Perianal abscess in childhood

A Systematic Review and Meta-Analysis of Comparing Drainage Alone versus Drainage with Primary Fistula Treatment for the Perianal Abscess in Children

This systematic review and meta-analysis of nonrandomized studies (NRSs) aimed to evaluate the clinical efficacy and safety of two types of surgical interventions (respectively drainage alone and drainage with primary fistula treatment) for perianal abscesses (PAs) in children. Studies from 1992 to July 2022 were searched in 10 electronic databases. All relevant NRSs with available data which compared surgical drainage with or without primary fistula treatment were included. Patients with underlying diseases which led to abscess formation were excluded. The Newcastle-Ottawa Scale was used to assess the risk of bias and quality of the included studies. The outcomes were the healing rate, fistula formation rate, fecal incontinence, and wound healing duration. A total of 16 articles with 1,262 patients were considered suitable for the final meta-analysis. Primary fistula treatment was associated with a significantly higher healing rate when compared with incision and drainage alone (odds ratio [OR]: 5.76, 95% confidence interval [CI]: 4.04-8.22). This aggressive procedure for PA resulted in an 86% reduction in the fistula formation rate (OR: 0.14, 95% CI: 0.06-0.32). Limited data showed patients who underwent primary fistula treatment have a minor effect on postoperative fecal incontinence. Primary fistula treatment demonstrates a better clinical efficacy in promoting the healing rate and decreasing the formation of fistulas in PAs in children. The available evidence for a minor impact on anal function after this intervention is less strong.

Video-assisted anal fistula treatment (VAAFT) combined with ozonide oil dressing: standardization of technique in pediatric patients

BACKGROUND

Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil.

METHODS

All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope.

RESULTS

Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed.

CONCLUSION

Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions.

Risk factors for therapy failure after incision and drainage alone for perianal abscesses in children

Background

It is well known that recurrent perianal abscesses (PAs) and fistula-in-ano (FIA) are the main causes of therapy failure following incision and drainage (I&D) for PAs. But few studies have focused on the risk factors for therapy failure after I&D for PAs in children. In this study, we retrospectively examine the risk factors for therapy failure after I&D for PAs in children in a pediatric tertiary care institution.

Methods

A retrospective review of all outpatient children with PA treated by I&D at Beijing Children's Hospital between January 2021 and December 2022 was performed. A follow-up was conducted in October 2023. Patients with other predisposing factors for perianal infection, such as inflammatory bowel disease, hematologic tumor, and anorectal surgery, were excluded from this study. Logistic regression yielding odds ratios (ORs) was used to assess the significance of variables for therapy failure.

Results

Of 160 children initially identified, follow-up was available for 146, with a total of 172 treatments. A total of 91% of children were male. The median (interquartile range) age at I&D was 2 (1, 15) months. The median follow-up duration was 20 (14, 25) months. Therapy failure occurred in 25 (15%) treatments performed for the prevention of recurrence of PA and in 35 (20%) treatments for the prevention of development of FIA. In the univariate analysis, a history of PA (P = 0.001), history of I&D (P = 0.014), and multilocal occurrence (P = 0.003) were associated with therapy failure. A sitz bath after I&D (P = 0.016) and regular cleaning of the wound after I&D (P = 0.024) were associated with therapy success. In the multivariate analysis, a history of PA (P = 0.015, OR = 3.374) and multilocal occurrence (P = 0.012, OR = 4.649) were independently associated with therapy failure. Regular cleaning of the wound (P = 0.017, OR = 0.341) and sitz bath (P = 0.001, OR = 0.128) after I&D were independently associated with therapy success.

Conclusions

A history of PA and multilocal occurrence were predictor factors for therapy failure before I&D. Regular cleaning of the wound and sitz bath after I&D were protective factors for therapy success. Therefore, regular cleaning of the wound and sitz bath after I&D should be emphasized in all children with PAs, especially in those with a history of PA and multilocal occurrence.

Perianal abscess in children: an evaluation of microbiological etiology and the effectiveness of antibiotics

PURPOSE

We aimed to evaluate the demographic characteristics of children with perianal abscess, distribution of microbiological etiology, antibiotic susceptibility, and identify the effectiveness and coverage of antibiotics due to culture results.

METHODS

A retrospective study was designed to evaluate pediatric patients with perianal abscesses between January 2013 and December 2022.

RESULTS

A total of 197 episodes in 135 patients were evaluated. The median age of the patients was 10 months (22 days-17 years). The isolated microorganisms were Gram-positive bacteria in 56 (28.4%) patients and Gram-negative bacteria in 141 (71.6%) patients. The most common isolated species was Escherichia coli (n = 70, 35.5%), followed by Klebsiella spp. (n = 48, 24.4%), Staphylococcus aureus (n = 37, 18.9%), and Enterobacter spp. (n = 9, 4.5%). Forthy-two percent (n = 58) of isolates were positive for extended-spectrum beta-lactamase, 8% (n = 11) were carbapenem-resistant in Gram-negative bacteria, and 37.5% (n = 21) were methicillin-resistant, 7.1% (n = 4) were vancomycin-resistant in Gram-positive bacteria. According to bacterial culture results, ertapenem plus glycopeptide had the highest antimicrobial coverage rate (92.3%), followed by ertapenem plus clindamycin (89.8%), ertapenem (81.7%), third-generation cephalosporin plus glycopeptide (82.2%), third-generation cephalosporin plus clindamycin (69.5%).

CONCLUSION

Ertapenem can be a good choice in the empirical treatment of perianal abscesses in children due to its high coverage rate.

The optimal primary treatment for pediatric perianal abscess and anal fistula: A systemic review and meta-analysis

BACKGROUND

Perianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients.

METHODS

Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis.

RESULTS

Thirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615-2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109-0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information.

CONCLUSION

Strong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence.

LEVEL OF EVIDENCE

Type of study: Systemic review; Evidence level: Level II.

Risk factors for therapy failure after surgery for perianal abscess in children

Purpose

The role of surgery in managing perianal abscesses in the pediatric population is debatable, and data on recurrence risk is rare. This study aimed to evaluate the efficiency of surgery for a perianal abscess in children and identify parameters that predict recurrence.

Methods

We performed a retrospective review of all children younger than age 14 requiring surgery for a perianal abscess from 2000 to 2018.

Results

Out of 103 enrolled patients, 27 (26%) had recurrent perianal disease. Recurrences appeared after a median of 5 months (range: 1-18 months), in 12 cases as perianal abscess and 15 cases as fistula in ano. Anal fistula probing was performed in 33% of all patients, of which 16 (15%) underwent fistulotomy. In univariate analysis, older age (p = 0.034), fistula probing (p = 0.006) and fistulotomy (p = 0.009) was associated with treatment success. History of perianal abscess, multilocal occurrence, and the presence of enteric flora in wound swabs was associated with treatment failure (p = 0.002, OR = 0.032). In multivariate analysis, anal fistula probing was independently associated with treatment success (p = 0.019, OR = 22.08), while the history of perianal abscess was associated with treatment failure (p = 0.002, OR = 0.032).

Conclusion

Our study identified probing for fistula as a predictor of therapy success, while the history of perianal abscess was identified as a predictor of treatment failure. Therefore, in all children with perianal abscess, fistula probing and if present, fistulotomy should be performed.

Incision and Drainage With Primary Fistulotomy of Perianal Abscess Is Safe and Effective in Neonates: A Long-Term Follow-Up Study

OBJECTIVE

Perianal abscess (PA) in neonates is poorly understood, and its management remains controversial. The aim of this study was to compare incision and drainage (ID) with or without primary fistulotomy in the management of neonatal first-time PA.

METHODS

A retrospective comparative study was conducted for neonates with first-time PA treated with incision and drainage with primary fistulotomy (IDF) vs. ID between 2008 and 2017.

RESULTS

In total, 138 patients (137 boys and 1 girl) were identified; 65 in the IDF group and 73 in the ID group. The median follow-up was 6.5 years (range 4-13 years). Baseline characteristics were similar between the 2 groups. The cure rate in the IDF group (98.5%, 64/65) was significantly higher than that in the ID group (80.8%, 59/73; p = 0.001). The rate of fistula formation in the IDF group (1.5%, 1/65) was significantly lower than that in the ID group (13.7%, 10/73; p = 0.01). The rate of abscess recurrence was not statistically different (p = 0.12), even though the IDF group (0%, 0/65) seemed to have a better outcome than the ID group (5.5%, 4/73). No fecal incontinence was observed in any of our patients.

CONCLUSIONS

First-time PA in neonates can be treated safely and effectively by the IDF or by ID alone. The former may be advantageous over the latter in terms of the rate of cure and fistula formation.

Efficacy of conservative treatment of perianal abscesses in children and predictors for therapeutic failure

BACKGROUND

The optimal management of perianal abscess in children is controversial.

PURPOSE

To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure.

METHODS

All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated.

RESULTS

Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group). Conservative treatment was initiated in 49 patients (primary conservative group) but was stopped because of inefficiency in 25 patients, who were referred for surgery after a median 7.03 days (range, 2 to 16 days). The other 24 patients (48%) initially achieved complete remission after conservative treatment, but 10 were readmitted after a median 34 months (range, 3 to 145 months) with recurrent disease. There were no significant differences in permanent success after conservative treatment between infants (10 of 29, 34%) and older children (4 of 20 [20%], P=0.122). Overall, conservative treatment alone was effective in only 14 of 113 patients. Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75). Univariate analysis of predictors for conservative treatment failure revealed inflammatory values (C-reactive protein and white blood count, P=0.017) and abscess size (P=0.001) as significant parameters, whereas multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant.

CONCLUSION

Conservative treatment of perianal abscess is permanently efficient in only a minority of children but is not associated with a higher recurrence rate after subsequent surgery. Abscess size is a predictor for therapy failure.

Perianal abscess in infants: Amenable to conservative treatment in selected cases

BACKGROUND

Perianal abscess is a common surgical condition in daily pediatric practice. Management is a subject of controversy and a variety of approaches are practiced. While the most frequent approach is drainage with/without fistulotomy, the superiority of this approach and the place of conservative approach has not been established. The aim of this study was to evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants.

METHODS

Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed.

RESULTS

Criteria for a conservative approach were: spontaneous drainage into the anal canal (n = 8) or perianal skin (n = 4), and phlegmonous infiltrate with fluid collection detected on ultrasound (n = 7). Mean age at symptom onset was 8.4 months. Twelve patients were managed for the first time. Previous care in seven patients included 1-4 drainage procedures (n = 4), spontaneous drainage (n = 1) and antibiotics (n = 2). Five patients were on oral antibiotics at presentation. After diagnosis, 18 patients received i.v. antibiotics and one, oral antibiotics. Three patients (15.7%) ultimately required surgical drainage; two were lost to follow up. During follow up (mean, 22.4 months) four patients (28.5%) had a single recurrent episode; abscess in three (managed conservatively in two and surgically in one) and fistula-in-ano in one patient that healed spontaneously. Thus, surgical intervention was prevented in 13/17 patients (76.4%) available for follow up.

CONCLUSIONS

Perianal abscess in infants is amenable to conservative management in selected cases. Avoiding surgical intervention is advantageous, especially given the high recurrence rate.

Combination therapy with traditional medicines for perianal abscess in children

BACKGROUND

Combination therapy with two different traditional medicine formulations called hainosankyuto and juzentaihoto (TJ-122 and TJ-48; Tsumura & Co, Tokyo, Japan) may be effective for perianal abscess (PA), but their effectiveness has not been established. The present study investigated the effectiveness of combination therapy with TJ-122 and TJ-48 as the most effective conservative treatment for PA.

METHODS

We identified 69 patients with PA under 2 years of age and divided them into four groups according to the formulations used: group 1, TJ-122 (n = 17); group 2, TJ-48 (n = 14); group 3, TJ-122 and TJ-48 (n = 19); and group 4, no traditional medicines (n = 19). Treatment was continued for 3-6 months after resolution of the PA in groups 1 and 2, and for 1 year in group 3. Age at presentation, duration of purulent discharge (PD), frequency of surgical intervention (incision and drainage [ID]; fistulotomy/fistulectomy), and recurrence rates were statistically analyzed.

RESULTS

Mean age (months) was 8.6 ± 9.2, 6.9 ± 7.3, 5.2 ± 4.7, and 3.8 ± 3.1 in groups 1, 2, 3, and 4, respectively (P = n.s.). Mean PD (weeks) was 2.5 ± 2.2, 7.1 ± 10.8, 2.0 ± 0.0, and 2.7 ± 1.0, respectively. Duration of PD was significantly longer in group 2 than in groups 1 and 3 (P < 0.05). Mean number of ID procedures was 1.0 ± 0.2, 2.3 ± 0.5, 0, and 1.6 ± 0.2, respectively. Group 1 had significantly less ID than group 2 (P < 0.01). Recurrence rates were 6%, 36%, 0%, and 32%, respectively. Groups 1 and 3 had significantly less recurrence than group 2 (P < 0.05), and group 3 had significantly less recurrence than group 4 (P < 0.01).

CONCLUSIONS

Combination therapy with TJ-122 and TJ-48 decreased recurrence and surgical intervention to zero in this study, demonstrating high effectiveness for treating PA in children.

[Perianal abscess in children: A pediatric infectious disease perspective]

INTRODUCTION

There are limited data on the aetiology and management of perianal abscesses (PAs). The aim of this retrospective study was to define the characteristics of children with PAs; describe our experience with PA from the perspective of paediatric infectious medicine and determine the factors that influence clinical outcomes.

METHODS

We performed a retrospective review of cases of PA in children with no underlying disease managed in a tertiary referral hospital between January 2005 and July 2015. We collected data on demographic characteristics, symptoms, abscess size and location, abscess recurrences, laboratory and microbiological findings, treatment modalities, diagnosis of systemic illness at the end of the diagnostic workup and clinical outcomes.

RESULTS

We included a total of 47 patients in the study, with a predominance of male patients (93.6 vs 6.4%, P<.001). The median age was 7.7 months (IQR 1.8-13.7 months), and 40 children (85.1%) were younger than 2 years of age. Four PAs drained spontaneously and 7 healed without need of drainage (23.4%). Drainage by simple incision was applied to 36 patients (76.5%) and six PAs required fistulotomy (12.7%). Recurrent abscesses were found in 25 patients (53.1%). Three patients with recurrent PA were diagnosed with inflammatory bowel disease at the end of the diagnostic evaluation.

CONCLUSIONS

Based on the findings of our study, measurement of white blood cell counts and serum levels of acute phase reactants may be useful in the initial evaluation of children with PA. In light of the high relapse rates observed in surgically managed patients, it seems reasonable to use a conservative approach in patients aged less than 2 years.

Anorectal Complaints: Hemorrhoids, Fissures, Abscesses, Fistulae

Anorectal complaints are not uncommon in pediatric care, but the etiology and management can differ significantly from adults. Age is an important factor when considering etiology and management, distinguishing between infants, children, and adolescents. For all ages, malignancy is rarely a consideration, but a thorough examination of infants and children typically requires deep sedation or general anesthesia. Very little primary literature or evidence exists to guide care; so there are many opportunities for careful study to enhance our understanding beyond personal experience and historical practice patterns.

Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial

BACKGROUND

Much controversy exists regarding the role of antibiotics in the development of fistula in-ano after incision and drainage. We evaluated the role of postoperative antibiotics in the prevention of fistula in-ano after incision and drainage of perianal abscess.

METHODS

In a randomized single blind clinical trial study, 307 patients were randomly selected from those referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran, during September 2013 to September 2014. Patients were allocated randomly either to receive 7 days of oral metronidazole and ciprofloxacin in addition to their standard care or to only receive standard care without any antibiotics after they were discharged from the hospital. Patients were followed for 3 months and final results were evaluated. The study was registered at the clinical trial registry (www.irct.ir; Irct201311049936n7).

RESULTS

Seven patients were lost to follow-up. Those who used prophylactic antibiotics (n = 155) had significantly lower rates of fistula formation compared with those who did not use any medication (n = 144; P < .001). Men had higher rates of fistula formation (P = .002). Patients who used more cigarettes had higher rates of fistula development (P = .001). In the univariate analysis, only postoperative antibiotic use showed a protective role against fistula formation (odds ratio = 0.426; confidence interval, 0.206-0.881). In the regression analysis postoperative antibiotic use remained protective against fistula development (odds ratio = 0.371; confidence interval, 0.196-0.703), furthermore male sex presented as a risk factor for developing fistula in-ano (odds ratio = 3.11; confidence interval, 1.31-7.38).

CONCLUSION

Postoperative prophylactic antibiotic therapy including ciprofloxacin and metronidazole play an important role in preventing fistula in-ano formation. Considering the complications of fistula in-ano formation and the minor side effects of antibiotic therapy, based on our results, a 7-10 course of postoperative antibiotics is advised after incision and drainage of perianal abscess.

Preliminary results of video-assisted anal fistula treatment (VAAFT) in children

BACKGROUND

Anal fistula is a common acquired anorectal disorder in children. Treatment methods that have been used are associated with inconsistent results and possible serious complications. In 2011 a minimally invasive approach, video-assisted anal fistula treatment (VAAFT) was described for adult patients. The aim of the present study was to assess the first series of pediatric patients treated with VAAFT.

METHODS

All patients who underwent VAAFT between August 2013 and May 2015 were included. Demographics, clinical features, preoperative imaging, surgical details, outcome, and medium-term data were prospectively collected for each patient.

RESULTS

Thirteen procedures were performed in nine patients. The male to female ratio was 8:1, and the median age was 9.6 years. Five fistulas were idiopathic, three iatrogenic, and one associated with Crohn's disease. Eight complete VAAFT procedures were performed. The remaining five procedures were either fistuloscopy and cutting seton placement or fistuloscopy and electrocoagulation, both without mucosal sleeve. The median length of surgery was 41 min. The median hospital stay was 24 h, and the median length of follow-up was 10 months. Resolution of the fistula was observed in all patients who underwent a complete VAAFT. In four out of five patients who underwent an incomplete procedure (without mucosal sleeve), the fistula recurred. No incontinence or soiling was reported in the medium term.

CONCLUSIONS

VAAFT proved to be feasible and safe in children. It also proved to be versatile as it could be applied to fistulas of different etiologies. The key to success seems to be an adequate mucosal sleeve. Older children and adolescents benefit most from VAAFT which is a valid alternative to available surgical procedures.

Outcomes of Various Interventions for First-Time Perianal Abscesses in Children

Introduction. In children treated surgically for first-time perianal abscesses, discovery and excision of concomitant fistulas may also be warranted. Aim. To evaluate children of varying age after incision and drainage of first-time perianal abscesses, examining recurrences rates with and without search for a fistula. Method. A retrospective review was conducted, analyzing children (ages 0–15 years) treated for first-time perianal abscesses at a tertiary pediatric surgical center, with a minimum follow-up of 6 months. Results. A total of 104 patients subjected to 112 treatments for first-time perianal abscesses were eligible. Surgical procedures constituted 84 (75%) of treatments, searching for fistulas in 49 (58%). In 34 (69%), fistulas were confirmed and treated. In the surgically treated subset, the recurrence rate was higher if no attempt was made to exclude a fistula (46%), as opposed to confirmed absence of a fistula (27%) or concurrent fistulotomy (9%; p = 0.02). Younger patients showed a higher recurrence rate (12/26; 46%), compared with older counterparts (11/58; 19%) (p = 0.002). Conclusion. In children surgically treated for first-time perianal abscess, recurrence rates appear to be lowered by locating and treating coexisting fistulas.

Long-term results of seton placement for fistula-in-ano in infants

BACKGROUND

The present study aimed to assess the long-term results of seton placement for fistula-in-ano (FIA) in infants.

METHODS

Data of patients aged <1 year who presented to our department with perianal abscess (PA) between January 2006 and February 2010 were retrospectively reviewed. Our standard initial treatment for PA was incision and drainage. Patients with systemic diseases and inflammatory bowel diseases were excluded.

RESULTS

Ninety-five patients were treated for PA and/or FIA during the 5-year period, and follow-up data were available for 90 patients. The mean follow-up duration in these patients was 49.8 ± 11.4 months, and mean age at presentation was 3.1 ± 2.7 months. Of the 90 patients, 36 (40%) developed FIA (39 lesions) and underwent seton placement. The condition healed in a mean period of 6.3 ± 4.0 weeks after the placement of a cutting seton. Healing of the fistula was achieved in 35 (97.2%) of 36 patients after the initial seton procedure, and one patient who showed recurrence underwent a second seton placement, resulting in successful healing of the FIA after 5 weeks.

CONCLUSIONS

The long-term success of seton placement indicates that this procedure should be a treatment option for FIA in infants.

Operative treatment of perianal abscess

Perianal abscess is a common disease. Due to the special anatomical position, management of perianal abscess is still controversial. Especially, the treatment of deep perianal abscess is very difficult, because it is difficult to confirm the relationship among internal opening, extent of deep anorectal abscess and anorectal sphincters. Correct treatment of the internal opening and extent of deep anorectal abscess is the key to success. Treating the fistula and the abscess at the same time by incision and drainage may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not later develop a fistula-in-ano. The results of current treatments for perianal abscess are not very satisfactory. More studies are needed in future.

Surgical treatment of perianal abscess and fistula-in-ano in childhood, with emphasis in children older than 2 years

BACKGROUND

Anal sepsis in children ranges from perianal abscess to fistula-in-ano. It is mostly observed in boys younger than 2 years. Most are treated conservatively. In contrast, anal sepsis in older children presents significant similarities to that of adults and is predominantly treated surgically. We report our outcomes after surgical treatment of anal abscess and fistula-in-ano in children older than 2 years.

PATIENTS AND METHODS

Ninety-eight (98) children were operated on for anal abscess (46 patients; 47%) and/or fistula-in-ano (52 patients; 53%). Incision and drainage of the abscess was performed as outpatients. In patients with fistulas, fistulotomy was the main treatment approach. All patients were healthy without risk factors for anal sepsis.

RESULTS

In patients with anal abscess treated with incision and drainage, low recurrence (13%) or fistula formation rates were observed. Most anal fistulas were simple entities. Significant involvement of the anal sphincter was found in 3 (6%) of 52 patients. An abscess cavity between the anal canal and the perianal skin was found in 4 (8%) of 52 patients, and an enlarged cryptic gland was found in 5 (10%) of 52 cases. Fistulotomy was performed in all patients with additional seton placement in 3 (6%) of 52 and a cryptotomy in 5 (10%) of 52 patients.

CONCLUSIONS

Anal abscesses in children are easily treated by incision and drainage with low recurrence of perianal sepsis. Fistulas can be treated successfully in most patients with a fistulotomy, whereas complex fistulas are uncommon.

Management of perianal abscess with hainosankyuto in neonates and young infants

BACKGROUND

Perianal abscess (PA) is a common condition acquired in infancy, yet its treatment method remains controversial. We reviewed the outcome of neonates and young infants with PA who were treated with the traditional Japanese medicine, hainosankyuto (TJ-122).

METHODS

Fifteen male infants with PA under the age of 3 months were reviewed. The median age of infants at disease onset was 33 days (range, 18-88 days) and the median bodyweight was 4.1 kg (range, 2.5-6.4 kg). TJ-122 was administered at a dose of 0.20 g/kg/day (n= 13) or 0.25 g/kg/day (n= 2) orally in two or three divided doses before meals. Antibiotics were not used in any of the patients.

RESULTS

Of the 15 patients, 14 were cured and had no recurrence, with a median TJ-122 administration of 28 days (range, 14-117 days). Eight patients were cured within 28 days (53%) and 12 were cured within 60 days (80%). One patient, who was later diagnosed with growth hormone deficiency, showed incomplete healing of PA with intermittent pus discharge and recurrence. The patient was cured by 1 year of age following repeated administration of TJ-122 and juzentaihoto (TJ-48).

CONCLUSION

Medical management with TJ-122 was effective in most neonates and young infants with PA. It appears prudent to manage these patients with hainosankyuto before resorting to surgical intervention.

Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome

PURPOSE

The aims of this study are to evaluate the clinical characteristics of perianal abscess and fistula-in-ano in children, and to assess our experience in treatment, and to identify factors that affected the clinical outcomes.

METHODS

A retrospective review of children with perianal abscess and fistula-in-ano was carried out in a tertiary care children's hospital from January 2005 to December 2010. Demographic information of the patients, localization of the lesions, treatment procedures, microbial organisms in pus, usage of antibiotics, abscess recurrence, development of fistula-in-ano, and duration of symptoms were recorded. Patients with systemic diseases and inflammatory bowel diseases were excluded from the study.

RESULTS

A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2 months (ranging 16 days to 18 years) were eligible for the study. Initial examination of the 136 patients revealed perianal abscess and 22 patients with fistula-in-ano. Primary treatment was incision and drainage (I/D) for the fluctuating perianal abscess (73.5%), and local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy. Patients were divided into two groups according to age distribution, 98 of the patients were younger than 12 months, and 60 were older than 12 months of age. There was no significant difference in sex distribution, localization of the lesions, treatment procedures, recurrence of abscess and fistula-in-ano formation between the two age groups (p > 0.05). Recurrence rates (27% in I/D and 30.6% in S/D, p > 0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p > 0.05) were not significant I/D and S/D groups. Kind of the microorganisms in pus swaps did not effect the fistula-in-ano formation. Usage of antibiotics significantly reduced the development of fistula-in-ano (p = 0.001), but did not effect the recurrence of perianal abscess (p > 0.05). The mean follow-up period was 10.6 ± 8.6 months. While the 9 of the overall 52 fistula-in-ano (22 initial, 30 after abscess treatment) were resolved spontaneously, 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy).

CONCLUSIONS

Although management of perianal abscess is still controversial, simple drainage of the perianal abscess with additional antibiotic therapy reduces the development of fistula-in-ano. Fistula-in-ano within children has a chance of spontaneous resolution thus the immediate surgical intervention should be avoided.

Clinical and microbiological analysis of adult perianal abscess

BACKGROUND

In Taiwan, Klebsiella pneumoniae is the predominant pathogen causing pyogenic liver abscess in patients with diabetes mellitus (DM). The purpose of our hospital-based study was to determine the predominant bacterial species causing perianal abscess in hospitalized patients with and without DM in Taiwan.

METHODS

Data on patients admitted and then operated on for perianal abscess during the period of March 2001 to December 2008 were reviewed. Information extracted from medical records included clinical information and laboratory data as well as culture and antibiotic sensitivity results.

RESULTS

A total of 183 patients underwent surgery for perianal abscess. The most common pathogen causing perianal abscess in non-DM patients was Escherichia coli (67.1%), and the most common pathogen isolated in DM patients was K pneumoniae (60%; p=0.009). Among the 25 patients with DM, incident DM was diagnosed in 24.0% (6 of 25). In addition, five patients had transient hyperglycemia.

CONCLUSIONS

Escherichia coli was the predominant pathogen isolated from perianal abscesses in patients without DM. Klebsiella pneumoniae, however, was the predominant pathogen isolated in DM patients. In both DM and non-DM patients, more than 90% of K pneumoniae isolates showed in vitro sensitivity to first-generation cephalosporins.

Clinical characteristics and treatment of perianal abscess and fistula-in-ano in infants

PURPOSE

The aims of this study were to evaluate the clinical characteristics of perianal abscess and fistula-in-ano in infants and to identify factors that affected the clinical outcomes.

METHOD

The authors retrospectively reviewed the clinical data of 112 infants who were treated for perianal abscess and fistula-in-ano by a single pediatric surgeon from January 2006 to December 2008.

RESULTS

All patients were male and the mean age of infants presented to our hospital was 6.0 ± 4.5 months. One hundred one patients (90.2%) had 1 or 2 perianal lesions, and 76 (67.9%) had lesions at the 3 and/or 9-o'clock directions. The use of oral antibiotics did not improve or aggravate the lesions in 29 of 37 cases. Ninety-seven patients (86.6%) were cured by conservative treatment with a mean duration of 5.2 ± 3.9 months from the onset of the disease to the cure. The mean age of curing was 9.0 ± 4.9 months. Feeding formula change showed improvement of stooling in 38 (62.3%) of 61 patients but did not affect the duration of conservative treatment. Multiple linear analysis revealed that the presence of multiple lesions was a significant independent variable (P = .001) for the duration of conservative treatment, but age of the onset and location of the lesion were not. Twelve patients (10.7%) underwent fistulectomy at a mean age of 15.0 ± 5.1 months. None of the patients had recurrences after operation for the mean follow-up period of 23.7 ± 11.7 months.

CONCLUSION

Conservative treatment of perianal abscess and fistula-in-ano has an excellent outcome and could be the first choice of treatment of these diseases.

Perianal abscess and fistula-in-ano in children: aetiology, management and outcome

AIM

We aimed to assess our experience in treatment and outcome of perianal abscess and/or fistula-in-ano in children.

METHOD

The patients who were treated for perianal abscess and/or fistula-in-ano from January 2000 to December 2005 were included. Age, sex, duration of symptoms, number and site of the perianal abscess and/or fistula-in-ano, treatment modality and recurrences were recorded.

RESULTS

The study consisted of 39 patients (36 boys) with a mean age of 29 +/- 49.1 months. At first examination the diagnosis was perianal abscess in 20 patients, perianal abscess with fistula in five patients and fistula-in-ano in 14 patients. No patients had an underlying illness. The primary local treatment of perianal abscess with or without fistula was incision and drainage (with or without antibiotic therapy) in 21 patients, and local care with antibiotic therapy was given to four patients. Of 20 patients with perianal abscess, 17 developed fistula-in-ano and three healed. One patient in the perianal abscess group who developed fistula-in-ano and two patients in the fistula group were lost to follow-up. Thirty-three patients with fistula-in-ano underwent surgical treatment either through a fistulotomy or through a fistulectomy. Five (15.1%) patients who experienced recurrent fistula-in-ano underwent fistulotomy were completely cured after the second operation.

CONCLUSION

Treatment of a perianal abscess either through incision and drainage with antibiotics or through antibiotics alone resulted in a high rate (85%) of fistula formation. Fistula-in-ano can be treated either by fistulotomy or by fistulectomy, both of which are associated with a reasonable chance of recurrence of fistula-in-ano formation. We obtained good results in our patients through surgical approach (fistulotomy or fistulectomy), for fistula-in-ano formed following treatment of perianal abscess.

[Progress in surgical treatment of perianal abscess]

There were more and more patients suffered from perianal abscess. The patient's condition will become even worse if the patients cannot be treated properly. Selecting proper operation method according to special condition is the key point of increasing curative effect, decreasing suffering and relapse rate and promoting quality of life of patients. The authors summarized operation methods, including abscess incision drainage, radical incision and thread-drawing, and staging incision and thread-drawing, etc. in treating perianal abscess in clinic.

Fistula in ano in infants: who recurs?

INTRODUCTION

Fistula in ano is a common malady in infancy. However, relatively little literature is devoted to it. Our aim was to describe the natural history and identify predictors of which children will ultimately recur.

METHODS

A retrospective review of patients less than 3 years old undergoing anal fistulotomy was performed between May 2002 and November 2007 at a tertiary children's hospital. Demographics, preoperative, operative, and postoperative characteristics were collected in each group and evaluated by biostatistical analysis. P values <0.05 were considered significant.

RESULTS

A total of 92 children undergoing anal fistulotomy were identified. The median age was 6 months. Twelve children (13%) had recurrences and two of the 12 had multiple recurrences. Children who had recurrences were older (12.9 vs. 7.5 months, P < 0.05) and were more likely to have a previous abscess (20 vs. 6%, P < 0.05). In addition, children with recurrences had pus noted at the time of surgery more than children who did not recur (23 vs. 8%, respectively, P < 0.05). There were no major complications.

CONCLUSIONS

Fistula in ano in infants is a relatively benign process with most children having no serious sequelae. However, a not insignificant portion (13%) of children developed recurrences. Older children who developed fistulas were more likely to have a recurrence than younger, and children who had previous episodes of perianal abscess or pus noted at the time of surgery were more likely to recur.

Common anorectal problems

Children, just as adults, have a variety of common anorectal problems that can be quite bothersome. The presentation of these problems may be age-specific. Abscesses, fistulas, and fissures appear more commonly in infants and young children, whereas hemorrhoids and pilonidal disease are more common in teens and young adults. Fissures often can be treated medically but may require surgical treatment with lateral internal sphincterotomy. Abscesses and fistulas are common in infant males, especially robust infants who are breastfed. They may resolve with medical therapy but anal fistulotomy is not infrequently required. Hemorrhoids are rare in young children but may be an issue for teenagers. Acute symptomatic lesions may require excision if local measures cannot control the symptoms. Finally, pilonidal disease is a difficult problem for the patient and the surgeon. Persistently symptomatic lesions demand some type of surgical treatment but wound healing is poor in the intergluteal cleft region. More extensive procedures requiring the transfer of fasciocutaneous flaps may be necessary to provide definitive relief. Anorectal problems in infants and children are frequent and bothersome. Although most are not associated with tremendous morbidity, they can lead to much patient and parent anxiety as well as frequent medical consultation until the problem is successfully treated or resolves.

Characteristics of perianal abscess and fistula-in-ano in healthy children

BACKGROUND

Probably because of the low frequency, perianal abscess (PA) and fistula-in-ano (FIA) in children older than 2 years have not been investigated except in those with a predisposing condition such as Crohn's disease. This study aims to summarize our experience about the characteristics and treatment of PA and FIA in healthy children.

METHODS

The charts of all children older than 24 months of age treated for PA and/or FIA from 1990 to 2003 were reviewed.

RESULTS

We found 40 patients, 37 of them boys (92.5%), ranging from 2 to 14 years of age (average: 7.19 years). At the first examination, the diagnosis was PA in 36 patients (mean age: 6.8 years; range: 2.3-13 years), and FIA in 4 patients (mean age: 10.8 years; range: 6-14 years). The primary local treatment of PA was drainage (needle aspiration in 26 patients, and incision and drainage in 4 patients) and local care in 6 patients. All patients received antibiotics. Overall, 29 children (80.6%) had primary cure of the abscess. Evolution included recurrent abscess in 3 patients (8.3%) and FIA in 4 patients (11.1%). Crohn's disease was diagnosed in only one boy with an abscess of long duration. No patient developed a new PA in another location or a recurrent FIA. Four male patients aged 6 to 14 years (range: 7.1 years) had a FIA of long duration. One patient underwent a fistulectomy. Crohn's disease was found in three other children and treated conservatively.

CONCLUSION

Drainage of PA by needle aspiration associated with antibiotics is effective in children older than 2 years of age with a low rate of evolution toward FIA. Associated pathology must be ruled out in children with FIA.

Perianal abscess and fistula-in-ano in infants: a different entity?

PURPOSE

The features of perianal abscess and fistula-in-ano in infants are different from those of older children, and there is controversy regarding their treatment. The aim of this study was to assess the efficacy of various methods used for their management.

METHODS

A retrospective analysis of the records was conducted for all infants younger than 24 months of age treated for perianal abscess, fistula-in-ano, or both from 1990 to 2002.

RESULTS

The study included 98 infants. Perianal abscess was found in 77 patients (75 males), and fistula-in-ano in 21. No infant had an underlying illness. Drainage was performed by needle aspiration in 47 patients and by incision and drainage in 5. Following drainage, 43 patients received antibiotics. Altogether, 6 infants were treated with antibiotics alone and 19 with local care alone. Twenty-eight boys (36.4 percent) had an evolution toward fistula-in-ano. Patients who received antibiotics following drainage were less likely to develop fistula-in-ano than were patients who underwent a drainage procedure alone (27.9 percent vs. 66.7 percent, P < 0.05). All patients with fistula-in-ano were male and had been previously treated for perianal abscess (21 patients elsewhere and 28 in our department). Spontaneous cure of fistula-in-ano occurred in 42.9 percent of them (average 3.2 months), and 57.1 percent underwent fistulectomy for persistent fistula-in-ano. Cryptotomy was added when an involved crypt was found (11 patients, 39.3 percent). No recurrence of fistula-in-ano was noted after fistulectomy.

CONCLUSIONS

Local treatment for perianal abscess during the early stage and drainage by needle aspiration during the progressive stage are effective. Antibiotics may be considered for patients undergoing drainage of perianal abscess. Fistula-in-ano can be managed conservatively for one to three months. For a persisting fistula, fistulectomy with cryptotomy (when abnormal anal crypts are found) is the preferred treatment.