Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both?

PURPOSE: The purpose of the study is to evaluate the diagnostic value of tridimensional endoanal ultrasound (3D-EAUS) and magnetic resonance (MR) in the preoperative assessment of both simple and complex anorectal fistulas. METHODS: All the patients referred for the treatment of anal fistulas were enrolled in this study and underwent, as preoperative assessment, anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS and MR. The results of imaging evaluation were compared with surgical findings, considered as reference standard. RESULTS: During the study period, 124 patients operated on for anal fistulas underwent complete preoperative imaging assessment. Perfect agreement between 3D-EAUS and surgery in the anal fistulas' severity grading was found (K = 1). The fistulas were classified as simple in 68/126 (53.9%) and complex in 58/126 (46.03%) cases, according to fistulas' Parks' classification and the most recent American Guidelines. In both simple and complex anal fistulas, 3D-EAUS did not show a significantly higher accuracy in the evaluation of internal openings, if compared with MR (P = 0.47; McNemar's Chi-square test). In the complex anal fistulas, MR showed a significantly higher accuracy in the evaluation of secondary extensions if compared with 3D-EAUS (P = 0.041; McNemar's Chi-square test), whereas in the simple anal fistulas, no significant difference was found. CONCLUSION: In the preoperative work-up of patients with anorectal fistulas, 3D-EAUS may represent the first-line diagnostic tool. In cases of fistulas classified as complex by 3D-EAUS, MR may be indicated as adjunctive diagnostic imaging examination, to more carefully describe the fistulas' complete anatomy.

Sphincter-saving surgery in low rectal cancer.

A correct surgical approach to rectal cancer today has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary and genital functions. Increased understanding of the natural history, the importance of preoperative accurate staging and new surgical techniques may influence future treatment strategies. The aim of this study was to review and make a reappraisal of the role of sphincter-preserving surgery in the treatment of carcinomas of the lower third of the rectum. From January 1999 to June 2004, 63 consecutive total rectal resections were performed at our surgical department. Thirty-five of these patients, who underwent surgery for a primary adenocarcinoma of the distal rectum (3.5 to 8 cm from the anal verge), were reviewed retrospectively. The preoperative clinical assessment was based largely on T staging, tumor size, fixation and distance from the anal verge. Patient stratification, based on the definitive pathological report, was 3 Dukes' stage A (T1 N0), 21 stage B (T2 N0) and 11 stage C (T2-3-4 N+). The distance from the anal verge was > 5 cm in 30 patients and < 5 cm in 5. Sphincter-saving procedures were performed in 28/35 patients (80%); 7 (20%) had abdominoperineal resections of the rectum for very distal, locally extensive tumours or local recurrence (2 patients). The overall recurrence rate was 11.4%. Postoperative morbidity related to the procedures was low: anastomotic leakage occurred in 10.7% (3/28). Perfect continence was documented in 86.3%. The minimum follow-up time is 12 months. Our data, in agreement with the findings of other Authors, appear to bear out the validity of sphincter-saving procedures in the treatment of cancer of the lower third of the rectum. This approach is possible for the majority of patients. Functional results are good, using an accurate nerve-sparing technique, and may be improved by employing a colonic reservoir in selected cases.

[Small intestinal polyposis in Peutz-Jeghers syndrome: combined treatment with surgery and intra-operative endoscopy]. / La poliposi del tenue nella sindrome di Peutz-Jeghers: trattamento combinato chirurgia-endoscopia intraoperatoria.

Polyps occur throughout the gastrointestinal tract in Peutz-Jeghers syndrome, but the most serious problems are encountered in the management of small bowel polyposis. We report here on a case of Peutz-Jeghers syndrome admitted to hospital for intestinal obstruction and anaemia. The patient was submitted to colonoscopy, oesophagogastro-duodenoscopy and small bowel enema. At laparotomy, multiple intussusceptions were found and we conducted a combined surgical-endoscopic approach. Most of the polyps were identified and removed endoscopically (snare polypectomy). Five enterotomies were performed to remove 18 very large polyps (> 3 cm). Finally, a limited portion of the jejunal tract (20 cm) was resected owing to the presence of multiple, large, obstructive polyps. None of the polyps showed cancerous transformation. The shortcomings of the traditional surgical approach include repeated small bowel resections and often early reoperation to manage complications caused by polyps missed at the time of previous surgery. If surgical intervention is required, intraoperative endoscopy is always indicated. Conservative surgical management, the role of intraoperative endoscopy, planned medical follow-up and the need for a national registration system are stressed.