Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : TC01 - TC05 Full Version

Comparison of Percutaneous Instillation of Aqueous Jelly with Intravenous Contrast for Magnetic Resonance Fistulography- A Prospective Cohort Study


Published: January 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51287.15836
Shyam N Kumar, B Padmini, Lokesh T Kumar, Saravana S Kumar

1. Senior Resident, Department of Radiology, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry, India. 2. Professor, Department of Radiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India. 3. Associate Professor, Department of Radiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India. 4. Associate Professor, Department of Radiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India.

Correspondence Address :
Dr. B Padmini,
Professor, Department of Radiology, Mahatma Gandhi Medical College and
Research Institute, Sri Balaji Vidiyapeeth (Deemed to be University),
Pillaiyarkuppam-607402, Puducherry, India.
E-mail: drbpadhmini@gmail.com

Abstract

Introduction: The perianal fistulae are complex clinical scenarios, often complicated by direct or blind surgical exploration. A precise preoperative evaluation of the perianal fistulous tract is not only an essential diagnostic requirement but a presurgical prognostic determinant. The usefulness of Magnetic Resonance Imaging (MRI) in such instances is established, but if aqueous jelly can be used instead of regular contrast during fistulography is not clear.

Aim: To evaluate the diagnostic accuracy of Magnetic Resonance (MR) percutaneous aqueous jelly compared to intravenous (i.v.) contrast enhanced MR fistulography in perianal fistulous tracts.

Materials and Methods: A prospective cohort study was carried out on 40 participants who were referred for MR fistulography (with suspected anal fistulae) to the Department of Radiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India, form March 2017 to October 2019. Total 40 subjects presented with signs and symptoms of perianal fistula were injected with i.v. contrast and MR Fistulography sequences were obtained. Same subjects were injected with aqueous jelly two days prior to surgery and MR fistulography sequences were obtained. Both the sequences obtained were compared with respect to primary tract, internal opening and lateral ramification. These MR fistulography results were compared with intraoperative findings. Presence and absence of internal opening was analysed using Chi-square test for comparison of intraoperative internal opening and aqueous jelly internal opening. The specificity, sensitivity, Positive Predictive Values (PPV), Negative Predictive Values (NPV) and accuracy were estimated.

Results: Patients included in the study ranged from 25-65 years with a mean age of 41.5±7.3 years. Among the 40 subjects included, 37 were male and three were females. Aqueous jelly showed a good sensitivity of 96.67% overall in diagnosing internal opening as compared to intravenous (i.v.) contrast. Sensitivity and specificity of aqueous jelly in identifying internal opening was found to be 89.47% and zero respectively with an accuracy of 85% as compared to intravenous (i.v.) contrast in Grade I and II intersphincteric fistula. The PPV was 94.44% and NPV was found to be zero with respect to comparison of aqueous jelly with i.v. contrast grade I and II fistula.

Conclusion: Overall results of this study demonstrated that the instillation of the aqueous jelly is safe and provided diagnostic accuracy in identifying internal openings as compared to surgical findings.

Keywords

Anal fistula, Gadolinium, Intersphincteric fistula, Magnetic resonance imaging, Radiography

Perianal fistula classically present as an abnormal connection between the epithelial surfaces of canal to the perianal skin by an identifiable opening (1). The prevalence of anal fistulae was observed to be 8.6 per 100,000 cases with a predominance of 12.3 per 100,000 cases in males as compared to 5.6 per 100,000 cases in females (2).

The anal fistulae are classified based as per the well-established Park’s classification (based on the location of its tract in relation to the anal sphincter muscle) into 4 major types, namely intersphincteric, trans-sphincteric, suprasphincteric and extrasphincteric fistulae (3). Also, based on St.James University Hospital classification, the perianal fistulas are classified into Grade I (simple linear intersphincteric fistula), Grade II (intersphincteric fistula with abscess formation or secondary tract) and Grade III (trans-sphincteric fistulae). The treatment modality for perianal fistula is based on its complex nature, severity, presence or absence of secondary tracts and abscess.

Surgery is the main stay of treatment for perianal fistula, however, it may lead to sphincter incontinence and recurrences due to over-excision and inadequate excisions (4),(5). In comparison to the operative findings, fistulography was the only imaging modality in the earlier days for the demonstration of anal fistula. Due to its unreliability to visualise anal sphincters and their relationship to fistula, Computed Tomography (CT) was used (6). However, the use of CT has limited value due to its poor resolution in analysing soft tissues for anal fistulas (7). Recently, the use of Magnetic Resonance Imaging (MRI) emerged as an efficient imaging modality for the preoperative classification of perianal fistulas. It helps in the direct visualisation of abscesses and tracts in combination to high soft tissue resolution. It can also identify the disease extension, which could otherwise be missed and affect the outcomes of patients. Hence, MRI was considered as a gold standard in the assessment and classification of anal fistulas (8),(9).

The Magnetic Resonance (MR) with intravenous (i.v.) gadolinium is predominantly based on the enhancement of tract wall inflammation (4),(10). However, the exorbitant cost of gadolinium along with false positives and negatives has necessitated the usage of newer media (10). In a study, percutaneous instillation of aqueous jelly into the sinus tract has enhanced the diagnostic efficacy of MR fistulography (1). It increased the prominence of tracts by expanding the tracts and provided an intrinsic contrast by terminating the need for gadolinium administration. There are very few studies (1),(11) available which compare the diagnostic accuracy of percutaneous instillation of aqueous jelly with other modalities. Therefore, to fill this paucity in literature, the current study was conducted to evaluate the effects and diagnostic accuracy between MR fistulography using percutaneous aqueous jelly and i.v. contrast enhanced MR fistulography in comparison to surgical and intraoperative delineation.

Material and Methods

This prospective cohort study was carried out on 40 participants who were referred for MR fistulography (with suspected anal fistulae) to the Department of Radiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidiyapeeth (Deemed to be University), Puducherry, India, form March 2017 to October 2019. The approval of Institutional Human Ethical Committee Clearance (Reference number: ECR/451/Inst/PO/2013/RR-16) from affiliated tertiary care hospital, was obtained prior to commencement of the study. Written informed consent was obtained from subjects participating in the study.

Inclusion and Exclusion criteria: The patients of all age groups, both genders with signs and symptoms of anal fistula were included in the study. Patients who had a history of an allergy to the contrast medium, in cases where we were unable to cannulate external opening, those with impaired renal function, claustrophobics, MRI contraindicated patients (metallic prosthesis/cochlear implants) and those with previous perianal surgeries were excluded from the study.

Radiologists recruited all the eligible subjects into the study by convenient sampling method. All the subjects were followed-up for a period of 3 years according to the treatment regimen.

Study Procedure

All the patients were injected with i.v. gadolinium (0.01 mL/kg body weight) in Diethylene Triamine Penta-Acetic acid (DTPA 0.1 mmol/kg at a rate of 1 mL/sec) agent and contrast enhanced MR fistulography sequences were obtained and fistulous tracts were assessed. The same group of patients (who were undergoing surgery) sorted into aqueous jelly group were subjected to percutaneous instillation of aqueous jelly (Tachyon Ultrasound jelly, Alex pharma, India), 1 or 2 days before surgery through external opening and MR fistulography sequences were obtained and fistulous tracts were assessed for diagnostic accuracy. The standards of MRI scan used are depicted in (Table/Fig 1).

During the percutaneous instillation of aqueous jelly, patients were placed in the prone position and external openings were identified. Sterile aqueous jelly was filled in a 10 mL syringe under aseptic conditions. The external openings were gently cannulated (20 G venous cannula attached to the syringe) by experienced radiologists. The patients were given approximately 3-5 mL of aqueous jelly per external opening ceased until the jelly started expelling out. MR fistulography of the patients was done immediately following the instillation of jelly using a 1.5 Tesla MRI scanner. The various sequences used in the study were T1W FSE, T2-weighted Fast Spin-Echo (T2W FSE), fat suppressed T1 with T2W FSE (axial, oblique and coronal), contrast enhanced T1W FSE fat-saturated (FAT SAT) and percutaneous installed aqueous jelly sequences (axial, coronal, sagittal), and T1 weighted sequences. (Table/Fig 1) provides the list of sequences for the Contrast-Enhanced MRI (CE-MRI) and the non contrast (jelly) MRI with important sequence details.

Data collection: Intraoperative/surgical findings were considered as the standard of reference and the diagnostic accuracies of CE-MRI and jelly-instilled MRI (jelly-MRI) and were subjected to comparison. The features such as the grade of fistulae, location of its internal opening, lateral ramifications were recorded and contrasted wherever necessary for diagnostic needs. The grade of fistulous tract was classified similar to that of Parks AG et al., (3). Primary tract was defined as any tract arising from external opening and any lateral ramifications were defined as any secondary tract arising from primary tracts. Location of internal opening was based on ‘O’ clock position wherein, internal opening of fistula was based on the location of fistula in relation to anal clock. The 12 O’clock refers to anterior perineum, 6 O’clock to posterior perineum, 3 O’clock to left lateral aspect and 9 O’clock to right anal canal (12).
Statistical Analysis

Data were interpreted using Statistical Package for the Social Sciences (IBM, SPSS version 22.0, USA). The presence and absence of internal opening was analysed using Chi-square test and the Odds ratio {with 95% Confidence Interval (CI)} was calculated for comparison of intraoperative internal opening and aqueous jelly defined internal opening. The specificity, sensitivity, Positive Predictive Values (PPV), Negative Predictive Values (NPV) and accuracy were calculated where in p-value <0.05 was considered statistically significant in all instances.

Results

Patients included in the study ranged from 25-65 years with a mean age of 41.5±7.3 years. Among the 40 subjects included, 37 were male and three were females. Out of the 40 patients, Grade III Transphincteric fistula was the most prevalent form observed and it accounted for 14 cases (35%) (Table/Fig 2).

The sensitivity, specificity, PPV, NPV and diagnostic accuracy of the aqueous jelly i.v. contrast in locating internal opening as opposed to identification on intraoperative way is shown in (Table/Fig 3).

With regards to the size, the mean length of fistulous tract in i.v. contrast group was 4.36 cm, whereas, the mean length of fistulous tract in the aqueous jelly group was 4.2 cm.

Among the 40 cases of perianal fistula, internal opening was detected intraoperatively in 32 cases, among this aqueous jelly located opening in 36 cases (Table/Fig 4). The odds of internal opening being detected were 16.51 times more with aqueous jelly as compared to i.v. contrast.

Comparison of aqueous jelly with i.v. contrast in delineating internal opening was presented in (Table/Fig 5). Considering i.v. contrast as the gold standard, out of 40 cases, aqueous jelly detected 36 cases.

A total of 20 cases were presented with Grade I and II intersphinteric fistula. Intravenous contrast detected internal openings in 19 cases as compared to aqueous jelly which detected internal openings in 18 cases (Table/Fig 6).

Sensitivity and specificity of aqueous jelly in identifying internal opening was found to be 89.47% and 0% respectively with an accuracy of 85% as compared to i.v. contrast in Grade I and II intersphincteric fistula. The PPV was 94.44% and NPV was found to be zero (Table/Fig 3).

Among the 20 cases of Grade III, IV and V trans-sphincteric fistula, i.v. contrast detected internal opening in 14 cases and aqueous jelly detected internal openings in 18 cases (Table/Fig 6). Hence, aqueous jelly was found to be 100% in identifying internal opening in Grade III, IV and V trans-sphincteric fistula in comparison to i.v. contrast. However, specificity was found to be 33.33% with an accuracy of 80%. The PPV and NPV were observed to be 77.77% and 100% respectively (Table/Fig 3).

Among the 20 cases with Grade I and II intersphincteric fistula, 18 cases showed internal opening per operatively. With respect to MR Fistulography (sequence of both i.v. contrast and aqueous jelly), 17 cases showed internal opening. The results demonstrated that there was no statistically significant difference between per operative and MR Fistulography findings with respect to internal opening for Grade I and II intersphincteric fistula. The sensitivity and specificity were observed to be 88.88% and 50% with 94.11% and 33.33% of PPV and NPV. Accuracy of detection was found to be 85%. With regards to Grade III, IV and V trans sphincteric fistula, both MR Fistulography and per operative findings detected 14 cases with sensitivity and specificity of 78.57% and 50%, respectively. The accuracy was observed to be 70% (Table/Fig 7).

Detection of primary tract in i.v. contrast/aqueous jelly MR fistulography in comparison with surgical findings showed 100% sensitivity, 100% specificity and 100% diagnostic accuracy. With regards to lateral ramifications, i.v. contrast showed 100% sensitivity as compared to aqueous jelly which showed 80% sensitivity. Intraoperatively, lateral ramifications were not delineated accurately (Table/Fig 8),(Table/Fig 9),(Table/Fig 10),(Table/Fig 11).

Discussion

Magnetic resonance fistulography provides a good preoperative roadmap for delineating perianal fistulous tract for surgeons. The preoperative evaluation of perianal fistulas with the advent of MR with its excellent soft tissue contrast and multiplanar imaging capabilities makes it an ideal choice as compared to the surgical exploration.

In the current study, aqueous jelly showed a good sensitivity of 96.67% in diagnosing internal opening with a statistically significant difference of 0.019. Whereas, i.v. contrast showed a sensitivity of 87.5% in diagnosing internal opening. These results were similar to the study conducted by Torkzad MR and Karlbom U wherein a comparison was made between i.v. contrast and aqueous jelly T1 and T2 weighted imaging protocol (12). The study results showed that the aqueous jelly was found to be 100% sensitive compared to i.v. contrast which showed 96% sensitivity. Similar study conducted by Aggarwal R et al., (1) showed 94.2% sensitivity and 100% specificity with aqueous jelly in identifying the internal opening. In the current study, the specificity was less but sensitivity was comparable with aqueous jelly.

Comparison of aqueous jelly with i.v. contrast on Grade I and Grade II intersphincteric fistula showed 89.5% sensitivity. With regards to the Grade III, IV and V, the sensitivity was significantly higher for aqueous jelly as compared to i.v. contrast MRI (13). On review of literature similar studies in this regard are absent. Thus, this is the first study conducted wherein the comparison of aqueous jelly with i.v. contrast for detecting the sensitivity of internal opening on different grades of perianal fistula was carried out.

The overall comparison of MR imaging (aqueous jelly/i.v. contrast) with intraoperative surgical findings showed that there was no statistically significant difference between per operative and MR Fistulography findings with respect to internal opening for Grade I and II intersphincteric fistula. However, comparison of MR imaging (aqueous jelly/i.v. contrast) with intraoperative surgical findings with regards to grade III, IV and V showed that both MR Fistulography and per operative findings detected 14 cases. In contrast to our findings, a study conducted by Morris J et al., reported MR imaging grades I and II were associated with satisfactory outcome as compared to grades III, IV and V which produced unsatisfactory outcome mandating the requirement of surgery (14).

The sensitivity of lateral ramification in the present study was 80% sensitive and 100% specific in delineating lateral ramification. A study conducted by Aggarwal R et al., also concluded sensitivity and specificity to be 90.5% and 100% in demarcation of lateral ramification with aqueous jelly (1). Hence, it was concluded that the sensitivity of lateral ramification was less in aqueous jelly. The advantage is lies in methodology of incorporating use of alternative for i.v. contrast.

Limitation(s)

The limitations such a smaller simple size and study conducted at a single centre do exist, call for larger population studies.

Conclusion

Percutaneous instillation of aqueous jelly prior to MR fistulography provides an accurate delineation of the complex anatomy of fistulae. This novel technique was proved to be reliable in detecting internal openings, and primary tract. The current study establishes a baseline data for anal fistulae in this specific geographical location. The accuracy of detection is significant to map the various complications and extent of disease in future.

References

1.
Aggarwal R, Soni BK, Kumar JU, George RA, Sivasankar R. MR Fistulography with percutaneous instillation of aqueous jelly: A cost effective technique innovation. Indian J Radiol Imaging. 2017;27(2):161-66. [crossref] [PubMed]
2.
Qureshi IP, Sahani IS, Qureshi S, Modi V. Clinical study of fistula in ano in patients attending surgical OPDs of a tertiary care teaching hospital, Central India. Int Surg J. 2018;5(11):3680-84. [crossref]
3.
Parks AG, Gordon PH, Hardcastle JD. A classification of fistula in ano. Br J Surg. 1976;63(1):01-12. [crossref] [PubMed]
4.
Alaat El Essawy MT. Magnetic Resonance imaging in assessment of anorectal fistulae and its role in management. J Gastroint Dig Syst. 2013;3(3):01-09.
5.
Yildirim N, Gökalp G, Öztürk E, Zorluoglu A, Yilmazlar T, Ercan I, 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 Intervent Radiol. 2012;18(1):11-19. [crossref]
6.
Jordán J, Roig JV, García-Armengol J, Garcia-Granero E, Solana A, Lledo S. Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis. 2010;12(3):254-60. [crossref] [PubMed]
7.
Baskan O, Koplay M, Sivri M, Erol C. Our experience with MR imaging of perianal fistulas. Pol J Radiology. 2014;79:490-97. [crossref] [PubMed]
8.
Berman L, Israel GM, McCarthy SM Jeffrey C, Weinreb, Longo WE. Utility of magnetic resonance imaging in anorectal disease. World J Gastroenterol. 2007;13(23):3153-58. [crossref] [PubMed]
9.
Buchanan G, Halligan S, Williams A et al: Effect of MRI on clinical outcome of recurrent fistula-in-ano. Lancet. 2002;360(9346):1661-62. [crossref]
10.
de Miguel Criado J, del Salto LG, Rivas PF, del Hoyo LF, Velasco LG, de las Vacas MI, et al. MR imaging evaluation of perianal fistulas: Spectrum of imaging features. Radiographics. 2011;32(1):175 94. [crossref] [PubMed]
11.
Bhat AH, Robbani I, Sheikh RR, Chowdri NA, Wani RA. Magnetic Resonance Fistulography of Perianal Fistulae Using Percutaneous Aqueous Jelly. JMS SKIMS. 2020;23(Suppl 1).
12.
Torkzad MR, Karlbom U. MRI assessment of anal fistula. Insights Imaging. 2010;1(2):62-71. [crossref] [PubMed]
13.
Kumar S, Padmini B, Kumar L. Intravenous contrast enhanced magnetic resonance imaging (mr) based adjunct imaging methods in perianal fistulography: A narrative review. International Journal of Scientific Research. 2020;9(3):55-56. [crossref]
14.
Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics. 2000;20(3):623-35. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/51287.15836

Date of Submission: Jul 07, 2021
Date of Peer Review: Sep 04, 2021
Date of Acceptance: Oct 28, 2021
Date of Publishing: Jan 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 08, 2021
• Manual Googling: Oct 28, 2021
• iThenticate Software: Nov 25, 2021 (15%)

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