DOI: 10.1148/rg.265055723
Anatomic and Pathologic Findings at External Phased-Array Pelvic MR Imaging after Surgery for Anorectal Disease1
Christine Hoeffel, MD,
Lionel Arrivé, MD,
Najat Mourra, MD,
Louisa Azizi, MD,
Maité Lewin, MD, PhD and
Jean-Michel Tubiana, MD
1 From the Departments of Radiology (C.H., L. Arrivé, L. Azizi, M.L., J.M.T.) and Pathology (N.M.), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571 Paris Cedex 12, France; and the Faculté de Médecine Cochin-Port-Royal, Université Paris–Descartes, Paris, France (C.H.). Received September 8, 2005; revision requested January 13, 2006, and received February 6; accepted March 3. All authors have no financial relationships to disclose.
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Figure 1. Rectus abdominis flap in a 70-year-old woman who underwent abdominoperineal resection for a low rectal tumor. Axial T1-weighted image shows a rectus abdominis flap (arrows) in the perineum surrounded by an omentoplasty (*).
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Figure 2. Omentoplasty in a 65-year-old man who underwent abdominoperineal resection for bulky low rectal cancer. Axial T2-weighted image shows an omentoplasty in the vacant rectal fossa (arrows).
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Figure 3. Postoperative findings in a 66-year-old man who underwent abdominoperineal resection for an epidermoid carcinoma of the anal canal. Sagittal T2-weighted image shows that the urinary bladder and seminal vesicles have fallen posteriorly (white arrows), whereas the prostate gland remains fixed (arrowheads). Note the discrete area of precoccygeal tissue scarring, which contains a small pocket of fluid (black arrow).
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Figure 4. Postoperative findings in a 68-year-old man who underwent abdominoperineal resection for bulky low rectal cancer. Axial T2-weighted image shows small bowel loops in the vacant rectal fossa (arrows) behind the muscle flap (arrowheads).
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Figure 6a. Postoperative findings in a 62-year-old man who underwent low anterior resection for rectal cancer with creation of a coloanal anastomosis and colonic J pouch. Coronal (a) and axial (b) T2-weighted images show two parallel loops of colon (arrows in a) that course separately upward (arrowheads). The colon loop on the right side is a blind-ending stump.
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Figure 6b. Postoperative findings in a 62-year-old man who underwent low anterior resection for rectal cancer with creation of a coloanal anastomosis and colonic J pouch. Coronal (a) and axial (b) T2-weighted images show two parallel loops of colon (arrows in a) that course separately upward (arrowheads). The colon loop on the right side is a blind-ending stump.
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Figure 7. Diagram of a transverse coloplasty.
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Figure 8. Postoperative findings in a 70-year-old patient who underwent low anterior resection for rectal cancer with creation of a coloanal anastomosis and transverse coloplasty. Sagittal T2-weighted image shows a small bulge in the posterior colonic wall (arrows) at the site of the transverse coloplasty; this bulge acts as a reservoir.
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Figure 9a. Presacral scarring in a 75-year-old man 14 months after proctectomy for rectal cancer. Sagittal T2-weighted (a) and axial gadolinium-enhanced fat-suppressed T1-weighted (b) images show significant soft-tissue thickening anterior to the sacrum and coccyx. The soft-tissue thickening has intermediate signal intensity on the T2-weighted image and enhances moderately on the gadolinium-enhanced image. It has a regular, thick, low-signal-intensity rim on both images (arrows). Although it appears nodular on the axial image, its margins are concave on the sagittal image.
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Figure 9b. Presacral scarring in a 75-year-old man 14 months after proctectomy for rectal cancer. Sagittal T2-weighted (a) and axial gadolinium-enhanced fat-suppressed T1-weighted (b) images show significant soft-tissue thickening anterior to the sacrum and coccyx. The soft-tissue thickening has intermediate signal intensity on the T2-weighted image and enhances moderately on the gadolinium-enhanced image. It has a regular, thick, low-signal-intensity rim on both images (arrows). Although it appears nodular on the axial image, its margins are concave on the sagittal image.
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Figure 10a. Precoccygeal scarring in a 60-year-old man 2 months after anterior resection for rectal cancer with creation of a colostomy. Sagittal T2-weighted (a) and axial gadolinium-enhanced fat-suppressed T1-weighted (b) images show precoccygeal scarring surrounding a pocket of fluid signal intensity (arrows in a). The fibrosis peripheral to the pocket of fluid has intermediate signal intensity on the T2-weighted image (arrowhead in a) and enhances moderately on the gadolinium-enhanced image (arrowheads in b).
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Figure 10b. Precoccygeal scarring in a 60-year-old man 2 months after anterior resection for rectal cancer with creation of a colostomy. Sagittal T2-weighted (a) and axial gadolinium-enhanced fat-suppressed T1-weighted (b) images show precoccygeal scarring surrounding a pocket of fluid signal intensity (arrows in a). The fibrosis peripheral to the pocket of fluid has intermediate signal intensity on the T2-weighted image (arrowhead in a) and enhances moderately on the gadolinium-enhanced image (arrowheads in b).
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Figure 11a. Normal anatomy after total coloproctectomy with intersphincteric dissection in a 43-year-old man with Crohn disease. (a, b) Axial contrast-enhanced fat-suppressed T1-weighted (a) and T2-weighted (b) images show that the internal sphincter is absent, but the external sphincters (arrows in a) and levators (arrows in b) are present. Arrowhead in b = central scar corresponding to the excised rectum. (c) Axial T2-weighted image shows the mesorectum surrounded by the mesorectal fascia (arrows). The central scar corresponds to the excised rectum (arrowhead).
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Figure 11b. Normal anatomy after total coloproctectomy with intersphincteric dissection in a 43-year-old man with Crohn disease. (a, b) Axial contrast-enhanced fat-suppressed T1-weighted (a) and T2-weighted (b) images show that the internal sphincter is absent, but the external sphincters (arrows in a) and levators (arrows in b) are present. Arrowhead in b = central scar corresponding to the excised rectum. (c) Axial T2-weighted image shows the mesorectum surrounded by the mesorectal fascia (arrows). The central scar corresponds to the excised rectum (arrowhead).
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Figure 11c. Normal anatomy after total coloproctectomy with intersphincteric dissection in a 43-year-old man with Crohn disease. (a, b) Axial contrast-enhanced fat-suppressed T1-weighted (a) and T2-weighted (b) images show that the internal sphincter is absent, but the external sphincters (arrows in a) and levators (arrows in b) are present. Arrowhead in b = central scar corresponding to the excised rectum. (c) Axial T2-weighted image shows the mesorectum surrounded by the mesorectal fascia (arrows). The central scar corresponds to the excised rectum (arrowhead).
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Figure 13. Postoperative findings in a 40-year-old woman with ulcerative colitis who underwent restorative proctocolectomy with creation of an ileoanal anastomosis and intervening J pouch. Axial T2-weighted image shows the large J pouch, which is identified by means of its two parallel rows of staples (arrows).
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Figure 14. Postoperative findings in a 45-year-old woman with ulcerative colitis who underwent restorative proctocolectomy with creation of an ileoanal anastomosis and intervening J pouch. Sagittal T2-weighted image shows the J pouch with its two rows of staples (arrowheads). The pouch is visible down to the anastomosis (arrows).
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Figure 15. Treatment of recurrent rectovaginal fistulas with a bulbocavernosus-labial flap. Axial T2-weighted image shows a bulbocavernosus-labial flap (arrows) transposed into a rectovaginal fistula. The fatty flap acts as an omentoplasty to heal the fistula. A small recurrent abscess is seen on the right side (arrowhead).
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Figure 16. Treatment of recurrent rectovaginal fistulas with omentoplasty in a 44-year-old woman with Crohn disease. Sagittal T2-weighted image shows an omentoplasty (arrows) transposed into the rectovaginal space.
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Figure 17a. Intersphincteric space fistula in a 38-year-old man with Crohn disease after coloproctectomy with intersphincteric dissection. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted image shows a complex fistula (arrows) in the intersphincteric space. The internal sphincter has been resected. (b) Axial T2-weighted image obtained after repeat surgery to treat the persistent fistula shows that the external sphincter has been excised and a flap of gluteus maximus has been interposed (arrows) to fill the proctectomy defect.
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Figure 17b. Intersphincteric space fistula in a 38-year-old man with Crohn disease after coloproctectomy with intersphincteric dissection. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted image shows a complex fistula (arrows) in the intersphincteric space. The internal sphincter has been resected. (b) Axial T2-weighted image obtained after repeat surgery to treat the persistent fistula shows that the external sphincter has been excised and a flap of gluteus maximus has been interposed (arrows) to fill the proctectomy defect.
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Figure 18a. Anastomotic leak in a 70-year-old man after low anterior resection for rectal cancer with creation of a coloanal anastomosis. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted image obtained in the postoperative period shows an anastomotic leak with a small dehiscence (arrows) at the posterior aspect of the anastomosis. The dehiscence appears as a small enhancing area posterior to the colonic wall. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted image obtained in the postoperative period shows the resulting fistula and small abscess in the left levator ani muscle (arrow). The patient underwent repeat surgery to treat the anastomotic leak and dehiscence.
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Figure 18b. Anastomotic leak in a 70-year-old man after low anterior resection for rectal cancer with creation of a coloanal anastomosis. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted image obtained in the postoperative period shows an anastomotic leak with a small dehiscence (arrows) at the posterior aspect of the anastomosis. The dehiscence appears as a small enhancing area posterior to the colonic wall. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted image obtained in the postoperative period shows the resulting fistula and small abscess in the left levator ani muscle (arrow). The patient underwent repeat surgery to treat the anastomotic leak and dehiscence.
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Figure 19a. Postoperative fistula in a 66-year-old man after low anterior resection for midrectal cancer with creation of a coloanal anastomosis. He received pre- and postoperative chemotherapy and radiation therapy. Axial T2-weighted (a) and sagittal gadolinium-enhanced fat-suppressed (b) images show a large fistula (arrows) between the urinary bladder and the colonic pouch posteriorly. The pouch is identified by means of its staples (arrowheads) and is thus distinguishable from an abscess.
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Figure 19b. Postoperative fistula in a 66-year-old man after low anterior resection for midrectal cancer with creation of a coloanal anastomosis. He received pre- and postoperative chemotherapy and radiation therapy. Axial T2-weighted (a) and sagittal gadolinium-enhanced fat-suppressed (b) images show a large fistula (arrows) between the urinary bladder and the colonic pouch posteriorly. The pouch is identified by means of its staples (arrowheads) and is thus distinguishable from an abscess.
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Figure 20a. Postoperative fistula in a 42-year-old woman with ulcerative colitis. (a) Axial fat-suppressed T1-weighted image obtained just below the anastomosis shows an anterior fistula (arrow) between the anal canal and the right labia. (b) Axial fat-suppressed T1-weighted image obtained at a lower level shows the resultant abscess (arrow).
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Figure 20b. Postoperative fistula in a 42-year-old woman with ulcerative colitis. (a) Axial fat-suppressed T1-weighted image obtained just below the anastomosis shows an anterior fistula (arrow) between the anal canal and the right labia. (b) Axial fat-suppressed T1-weighted image obtained at a lower level shows the resultant abscess (arrow).
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Figure 21a. Postoperative fistula in a 37-year-old man with ulcerative colitis who underwent restorative proctocolectomy. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted image shows an abscess (arrowheads) to the left of the ileoanal anastomosis (arrows). The abscess was due to a complex fistula. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted image obtained just below the ileoanal anastomosis shows a transsphincteric fistula drained by a loose seton (arrow).
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Figure 21b. Postoperative fistula in a 37-year-old man with ulcerative colitis who underwent restorative proctocolectomy. (a) Axial gadolinium-enhanced fat-suppressed T1-weighted image shows an abscess (arrowheads) to the left of the ileoanal anastomosis (arrows). The abscess was due to a complex fistula. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted image obtained just below the ileoanal anastomosis shows a transsphincteric fistula drained by a loose seton (arrow).
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Figure 22. Fistula involving the membranous urethra in a 24-year-old man after multiple operations for anorectal malformation. Axial T2-weighted image shows a fistula (straight arrows) that links a new cavity (curved arrow) and the membranous urethra. The new cavity is located behind the colon (arrowhead), which has been lowered to the perineum.
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Figure 23. Postoperative fistula in a 44-year-old man who underwent pre-operative radiation therapy and anterior resection with creation of a colorectal anastomosis for midrectal cancer. Sagittal T2-weighted image shows a fistula (arrowhead) between the urinary bladder and several presacral abscesses filled with air and fluid (arrows).
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Figure 24. Persistent perineal sinus after coloproctectomy with resection of both the internal and external sphincters in a 37-year-old woman with Crohn disease. Axial fat-suppressed T1-weighted image shows a persistent perineal sinus (arrowheads) and inflammation of the perineum (ie, fat stranding) (arrows).
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Figure 25. Persistent perineal sinus after coloproctectomy and intersphincteric dissection in a 30-year-old man with Crohn disease. Axial gadolinium-enhanced fat-suppressed T1-weighted image shows a strongly enhancing structure at the proctectomy site (arrowhead). The persistent perineal sinus is limited by the external sphincter (arrows).
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Figure 26. Perineal hernia in a 65-year-old woman 4 years after abdominoperineal resection for low rectal cancer. Sagittal T2-weighted image obtained for suspicion of bone metastases shows ptosis of a bowel loop surrounded by peritoneal fluid and an omentoplasty (arrowheads). Note the bone metastases (arrows).
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Figure 27. Perineal hernia in a 70-year-old woman 4 months after abdominoperineal resection for a low rectal tumor. Sagittal T2-weighted image shows prolapse of the omentum, which contains a bowel loop and a myocutaneous flap (arrows). Note the typical presacral scarring (arrowheads).
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Figure 28. Peritoneal inclusion cyst in a 43-year-old woman who underwent restorative coloproctectomy for ulcerative colitis. Coronal T2-weighted image shows a typical peritoneal inclusion cyst (arrows) surrounding the right ovary. Note the ileal pouch lateral to the cyst (arrowheads).
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Figure 29a. Tumor recurrence in a 62-year-old man 16 months after low anterior resection for rectal cancer with creation of a colorectal anastomosis. Sagittal T2-weighted (a) and axial gadolinium-enhanced fat-suppressed T1-weighted (b) images show anastomotic and presacral tumor recurrence. The presacral recurrence has intermediate signal intensity on the T2-weighted image (arrowheads in a) and shows enhancement on the gadolinium-enhanced image (arrowheads in b); it is nodular and has irregular margins. The staples of the anastomosis are seen within the tumoral mass (arrows in b).
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Figure 29b. Tumor recurrence in a 62-year-old man 16 months after low anterior resection for rectal cancer with creation of a colorectal anastomosis. Sagittal T2-weighted (a) and axial gadolinium-enhanced fat-suppressed T1-weighted (b) images show anastomotic and presacral tumor recurrence. The presacral recurrence has intermediate signal intensity on the T2-weighted image (arrowheads in a) and shows enhancement on the gadolinium-enhanced image (arrowheads in b); it is nodular and has irregular margins. The staples of the anastomosis are seen within the tumoral mass (arrows in b).
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Figure 30. Perineal recurrence in a 70-year-old man 2 years after abdominoperineal resection for rectal cancer. Axial gadolinium-enhanced fat-suppressed T1-weighted image shows a strongly enhancing heterogeneous mass in the perineum (arrows).
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Figure 31. Presacral recurrence in a 57-year-old woman 1 year after low anterior resection for rectal cancer with creation of a coloanal anastomosis and a colonic J pouch. Sagittal T2-weighted image shows the recurrence (arrows), which has intermediate signal intensity, is nodular, and infiltrates the presacral planes.
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Figure 32a. Tumor recurrence in a 56-year-old man 1 year after low anterior resection for a mucinous rectal tumor with creation of a coloanal anastomosis and a J pouch. (a) Coronal T2-weighted image shows heterogeneous nodules with high signal intensity (arrows) on the right levator muscle. (b) Axial gadolinium-enhanced T1-weighted image shows peripheral enhancement of the nodules (arrows).
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Figure 32b. Tumor recurrence in a 56-year-old man 1 year after low anterior resection for a mucinous rectal tumor with creation of a coloanal anastomosis and a J pouch. (a) Coronal T2-weighted image shows heterogeneous nodules with high signal intensity (arrows) on the right levator muscle. (b) Axial gadolinium-enhanced T1-weighted image shows peripheral enhancement of the nodules (arrows).
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Figure 33. Lymph node metastasis in a 32-year-old man 1 year after transanal local excision of a pT1 rectal carcinoid tumor. Axial gadolinium-enhanced fat-suppressed T1-weighted image shows enhancing lymphad-enopathy in the mesorectum (arrow).
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Figure 34. Metastases in a 50-year-old woman. Sagittal T2-weighted image shows pelvic recurrence of a rectal mucinous carcinoma (arrows) and ovarian metastases (arrowheads), which display the typical high signal intensity.
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Copyright © 2006 by the Radiological Society of North America.
