Patient-Generated Images in Perianal Disease: An Evolving Tool in Proctology.

This article explores the potential benefits and challenges of incorporating Patient-Generated Images (PGIs) into the clinical practice for perianal conditions. PGIs refer to photographs (and video) captured by patients themselves of affected areas of their own bodies to illustrate potential pathologies. It facilitates remote patient assessments and swift evaluation for coloproctologist. They potentially reduce the need for in person follow-up particularly after operation if the patient is asymptomatic. However, concerns with PGI include quality of images, risk of misinterpretation, ethical, legal, and practical problems, especially when imaging private or sensitive body regions. Any platform transmitting and storing PGIs should prioritize data protection with advanced encryption. Comprehensive guidelines should be developed by collaboration between healthcare administrators, regulators, and professionals, and a thorough framework formulated to ensure that quality care is delivered always while respecting patient privacy and dignity. It should be considered as complementary to, rather than a replacement for, traditional clinical consultations. However, patient awareness and education regarding the limitations are key to ensuring that this modality is not misinterpreted or misused.

Should an Incidental Meckel Diverticulum Be Resected? A Systematic Review.

Background: Meckel Diverticulum [MD), a common congenital anomaly of the gastrointestinal tract, poses a dilemma when incidentally encountered during surgery. Despite historical descriptions and known complications of symptomatic MD, the decision to resect an incidental MD (IMD) lacks clear guidelines. This study aims to assess whether resecting IMDs is justified by synthesizing evidence from studies published between 2000 and 2023. Factors influencing this decision, such as demographic risks, surgical advancements and complications, are systematically examined. Methods and Material: Following the PRISMA 2020 guidelines, this review incorporates 42 eligible studies with data on outcomes of asymptomatic MD management. Studies, both favoring and opposing resection, were analyzed. Results: Considering complications, malignancy potential, and operative safety, the risk-benefit analysis presents a nuanced picture. Some authors propose conditional resection based on specific criteria, emphasizing patient-specific factors. Of 2934 cases analyzed for short- and long-term complications, the morbidity rate was 5.69%. Of 571 cases where mortality data were available, all 5 fatalities were attributed to the primary disease rather than IMD resection. Conclusion: The sporadic, unpredictable presentation of IMD and the variability of both the primary disease and the patient make formulation of definitive guidelines challenging. The non-uniformity of complications reporting underscores the need for standardized categorization. While the balance of evidence leans towards resection of IMDs, this study acknowledges the individualized nature of this decision. Increased safety in surgery and anesthesia, along with better understanding and management of complications favor a judicious preference for resection, while taking into account patient characteristics and the primary disease.

An incarcerated epigastric hernia containing stomach.

Most epigastric hernia contains preperitoneal fat or the omentum. Intraabdominal organ herniation is rare and, if present, contains mostly small bowel. Incarcerated epigastric hernia having the stomach as content is infrequent, and only one case has been reported in the literature so far. Herein, we report a rare case of incarcerated epigastric hernia that contains the stomach and was managed with emergency hernioplasty.

Non-Locatable Internal Opening in Anal Fistula Associated with Acute Abscess and Its Definitive Management by Garg Protocol.

Background: Definitive management of acute fistula-abscess (anal fistulas associated with acute abscess) is gaining popularity against the two-staged approach (early abscess drainage with deferred fistula management). However, locating an internal opening (IO) in acute fistula-abscess can be difficult. A recent protocol (Garg protocol) has been shown to be effective in managing anal fistulas with non-locatable IO. Purpose: To test the efficacy of the Garg protocol in managing acute fistula-abscess with non-locatable IO. Methods: Patients with acute fistula-abscess operated by a definitive procedure were included. A preoperative MRI was done in all patients. Patients in whom the IO was non-locatable after clinical, MRI, and intraoperative examination were managed by the three-step Garg protocol. Garg protocol: 1) Reassessment of MRI; 2) In non-horseshoe fistulas, the IO was assumed to be at the point where the fistula tract reached closest to the sphincter-complex; 3) In horseshoe fistulas, the IO was assumed to be located in the midline (anterior or posterior as per the horseshoe location). Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. The long-term healing rate and change in continence (Vaizey scores) were evaluated. Results: A total of 201 patients with acute fistula-abscess were operated over six years, and 19 were lost to follow-up. A total of 182 patients (154-males) were followed up (median-37 months). The IO was locatable in 133/182 (73.1%) (control group) and was non-locatable in 49/182 (26.9%) (study group). The study group was managed as per the Garg protocol. The age, sex-ratio, and fistula parameters were comparable in both groups. The long-term healing rate was 112/133(84.2%) in the IO-locatable group and 43/49 (87.8%) in the IO-non-locatable group (p=0.64, not-significant). The objective continence scores did not change significantly after surgery in both groups. Conclusion: Acute fistula-abscess with non-locatable IO can be managed successfully by the Garg protocol without any risk of incontinence.

Garg scoring system to predict long-term healing in cryptoglandular anal fistulas: a prospective validation study.

Purpose: Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing. Methods: In patients operated for cryptoglandular anal fistulas, preoperative magnetic resonance imaging (MRI) and postoperative MRI was done at 3 months to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system. Results: Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2± 12.4 years; 46 males) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (30.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (specificity and high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting non-healing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%). Conclusion: GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting non-healing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery.

BACKGROUND: The transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS). AIM: To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division. METHODS: Patients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10th postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey's scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE. RESULTS: Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test). CONCLUSION: Division of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).

Including video and novel parameter-height of penetration of external anal sphincter-in magnetic resonance imaging reporting of anal fistula.

The main purpose of a radiologist's expertise in evaluation of anal fistula magnetic resonance imaging (MRI) is to benefit patients by decreasing the incontinence rate and increasing the healing rate. Any loss of vital information during the transfer of this data from the radiologist to the operating surgeon is unwarranted and is best prevented. In this regard, two methods are suggested. First, a short video to be attached with the standardized written report highlighting the vital parameters of the fistula. This would ensure minimum loss of information when it is conveyed from the radiologist to the operating surgeon. Second, inclusion of a new parameter, the amount of external sphincter involvement by the anal fistula. This parameter is usually not included in the MRI report. This can be evaluated as the height of penetration of the external anal sphincter (HOPE) by the fistula. The external anal sphincter plays a pivotal role in maintaining continence. This parameter (HOPE) is distinct from the 'height of internal opening' and assumes immense importance as its knowledge is paramount to prevent damage to the external anal sphincter by the surgeon during surgery.

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

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.

A Novel MRI and Clinical-Based Scoring System to Assess Post-Surgery Healing and to Predict Long-Term Healing in Cryptoglandular Anal Fistulas.

BACKGROUND: Anal fistulas cause great uncertainty and anxiety in patients and surgeons alike. This is largely because of the inability to accurately confirm postoperative fistula healing, especially long-term healing. There is no scoring system available that can objectively assess cryptoglandular anal fistulas for postoperative healing and can also accurately predict long-term healing. METHODS: Several parameters that could indicate anal fistula healing were assessed. Out of these, six parameters (four MRI-based and two clinical) were finalized, and a weighted score was given to each parameter. A novel scoring system (NSS) was developed. A minimum possible score (zero) indicated complete healing whereas the maximum weighted score (n = 20) indicated confirmed non-healing. Scoring was done with postoperative MRI (at least 3 months post-surgery), then compared with the actual healing status, and subsequently correlated with the final long-term clinical outcome. RESULTS: The NSS was validated in 183 operated cryptoglandular fistula-in-ano patients over a 3-year period in whom 283 MRIs (preoperative plus postoperative) were performed. The postoperative follow-up was 12-48 months (median-30 months). The NSS was found to have a very high positive predictive value (98.2%) and moderately high negative predictive value (83.7%) for long-term fistula healing. Additionally, its sensitivity and specificity in predicting healing were 93.9% and 94.7%, respectively. CONCLUSION: Thus, this new scoring system is highly accurate and would be a useful tool for surgeons and radiologists managing anal fistulas. By objectivizing the assessment of postoperative healing, it can both ease and streamline management. Moreover, reliable prediction of recurrence-free long-term healing will greatly allay the apprehensions associated with this dreaded disease.

Migration of biliary stent into the gallbladder: A surprising intraoperative finding.

Post-endoscopic retrograde cholangiopancreatography stenting is a well-established treatment for benign as well as malignant biliary obstruction. The most frequently encountered complication is stent clogging. Stent migration (proximal or distal), on the other hand, is not very common. Proximal migration of a choledochal endoprosthesis into the gallbladder has not yet been reported in the literature.