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Anal fistulae - Three-dimensional endoanal ultrasound and outcomes of collagen plug treatment

Fält, Ursula LU orcid (2023) In Lund University, Faculty of Medicine Doctoral Dissertation Series
Abstract
Background: The treatment of complex anal fistulae remains a therapeutic challenge. Early anal fistula plug (AFP) studies showed high success rates, while later reports demonstrated success rate of 13-100% at usual follow-up of 6-24 months. Very little is known about morphological findings related to success and failure of the AFP, especially if three-dimensional (3D) endoanal ultrasound (EAUS) is used for radiological follow-up. No documentation is available for the use of a high-resolution transducer for assessment of anal fistulae and anal canal length.

Aims: I: To evaluate the long-term success rate of the AFP in the treatment of complex anal fistulae. II: To explore the utilisation of 3D EAUS for the follow-up of the AFP.... (More)
Background: The treatment of complex anal fistulae remains a therapeutic challenge. Early anal fistula plug (AFP) studies showed high success rates, while later reports demonstrated success rate of 13-100% at usual follow-up of 6-24 months. Very little is known about morphological findings related to success and failure of the AFP, especially if three-dimensional (3D) endoanal ultrasound (EAUS) is used for radiological follow-up. No documentation is available for the use of a high-resolution transducer for assessment of anal fistulae and anal canal length.

Aims: I: To evaluate the long-term success rate of the AFP in the treatment of complex anal fistulae. II: To explore the utilisation of 3D EAUS for the follow-up of the AFP. III: To evaluate the accuracy of 3D EAUS alone for assessment of newly diagnosed cryptoglandular fistulae, compared to intraoperative findings in combination with intraoperative 3D EAUS (gold standard). IV: To explore the use of 3D EAUS for the measurement of anal canal length in patients with newly diagnosed cryptoglandular fistulae.

Methods: Two prospective cohort study projects, each designed to produce two papers. Papers I & II: A single-centre study of consecutive patients with complex anal fistulae treated in May 2006-October 2009. Patients with ano/rectovaginal fistulas were excluded. Papers III & IV: A single-centre study of consecutive patients with newly diagnosed cryptoglandular anal fistulae and no history of fistula surgery treated between June 2018-March 2020. Patients with inflammatory bowel disease, ano/rectovaginal fistulae, more than one fistula, or a fistula with more than one internal orifice (IO) were excluded.

Main outcomes: Paper I: AFP success rate >7 years postoperatively, Paper II: Morphological 3D EAUS findings and relation to AFP failure, Paper III: Agreement between 3D EAUS alone and the gold standard, Paper IV: the mean anal canal length in female and male with transducers 2052 and 8838.

Results and conclusions: Paper I: The overall success rate 93-138 months after the AFP was 38%. It is acceptable considering the low morbidity of the procedure in a complex disease with high recurrence rates over time.
Paper II: 3D EAUS may be utilised for AFP follow-up. Postoperative 3D EAUS at three months or later, especially in combination with clinical symptoms, can be used to predict long-term AFP failure.
Paper III: 3D EAUS alone has high precision in identifying IO of anal fistulae. The method may be utilised even by relatively inexperienced surgeons to identify fistulae suitable for fistulotomy.
Paper IV: Measurements of anal canal length in female and male patients assessed by two different transducers for 3D EAUS are reported with generally acceptable reproducibility and repeatability.
(Less)
Abstract (Swedish)
Bakgrund: Behandling av komplicerade analfistlar försätter att vara en stor utmaning. Tidiga studier på anal fistelplugg (AFP) visade att högt andel av patienter blir bra men senare har man rapporterad väldig varierande behandlingsframgång (13-100%) för uppföljningstider på 6-24 månader. Kunskap om de morfologiska fynd som kan relateras till framgångsrik eller misslyckad operationsresultat efter AFP är väldigt begränsad, framför allt om tredimensionellt (3D) endoanalt ultraljud (EAUS) används som uppföljande modalitet. Ingen dokumentation finns om användning av en transducer med hög upplösning för utvärdering av analfistlar eller mätning av analkanalens längd.

Syfte: I: Att utvärdera långtidsresultat för AFP vid behandling av... (More)
Bakgrund: Behandling av komplicerade analfistlar försätter att vara en stor utmaning. Tidiga studier på anal fistelplugg (AFP) visade att högt andel av patienter blir bra men senare har man rapporterad väldig varierande behandlingsframgång (13-100%) för uppföljningstider på 6-24 månader. Kunskap om de morfologiska fynd som kan relateras till framgångsrik eller misslyckad operationsresultat efter AFP är väldigt begränsad, framför allt om tredimensionellt (3D) endoanalt ultraljud (EAUS) används som uppföljande modalitet. Ingen dokumentation finns om användning av en transducer med hög upplösning för utvärdering av analfistlar eller mätning av analkanalens längd.

Syfte: I: Att utvärdera långtidsresultat för AFP vid behandling av komplicerade analfistlar.
II: Att utforska användning av 3D EAUS för uppföljning av AFP.
III: Att utvärdera användning av 3D EAUS för bedömning av nydiagnosticerade kryptoglandulära analfistlar jämfört med kombinationen av 3D EAUS och intraoperativa fynd (gold standard).
IV: Att utforska användning av 3D EAUS för mätning av analkanalens längd hos patienter med nydiagnosticerade kryptoglandulära analfistlar.

Metoder: Två prospektiva kohortstudier, båda designade att generera två delarbeten.
Delarbete I & II: Singelcenterstudie av konsekutiva patienter med komplicerade analfistlar behandlade mellan maj 2006 och oktober 2009. Patienter med ano/rektovaginala fistlar exkluderades.
Delarbete III & IV: Singelcenterstudie av konsekutiva patienter med nydiagnosticerade kryptoglandulära analfistlar behandlade mellan juni 2018 och mars 2020. Patienter med inflammatorisk tarmsjukdom, ano/rektovaginala fistlar, mer än en fistel eller fistel med mer än en inre öppning (IO) exkluderades.

Huvudsakliga retsultatsmått:
Delarbete I: AFPs behandlingsframgång >7 år postoperativt.
Delarbete II: Morfologiska fynd på 3D EAUS och relation till misslyckad AFP.
Delarbete III: Överensstämmelse (interobserver agreement) mellan 3D EAUS och gold standard.
Delarbete IV: Analkanalens längd i kvinnor och män med transducers 2052 and 8838.

Resultat och konklusioner:
Delarbete I: Andelen lyckade operationer 93-138 månader efter AFP var 38%. Det kan betraktas vara acceptabelt med tanke på låg postoperativ morbiditet i en komplicerad sjukdom med hög recidvfrekvens över tid.
Delarbete II: 3D EAUS kan användas för uppföljning av AFP. Postoperativ 3D EAUS tre månader postoperativt eller senare, speciellt i kombination med kliniska symtom, kan prediktera risk för recidiv på lång sikt.
Delarbete III: 3D EAUS har hög precision för att identifiera fistelns inre mynning. Metoden kan användas även tidigt under den kirurgiska karriären för att identifiera fistlar som är lämpliga att klyvas.
Delarbete IV: Mätningar av analkanalens längd i kvinnor och män gjorda med två olika transducers för 3D EAUS rapporteras med allmänt acceptabel repeterbarhet. och pålitlighet men relativt breda intervaller för gränser av överrensstämmelse. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Associate Professor Myrelid, Pär, Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping
organization
alternative title
Anala fistlar : Tredimensionellt endoanalt ultraljud och resultat av behandling med kollagenplugg
publishing date
type
Thesis
publication status
published
subject
keywords
analfistel, Crohns sjukdom, kryptoglandulär fistel, kollagenplugg, komplicerad analfistel, tredmensionellt endoanalt ultraljud, analkanalens längd, analkanalens anatomi, anal fistula, Crohn's disease, cryptoglandular fistula, anal fistula plug, Complex anal fistula, three-dimensional endoanal ultrasound, anal canal length, anal canal anatomy
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
issue
2023:138
pages
149 pages
publisher
Lund University, Faculty of Medicine
defense location
Lilla aulan, Jan Waldenströms gata 5, Skånes Universitetssjukhus i Malmö
defense date
2023-12-01 09:00:00
ISSN
1652-8220
ISBN
978-91-8021-480-3
project
3D Endoanal Ultrasound in advanced proctology
Treatment of complex anal fistulas
Anal fistulae - Three-dimensional endoanal ultrasound and outcomes of collagen plug treatment
language
English
LU publication?
yes
id
166dac76-0462-4b35-972a-1b5862f978a0
date added to LUP
2023-10-21 11:40:48
date last changed
2023-11-13 11:59:53
@phdthesis{166dac76-0462-4b35-972a-1b5862f978a0,
  abstract     = {{Background: The treatment of complex anal fistulae remains a therapeutic challenge. Early anal fistula plug (AFP) studies showed high success rates, while later reports demonstrated success rate of 13-100% at usual follow-up of 6-24 months. Very little is known about morphological findings related to success and failure of the AFP, especially if three-dimensional (3D) endoanal ultrasound (EAUS) is used for radiological follow-up. No documentation is available for the use of a high-resolution transducer for assessment of anal fistulae and anal canal length.<br/><br/>Aims: I: To evaluate the long-term success rate of the AFP in the treatment of complex anal fistulae. II: To explore the utilisation of 3D EAUS for the follow-up of the AFP. III: To evaluate the accuracy of 3D EAUS alone for assessment of newly diagnosed cryptoglandular fistulae, compared to intraoperative findings in combination with intraoperative 3D EAUS (gold standard). IV: To explore the use of 3D EAUS for the measurement of anal canal length in patients with newly diagnosed cryptoglandular fistulae.<br/><br/>Methods: Two prospective cohort study projects, each designed to produce two papers. Papers I &amp; II: A single-centre study of consecutive patients with complex anal fistulae treated in May 2006-October 2009. Patients with ano/rectovaginal fistulas were excluded. Papers III &amp; IV: A single-centre study of consecutive patients with newly diagnosed cryptoglandular anal fistulae and no history of fistula surgery treated between June 2018-March 2020. Patients with inflammatory bowel disease, ano/rectovaginal fistulae, more than one fistula, or a fistula with more than one internal orifice (IO) were excluded.<br/><br/>Main outcomes: Paper I: AFP success rate &gt;7 years postoperatively, Paper II: Morphological 3D EAUS findings and relation to AFP failure, Paper III: Agreement between 3D EAUS alone and the gold standard, Paper IV: the mean anal canal length in female and male with transducers 2052 and 8838.<br/><br/>Results and conclusions: Paper I: The overall success rate 93-138 months after the AFP was 38%. It is acceptable considering the low morbidity of the procedure in a complex disease with high recurrence rates over time.<br/>Paper II: 3D EAUS may be utilised for AFP follow-up. Postoperative 3D EAUS at three months or later, especially in combination with clinical symptoms, can be used to predict long-term AFP failure. <br/>Paper III: 3D EAUS alone has high precision in identifying IO of anal fistulae. The method may be utilised even by relatively inexperienced surgeons to identify fistulae suitable for fistulotomy.<br/>Paper IV: Measurements of anal canal length in female and male patients assessed by two different transducers for 3D EAUS are reported with generally acceptable reproducibility and repeatability.<br/>}},
  author       = {{Fält, Ursula}},
  isbn         = {{978-91-8021-480-3}},
  issn         = {{1652-8220}},
  keywords     = {{analfistel; Crohns sjukdom; kryptoglandulär fistel; kollagenplugg; komplicerad analfistel; tredmensionellt endoanalt ultraljud; analkanalens längd; analkanalens anatomi; anal fistula; Crohn's disease; cryptoglandular fistula; anal fistula plug; Complex anal fistula; three-dimensional endoanal ultrasound; anal canal length; anal canal anatomy}},
  language     = {{eng}},
  number       = {{2023:138}},
  publisher    = {{Lund University, Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{Anal fistulae - Three-dimensional endoanal ultrasound and outcomes of collagen plug treatment}},
  url          = {{https://lup.lub.lu.se/search/files/163012442/Ursula_Aho_Fa_lt_WEBB.pdf}},
  year         = {{2023}},
}