The Pelvic Floor Center at Skåne University Hospital is the only one of its kind in Sweden. Its five surgeons and support staff dedicate their expertise to advanced proctology, and their combined knowledge and experience make the center Sweden’s most advanced referral unit for complex colorectal issues.
Dr. Antoni Zawadzki has worked at the center since 2003, and as head of the Pelvic Floor Center, he handles some of the department’s most complex cases, on occasions treating patients who have had over 50 unsuccessful procedures at other hospitals and clinics. He advocates for the benefits of ultrasound in colorectal and pelvic floor examination and treatment, routinely examining patients with ultrasound as opposed to MRI.
“The ultrasound images from the BK Medical 3D endocavity transducer (X14L4) on the bk5000 system offer image quality for colorectal procedures that almost match the quality of MRI imaging. Of course, MRI displays more information in the form of bone and tissue, but by the time of the operation, the MRI data may be a month or two old,” says Dr. Zawadzki.
“Ultrasound is a real-time examination and is much better than MRI for the visualization of fistulae and polyps. It is also superb for imaging muscle and detecting IBD, obstructed defecation, and prolapse issues. You know the patient’s symptoms, and you can see the complications while they are right in front of you. Ultrasound images show the present state of the fistula, as opposed to how it might have looked several weeks earlier.
I can plan the next steps for treatment right away, and I can continue to rely on ultrasound throughout the operation and the continuity of patient care. By scanning the patient during every meeting in the outpatient clinic as well as in the operating room, I can use those 10-15 different rounds of imaging to construct a detailed picture of the disease’s status. It is too expensive to image this intensively with MRI.”
However, not all colorectal surgeons routinely use ultrasound to the extent that Dr. Zawadzki does. Many others rely on MRI or DREs (Digital Rectal Examinations), which Dr. Zawadzki says could make it harder to spot every crucial anatomical detail. He elaborates:
“A patient presented to a different Swedish hospital for the first time in September 2017. He came to the emergency room with pain, fever, and signs of serious infection. The surgeon diagnosed an abscess and proceeded to drain it, via an incision in the external anal sphincter. The patient received two days of antibiotic treatment and then went home. No follow-up was planned, as patients with first-time abscesses are generally not referred to our center.
Eight months later, in May 2018, the patient unexpectedly returned and presented with the same symptoms – pain, fever, and signs of serious infection. The examining surgeon located an abscess that spontaneously ruptured in the anal canal after pressure was applied to it. After probing the abscess through the external anal sphincter, an internal opening of a fistula was found three centimeters above the dentate line in the rectum, which is very unusual. A seton (surgical thread that helps drain fistulae) was placed and the patient was sent to us for follow-up.
The patient arrived at our clinic for follow-up in July 2018. When we imaged the patient with the 3D endocavity transducer (X14L4), we could clearly see the fistula with the seton and the unusual internal opening above the dentate line. Then we saw something we did not expect to see: a previously undetected major, cryptoglandular fistula at 7 o’clock in the dentate line, next to the now evidently iatrogenic (unintentional) fistula created by the initial doctor at 6 o’clock.
The investigating surgeon had not used ultrasound when he located and drained the patient’s abscess. As such, he was not aware of the primary cryptoglandular fistula that had caused the abscess. Without knowledge of the origin, the abscess was drained in a manner, which created an iatrogenic fistula in very close proximity to the cryptoglandular fistula. Iatrogenic fistulas can be difficult to treat. With the use of ultrasound, a correct diagnosis and subsequently a treatment plan could have been made earlier.”