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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Holroyd DJ, Banerjee S, Beavan M, Prentice R, Vijay V, Warren SJ. Colovaginal and colovesical fistulae: the diagnostic paradigm. Tech Coloproctol. 16(2):119-26, 2012 Apr. Observational-Dx 37 Patients To develop an algorithm for the investigation of suspected CVF in order to improve diagnosis and subsequent management. A total of 87.5% patients with a colovesical fistula presented with pathognomic symptoms of faecaluria or pneumaturia. The commonest aetiologies were diverticular disease (72.9%), colonic and gynaecological neoplasia (10.8% each). Computerised tomography (CT) was the most frequently performed investigation (91.9%) and was most sensitive in detecting the fistula (76.5%) and underlying aetiology (94.1%). Colonoscopy was most sensitive in detecting an underlying colonic malignancy (100%). Resectional surgery was performed in 62.1% of cases, although morbidity and 1-year mortality was significant, with rates of 21.7 and 17.4%, respectively. 4
2. Toyonaga T, Mibu R, Matsuda H, et al. Endoanal Ultrasonography of Mucinous Adenocarcinoma Arising from Chronic Fistula-in-ano: Three Case Reports. J. anus rectum colon. 1(3):100-105, 2017. Review/Other-Dx 3 male patients To demonstrate the characteristic endoanal ultrasonography (EAUS) findings in the three patients with mucinous adenocarcinoma arising from fistula-in-ano. We also describe the usefulness of sonography-guided biopsy under anesthesia for the definitive diagnosis of mucinous adenocarcinoma. Three male patients with a 5- to 20-year history of anal fistula were referred to our hospital due to perianal induration, progressive anal pain, or mucopurulent secretion. In all three patients, endosonography revealed a multiloculated complex echoic mass with isoechoic solid components communicating with a trans-sphincteric fistula and sonography-guided biopsy under anesthesia revealed mucinous adenocarcinoma. All patients underwent abdominoperineal resection with lymph node dissection. One patient with a local recurrence died 3 years after surgery and two have remained disease-free for >6 years. 4
3. Yamamoto T, Kotze PG, Spinelli A, Panaccione R. Fistula-associated anal carcinoma in Crohn's disease. [Review]. Expert rev. gastroenterol. hepatol.. 12(9):917-925, 2018 Sep. Review/Other-Dx N/A To evaluate the clinical features, pathology, treatment, and prognosis of fistula-associated anal carcinoma in patients with Crohn's disease (CD). No results stated in abstract. 4
4. Chawla A, Tan MO, Subramanian M, Bosco JI. The perianal "horseshoe". Abdom Radiol. 41(1):203-4, 2016 Jan. Review/Other-Dx N/A To describe the perianal horseshoe. No results stated in abstract. 4
5. Abcarian H.. Anorectal infection: abscess-fistula. Clin. colon rectal surg.. 24(1):14-21, 2011 Mar. Review/Other-Dx N/A To discuss anorectal abscess and fistula. No results stated in abstract. 4
6. Foxx-Orenstein AE, Umar SB, Crowell MD. Common anorectal disorders. Gastroenterol Hepatol (N Y). 10(5):294-301, 2014 May. Review/Other-Dx N/A To review the most common anorectal disorders, including hemorrhoids, anal fissures, fecal incontinence, proctalgia fugax, excessive perineal descent, and pruritus ani, and provide guidelines on comprehensive evaluation and management. No results stated in abstract. 4
7. Eglinton TW, Barclay ML, Gearry RB, Frizelle FA. The spectrum of perianal Crohn's disease in a population-based cohort. Dis Colon Rectum 2012;55:773-7. Review/Other-Dx 1421 patients To document the rate, classification, and time course of symptomatic perianal Crohn's disease in a population-based cohort. Ninety-one percent of IBD patients in the region were recruited. Seven hundred fifteen patients had Crohn's disease, of which 190 (26.6%) patients had symptomatic perianal disease. The median age of patients with perianal disease was 37 years (range, 4-82 years) and 58.4% were female. Median follow-up was 9 years (range, 2 months to 45 years) from Crohn's disease diagnosis. Onset of perianal disease ranged from 18 years pre-Crohn's diagnosis to 33 years post-Crohn's diagnosis. Fistulas were the most common lesion (50% of patients), followed by perianal abscesses (42.1%), fissures (32.6%), skin tags (11.1%), strictures (7.4%), and hemorrhoids (1.6%). The cumulative probability at 20 years of any perianal Crohn's disease was 42.7% and of a perianal fistula 28.3%. 4
8. Schwartz DA, Loftus EV, Jr., Tremaine WJ, et al. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002;122:875-80. Review/Other-Dx 59 Patients To estimate the cumulative incidence and natural history of fistulas in Crohn's disease in the community. At least 1 fistula occurred in 59 patients (35%), including 33 patients (20%) who developed perianal fistulas. Twenty-six (46%) developed a fistula before or at the time of formal diagnosis. Assuming that the 9 patients with fistula before Crohn's disease diagnosis were instead simultaneous diagnoses, the cumulative risk of any fistula was 33% after 10 years and was 50% after 20 years (perianal, 21% after 10 years and 26% after 20 years). At least 1 recurrent fistula occurred in 20 patients (34%). Most fistulizing episodes (83%) required operations, most of which were minor. However, 11 perianal fistulizing episodes (23%) resulted in bowel resection. 4
9. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB, American Gastroenterological Association Clinical Practice Committee. AGA technical review on perianal Crohn's disease. [Review] [223 refs]. Gastroenterology. 125(5):1508-30, 2003 Nov. Review/Other-Dx N/A To provide a technical review of the normal anatomy, definitions, etiology, classification, epidemiology, diagnosis, disease activity assessment, and medical and surgical treatment of perianal Crohn’s disease. No abstract available. 4
10. Ong EM, Ghazi LJ, Schwartz DA, Mortele KJ, Crohn's & Colitis Foundation of America, Inc. Guidelines for imaging of Crohn's perianal fistulizing disease. Inflamm Bowel Dis. 21(4):731-6, 2015 Apr. Review/Other-Dx N/A To discuss the practical indications of imaging in patients with Crohn's disease and perianal fistulas; and to address the inherent advantages and disadvantages of the vast array of imaging tests currently available and address the role of imaging in monitoring treatment options. No abstract available. 4
11. Caliste X, Nazir S, Goode T, et al. Sensitivity of computed tomography in detection of perirectal abscess. Am Surg. 77(2):166-8, 2011 Feb. Observational-Dx 113 Patients To determine the sensitivity of CT scan in detecting perirectal abscesses and to see if immune status impacts the accuracy of CT. One hundred thirteen patients were included in this study. Seventy-four (65.5%) were male and the average age was 47 years. Eighty-seven of 113 (77%) patients were positive on CT for anorectal abscess. Sixty of 113 (53%) patients included in this study were immunocompromised. CT missed 26 of 113 (23%) patients with confirmed perirectal abscess. Eighteen (69%) of these patients were immunocompromised compared with CT-positive patients (42 [48%], P = 0.05). The overall sensitivity of CT in identifying abscess was 77 per cent. 3
12. Schratter-Sehn AU, Lochs H, Vogelsang H, Schurawitzki H, Herold C, Schratter M. Endoscopic ultrasonography versus computed tomography in the differential diagnosis of perianorectal complications in Crohn's disease. Endoscopy. 25(9):582-6, 1993 Nov. Observational-Dx 25 Patients To compare the performance of transrectal or transvaginal endoscopic ultrasonography (EUS) with that of computed tomography (CT) in the diagnosis of perirectal fistulae, abscesses and diffuse inflammatory changes in the lower pelvis in 25 patients with Crohn's disease EUS was superior to CT in diagnosing fistulae (14 vs 4 correct diagnoses) and inflammatory infiltration of the lower pelvic muscles (11 vs 2 correct diagnoses). The methods were equivalent in diagnosing perianorectal abscesses. CT was superior in the detection of inflammatory changes in the pararectal fasciae and fatty tissue which could not be detected by EUS. 4
13. Weisman RI, Orsay CP, Pearl RK, Abcarian H. The role of fistulography in fistula-in-ano. Report of five cases. Dis Colon Rectum. 34(2):181-4, 1991 Feb. Review/Other-Dx 27 patients To present a retrospective review of 27 patients undergoing anal fistulography. Twenty-six fistulograms revealed either direct communication with the anus or rectum, or abscess cavities/tracts, or both. Two fistulograms revealed no radiographic evidence of fistula (one patient had two fistulograms). In 13 of the 27 patients (48 percent) information obtained from the fistulograms revealed either unexpected pathology (n = 7) or directly altered surgical management (n = 6). 4
14. Liang C, Lu Y, Zhao B, Du Y, Wang C, Jiang W. Imaging of anal fistulas: comparison of computed tomographic fistulography and magnetic resonance imaging. Korean J Radiol. 15(6):712-23, 2014 Nov-Dec. Review/Other-Dx N/A To compare the different imaging features of the CT and MRI to demonstrate the relative accuracy of CT fistulography for the preoperative assessment of fistula in ano. No results stated in abstract. 4
15. Soker G, Gulek B, Yilmaz C, et al. The comparison of CT fistulography and MR imaging of perianal fistulae with surgical findings: a case-control study. Abdominal Radiology. 41(8):1474-83, 2016 Aug. Observational-Dx 41 patients To evaluate the diagnostic efficacies of CT fistulography and MRI, in the diagnostic work-up of perianal fistula patients. CT fistulography predicted the correct perianal fistula classification in 30 (73.1%) of the 41 patients, whereas MRI correctly defined fistula classification in 38 (92.7%) of these patients (the K values were 0.621 and 0.896, respectively; with p < 0.001). CT fistulography depicted 29 secondary extensions in 16 patients, whereas MR imaging revealed 28 secondary extensions in 15 patients. A substantial agreement was found between surgical findings and two modalities (K value was 0.789 and 0.793 for CT fistulography and MRI, respectively, with a p value < 0.001). In terms of locations of internal openings, CT fistulography was able to detect the locations in 28 patients (68.2%), whereas MRI was more successful in this aspect, with a number of 35 patients (85.3%). Granulation tissues, inflammation and edema around the fistula, abscesses, and fistular wall fibrosis were also evaluated. 4
16. Kuijpers HC, Schulpen T. Fistulography for fistula-in-ano. Is it useful?. Dis Colon Rectum. 28(2):103-4, 1985 Feb. Review/Other-Dx 25 fistulograms To assess fistulography for anal fistula by reviewing 25 fistulograms. The results as for extensions and internal openings were compared with the surgical findings. Fistulograms were correct in only 16 percent. False-positive results occurred in 10 percent. 4
17. deSouza NM, Gilderdale DJ, Coutts GA, Puni R, Steiner RE. MRI of fistula-in-ano: a comparison of endoanal coil with external phased array coil techniques. Journal of Computer Assisted Tomography. 22(3):357-63, 1998 May-Jun. Observational-Dx 20 patients To compare MRI of fistulas-in-ano using an endoanal coil with that using a pelvic phased array coil and to assess the value of a combined approach by correlating the findings with those at surgery. The concordance between MR and surgery for identifying the presence and site of the collection, the primary track, and the internal opening in both simple and complex cases was superior using the endoanal coil as compared with the phased array. Both coils together reflected the findings of the endoanal coil used alone. However, for supralevator/subcutaneous extension, concordance was superior using the phased array compared with the endoanal coil, and a combined approach reflected the values of the phased array coil used alone. 4
18. Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG. MR Imaging of Perianal Crohn Disease. [Review]. Radiology. 282(3):628-645, 2017 Mar. Review/Other-Dx N/A To summarize current imaging strategies and objectives in patients with perianal Crohn disease (CD), focusing on modern therapeutic strategies and imaging findings, which will assist the gastroenterologist and surgeon in planning palliative or curative treatment options. No results stated in abstract 4
19. Dohan A, Eveno C, Oprea R, et al. Diffusion-weighted MR imaging for the diagnosis of abscess complicating fistula-in-ano: preliminary experience. Eur Radiol. 24(11):2906-15, 2014 Nov. Observational-Dx 24 patients To investigate the role of diffusion-weighted magnetic resonance imaging (DWMRI) in the diagnosis of abscess-complicating fistula-in-ano. Sensitivity was 91.2 % [95 % CI: 76 %-98 %] for T2-weighted TSE MRI and 100 % [95 % CI: 90 %-100 %] for DWMRI detecting fistulas. ADC values were lower in abscesses than in inflammatory masses (P?=?0.714.10(-6)). The area under the ROC curve was 0.971 and the optimal cut-off ADC value was 1.186?×?10(-3) mm(2)/s, yielding a sensitivity of 100 % [95 % CI: 77 %-100 %], a specificity of 90 % [95 % CI: 66 %-100 %], a positive predictive value of 93 % [95 % CI: 82.8 %-100 %] and a negative predictive value of 90 % [95 % CI: 78 %-100 %] for an abscess diagnosis. Fistula conspicuity was greater with DWMRI than with T2-TSE MRI for the two observers (P?=?0.0034 and P?=?0.0007). 3
20. Halligan S, Bartram CI. MR imaging of fistula in ano: are endoanal coils the gold standard?. AJR Am J Roentgenol. 171(2):407-12, 1998 Aug. Observational-Dx 32 Patients To determine the advantage of using endoanal receiver coils to assess fistula in ano by prospective comparison with conventional body coil imaging. Five patients could not tolerate coil insertion. In the remaining 25 patients, endoanal imaging revealed no abnormalities in three patients in whom the body coil image correctly showed Crohn's disease, a sinus, and a transsphincteric fistula. Imaging with both coils revealed sepsis in 16 patients, allowing radiologists to make correct primary track classification in 13 patients on endoanal imaging compared with 15 patients on body coil imaging. Endoanal imaging revealed 10 secondary extensions in eight patients, but further extensions in two of these patients and in a third patient were undetected. All these extensions were seen on body coil imaging. Overall, surgical concordance was 68% for endoanal imaging compared with 96% for conventional body coil imaging. 3
21. Zbar AP, Armitage NC. Complex perirectal sepsis: clinical classification and imaging. [Review] [109 refs]. Tech Coloproctol. 10(2):83-93, 2006 Jul. Review/Other-Tx N/A To provide personal recommendations for the use of specific imaging techniques in complex perirectal sepsis cases along with their clinical limitations. The advantages and limitations of the main forms of imaging are discussed in this review with emphasis on EAUS and endoanal or pelvic phased-array MR fistulography. The new technique of transperineal sonography is highlighted. A small but important group of patients with complex fistula-in-ano require specialized imaging. There are specific limitations of endoanal ultrasound (EAUS) which necessitate pelvic phased-array MR imaging. Initial work suggests that EAUS may have a role in intraoperative use for image-guided drainage of recurrent abscesses where operative interpretation can be difficult. The coloproctologist in a tertiary referral center must acquire the skills of ultrasound performance in order to successfully treat fistulous disease, suggesting a role for formal imaging accreditation as part of coloproctological training. 4
22. Sahni VA, Ahmad R, Burling D. Which method is best for imaging of perianal fistula?. [Review] [17 refs]. Abdom Imaging. 33(1):26-30, 2008 Jan-Feb. Review/Other-Dx N/A To find, using "evidence based medicine" (EBM) methods, the optimal technique for fistula classification: MRI, anal endosonography (AES) or clinical examination. The highest-ranking evidence found was level 1b. MRI is more sensitive 0.97(CI 0.92-1.01) than clinical examination, 0.75(0.65-0.86) but comparable to AES, 0.92(0.85-0.99) for discriminating complex from simple disease. The positive LR for MRI confirming complex disease is 22.7 compared to 2.1 and 6.2 for clinical examination and AES, respectively. 4
23. Lo Re G, Tudisca C, Vernuccio F, et al. MR imaging of perianal fistulas in Crohn's disease: sensitivity and specificity of STIR sequences.[Erratum appears in Radiol Med. 2016 Apr;121(4):252; PMID: 26828908]. Radiol Med (Torino). 121(4):243-51, 2016 Apr. Observational-Dx 31 patients To evaluate the role of the STIR sequence in the detection and characterization of perianal fistulae comparing it to the post-contrast T1 sequence and correlating it with rectal examination under anesthesia. 29 fistulas were detected in 25 patients who underwent an MR study. There was no significant difference between MR imaging and exploration under anesthesia. For the detection of perianal fistulas of any type, there was a perfect statistical agreement between gadolinium-enhanced and STIR sequences (kappa value = 1). 4
24. Yildirim N, Gokalp G, Ozturk E, et al. Ideal combination of MRI sequences for perianal fistula classification and the evaluation of additional findings for readers with varying levels of experience. Diagn Interv Radiol. 18(1):11-9, 2012 Jan-Feb. Observational-Dx 33 MRI examinations in 26 patients To assess the contribution of various magnetic resonance imaging (MRI) sequences in determining the type of perianal fistula and in obtaining critical information for surgical decisions, as well as to define the optimal combination of sequences for readers with varying levels of experience. A statistically significant concordance between the fistula classification and surgery was achieved with the FS-CE-T1W-GRE sequence for Reader 1 (Cramer's V=0.701, P = 0,022) and Reader 3 (Cramer's V=0.716, P = 0,043). For Reader 2, statistically significant concordance between fistula classification and surgery was achieved with the FS-CE-T1W-GRE (Cramer's V=0.703, P = 0,011) and the T2W images (Cramer's V=0.648, P = 0,027). For all sequences, there was statistically significant agreement between readers for fistula classification, internal opening location, and the presence of sinus tracts, abscess, a horseshoe component, and inflammation. 3
25. Visscher AP, Felt-Bersma RJ. Endoanal ultrasound in perianal fistulae and abscesses. [Review]. ULTRASOUND Q.. 31(2):130-7, 2015 Jun. Review/Other-Dx N/A To review the use of endoanal ultrasound in perianal fistulae and abscesses. No results stated in abstract. 4
26. Buchanan GN, Bartram CI, Williams AB, Halligan S, Cohen CR. Value of hydrogen peroxide enhancement of three-dimensional endoanal ultrasound in fistula-in-ano. Dis Colon Rectum. 48(1):141-7, 2005 Jan. Observational-Dx 19 patients To compare the accuracy of three-dimensional endoanal ultrasound with that of hydrogen peroxide enhanced three-dimensional endoanal ultrasound in diagnosing recurrent or complex fistula-in-ano. Patients had previously undergone a median of three fistula operations. Four had Crohn's disease. There were 21 internal openings and primary tracks in 19 patients: 1 superficial, 1 intersphincteric, 18 transsphincteric, and 1 extrasphincteric. Fourteen patients had 19 secondary tracks. Both techniques detected fistula tracks in 19 of 21 (90 percent) patients. There was no significant difference between three-dimensional endoanal ultrasound and hydrogen peroxide-enhanced three-dimensional endoanal ultrasound in classifying internal openings (19/21 (90 percent) vs. 18/21 (86 percent)), primary tracks (17/21 (81 percent) vs. 15/21 (71 percent)), or secondary tracks (13/19 (68 percent) vs. 12/19 (63 percent)). Where three-dimensional endoanal ultrasound correctly detected an internal opening, gas from hydrogen peroxide enhancement was present in 8 of 18 (44 percent) studies. Similarly, gas made primary tracks more conspicuous in 6 of 19 (32 percent) and secondary tracks in 6 of 13 (46 percent) of those detected. 4
27. Sun Y, Cui LG, Liu JB, Wang JR, Ping H, Chen ZW. Utility of 360degree Real-time Endoanal Sonography for Evaluation of Perianal Fistulas. J Ultrasound Med. 37(1):93-98, 2018 Jan. Observational-Dx 122 patients To assess the diagnostic accuracy and performance of 360° endoanal sonography for preoperative evaluation of perianal fistulas using surgical results as a reference standard. The 122 patients studied included 111 male and 11 female patients. Endoanal sonography was able to show and track hypoechoic lesions, their locations, and internal openings of the fistulas. Compared with surgical results, endoanal sonography had sensitivity of 92.2%, specificity of 100%, and accuracy of 93.4% for the diagnosis of perianal fistulas. Also, endoanal sonography had accuracy of 87.4% for determining fistula types based on the Parks classification and 94.6% for identifying internal openings of the fistulas. 3
28. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology. 233(3):674-81, 2004 Dec. Observational-Dx 104 patients To prospectively evaluate the relative accuracy of digital examination, anal endosonography, and magnetic resonance (MR) imaging for preoperative assessment of fistula in ano by comparison to an outcome-derived reference standard. There was a significant linear trend (P < .001) in the proportion of fistula tracks (n = 108) correctly classified with each modality, as follows: clinical examination, 66 (61%) patients; endosonography, 87 (81%) patients; MR imaging, 97 (90%) patients. Similar trends were found for the correct anatomic classification of abscesses (P < .001), horseshoe extensions (P = .003), and internal openings (n = 99, P < .001); endosonography was used to correctly identify the internal opening in 90 (91%) patients versus 96 (97%) patients with MR imaging. Agreement between the outcome-derived reference standard and digital examination, endosonography, and MR imaging for classification of the primary track was fair (kappa = 0.38), good (kappa = 0.68), and very good (kappa = 0.84), respectively, and fair (kappa = 0.29), good (kappa = 0.64), and very good (kappa = 0.88), respectively, for classification of abscesses and horseshoe extensions combined. 2
29. Cheong DM, Nogueras JJ, Wexner SD, Jagelman DG. Anal endosonography for recurrent anal fistulas: image enhancement with hydrogen peroxide. Dis Colon Rectum. 36(12):1158-60, 1993 Dec. Review/Other-Dx 2 patients To accentuate tissue interface layers imaging at the level of the fistula tract by introducing hydrogen peroxide. In order to accentuate tissue interface layers at the level of the fistula tract, we introduced hydrogen peroxide into the fistula tract through the external opening during anal ultrasonography in two patients with recurrent anal fistula. Hydrogen peroxide injection resulted in hyperechoic imaging of the preinjection hypoechoic horseshoe fistula tract. Endosonographic findings were confirmed at the time of surgery in both patients. 4
30. West RL, Zimmerman DD, Dwarkasing S, et al. Prospective comparison of hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas. Diseases of the Colon & Rectum. 46(10):1407-15, 2003 Oct. Review/Other-Dx 21 patients To determine agreement between hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in the preoperative assessment of perianal fistulas and to compare these results with the surgical findings. The median time between hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging was 66 (interquartile range, 21-160) days; the median time between the last study (hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography or endoanal magnetic resonance imaging) and surgery was 154 (interquartile range, 95-189) days. Agreement for the classification of the primary fistula tract was 81 percent for hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and surgery, 90 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. For secondary tracts, agreement was 67 percent for hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and surgery, 57 percent for endoanal magnetic resonance imaging and surgery, and 71 percent for hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in case of circular tracts and 76 percent, 81 percent, and 71 percent, respectively, in case of linear tracts. Agreement for the location of an internal opening was 86 percent for hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and surgery, 86 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. 4
31. Brillantino A, Iacobellis F, Reginelli A, et al. Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both?. Radiol Med (Torino). 124(5):339-349, 2019 May. Observational-Dx 124 patients 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. 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. 3
32. Senatore PJ Jr.. Anovaginal fistulae. [Review] [36 refs]. Surg Clin North Am. 74(6):1361-75, 1994 Dec. Review/Other-Dx N/A To review anovaginal fistulae. No results stated in abstract. 4
33. Andreani SM, Dang HH, Grondona P, Khan AZ, Edwards DP. Rectovaginal fistula in Crohn's disease. [Review] [65 refs]. Dis Colon Rectum. 50(12):2215-22, 2007 Dec. Review/Other-Dx 53 articles To review the current strategic options to best manage rectovaginal fistula in Crohn's disease. The management of rectovaginal fistula, representing 9 percent of all fistulas, remains a challenge in the setting of Crohn's disease. Medical treatments are not favorable with low rates of long-term symptomatic control and unacceptable high rates of recurrence. Several novel and new surgical techniques have been described, and rectal advancement flap, in selected patients, seems to have the most successful results. 4
34. Champagne BJ, McGee MF. Rectovaginal fistula. [Review] [76 refs]. Surg Clin North Am. 90(1):69-82, Table of Contents, 2010 Feb. Review/Other-Dx N/A To offer a disease-based review of traditional management strategies and highlights the variety of technical approaches that are currently effective for rectovaginal fistula. No results stated in abstract. 4
35. Kuhlman JE, Fishman EK. CT evaluation of enterovaginal and vesicovaginal fistulas. J Comput Assist Tomogr. 14(3):390-4, 1990 May-Jun. Review/Other-Dx 25 cases To review computed tomography of 25 cases of enterovaginal or vesicovaginal fistula. A CT finding of contrast within the vagina provided definitive confirmation of the suspected diagnosis of vaginal fistula in 60% of patients (15 of 25), a detection rate superior to conventional examinations in our series. Other CT findings suggestive of vaginal fistulas included detection of air (20 of 25) and/or fluid (5 of 25) within the vagina. 4
36. Giordano P, Drew PJ, Taylor D, Duthie G, Lee PW, Monson JR. Vaginography--investigation of choice for clinically suspected vaginal fistulas. Dis Colon Rectum 1996;39:568-72. Review/Other-Dx 27 Patients To review our total experience of vaginography to fully assess its capabilities for diagnosis and evaluation of suspected vaginal fistulas. Vaginography successfully identified 19 of 24 fistulas, giving a sensitivity of 79 percent. In our series, barium enema was only able to identify 9 percent of fistulas arising from the colon. 4
37. Wychulis AR, Pratt JH. Sigmoidovaginal fistulas. A study of 37 cases. Arch Surg. 92(4):520-4, 1966 Apr. Review/Other-Dx 37 patients To review different cases of fistulas. No results stated in abstract. 4
38. Amendola MA, Agha FP, Dent TL, Amendola BE, Shirazi KK. Detection of occult colovesical fistula by the Bourne test. AJR. American Journal of Roentgenology. 142(4):715-8, 1984 Apr. Observational-Dx 28 patients To study the value of different diagnostic tests in the detection of colovesical fistulas. The fistulas were demonstrated by barium enema in 10 of 20 patients and by cystography in eight of 26. Cystoscopy was diagnostic in 11 of 25 patients and sigmoidoscopy in four of 24. Methylene blue test was positive in five of six patients, and in one patient given a charcoal enema the material appeared in the urine. The Bourne test, consisting of radiography of the centrifuged urine samples obtained immediately after a nondiagnostic barium enema, was positive in nine of 10 patients. In seven of these 10 patients, the Bourne test was the only positive evidence of an otherwise occult colovesical fistula later proven at surgery. 4
39. Hsieh JH, Chen WS, Jiang JK, Lin TC, Lin JK, Hsu H. Enterovesical fistula: 10 years experience. Chung Hua I Hsueh Tsa Chih (Taipei). 59(5):283-8, 1997 May. Observational-Dx 30 patients To investigate the most appropriate diagnostic method and to discuss the choice among different surgical managements for enterovesical fistulas. Recurrent urinary tract infection (UTI) accounted for 73% and was the most common presenting symptom. Fecaluria (43%) and urine per rectum (40%) were another two common presenting symptoms. The major cause of these cases was malignancy (36%), followed by postoperative radiotherapy (17%) and iatrogenic injury (17%). Most of these cases were diagnosed by cystography (90%), barium enema (75%) or cystoscopy (69%). The rectum (52%) was the most common site involved, followed by the sigmoid colon (39%). The surgical management was individualized for each patient according to the general condition and the disease process. 4
40. Botsikas D, Pluchino N, Kalovidouri A, et al. CT vaginography: a new CT technique for imaging of upper and middle vaginal fistulas. Br J Radiol. 90(1073):20160947, 2017 May. Review/Other-Dx 3 patients To test the feasibility and to explore the potential role of a new CT imaging technique implementing vaginal introitus obstruction and opacification of the vagina with iodine contrast agent, to show patency of a fistula. The examinations were technically successful. In one patient, it revealed the presence of fistulous pathways from the vaginal fornix along the bilateral infected surgical prostheses. In a second patient, it showed a fistula between the vagina and the necrotic cavity of a recurrent cervical cancer. In a third patient, it proved the absence of a suspected vaginal fistula. 4
41. COE FO.. VAGINOGRAPHY. Am J Roentgenol Radium Ther Nucl Med. 90:721-2, 1963 Oct. Review/Other-Dx N/A To discuss different cases where vaginography was performed. No results stated in abstract. 4
42. WOLFSON JJ.. VAGINOGRAPHY FOR DEMONSTRATION OF URETEROVAGINAL, VESICOVAGINAL, AND RECTOVAGINAL FISTULAS, WITH CASE REPORTS. Radiology. 83:438-41, 1964 Sep. Review/Other-Dx N/A To present three well-known types of fistula in terms of their demonstration by a procedure which has been entitled "vaginography". No results stated in abstract. 4
43. Stoker J, Rociu E, Schouten WR, Lameris JS. Anovaginal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR. American Journal of Roentgenology. 178(3):737-41, 2002 Mar. Observational-Dx 19 patients To compare the accuracy of endoluminal sonography and endoluminal MR imaging in revealing the location of anovaginal and rectovaginal fistulas. In 12 of the 13 patients, the fistula was found during surgery: seven of the fistulas were anovaginal, and five were rectovaginal. Findings of endoluminal sonography were true-positive in 11 patients, true-negative in one, and false-negative in one. Findings of endoluminal MR imaging were true-positive in 11 patients, false-negative in one, and false-positive in one. Positive predictive value for endoluminal sonography and endoluminal MR imaging were 100% and 92%, respectively. Imaging findings for anal sphincter defects were comparable. 4
44. Yee LF, Birnbaum EH, Read TE, Kodner IJ, Fleshman JW. Use of endoanal ultrasound in patients with rectovaginal fistulas. Diseases of the Colon & Rectum. 42(8):1057-64, 1999 Aug. Observational-Dx 25 patients To define the role of endoanal ultrasound in the evaluation and management of patients with rectovaginal fistula. Twenty-five females underwent endoanal ultrasound before rectovaginal fistula repair. Mean age was 34 years. Rectovaginal fistulas were caused by obstetric trauma (19 patients; 76 percent), cryptoglandular disease (5 patients; 20 percent), and Crohn's disease (1 patient; 4 percent). Previous rectovaginal fistula repair had been performed in ten patients (40 percent). A history of anal incontinence was present in ten patients (40 percent). Rectovaginal fistula location was above (15 patients), at (7 patients), or below (3 patients) the dentate line. Rectovaginal fistula size was <5 mm (19 patients; 76 percent) or >5 mm (6 patients; 24 percent). Anal manometry revealed decreased sphincter pressures (resting or squeeze) in 12 patients (48 percent). Pudendal nerve latency was abnormal in three patients (9 percent). Endoanal ultrasound identified the rectovaginal fistula in 7 patients (28 percent) and an anterior sphincter defect in 23 patients (92 percent). At surgery sphincter injuries were identified in 23 patients (92 percent). Treatment was either sliding flap repair with anal sphincter reconstruction (22 patients; 88 percent) or sliding flap repair alone (3 patients; 12 percent). Repair of the rectovaginal fistula was successful in 23 patients (92 percent). Complications occurred in 11 patients (44 percent): two recurrent rectovaginal fistulas, five infections, two skin separations, one ectropion, and one hematoma. The two patients with recurrent rectovaginal fistula had prior repairs, and both were subsequently repaired successfully. Of the 11 patients with preoperative anal incontinence, 6 patients (54 percent) were continent and 2 (18 percent) improved after surgery. Cause, size, location, and previous repair of fistula had no effect on final outcome. 3
45. Yin HQ, Wang C, Peng X, et al. Clinical value of endoluminal ultrasonography in the diagnosis of rectovaginal fistula. BMC med. imaging. 16:29, 2016 Apr 06. Observational-Dx 30 Patients To explore the clinical value of endoluminal biplane ultrasonography in the diagnosis of rectovaginal fistula (RVF). All of the internal openings located at the anal canal and rectum of the 28 patients and confirmed during surgery were revealed by preoperative endosonography, which showed a positive predictive value of 100%. Regarding the 30 internal openings located in the vagina during surgery, the positive predictive value of preoperative endosonography was 93%. The six cases of simple fistulas confirmed during surgery were revealed by endosonography; for the 22 cases of complex fistula confirmed during surgery, the positive predictive value of endosonography was 90%. Surgery confirmed 14 cases of anal fistula and 14 cases of RVF, whereas preoperative endoluminal ultrasonography suggested 16 cases of anal fistula and 12 cases of RVF, resulting in positive predictive values of 92.3 and 93%, respectively. 4
46. Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR. Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 2007;94:333-40. Observational-Dx 1885 IPAA operations To assess functional outcome, complications and quality of life (QoL) after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis using data from a prospective database and annual standardized questionnaires. Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. 4
47. Reber JD, Barlow JM, Lightner AL, et al. J Pouch: Imaging Findings, Surgical Variations, Natural History, and Common Complications. [Review]. Radiographics. 38(4):1073-1088, 2018 Jul-Aug. Review/Other-Dx N/A To list the most common indications for J pouch formation and describe the relative strengths and weaknesses of the surgical variations; to describe the indications for CT, MR imaging, fluoroscopic, and US evaluation of the J pouch and associated complications; and to discuss the most common structural, inflammatory, and neoplastic complications after J pouch surgery No results stated in abstract. 4
48. Liszewski MC, Sahni VA, Shyn PB, et al. Multidetector-row computed tomography enterographic assessment of the ileal-anal pouch: descriptive radiologic analysis with endoscopic and pathologic correlation. J Comput Assist Tomogr. 36(4):394-9, 2012 Jul-Aug. Observational-Dx 35 patients To describe the multidetector-row computed tomography enterographic (MD-CTE) features of the ileal-anal pouch after ileal pouch anal anastomosis (IPAA) surgery and correlate them with pouch endoscopy and histopathologic findings. Of the 35 patients, 33 (94%) had at least one MD-CTE finding of active or chronic pouch inflammation and 27 patients (77%) had at least one MD-CTE finding of active pouch inflammation. Of the 13 patients who underwent endoscopy and biopsy, the total radiographic score demonstrated a strong positive correlation with endoscopic score (r = 0.81; P = 0.001) and a moderate positive correlation with histopathologic score (r = 0.56; P = 0.047). The radiographic active inflammation score demonstrated a strong positive correlation with endoscopic score (r = 0.83; P = 0.0004), but only a weak nonsignificant positive correlation with histopathologic score (r = 0.492, P = 0.087). 3
49. Berry N, Sinha SK, Bhattacharya A, et al. Role of Positron Emission Tomography in Assessing Disease Activity in Ulcerative Colitis: Comparison with Biomarkers. Dig Dis Sci. 63(6):1541-1550, 2018 Jun. Observational-Dx 60 patients To conduct a prospective observational study with the aim of assessing and correlating ulcerative colitis (UC) disease activity by clinical criteria, endoscopy, histology, serum and fecal biomarkers, and FDG PET-CT. Of 60 enrolled patients, 10% patients had proctitis, 43.3% left-sided colitis, and 46.7% extensive colitis. ESR, CRP, FC levels, and rectal PET activity were significantly higher in groups with moderate and severe disease activity. Rectal PET activity showed a significant correlation with the Mayo score (k?=?0.465, p?<?0.001), endoscopic subscore (k?=?0.526, p?<?0.001), histological score (k?=?0.496, p?<?0.001), and FC (k?=?0.279, p?=?0.031). Extent evaluation by FDG PET-CT and colonoscopy showed a significant correlation (k?=?0.582, p?<?0.001). Besides, FDG PET-CT identified sacroiliitis in one patient and adenocarcinoma in one patient. 3
50. Shyn PB.. 18F-FDG positron emission tomography: potential utility in the assessment of Crohn's disease. [Review]. Abdom Imaging. 37(3):377-86, 2012 Jun. Review/Other-Dx N/A To review the potential utility of 18F-FDG positron emission tomography in the assessment of Crohn's disease. No results stated in abstract. 4
51. Shyn PB, Mortele KJ, Britz-Cunningham SH, et al. Low-dose 18F-FDG PET/CT enterography: improving on CT enterography assessment of patients with Crohn disease. Journal of Nuclear Medicine. 51(12):1841-8, 2010 Dec. Observational-Dx 13 patients To evaluate the diagnostic efficacy of low-dose, combined 18F-FDG PET/CT enterography (PET/CTE), compared with CT enterography (CTE) alone, in theassessment of patients with Crohn disease. In 3 (23.1%) of 13 patients, 18F-FDG uptake using PET/CTE revealed active inflammation in a bowel segment not evident using CTE (n = 2) or revealedan enterocolic fistula missed with CTE (n = 1). Visual interpretation of both PET/CTE and CTE images detected the presence of disease in all bowel segments with more than mild inflammation (sensitivity, 100%; specificity, 89.7%; positive predictive value, 78.9%; and negative predictive value, 100%). Correlation to inflammation grade per patient was the strongest for the SUVmax ratio (0.735, P = 0.004) and SUVmax (0.67, P = 0.013), as compared with the CTE score (0.62, P = 0.024). Correlation with inflammation per bowel segment was higher for the CTE score (0.79, P < 0.0001) than the SUVmax ratio (0.62, P < 0.0001) or SUVmax (0.48, P < 0.0001). SUVmax correlated strongly with serum C-reactive protein (0.82, P = 0.023), but CTE score did not. 2
52. Brown JJ, Balfe DM, Heiken JP, Becker JM, Soper NJ. Ileal J pouch: radiologic evaluation in patients with and without postoperative infectious complications. Radiology. 174(1):115-20, 1990 Jan. Observational-Dx 18 patients To study the ileograms and computed tomographic (CT) examinations of 18 patients who had undergone surgical construction of an ileal J pouch and ileoanal anastomosis. 10 had developed postoperative infectious complications and eight had not. The initial ileograms obtained 4 weeks postoperatively proved to be unhelpful in predicting future infectious complications, showing abnormalities in only two of 10 patients. Ileography and CT performed at the time of the complications showed abnormalities in eight of nine and nine of 10 patients, respectively. 4
53. Sahi KS, Lee KS, Moss A, et al. MR Enterography of the Ileoanal Pouch: Descriptive Radiologic Analysis With Endoscopic and Pathologic Correlation. AJR Am J Roentgenol. 205(5):W478-84, 2015 Nov. Observational-Dx 54 patients To describe the MR enterography (MRE) appearance of inflammation of the ileoanal pouch after ileal pouch-anal anastomosis (IPAA) surgery and to correlate it with pouch endoscopic and histopathologic findings. The composite MRI score had strong positive correlation with the endoscopic score (r = 0.61; p = 0.0005) but weak positive correlation with the histopathologic score (r = 0.31; p = 0.10, not statistically significant). The active inflammation MRI score had moderate positive correlation with the endoscopic score (r = 0.57; p = 0.0017) and weak positive correlation with the histopathologic score (r = 0.20; p = 0.31, not statistically significant). An MRI score >/= 4 indicated the best results, with sensitivity of 86%, specificity of 79%, positive predictive value of 80%, negative predictive value of 85%, and accuracy of 82% for pouch inflammation. A positive likelihood ratio of 4.00 and negative likelihood ratio of 0.18 were obtained. 3
54. Tutein Nolthenius CJ, Bipat S, Mearadji B, et al. MRI characteristics of proctitis in Crohn's disease on perianal MRI. Abdominal Radiology. 41(10):1918-30, 2016 Oct. Observational-Dx 58 Patients To study which MRI features are valuable in assessing proctitis. Perianal MRI of 58 CD patients were included. Wall thickness, rectal mural fat, creeping fat, and size of mesorectal lymph nodes showed a significant correlation with endoscopy for =2 observers (p = 0.000-0.023, p = 0.011-0.172, p = 0.007-0.011 and p = 0.000-0.005, respectively) with a kappa/intraclass correlation coefficient of =0.60 for =2 observer pairs. Perimural T2 signal and perimural enhancement significantly correlated to endoscopy (all p values =0.05) for all three observers and the reproducibility was =0.40 for =2 observer pairs. Mural T2 signal and degree and pattern of T1 enhancement showed significant correlation to endoscopy for two observers, but with poor to moderate reproducibility 3
55. Nadgir RN, Soto JA, Dendrinos K, Lucey BC, Becker JM, Farraye FA. MRI of complicated pouchitis. AJR Am J Roentgenol. 187(4):W386-91, 2006 Oct. Observational-Dx 9 Patients To assess the ability of MRI to identify the presence of inflammation related to the pouch reservoir in symptomatic patients with an ileal pouch-anal anastomosis who present with clinically suspected complicated pouchitis. MRI showed mucosal disease (pouch wall thickening and enhancement) in five of the nine patients and was confirmed by both endoscopic and pathologic impressions in all five cases. MRI showed findings of extramucosal disease (peripouch fat stranding, fluid collection, fistula or sinus tract formation, lymphadenopathy, fatty proliferation) in seven of the nine patients. Thus, two patients with normal pouch mucosa by endoscopic and pathologic evaluations had evidence of extramucosal disease on MRI. Of these two, one patient had a large pelvic peripouch abscess, and the other had a small ischiorectal abscess, both of which were drained under CT guidance. The two remaining patients showed normal results according to MRI, endoscopic, and histopathologic criteria. Of the nine patients imaged, seven have a final diagnosis of Crohn's disease, while the remaining two continue to have a diagnosis of ulcerative colitis. The final diagnosis of Crohn's disease was made by the patients' gastroenterologist and surgeon using histologic and endoscopic criteria along with laboratory results and clinical course. 4
56. Cao F, Ma TH, Liu GJ, et al. Correlation between Disease Activity and Endorectal Ultrasound Findings of Chronic Radiation Proctitis. Ultrasound in Medicine & Biology. 43(10):2182-2191, 2017 10. Observational-Dx 70 Patients To summarize the imaging features of chronic radiation proctitis (CRP) on endorectal ultrasound (ERUS) and investigate the value of ERUS in the evaluation of disease activity. 40 CRP patients and 30 control patients were investigated by ERUS. Rectal wall thickness and layers, ulcers and rectovaginal fistulas were evaluated by B-mode ultrasound. Power Doppler imaging was used to evaluate the vascularity of the rectal wall using a semiquantitative score. Disease activity was calculated according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 (CTCAE 4.0). Imaging findings for patients with mild and severe CRP were compared. For 30 patients in the control group, the average maximum thickness of the rectal wall was 3.07 ± 0.73 mm, with all exhibiting typical wall stratification and level 0 vascularity. For the 40 CRP patients, there was marked thickening of the rectal wall (average thickness = 9.42 ± 1.94 mm), which was significantly thicker than in the control group (p < 0.05). The rectal walls of the mild group were significantly thinner than those of the severe group (8.71 ± 1.67 mm vs. 10.00 ± 2.00 mm, p < 0.05). Among the 22 severe cases, 19 cases (19/22, 86.4%) exhibited hyper-vascularity (level IV) or blurred wall stratification (including hypo-echoic submucosa, ulcer and fistula); 12 of the 18 mild cases (166.7%) exhibited a vascularity of level III and typical wall stratification. A significant association (p < 0.05) was observed between stratification and vascularity of the rectal wall and CRP activity. When ERUS findings of blurred rectal wall stratification or increasing vascularity (level IV) were used to evaluate CRP activity, the sensitivity was 86.4% (95% confidence interval: 64.0-96.4) and the specificity was 66.7% (95% confidence interval: 41.2-85.6). 4
57. Thoeni RF, Fell SC, Engelstad B, Schrock TB. Ileoanal pouches: comparison of CT, scintigraphy, and contrast enemas for diagnosing postsurgical complications. AJR Am J Roentgenol. 154(1):73-8, 1990 Jan. Observational-Dx 44 patients To assess the value of CT of the pelvis, 111In-labeled leukocyte scintigraphy, and contrast enema (pouchography) for detecting postsurgical complications in patients with total colectomy, rectal mucosectomy, and ileoanal pouches. A total of 57 sets of examinations revealed 22 cases of normal postoperative findings, 22 of pouchitis, 13 of abscess, and three of fistula. Overall sensitivity for detecting complications with pouchography was 60% (18 of 30 findings); with CT, 78% (28 of 36 findings); and with scintigraphy, 79% (23 of 29 findings). Pouchitis was best diagnosed by scintigraphy (sensitivity, 80%), followed by CT (sensitivity, 71%) and pouchography (sensitivity, 53%). Only CT correctly diagnosed all cases of abscess. Fistulas were frequently missed by all three methods. If tests were combined, the overall sensitivity rose to 93% for the combination CT/scintigraphy and to 86% for CT/pouchography, but did not improve for pouchography/scintigraphy (78%). 4
58. Matthiessen P, Lindgren R, Hallbook O, Rutegard J, Sjodahl R, Rectal Cancer Trial on Defunctioning Stoma Study Group. Symptomatic anastomotic leakage diagnosed after hospital discharge following low anterior resection for rectal cancer. Colorectal Dis. 12(7 Online):e82-7, 2010 Jul. Observational-Dx 234 Patients To investigate patients with symptomatic anastomotic leakage diagnosed after hospital discharge. In the late leakage (LL) patients the median age was 69 years, 61% were female patients, and 6% had stage IV cancer disease. On postoperative day 5, the LL group had a postoperative course similar to the no leakage (NL) group regarding temperature, oral intake and bowel function. The proportion of patients on antibiotic treatment on postoperative day 5, regardless of indication, was 28% in the LL compared with 4% in the NL group (P < 0.001). The median initial hospital stay was 10 days for both groups. When readmission for any reason was added, the hospital stay rose to a median of 21.5 and 13 days in the LL and the NL groups respectively (P < 0.001). 4
59. Hueting WE, Buskens E, van der Tweel I, Gooszen HG, van Laarhoven CJ. Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients. Dig Surg 2005;22:69-79. Meta-analysis 43 studies comprising 9,317 patients To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. Good
60. Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg. 245(2):254-8, 2007 Feb. Review/Other-Dx 1223 patients To use a prospective database to define the true incidence and presentation of anastomotic leakage after intestinal anastomosis. A total of 1223 patients underwent resection and anastomosis during the study period. Mean age was 59.1 years. Leaks occurred in 33 patients (2.7%). Diagnosis was made a mean of 12.7 days postoperatively, including four beyond 30 days (12.1%). There was no difference in leak rate by surgeon (3.6% vs. 2.2%; P = 0.08). The leak rate was similar by surgical site except for a markedly increased leak rate with ileorectal anastomosis (P = 0.001). Twelve leaks were diagnosed clinically versus 21 radiographically. Contrast enema correctly identified only 4 of 10 leaks, whereas CT correctly identified 17 of 19. A total of 14 of 33 (42%) patients had their leak diagnosed only after readmission. Fifteen patients required fecal diversion, whereas 18 could be managed nonoperatively. 4
61. Kaur P, Karandikar SS, Roy-Choudhury S. Accuracy of multidetector CT in detecting anastomotic leaks following stapled left-sided colonic anastomosis. Clin Radiol. 2014;69(1):59-62. Observational-Dx 170 patients To assess accuracy of MDCT and individual radiological signs in the diagnosis of anastomotic leaks. 17% (30/170) of the anterior resections were suspected to have an anastomotic leak. 93% (28/30) of patients underwent MDCT. 7.6%t (11+2/170) had a confirmed leak. Two patients underwent surgery without MDCT. A leak was confirmed by MDCT in 91% (10/11) of patients. The sensitivity, specificity, and PPV and NPV of MDCT in diagnosing a leak was 0.91, 1, 1, and 0.95, respectively. The sensitivity of peri-anastomotic air, peri-anastomotic collection, extravasation of rectal contrast medium, and staple line integrity was 0.81, 0.63, 0.54, and 0.72, respectively. Use of rectal contrast medium (8/11 cases) increased the subjective ease of diagnosis and was the only sign in 1 patient. 3
62. Tang L, Cai H, Moore L, Shen B. Evaluation of endoscopic and imaging modalities in the diagnosis of structural disorders of the ileal pouch. Inflamm Bowel Dis. 16(9):1526-31, 2010 Sep. Observational-Dx 66 Patients To compare the imaging techniques computerized tomography enterography (CTE), gastrograffin enema (GGE), magnetic resonance imaging (MRI), and pouch endoscopy (PES) to each other and to optimize diagnosis of pouch disorders by using a combination of these diagnostic modalities. A total of 66 patients underwent evaluation with PES and 1 other imaging modality as follows: PES + CTE (n = 23), PES + GGE (n = 34), and PES + MRI (n = 26). The mean age was 41.5 +/- 14.5 years, with 28 being female (42.4%). Sixty patients (90.9%) had J pouches and 59 (89.4%) had a preoperative diagnosis of ulcerative colitis. Overall, CTE, GGE, MRI, and PES all had reasonable accuracy for the diagnosis of small bowel and inlet strictures (73.9%-95.4%), outlet strictures (87.9%-92.3%), fistula (76.9%-84.8%), sinus (68.0%-93.9%), and pouch leak (83-93.9%). CTE had the lowest accuracy for small bowel and inlet strictures (73.9%) and MRI had the lowest accuracy for pouch sinus (68.0%). Combining 2 imaging tests can increase the accuracy of diagnosis to 100% for strictures, fistulas, sinus, and pouch leaks. 4
63. Dolinsky D, Levine MS, Rubesin SE, Laufer I, Rombeau JL. Utility of contrast enema for detecting anastomotic strictures after total proctocolectomy and ileal pouch-anal anastomosis. AJR Am J Roentgenol. 189(1):25-9, 2007 Jul. Observational-Dx 42 patients To determine the utility of contrast enemas for detecting clinically relevant anastomotic strictures after total proctocolectomy and ileal pouch-anal anastomosis and to facilitate management by defining a critical anastomotic caliber at or below which obstruction is likely to develop after ileostomy closure. Six (14%) of the 42 patients who underwent total proctocolectomy and ileal pouch-anal anastomosis had strictures at the ileoanal anastomosis on contrast enemas. The mean diameter of the anastomosis was 5.8 mm in the six patients with anastomotic strictures versus 15 mm in the 36 patients without strictures (p = 0.0002). If an anastomotic diameter of 8 mm is defined as the critical caliber at or below which clinically relevant strictures are present, the sensitivity of contrast enemas for detecting strictures at the ileoanal anastomosis was 100% (six of six patients) and the specificity was 92% (33 of 36 patients). 3
64. Karsten BJ, King JB, Kumar RR. Role of water-soluble enema before takedown of diverting ileostomy for low pelvic anastomosis. Am Surg. 75(10):941-4, 2009 Oct. Review/Other-Dx 50 Patients To determine the impact of routine water-soluble enema studies (WSE) in our patient population with low pelvic anastomosis. Thirty-eight patients were evaluated by WSE and 12 were not. Twenty-five patients (66%) were noted to have normal WSE studies before ostomy takedown. Thirteen patients (26%) were noted to have abnormalities on WSE. Two stenoses were clinically significant. Water-soluble enema study was 100 per cent sensitive and 69 per cent specific for detecting significant pathology. Digital rectal examination (DRE), colonoscopy, and flexible sigmoidoscopy were also 100 per cent sensitive in detecting substantial pathology. Routine use of WSE failed to demonstrate a significant impact on patients with low pelvic anastomosis undergoing ileostomy takedown. 4
65. Libicher M, Scharf J, Wunsch A, Stern J, Dux M, Kauffmann GW. MRI of pouch-related fistulas in ulcerative colitis after restorative proctocolectomy. Journal of Computer Assisted Tomography. 22(4):664-8, 1998 Jul-Aug. Observational-Dx 44 Patients To determine the value of MRI in diagnosing pouch-related fistulas in patients with ulcerative colitis and to compare pulse sequences with and without contrast enhancement in their performance of visualization. MRI detected 23 of 26 cases of fistulas; there were no false-positive diagnoses. Surgery revealed fistulas in three cases in which no pathology was found on MRI. Two patients had a short sinus tract at the pouch-anal anastomosis, and a third patient had a pouch-vaginal fistula. The Gd-enhanced FLASH sequence obtained the highest score, and second best was the T2-weighted fat saturation technique. 4
66. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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