Banner MD Anderson Cancer Center, 2332 E. State Avenue, Phoenix, AZ, 85020-4734, USA.
University of Pittsburgh Medical Center-Hamot, Erie, PA, USA.
Tech Coloproctol. 2020 Apr;24(4):317-321. doi: 10.1007/s10151-020-02167-z. Epub 2020 Feb 27.
On May 6, 1887 at a meeting of the West London Medico-Chirurgical Society, original observations attributed to D. H. Goodsall described an association between the secondary (external) sinus opening and the location of the primary (internal) opening of an anal fistula: posterior external sinuses had a midline origin and anterior external sinuses took a straight path to their internal origin-eponymously known as Goodsall's Rule. However, over the last century, published reports support the midline as the primary (internal) origin of all anal fistulas, thus challenging the predictive accuracy of Goodsall's Rule and prompting this expansive review.
A literature search was performed for studies describing the relationship between the secondary (external) opening and the primary (internal) opening of anal fistulas, including recent reports of the positive predictive value (PPV) of Goodsall's Rule. The studies were evaluated to determine the validity of Goodsall's observations.
The midline was the dominant, primary (internal) opening site of all anal fistulas with up to 95% accuracy. Goodsall's Rule was inaccurate when applied to anal fistulas with an anterior off-midline external sinus opening which tend to mirror posterior off-midline external sinuses and curve to a midline origin, rather than take a straight course to a primary (internal) opening, as predicted by Goodsall. Use of the Midline Rule had superior predictive accuracy, reflected in an increase in overall PPV of the location of the primary (internal) origin from 49% using Goodsall's Rule to 71% using the Midline Rule (57-62% for men, 31-90% for women).
Goodsall's Rule falls short in predicting the natural course of anal fistulas with an anterior off-midline external sinus opening, especially for women. Given the increased risk of fecal incontinence related to surgical intervention for anterior-based anal fistulas, especially in women, dependence on Goodsall's Rule to guide the surgeon may result in "disastrous consequences". The preponderance of evidence over the last century favors the Midline Rule as a more accurate predictor of the true and natural course of anal fistulas, regardless of the location of the external sinus opening.
1887 年 5 月 6 日，在伦敦西部医学外科学会的一次会议上，D.H.古兹沃斯（D. H. Goodsall）最初的观察结果描述了继发性（外部）窦道开口与原发性（内部）肛痿开口之间的关联：外部后窦道从中线起源，而外部前窦道则直接通向其内部起源——即以古兹沃斯（Goodsall）的名字命名的法则。然而，在上个世纪，已发表的报告支持中线是所有肛痿的原发性（内部）起源，从而挑战了古兹沃斯法则的预测准确性，并促使对此进行广泛的审查。
对描述继发性（外部）开口与肛痿原发性（内部）开口之间关系的文献进行了检索，包括古兹沃斯法则阳性预测值（PPV）的最新报告。评估这些研究以确定古兹沃斯观察的有效性。
在所有肛痿中，中线是主要的原发性（内部）开口部位，准确率高达 95%。当应用于具有前中线外部窦道开口的肛痿时，古兹沃斯法则不准确，因为这些肛痿倾向于反映后中线外部窦道，并向中线起源处弯曲，而不是像古兹沃斯所预测的那样直接通向原发性（内部）开口。使用中线法则具有更高的预测准确性，这反映在使用古兹沃斯法则时原发性（内部）开口位置的总 PPV 从 49%增加到使用中线法则时的 71%（男性为 57-62%，女性为 31-90%）。
古兹沃斯法则在预测具有前中线外部窦道开口的肛痿的自然病程方面存在不足，尤其是对于女性。鉴于与前基于肛痿相关的手术干预相关的粪便失禁风险增加，特别是对于女性，依赖古兹沃斯法则来指导外科医生可能会导致“灾难性后果”。在上个世纪的大量证据支持中线法则作为肛痿真实和自然病程的更准确预测指标，而与外部窦道开口的位置无关。
