abscess and a supralevator abscess. Primary healing was observed in 79% of the patients. The 3 patients without primary healing had a supralevator abscess. In these patients, healing was obtained after a second, third, and fourth procedure. The overall healing rate was 100%. Median postoperative Rockwood score was 0 (range, 0-15).</p><p>LIMITATIONS:</p><p>Retrospective design and lack of baseline continence data were the limitations of this study.</p><p>CONCLUSIONS:</p><p>Since most high intersphincteric fistulas have no external opening and are frequently associated with abscesses, preoperative imaging is useful. Flap repair with adequate drainage of the abscesses is successful, except in fistulas with supralevator extension. However, healing may be achieved by additional procedures.</p>

Pro-inflammatory cytokines in cryptoglandular anal fistulas

Sphincter-preserving procedures for the treatment of transsphincteric fistulas fail in at least one out of every three patients. It has been suggested that failure is due to ongoing disease in the remaining fistula tract. Cytokines play an important role in inflammation. At present, biologicals targeting cytokines are available. Therefore, detection and identification of cytokines in anal fistulas might have implications for future treatment modalities. The objective of the present study was to assess local production of a selected panel of cytokines in anal fistulas, including pro-inflammatory interleukin (IL)-1 beta and tumor necrosis factor alpha (TNF-alpha). Fistula tract tissue was obtained from 27 patients with a transsphincteric fistula of cryptoglandular origin who underwent flap repair, ligation of the intersphincteric fistula tract or a combination of both procedures. Patients with a rectovaginal fistula or a fistula due to Crohn's disease were excluded. Frozen tissue samples were sectioned and stained using advanced immuno-enzyme staining methods for detection of selected cytokines, IL-1 beta, IL-8, IL-10, IL-12p40, IL-17A, IL-18, IL-36 and TNF-alpha. The presence and frequencies of cytokine-producing cells in samples were quantitated. The key finding was abundant expression of IL-1 beta in 93 % of the anal fistulas. Frequencies of IL-1 beta-producing cells were highest (> 50 positive stained cells) in 7 % of the anal fistulas. Also, cytokines IL-8, IL-12p40 and TNF-alpha were present in respectively 70, 33 and 30 % of the anal fistulas. IL-1 beta is expressed in the large majority of cryptoglandular anal fistulas, as well as several other pro-inflammatory cytokines

A multicenter experience with peri-rectal tumors: The risk of local recurrence

Peri-rectal tumors are rare and their management is challenging, especially when presenting with local recurrence. The aim of the current study was to report a multicenter series of peri-rectal tumors, focusing on the risk of recurrence

Multispectral MRI centerline tracking in carotid arteries

We propose a minimum cost path approach to track the centerlines of the internal and external carotid arteries in multispectral MR data. User interaction is limited to the annotation of three seed points. The cost image is based on both a measure of vessel medialness and lumen intensity similarity in two MRA image sequences: Black Blood MRA and Phase Contrast MRA. After intensity inhomogeneity correction and noise reduction, the two images are aligned using affine registration. The two parameters that control the contrast of the cost image were determined in an optimization experiment on 40 training datasets. Experiments on the training datasets also showed that a cost image composed of a combination of gradient-based medialness and lumen intensity similarity increases the tracking accuracy compared to using only one of the constituents. Furthermore, centerline tracking using both MRA sequences outperformed tracking using only one of these MRA images. An independent test set of 152 images from 38 patients served to validate the technique. The centerlines of 148 images were successfully extracted using the parameters optimized on the training sets. The average mean distance to the reference standard, manually annotated centerlines, was 0.98 mm, which is comparable to the in-plane resolution. This indicates that the proposed method has a high potential to replace the manual centerline annotation.Image Science and TechnologyApplied Science

Oncological Safety and Potential Cost Savings of Routine vs Selective Histopathological Examination After Appendectomy: Results of the Multicenter, Prospective, Cross-Sectional FANCY Study

Objective: To investigate the oncological safety and potential cost savings of selective histopathological examination after appendectomy. Background: The necessity of routine histopathological examination after appendectomy has been questioned, but prospective studies investigating the safety of a selective policy are lacking. Methods: In this multicenter, prospective, cross-sectional study, inspection and palpation of the (meso)appendix was performed by the surgeon in patients with suspected appendicitis. The surgeon's opinion on additional value of histopathological examination was reported before sending all specimens to the pathologist. Main outcomes were the number of hypothetically missed appendiceal neoplasms with clinical consequences benefiting the patient (upper limit two-sided 95% confidence interval below 3:1000 considered oncologically safe) and potential cost savings after selective histopathological examination. Results: Seven thousand three hundred thirty-nine patients were included. After a selective policy, 4966/7339 (67.7%) specimens would have been refrained from histopathological examination. Appendiceal neoplasms with clinical consequences would have been missed in 22/4966 patients. In 5/22, residual disease was completely resected during additional surgery. Hence, an appendiceal neoplasm with clinical consequences benefiting the patient would have been missed in 1.01:1000 patients (upper limit 95% confidence interval 1.61:1000). In contrast, twice as many patients (10/22) would not have been exposed to potential harm due to re-resections without clear benefit, whereas consequences were neither beneficial nor harmful in the remaining seven. Estimated cost savings established by replacing routine for selective histopathological examination were 725,400 per 10,000 patients. Conclusions: Selective histopathological examination after appendectomy for suspected appendicitis is oncologically safe and will likely result in a reduction of pathologists' workload, less costs, and fewer re-resections without clear benefit