FIA is a complex and challenging condition while MRI done properly is modality of choice- Dr.Zafar Sajjad


Surgical Week for Colorectal Diseases at JPMC-IV

FIA is a complex and challenging condition
while MRI done properly is modality
of choice - Dr. Zafar Sajjad

MRI is routinely used for pre operative staging and  it is more
reliable in management of colorectal cancer- Dr. Naveed Ahmed

KARACHI: FIA is a complex and challenging condition. MRI done properly is modality of choice. One should use contrast as a routine. Clinical examination and EUA may underestimate the extent of the disease. This was stated by Dr. Zafar Sajjad, Consultant Radiologist at Aga Khan University Hospital. He was making a presentation on Role of MRI Perineum in Complex Anal Fistula at the 9th Annual Surgical Week for Colorectal Disease at the JPMC on October 2nd 2014. He was one of the invited guest speakers in the course. This particular session was dedicated to the memory of late Prof. Sami Ashraf the father of Dr. Zafar Sajjad. The other radiologist who was invited to make presentation during the course was Dr. Naveed Ahmed from JPMC and his topic was Role of MRI in Rectal Cancer Staging.


Prof. Mumtaz Maher presenting a mementoe to Dr. Zafar Sajjad from
Aga Khan University Hospital who was one of the invited guest speakers
at the Surgical Week for Colorectal Diseases held at JPMC recently.

Defining FIA, Dr. Zafar Sajjad said that it is a communication between anal canal and skin. Most FIAs, he said are Denovo. It is more common in men and mean age is 39 Years. He then discussed why these fistulas develop. Speaking about various imaging modalities he mentioned Fistulography which is unpleasant for the patient as well as for the operator. It is accurate only in 16% of the cases. Then comes Endo Anal Ultrasound (EAU) which is operator dependent and highly accurate. However, MRI is the most accurate imaging modality and the accurate predictor. It is better at predicting outcome as compared to surgery. He then showed results from a study stating that it should be used in all cases. Contrast, he further stated, has lot of value.

Continuing Dr. Zafar Sajjad said that Park’s classification of Fistula was published in 1976. Later St James University Hospital classification was published which was based on MRI. He then talked about the MRI imaging classification of perianal fistula Grade-I, Grade-II and Grade-III which are Trans sphincteric fistula. Grade-IV is with abscess or secondary track. It can be formed anywhere. Grade-V is supra elevator and Trans elevator disease. He also showed some illustrative cases and emphasized that MRI with contrast has many advantages.

During the discussion it was stated that one can get track on hard copy or soft copy. It gives much better information. MRI helps in locating the exact location of internal opening and it can be found in 95% of the cases. Endo Anal Probes, it was stated, are used by some but they are disposable and very expensive. It costs about fifteen hundred US dollars each. We do get pre operative ultrasound but one can also get per operative MRI. Dr. Zafar Sajjad said that having an Endo Anal Ultrasound probe in the back for twenty minutes is not easy and not at all comfortable for the patient.

Participating in the discussion Prof. Mumtaz Maher said that these are some of the advances in the imaging modalities with which we are not familiar and update. We need to have more collaboration between MRI people and Surgeons. What it means for the surgeons, it should be helping the surgeons.

Role of MRI in Staging of Colorectal Cancer

Dr. Naveed Ahmed, Consultant Radiologist at JPMC made a presentation on Role of MRI in Staging of Colorectal Cancer on September 30th, Second Day of the Course. He discussed at length the TNM staging and said that overall survival is about 65%.However, most patients in Pakistan present very late. We need to give importance to creating awareness, screening and prevention of colorectal cancer. There is no alternative to good clinical evaluation. Various imaging modalities include Ultrasound, MRI Pelvis and DCBE. In DCBE cost is low but it is operator and equipment dependent. He also referred to Trans Rectal Ultrasound, Endo Rectal Ultrasound besides ERUS vs MRI. While ERUS is cost effective, MRI is good for assessment of CRM and also good for T2 lesions. He also referred to abdominal ultrasound and CT scan. MRI Dr. Naveed said is somewhat better and it is routinely used for pre operative staging. It is more reliable in management of colorectal cancer. However, MRI cannot differentiate between T1 and T2 cancer. He also talked about MR anatomy. Pet CT, he said, is most common Tracer used. At present it is not used as primary staging modality. MRI has been shown as highly accurate. He also discussed the prognostic indicators for colorectal cancer. He then showed a few selected cases. During CT patient is exposed to radiation but in MRI there is no radiation and no need for contrast, Dr. Naveed Ahmed concluded.