Transperineal Ultrasound-Guided Endoscopic Sinusotomy for Recurrent Perianal Sinus in Crohn Disease
Bibliographic record
Abstract
{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_ztnfwkwx"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} CASE REPORT A 30-year-old woman with Crohn disease (Montreal classification A2L3B2p) who had prior history of sigmoid colectomy, ileocecal resection, and 2 surgical fistulectomies for perianal fistula currently presented with recurrent discharge for last 2 months at a prior fistulectomy site. She had been in stable remission on adalimumab 40 mg every other week and azathioprine (2 mg/kg) for the last 2 years. Point of care transperineal ultrasound showed trans-sphincteric fistula extending from 6 o'clock of anal canal extending posteriorly up to the level of coccyx (Figures 1–2). While escalation of therapy was planned, an endoscopic seton was attempted to establish effective drainage using a stiff guidewire with hydrophilic tip (Jag wire, Boston Scientific, Marlborough, MA). Colonoscopy showed normal sigmoid anastomosis and few superficial ulcers at ileal inlet, however, failed to identify any internal opening of fistula. The guidewire could not be passed across external opening of fistula with suspicion of angulated tract or sinus. Hence, a magnetic resonance imaging (MRI) pelvis was done, which showed the possibility of a sinus tract as internal fistula opening could not be seen properly (Figure 3). Fistulography injecting iodinated contrast Omnipaque 350 (Iohexol, 350 mg I/mL, GE Healthcare, Shanghai, China) confirmed the diagnosis of sinus as no contrast was draining into rectum (Figure 4). After multidisciplinary meeting, a minimally invasive endoscopic sinusotomy was done as a day-care procedure under conscious sedation. Endoscopic sinusotomy was done using a needle knife (Olympus Medical Systems Corporation, Tokyo, Japan) making radial incisions using free hand technique with electrocautery settings of Endocut I (effect 3, cut duration 1, cut interval 3) (ERBE Elektromedizin GmbH, Tübingen, Germany), to lay open the tract and facilitate drainage (Figures 5 and 6). The procedure was completed in 20 minutes without complications, and the patient was discharged the same day. Adalimumab therapy was escalated to a weekly regimen along with azathioprine (1 mg/kg: dose reduced due to leucopenia), and ciprofloxacin was continued for 8 weeks. At the 3-month follow-up, the patient remained symptom-free, without any fistula discharge.Figure 1.: Transperineal ultrasound showing trans-sphincteric fistula tract originating from the 6 o'clock position of the anal canal.Figure 2.: Transperineal ultrasound image revealing posterior extension of the fistulous tract reaching up to the level of the coccyx.Figure 3.: Magnetic resonance imaging pelvis demonstrating sinus tract without clear visualization of an internal opening.Figure 4.: Fistulogram using iodinated contrast confirming sinus tract without communication to rectum.Figure 5.: Endoscopic view during sinusotomy using needle knife.Figure 6.: Post-procedure image showing decompressed sinus tract after completion of endoscopic fistulotomy.This case highlights the role of transperineal ultrasound in precise mapping of perianal fistulas, facilitating targeted, sphincter-preserving, minimally invasive endoscopic fistulotomy.1 The combination of real-time ultrasound guidance with adjunctive magnetic resonance imaging and fistulography enhanced diagnostic accuracy and ensured optimal treatment planning. Endoscopic fistulotomy is a safe, effective, and well-tolerated procedure, providing a day-care alternative to conventional surgery with faster recovery and favorable long-term outcomes in Crohn's-related perianal fistula and sinus.2,3 DISCLOSURES Author contributions: P. Pal conceptualized the case, performed the procedure, and drafted the initial manuscript. MA Mateen conducted the transperineal ultrasound and contributed to manuscript revision. R. Gupta, M. Tandan, and DN Reddy critically reviewed the manuscript and provided expert input. All authors approved the final version of the manuscript. P. Pal is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.
Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.
How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".