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Reza L, Gottgens K, Kleijnen J, Breukink S, Ambe PC, Aigner F, Aytac E, Bislenghi G, Nordholm-Carstensen A, Elfeki H, Gallo G, Grossi U, Gulcu B, Iqbal N, Jimenez-Rodriguez R, Leventoglu S, Lisi G, Litta F, Lung P, Millan M, Ozturk E, Sackitey C, Shalaby M, Stijns J, Tozer P, Zimmerman D. European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula. Colorectal Dis 2024; 26:145-196. [PMID: 38050857 DOI: 10.1111/codi.16741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 12/07/2023]
Abstract
AIM The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.
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Affiliation(s)
| | | | - Jos Kleijnen
- KSR Ltd & Maastricht University Medical Center (MUMC+) -CAPHRI, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | - Ugo Grossi
- Treviso Regional Hospital, Treviso, Italy
| | | | | | | | | | | | | | | | - Monica Millan
- La Fe University and Polytechnic Hospital, Valencia, Spain
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van Oostendorp JY, Dekker L, van Dieren S, Bemelman WA, Han-Geurts IJM. Antibiotic Treatment foLlowing surgical drAinage of perianal abScess (ATLAS): protocol for a multicentre, double-blind, placebo-controlled, randomised trial. BMJ Open 2022; 12:e067970. [PMID: 36351727 PMCID: PMC9644350 DOI: 10.1136/bmjopen-2022-067970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Perianal fistula is a burdening disease with an annual incidence of 6-12/100 000 in Western countries. More than 90% of crypto-glandular fistulas originate from perianal abscess. Despite adequate drainage, up to 83% recur or result in an anal fistula, the majority developing within 12 months. There is some evidence that gut-derived bacteria play a role in the development of perianal fistula. Up till now, it is not common practice to routinely administer prophylactic antibiotics to prevent anal fistula development. There is a need for a study to establish whether adding antibiotic treatment to surgical drainage of perianal abscess results in a reduction in perianal fistulas. METHODS AND ANALYSIS This multicentre, double-blind, randomised, placebo-controlled trial investigates whether addition of antibiotics (ciprofloxacin and metronidazole) to surgical drainage of a perianal abscess is beneficial compared with surgical drainage alone. The primary outcome is the development of a perianal fistula within 1 year. Secondary outcomes include quality of life, treatment costs, need for repeated drainage, patient-reported outcomes and other clinical outcomes. Participants are recruited in one academic and seven peripheral Dutch clinics. To demonstrate a reduction of perianal fistula from 30% to 15% when treated with adjuvant antibiotics with a two-sided alpha of 0.05, a power of 80% and taking a 10% loss to follow-up percentage into account, the total sample size will be 298 participants. Data will be analysed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers (nr. 2021_010). Written consent is obtained from each participant prior to randomisation into the study. The results of this trial will be submitted for publication in international peer-reviewed journals, presented at conferences and spread to coloproctological associations. TRIAL REGISTRATION NUMBERS 2020-004449-35; NCT05385887.
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Affiliation(s)
- Justin Y van Oostendorp
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands
| | - Lisette Dekker
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results. Cir Esp 2021; 100:25-32. [PMID: 34876366 DOI: 10.1016/j.cireng.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/13/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001). CONCLUSION After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.
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Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, Abongwa H, De Simone B, Gallo G, Rossi G, Abu-Zidan F, Agnoletti V, de'Angelis G, de'Angelis N, Ansaloni L, Baiocchi GL, Carcoforo P, Ceresoli M, Chichom-Mefire A, Di Saverio S, Gaiani F, Giuffrida M, Hecker A, Inaba K, Kelly M, Kirkpatrick A, Kluger Y, Leppäniemi A, Litvin A, Ordoñez C, Pattonieri V, Peitzman A, Pikoulis M, Sakakushev B, Sartelli M, Shelat V, Tan E, Testini M, Velmahos G, Wani I, Weber D, Biffl W, Coccolini F, Catena F. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16:48. [PMID: 34530908 PMCID: PMC8447593 DOI: 10.1186/s13017-021-00384-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesco Azzaroli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Hariscine Abongwa
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Belinda De Simone
- Department of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, Poissy, France
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giorgio Rossi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Gianluigi de'Angelis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Ital - Université Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- Department of Emergency and general Surgery, Pavia University Hospital, Pavia, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Alain Chichom-Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Salomone Di Saverio
- General surgery 1st unit, Department of General Surgery, University of Insubria, Varese, Italy
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Carlos Ordoñez
- Department of Surgery, Fundacion Valle del Lili - Universidad del Valle, Cali, Colombia
| | | | - Andrew Peitzman
- University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Manos Pikoulis
- 3rd Department of Surgery, National & Kapodistrian University of Athens, Athens, Greece
| | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Plovdiv, Bulgaria
| | | | - Vishal Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Edward Tan
- Department of Surgery, Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mario Testini
- Academic Unit of General Surgery "V. Bonomo" Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, Cesena, Italy
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Intersphincteric Exploration With Ligation of Intersphincteric Fistula Tract or Attempted Closure of Internal Opening for Acute Anorectal Abscesses. Dis Colon Rectum 2021; 64:438-445. [PMID: 33394781 DOI: 10.1097/dcr.0000000000001867] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acute anorectal abscesses of cryptoglandular origin are commonly managed by incision and drainage, which results in fistula development in up to 73% of cases, requiring subsequent definitive fistula surgery. However, given that fistula tracts may already be present at the initial presentation, primary closure of the tract as secondary prevention of fistula formation, using ligation of intersphincteric fistula tract, may be useful. OBJECTIVE This study aims to examine the feasibility and outcomes of performing intersphincteric exploration with ligation of intersphincteric fistula tract or attempted closure of internal opening for acute anorectal abscesses. DESIGN This is a retrospective study of patients with acute anorectal cryptoglandular abscesses who underwent surgery between January 2014 and December 2016. SETTINGS The patients were treated at a tertiary referral center in Thailand. PATIENTS Eighty-six patients with acute anorectal abscesses without previous surgery were included. INTERVENTIONS Intersphincteric dissection was performed. Further surgical intervention was dependent on the intersphincteric findings. MAIN OUTCOME MEASURE The main outcome measure was the 90-day healed rate. RESULTS Of the 86 patients, 3 had low intersphincteric abscesses, 26 had low transsphincteric abscesses, 25 had anterior high transsphincteric abscesses, 27 had posterior high transsphincteric abscesses, and 5 had high intersphincteric abscesses. Ligation of intersphincteric fistula tract was successfully performed in 66 patients with an identifiable intersphincteric tract. Intersphincteric exploration with attempted closure of the internal opening was performed in the remaining 20 patients. The success rates were 86% and 70%. Unidentified internal opening and intersphincteric pathology were risk factors for nonhealing. No patients reported fecal incontinence postoperatively. LIMITATIONS The limitation of this study is its retrospective nature and that all operations were performed by a single surgeon; therefore, the results may vary according to the individual surgeon's expertise. CONCLUSIONS Fistula tract formation was found in most cases of acute anorectal abscesses. Definitive surgery using this strategy provides promising results. See Video Abstract at http://links.lww.com/DCR/B451. EXPLORACIN INTERESFINTRICA CON LIGADURA DEL TRAYECTO EN LA FSTULA INTERESFINTRICA O INTENTO DE CIERRE DEL ORIFICIO INTERNO EN ABSCESOS ANORRECTALES AGUDOS ANTECEDENTES:Los abscesos anorrectales agudos de origen criptoglandular, comúnmente se manejan mediante incisión y drenaje, lo que resulta en el desarrollo de una fístula hasta en un 73% de los casos, requiriendo posteriormente cirugía definitiva de la fístula. Sin embargo, dado que los trayectos de la fístula ya pueden estar inicialmente presentes, puede ser útil el cierre primario del trayecto, como prevención secundaria en la formación de la fístula, mediante la ligadura del trayecto de la fístula interesfintérica.OBJETIVO:El estudio tiene como objetivo, examinar la viabilidad y los resultados en realizar exploración interesfintérica, con ligadura del trayecto de fístula interesfintérica o intento de cierre del orificio interno para abscesos anorrectales agudos.DISEÑO:Se trata de un estudio retrospectivo de pacientes con abscesos criptoglandulares anorrectales agudos, que fueron operados entre enero de 2014 y diciembre de 2016.AJUSTES:Los pacientes fueron tratados en un centro de referencia terciario en Tailandia.PACIENTES:Se incluyeron 86 pacientes con abscesos anorrectales agudos, sin cirugía previa.INTERVENCIONES:Se realizó disección interesfintérica. La intervención quirúrgica adicional dependió de los hallazgos interesfintéricos.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado, fue la tasa de cicatrización a 90 días.RESULTADOS:De los 86 pacientes, hubo 3 abscesos interesfintéricos bajos, 26 abscesos transesfintéricos bajos, 25 abscesos transesfintéricos anteriores altos, 27 abscesos transesfintéricos posteriores altos y 5 abscesos interesfintéricos altos. La ligadura del tracto de la fístula interesfintérica, con tracto interesfintérico identificable, se realizó con éxito en 66 pacientes. Se realizó exploración interesfintérica, con intento de cierre del orificio interno en los 20 pacientes restantes. Las tasas de éxito fueron 86% y 70% respectivamente. Orificio interno no identificado y patología interesfintérica, fueron factores de riesgo para la falta de cicatrización. Ningún paciente reportó incontinencia fecal posoperatoria.LIMITACIONES:La limitación de este estudio, es su naturaleza retrospectiva y que todas las operaciones fueron realizadas por un solo cirujano, por lo tanto, los resultados pueden variar según la experiencia de cada cirujano.CONCLUSIONES:En la mayoría de los casos de abscesos anorrectales agudos, se encontró formación de trayectos fistulosos. La cirugía definitiva con esta estrategia, proporciona resultados prometedores. Consulte Video Resumen en http://links.lww.com/DCR/B451.
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Chaveli Díaz C, Esquiroz Lizaur I, Eguaras Córdoba I, González Álvarez G, Calvo Benito A, Oteiza Martínez F, de Miguel Velasco M, Ciga Lozano MÁ. Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results. Cir Esp 2020; 100:S0009-739X(20)30384-5. [PMID: 33358408 DOI: 10.1016/j.ciresp.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/05/2020] [Accepted: 11/13/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001) CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.
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Affiliation(s)
- Carlos Chaveli Díaz
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España.
| | - Irene Esquiroz Lizaur
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Inés Eguaras Córdoba
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | | | - Ana Calvo Benito
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Fabiola Oteiza Martínez
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Mario de Miguel Velasco
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Miguel Ángel Ciga Lozano
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
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Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission? Dis Colon Rectum 2020; 63:1127-1133. [PMID: 32251145 DOI: 10.1097/dcr.0000000000001653] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Perirectal abscess is a common problem. Despite a seemingly simple disease to manage, clinical outcomes of perirectal abscesses can vary significantly given the wide array of patients who are susceptible to this disease. OBJECTIVE Our aims were to evaluate the outcomes after operative incision and drainage for perirectal abscess and to examine factors associated with length of stay, reoperations, and readmissions. DESIGN This was a retrospective analysis of the National Surgical Quality Improvement Program database. SETTINGS The study was conducted with hospitals participating in the surgical database. PATIENTS Adult patients undergoing outpatient perirectal abscess procedures from 2011 through 2016 were included. MAIN OUTCOME MEASURES Study outcomes were length of stay, reoperation, and readmission. RESULTS We identified 2358 patients undergoing incision and drainage for perirectal abscesses. Approximately 35% of patients required hospital stay. Reoperations occurred in 3.4%, with median time to reoperation of 15.5 days. The majority of reoperations (79.7%) were performed for additional incision and drainage. Readmissions rate was 3.0%, with median time to readmission of 10.5 days. Common indications for readmissions included recurrent/persistent abscess (41.4%) and fever/sepsis (8.6%). Risk factors for hospitalization in multivariable analysis were preoperative sepsis, bleeding disorder, and non-Hispanic black and Hispanic races. For reoperations, risk factors included morbid obesity, preoperative sepsis, and dependent functional status. Lastly, for readmissions, female sex, steroid/immunosuppression, and dependent functional status were significant risk factors. LIMITATIONS The study was limited by its retrospective analysis and potential selection bias in decisions on hospital stay, reoperation, and readmission. CONCLUSIONS Suboptimal outcomes after outpatient operative incision and drainage for perirectal abscesses are not uncommon in the United States. In the era of value-based care, additional work is needed to optimize use outcomes for high-risk patients undergoing perirectal incision and drainage. Strategies to prevent inadequate drainage at the time of the initial operative incision and drainage (ie, use of imaging modalities and thorough examination under anesthesia) are warranted to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/B229. INCISIÓN Y DRENAJE QUIRÚRGICOS DE ABSCESOS PERIRRECTALES: CUALES SON LOS FACTORES DE RIESGO PARA UNA ESTADÍA PROLONGADA, REINTERVENCIÓN Y READMISION?: Los abscesos perirrectales son un problema frecuente. A pesar que parecen ser una afección aparentemente simple de manejar, los resultados clínicos de la incisión y drenaje quirúrgicos pueden variar significativamente dada la amplia variedad de pacientes susceptibles de sufrir esta afección.Evaluar los resultados después de la incisión y el drenaje quirúrgicos de un absceso perirrectal y analizar los factores asociados con la duración de la hospitalización, la reoperación y la readmisión.Análisis retrospectivo de la base de datos del Programa Americano de Mejora de la Calidad Quirúrgica.Hospitales que participan en la base de datos quirúrgica.Pacientes adultos sometidos a incisión y drenaje quirúrgico ambulatorio de un absceso perirrectal desde 2011 hasta 2016.Los resultados del estudio fueron la duración de la hospitalización, la reoperación y el reingreso.Fueron estudiados 2,358 pacientes sometidos a incisión y drenaje por abscesos perirrectales. Aproximadamente el 35% de los pacientes requirieron hospitalización. Las reoperaciones ocurrieron en 3.4% con una mediana de tiempo de reoperación de 15.5 días. La mayoría de las reoperaciones (79.7%) se realizaron para una incisión y drenaje adicionales. La tasa de reingreso fue del 3.0% con una mediana de tiempo de reingreso de 10.5 días. Las indicaciones comunes para los reingresos incluyeron abscesos recurrentes / persistentes (41.4%) y fiebre / sepsis (8.6%). Los factores de riesgo para la hospitalización en el análisis multivariable fueron sepsis preoperatoria, trastorno hemorrágico, raza negra no hispánica y raza hispana. Para las reoperaciones, los factores de riesgo incluyeron obesidad mórbida, sepsis preoperatoria y estado funcional dependiente. Por último, para los reingresos, el sexo femenino, uso de corticoides / inmunosupresores y un estadío funcional dependiente fueron factores de riesgo significativos.Análisis retrospectivo y posible sesgo de selección en las decisiones sobre hospitalización, reoperación y reingreso.Un resultado poco satisfactorio después de la incisión quirúrgica el drenaje de abscesos perirrectales ambulatoriamente no son infrecuentes en los Estados Unidos. En la era de la atención basada en los resultados, se necesita mucho más trabajo para optimizar los mismos en pacientes de alto riesgo sometidos a incisión y drenaje perirrectales. Las estrategias para prevenir el drenaje inadecuado en el momento de la incisión quirúrgica inicial y el drenaje (es decir, el uso de modalidades de imágenes, un examen completo bajo anestesia) son una garantía para mejorar los resultados en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B229.
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Sahnan K, Adegbola S, Iqbal N, Twum-Barima C, Reza L, Lung P, Warusavitarne J, Hart A, Tozer P. Managing non-IBD fistulising disease. Frontline Gastroenterol 2020; 12:524-534. [PMID: 34712471 PMCID: PMC8515280 DOI: 10.1136/flgastro-2019-101234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kapil Sahnan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Samuel Adegbola
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Nusrat Iqbal
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Charlene Twum-Barima
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Lillian Reza
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Phillip Lung
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
- IBD Unit, St Mark's Hospital, Harrow, UK
| | - Phil Tozer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
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He Z, Du J, Wu K, Chen J, Wu B, Yang J, Xu Z, Fu Z, Pan L, Wen K, Wang X. Formation rate of secondary anal fistula after incision and drainage of perianal Sepsis and analysis of risk factors. BMC Surg 2020; 20:94. [PMID: 32375721 PMCID: PMC7204285 DOI: 10.1186/s12893-020-00762-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/28/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The choice of surgery for perianal sepsis is currently controversial. Some people advocate one-time radical surgery for perianal sepsis, while others advocate incision and drainage. The objective of this study is to observe the formation probability of secondary anal fistula after incision and drainage in patients with perianal sepsis and determine factors that contribute to secondary anal fistula after incision and drainage. METHODS A retrospective descriptive analysis was conducted in 288 patients with perianal sepsis who were treated with anorectal surgery in the Suzhou Hospital of Traditional Chinese Medicine from January 2016 to June 2018. The patients were followed by telephone, physical examination, and pelvic MRI examination for at least 1 year after surgery. RESULTS Three patients were not followed, 98 patients did not receive surgical treatment or one-time radical surgery for perianal sepsis, and 187 patients were ultimately identified for the study. Anal fistula was present in 105 patients, and the rate of formation of secondary anal fistula was 56.15%. There was no statistically significant difference in the fistula formation rate between different types of sepsis (P>0.05). And, in patients with secondary anal fistula, there was no significant correlation between the location of sepsis and the type of secondary anal fistula (P>0.05). CONCLUSIONS The incidence of secondary anal fistula after incision and drainage of perianal sepsis is 56.15%, which is lower than the incidence found in previous study. Young is a risk factor for secondary anal fistula after incision and drainage of perianal sepsis. There is no significant correlation between the location of sepsis and the type of secondary anal fistula. Simple incision and drainage is a suitable choice for patients with acute perianal sepsis.
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Affiliation(s)
- Zongqi He
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Jun Du
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Kaiwen Wu
- Department of Anorectal Surgery, Kunshan Fourth Peoples Hospital, No. 21, Zhenbei Road, Kunshan, Jiangsu, China
| | - Jiajia Chen
- Department of Radiology, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Bensheng Wu
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Jianhua Yang
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Zhizhong Xu
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Zhihui Fu
- Department of Radiology, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Li Pan
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Ke Wen
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China.
| | - Xiaopeng Wang
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China.
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Lopez MPJ, Onglao MAS, Monroy Iii HJ. Initial Experience With Video-Assisted Anal Fistula Treatment in the Philippines. Ann Coloproctol 2020; 36:112-118. [PMID: 32178505 PMCID: PMC7299567 DOI: 10.3393/ac.2020.02.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE We determined the outcomes of patients undergoing video-assisted anal fistula treatment (VAAFT) for fistulain-ano at the Philippine General Hospital. METHODS Twenty consecutive adult patients who underwent the VAAFT procedure from 2016-2018 were included in this investigation. Information detailing baseline demographic and clinical data, fistula type and classification, and previous surgeries were retrieved from in-hospital and operative records. Operative time, identification of the internal opening, method of internal opening closure, and occurrence of immediate postoperative complications were determined. The status of the fistula was assessed at one month, 3 months, and 6 months postoperatively based on outpatient follow-up records. The primary outcomes were healing rate and recurrence rate. Secondary outcomes were 30-day morbidity, postoperative complications, and incontinence using the Wexner score. RESULTS Eighteen patients (90%) had a preoperative diagnosis of complex fistula, and 13 patients (65%) had undergone a previous fistula surgery. Primary healing rate was 55% at 1 month, 63.16% at 3 months, and 78.95% at 6 months postoperatively. Eighteen patients (94.74%) maintained continence (Wexner score = 0) at 6 months. CONCLUSION Our study results suggest that VAAFT is a safe, minimally invasive technique for treatment of anal fistula and can preserve anal sphincter function. The technique has an acceptable healing rate with minimal complications.
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Affiliation(s)
- Marc Paul J Lopez
- Division of Colorectal Surgery, Philippine General Hospital, University of the Philippines Manila, Manila, the Philippines
| | - Mark Augustine S Onglao
- Division of Colorectal Surgery, Philippine General Hospital, University of the Philippines Manila, Manila, the Philippines
| | - Hermogenes J Monroy Iii
- Division of Colorectal Surgery, Philippine General Hospital, University of the Philippines Manila, Manila, the Philippines
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12
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Konstantinos PS, Andreas D, Kleoniki K, Dimitrios F. Extraperitoneal Spread of Anorectal Abscess: A Case Report and Literature Review. Ann Coloproctol 2020; 37:S11-S14. [PMID: 32054249 PMCID: PMC8359701 DOI: 10.3393/ac.2020.01.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022] Open
Abstract
Supralevator abscess is a rare form of anorectal disease responsible for very rare but morbid manifestations, one of which is superior spread through fascial planes. We present a rare case of a spreading anorectal abscess in a patient who presented with only diffuse abdominal pain, and we review similar cases in the literature according to anatomical considerations, presentation, diagnostic procedures, and treatment options. We identified 7 previously reported cases of spreading anorectal abscesses. Most abscesses had a horseshoe morphology, and all patients presented or developed abdominal pain. All patients had perianal swelling and pain. Five out of 7 patients were previously mistreated. Only 2 abscesses spread through both the pre- and retroperitoneal planes. Abdominal pain is a dominant feature of extraperitoneal inflammation originating from anorectal abscesses. The absence of perianal signs is rare, and proper inspection of the patient along with the medical history can lead to quicker diagnosis and decisive treatment.
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Affiliation(s)
| | - Dimopoulos Andreas
- Deparment of General Surgery, General Hospital of Patras, Patras, Greece
| | - Kordeni Kleoniki
- Deparment of General Surgery, General Hospital of Patras, Patras, Greece
| | - Filis Dimitrios
- Deparment of General Surgery, General Hospital of Patras, Patras, Greece
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13
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Erol T, Mentes B, Bayri H, Osmanov I, Leventoglu S, Yildiz A, Yorubulut M, Sungurtekin U. Preventing the recurrence of acute anorectal abscesses utilizing a loose seton: a pilot study. Pan Afr Med J 2020; 35:18. [PMID: 32341739 PMCID: PMC7170736 DOI: 10.11604/pamj.2020.35.18.21029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/10/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction This pilot study aimed to document our results of treating anorectal abscesses with drainage plus loose seton for possible coexisting high fistulas or drainage plus fistulotomy for low tracts at the same operation. Methods Drainage plus fistulotomy were performed only in cases with subcutaneous mucosa, intersphincteric, or apparently low transsphincteric fistula tracts. For all other cases with high transsphincteric fistula or those with questionable sphincter involvement, a loose seton was placed through the tract. Drainage only was carried out in 17 patients. Results Twenty-three patients underwent drainage plus loose seton. Drainage plus fistulotomy were performed in four cases. None of the patients developed recurrent abscess during a follow-up of 12 months. Not surprisingly, the incontinence scores were similar pre and post-operatively (p=0.564). Only minor complications occurred in 4 cases (14.8 percent). Secondary interventions following loose seton were carried out in 13 patients (48.1 percent). At 12 months, drainage only was followed by 10 recurrences (58.8 percent; p<0.0001, compared with concomitant surgery). Conclusion Concomitant loose seton treatment of high fistula tracts associated with anorectal abscess prevents abscess recurrence without significant complications or disturbance of continence. Concomitant fistulotomy for associated low fistulas also aids in the same clinical outcome. Concomitant fistula treatment with the loose seton may suffice in treating the whole disease process in selected cases. Even in patients with high fistula tracts, the loose seton makes fistula surgery simpler with a mature tract. Abscess recurrence is high after drainage only.
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Affiliation(s)
- Timucin Erol
- Department of Surgery/Proctology, Memorial Ankara Hospital, Ankara, Turkey
| | - Bulent Mentes
- Department of Surgery/Proctology, Memorial Ankara Hospital, Ankara, Turkey
| | - Hakan Bayri
- Department of Surgery/Proctology, Memorial Ankara Hospital, Ankara, Turkey
| | - Igbal Osmanov
- Department of Surgery/Proctology, Memorial Ankara Hospital, Ankara, Turkey
| | - Sezai Leventoglu
- Department of Surgery, Gazi University Medical School, Ankara, Turkey
| | - Alp Yildiz
- Department of Surgery, Yildirim Beyazit University, Yenimahalle Research and Training Hospital, Ankara, Turkey
| | | | - Ugur Sungurtekin
- Department of Surgery, Pamukkale University Medical School, Denizli, Turkey
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14
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Lu D, Lu L, Cao B, Li Y, Cao Y, Li Z, Wang Z, Lu J. Relationship Between Body Mass Index and Recurrence/Anal Fistula Formation Following Initial Operation for Anorectal Abscess. Med Sci Monit 2019; 25:7942-7950. [PMID: 31642447 PMCID: PMC6822332 DOI: 10.12659/msm.917836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The association between body mass index (BMI) and recurrence of anorectal abscess remains controversial. This study investigated the exact relationship between BMI and anorectal abscess recurrence or anal fistula formation following initial surgery. MATERIAL AND METHODS This was a retrospective registry-based study conducted at the First Affiliated Hospital of Guizhou University of Chinese Medicine. Patients treated for anorectal abscess from 01/2015 to 03/2016 were included. Clinical data and time to recurrence were recorded. The Cox regression model was used to estimate the association between BMI and recurrence. RESULTS A total of 790 patients were operated on during the study period. The average age of the participants was 38.3±11.6 years, and 83.2% were male. Median follow-up was 27 (range, 1-38) months. Compared with the low BMI (range, 15.7-22.8 kg/m²) patients, the high BMI (range, 26.0-40.6 kg/m²) patients showed higher risk of recurrence (HR=1.75, 95% CI: 1.15-2.67). In the non-adjusted model, high BMI was found to be positively correlated with recurrence (HR=1.62, 95% CI: 1.10-2.40, P=0.02), and a stronger association was found in the fully adjusted model (HR=1.75, 95% CI: 1.15-2.67, P=0.01). BMI was also used as a continuous variable for sensitivity analysis, and a similar trend was observed (P=0.01 for trend). CONCLUSIONS Elevated BMI is an independent risk factor of anorectal abscess recurrence and for increased risk of abscess recurrence or anal fistula formation.
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Affiliation(s)
- Dan Lu
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland).,Department of Surgery Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Linyuan Lu
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Bo Cao
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Yunfei Li
- Department of Surgical Nursing, Guizhou Nursing Vocational Institute, Guiyang, Guizhou, China (mainland)
| | - Yongqing Cao
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Zhi Li
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Ziming Wang
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Jingen Lu
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
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15
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Ratto C, Grossi U, Litta F, Di Tanna GL, Parello A, De Simone V, Tozer P, DE Zimmerman D, Maeda Y. Contemporary surgical practice in the management of anal fistula: results from an international survey. Tech Coloproctol 2019; 23:729-741. [PMID: 31368010 PMCID: PMC6736896 DOI: 10.1007/s10151-019-02051-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/19/2019] [Indexed: 12/22/2022]
Abstract
Background Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. Methods An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques. Results In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease. Conclusions Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers. Electronic supplementary material The online version of this article (10.1007/s10151-019-02051-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - U Grossi
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy. .,National Bowel Research Centre, Queen Mary University of London, London, UK.
| | - F Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G L Di Tanna
- Statistics Division, The George Institute for Global Health, UNSW, Sydney, Australia
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Tozer
- Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK.,Imperial College London, London, UK
| | - D DE Zimmerman
- Department of Surgery, ETZ (Elisabeth-TweeSteden Hospital), Tilburg, The Netherlands
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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Abstract
BACKGROUND The characteristics of patients who develop a fistula-in-ano after an anorectal abscess are unclear. OBJECTIVE Our study explored this relationship and patient factors associated with fistula development. DESIGN International Classification of Diseases, 10 Revision, and Classification of Interventions and Procedures, version 4, codes were used to identify all of the patients with a primary anorectal abscess. Multivariable analysis was used to identify factors predictive of fistula formation. SETTINGS The study was conducted in a district general hospital. PATIENTS Patients with anorectal abscess who were admitted to our institution (2004-2015) were included. MAIN OUTCOMES MEASURES The rate of subsequent fistula formation was measured. RESULTS A total of 1970 abscess patients were identified; 70.0% (n = 1379) were men, and 7.3% (n = 144) had Crohn's disease. Fistulas occurred in 16.2% (n = 319) at a median of 7 months (interquartile range, 3-7 mo). Patients with Crohn's disease were more than twice as likely to develop a fistula than patients without Crohn's disease (32.6% vs 14.9%; OR = 2.5 (95% CI, 1.7-3.7); p < 0.001). Patients with Crohn's disease with a fistula were more likely to be women (55.3% vs 34.6%; p = 0.007) and aged <30 years (51.1% vs 24.3%; p< 0.001) versus patients without Crohn's disease with a fistula. At multivariable analysis of the entire cohort, male sex (OR = 0.7 (95% CI, 0.5-0.9); p = 0.005) and diabetes mellitus (OR = 0.5 (95% CI, 0.3-0.9); p = 0.027) were associated with a reduced likelihood of developing a fistula after abscess formation. LIMITATIONS The study was limited by its single-center scope, retrospective analysis, and lack of a standardized definition for Crohn's disease. CONCLUSIONS Abscesses are more common in men, but progression to fistula is more likely in women. The rate of fistula progression in Crohn's disease is twice that in patients without Crohn's disease. Identification of patients at risk may help delineate those who will benefit from a more conservative surgical approach, enhanced follow-up, or investigation after abscess drainage. See Video Abstract at http://links.lww.com/DCR/A798.
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Pastor C, Hwang J, Garcia-Aguilar J. Reprint to: Fistulotomy. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Yamana T. Japanese Practice Guidelines for Anal Disorders II. Anal fistula. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 2:103-109. [PMID: 31559351 PMCID: PMC6752149 DOI: 10.23922/jarc.2018-009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/13/2018] [Indexed: 12/21/2022]
Abstract
Anal fistulas usually result from an anal gland infection in the intersphincteric space, which is caused by bacteria entering through the anal crypt (cryoptglandular infection). Reports of anal fistulas have been as high as 21 people in 100,000. Anal fistulas are 2-6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s. Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever. Purulent discharge or intermittent perianal swelling and pain are most often consistent with anal fistula symptoms. Methods for diagnosing anal fistulas include visual inspection, palpation, digital examination, anoscopic examination, barium enema, fistulography, as well as imaging, such as ultrasound, CT, and MRI. Parks classification is widely adapted in the West; however, Japan usually employs Sumikoshi classification. Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage. The site and size of incision and drainage depend upon the abscess type and location. Incisions should be performed taking care not to damage the sphincter muscles and with possible future fistula surgery in mind. As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas. Several approaches are utilized for anal fistulas. A specific procedure may be chosen depending upon curability and anal function. Postsurgical outcomes vary from study to study. Fecal incontinence may occur after fistula surgery, but reports vary.
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Affiliation(s)
- Tetsuo Yamana
- Department of Coloproctology, Tokyo Yamate Medical Center
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19
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Sahnan K, Askari A, Adegbola SO, Tozer PJ, Phillips RKS, Hart A, Faiz OD. Natural history of anorectal sepsis. Br J Surg 2017; 104:1857-1865. [DOI: 10.1002/bjs.10614] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/28/2017] [Accepted: 05/11/2017] [Indexed: 12/26/2022]
Abstract
Abstract
Background
Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation.
Methods
The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation.
Results
A total of 165 536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158 713 (95·9 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4·1 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20·2 per 100 000. The rate of subsequent fistula formation following an abscess was 15·5 per cent (23 012 of 148 286) in idiopathic cases and 41·6 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26·7 per cent coded concurrently as ulcerative colitis; 47·2 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67·5 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3·51; P < 0·001), ulcerative colitis (HR 1·82; P < 0·001), female sex (HR 1·18; P < 0·001), age at time of first abscess 41–60 years (HR 1·85 versus less than 20 years; P < 0·001), and intersphincteric (HR 1·53; P < 0·001) or ischiorectal (HR 1·48; P < 0·001) abscess location compared with perianal. Some 2·9 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14 months.
Conclusion
The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.
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Affiliation(s)
- K Sahnan
- Surgical Epidemiology, Trials and Outcome Centre, St Mark's Hospital and Academic Institute, Harrow, UK
- Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - A Askari
- Surgical Epidemiology, Trials and Outcome Centre, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - S O Adegbola
- Surgical Epidemiology, Trials and Outcome Centre, St Mark's Hospital and Academic Institute, Harrow, UK
- Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - P J Tozer
- Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - R K S Phillips
- Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - A Hart
- Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - O D Faiz
- Surgical Epidemiology, Trials and Outcome Centre, St Mark's Hospital and Academic Institute, Harrow, UK
- Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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20
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Ghahramani L, Minaie MR, Arasteh P, Hosseini SV, Izadpanah A, Bananzadeh AM, Ahmadbeigi M, Hooshanginejad Z. Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial. Surgery 2017; 162:1017-1025. [PMID: 28822559 DOI: 10.1016/j.surg.2017.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Leila Ghahramani
- Department of surgery, Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Minaie
- Department of surgery, Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Arasteh
- Non communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Iran; MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Seyed Vahid Hosseini
- Department of surgery, Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Izadpanah
- Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Mohammad Bananzadeh
- Department of surgery, Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahboobe Ahmadbeigi
- Post Graduate Dental Student, Student Research Committee, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
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21
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Sugrue J, Nordenstam J, Abcarian H, Bartholomew A, Schwartz JL, Mellgren A, Tozer PJ. Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review. Tech Coloproctol 2017. [PMID: 28620877 DOI: 10.1007/s10151-017-1645-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.
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Affiliation(s)
- Jeremy Sugrue
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S Wood St, Suite 376-CSN, Chicago, IL, 60612, USA.
| | - Johan Nordenstam
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S Wood St, Suite 376-CSN, Chicago, IL, 60612, USA
| | - Herand Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S Wood St, Suite 376-CSN, Chicago, IL, 60612, USA
| | - Amelia Bartholomew
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Joel L Schwartz
- Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Anders Mellgren
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S Wood St, Suite 376-CSN, Chicago, IL, 60612, USA
| | - Philip J Tozer
- St. Mark's Hospital, London, UK.,Imperial College London, London, UK
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22
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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23
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24
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Ortega AE, Cologne KG, Shin J, Lee SW, Ault GT. Treatment-Based Three-Dimensional Classification and Management of Anorectal Infections. World J Surg 2016; 41:574-589. [DOI: 10.1007/s00268-016-3767-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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25
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Fisher OM, Raptis DA, Vetter D, Novak A, Dindo D, Hahnloser D, Clavien PA, Nocito A. An outcome and cost analysis of anal fistula plug insertion vs endorectal advancement flap for complex anal fistulae. Colorectal Dis 2015; 17:619-26. [PMID: 25641401 DOI: 10.1111/codi.12888] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 11/23/2014] [Indexed: 12/16/2022]
Abstract
AIM The study aimed to compare the rate of success and cost of anal fistula plug (AFP) insertion and endorectal advancement flap (ERAF) for anal fistula. METHOD Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than a third of the longitudinal length of of the anal sphincter, were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost. RESULTS Seventy-one patients (AFP 31, ERAF 40) were analysed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF group (P = 1.00). The median length of stay was 1.23 and 2.0 days (P < 0.001), respectively, and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 (P = 0.021), respectively. On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost (P = 0.023). CONCLUSION Anal fistula plug and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay.
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Affiliation(s)
- O M Fisher
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D Vetter
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - A Novak
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D Dindo
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - P-A Clavien
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - A Nocito
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Surgery, Cantonal Hospital Baden, Baden, Switzerland
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26
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Cadeddu F, Salis F, Lisi G, Ciangola I, Milito G. Complex anal fistula remains a challenge for colorectal surgeon. Int J Colorectal Dis 2015; 30:595-603. [PMID: 25566951 DOI: 10.1007/s00384-014-2104-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2014] [Indexed: 02/04/2023]
Abstract
AIM Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. MATERIAL AND METHODS A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm. RESULTS The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities. CONCLUSIONS Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.
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Affiliation(s)
- F Cadeddu
- Department of Surgery, San Francesco Hospital, Via Mannironi, 08020, Nuoro, Italy,
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27
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Adamina M, Ross T, Guenin MO, Warschkow R, Rodger C, Cohen Z, Burnstein M. Anal fistula plug: a prospective evaluation of success, continence and quality of life in the treatment of complex fistulae. Colorectal Dis 2014; 16:547-54. [PMID: 24521307 DOI: 10.1111/codi.12594] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/12/2014] [Indexed: 02/08/2023]
Abstract
AIM Curing complex anal fistula without compromising continence can be extremely challenging. This study investigated the healing rate, continence and quality of life of patients after treatment of complex anal fistula of cryptoglandular origin with a bioprosthetic plug. METHOD Consecutive patients were prospectively followed in four referral centres. Following seton conditioning, a bioprosthetic plug was inserted into the fistula and sutured to the anal sphincter. Clinical evaluation was performed at 10 days, 6 weeks and 6 months after surgery, and was completed by telephone interviews. Anal continence and quality of life were evaluated using the Fecal Incontinence Score Index and the Short Form-36 Health Survey, version 2 (SF-36 v2) questionnaire. RESULTS Forty-six patients presenting with a complex anal fistula and a median of three previous fistula surgeries were included. The 6-month recurrence rate was 30.7% (95% CI: 15.9-42.8%), increasing to 48.0% (95% CI: 30.6-61.1%) after 2 years. Follow up was continued for a median of 68.1 months, and 26 (56.5%) recurrences were identified. Anal continence improved from a median of 19 points to 12 points at 6 months of follow up (P = 0.008). Quality of life markedly improved in all scales. The physical summary score increased from 47.2 to 56.2 (P < 0.001), and the mental summary score increased from 48.5 to 55.3 (P = 0.013). CONCLUSION The bioprosthetic fistula plug demonstrated a healing rate close to 50% in complex cryptoglandular fistula. Also, it markedly improved anal continence and quality of life. These data support the use of a bioprosthetic plug as first-line therapy for complex fistula instead of more aggressive and potentially debilitating surgical options.
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Affiliation(s)
- M Adamina
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Surgery, Women's College Hospital, Toronto, ON, Canada; Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada; Department of Surgery, St Michael's Hospital, Toronto, ON, Canada
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28
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Wu J, Wang ZY, Sun JH. Operative treatment of perianal abscess. Shijie Huaren Xiaohua Zazhi 2013; 21:3842-3847. [DOI: 10.11569/wcjd.v21.i34.3842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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29
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Abstract
Benign anorectal diseases, such as anal abscesses and fistula, are commonly seen by primary care physicians, gastroenterologists, emergency physicians, general surgeons, and colorectal surgeons. It is important to have a thorough understanding of the complexity of these 2 disease processes so as to provide appropriate and timely treatment. We review the pathophysiology, presentation, diagnosis, and treatment options for both anal abscesses and fistulas.
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30
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Czeiger D, Shaked G, Igov I, Pinsk I, Peiser J, Sebbag G. High occurrence of perianal abscess among Bedouin compared to Jews in the southern region of Israel. BMC Surg 2013; 13:35. [PMID: 24028279 PMCID: PMC3847173 DOI: 10.1186/1471-2482-13-35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 09/10/2013] [Indexed: 11/12/2022] Open
Abstract
Background This study assessed the ethnic differences of perianal abscess between Bedouin and the general population in southern region of Israel. Israeli-born Arabs have much less colorectal cancer than Israeli-born Jews. It is not clear whether other colorectal diseases have the same ethnic occurrence. Method This is a retrospective case series of patients who had perianal abscess. Patients' demographics, managements and course of disease were analyzed. Results Bedouin male constituted 29.7% of all patients, while they constitute only 15.7% of the population relative risk of 2.27 (p< 0. 001). 16.4% of the patients experienced perianal abscess recurrence. 39% of the males with recurrent abscess formation were Bedouin, relative risk of 1.8 (p<0. 001). Conclusion Bedouin males have high relative risk to develop perianal abscess. Bedouin males as others with first recurrence have high relative risk for recurrence. Thus for both groups of patients, there is an indication to operate in order to treat the abscess and coexisting fistula.
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Affiliation(s)
- David Czeiger
- Department of Surgery, Soroka University Medical Center and Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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31
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Acute abscess with fistula: long-term results justify drainage and fistulotomy. Updates Surg 2013; 65:207-11. [PMID: 23784672 DOI: 10.1007/s13304-013-0218-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/20/2013] [Indexed: 01/29/2023]
Abstract
Conventional treatment of anal abscess by a simple drainage continues to be routine in many centers despite retrospective and randomized data showing that primary fistulotomy at the time of abscess drainage is safe and efficient. The purpose of this study is to report the long-term results of fistulotomy in the treatment of anal abscesses. This is a prospective nonrandomized study of 165 consecutive patients treated for anal abscess in University Hospital Hassan II, Fez, Morocco, between January 2005 and December 2010. Altogether 102 patients were eligible to be included in the study. Among them, 52 were treated by a simple drainage and 50 by drainage with fistulotomy. The results were analyzed in terms of recurrence and incontinence after a median follow-up of 3.2 years (range 2-6 years). The groups were comparable in terms of age, gender distribution, type and size of abscess. The recurrence rate after surgery was significantly higher in the group treated by drainage alone (88 %) compared to other group treated by drainage and fistulotomy (4, 8 %) (p < 0.0001). However, there was a tendency to a higher risk of fecal incontinence in the fistulotomy group (5 % vs 1 %), although this difference was not significant (p = 0.27). In the group treated by drainage and fistulotomy, high fistula tract patients are more prone to develop incontinence and recurrence, mainly within the first year. A long-term follow-up seems not to influence the results of fistulotomy group. These findings confirm that fistulotomy is an efficient and safe treatment of anal abscess with good long-term results. An exception is a high fistula, where fistulotomy may be associated with a risk of recurrence and incontinence.
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32
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Cariati A. Fistulotomy or seton in anal fistula: a decisional algorithm. Updates Surg 2013; 65:201-5. [PMID: 23729353 DOI: 10.1007/s13304-013-0216-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 05/08/2013] [Indexed: 12/19/2022]
Abstract
Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4-6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.
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Affiliation(s)
- Andrea Cariati
- General Surgery, San Martino, IST Hospital, Via Fratelli Coda 67/5 a, 16166, Genoa, Italy,
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33
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Chen CY, Cheng A, Huang SY, Sheng WH, Liu JH, Ko BS, Yao M, Chou WC, Lin HC, Chen YC, Tsay W, Tang JL, Chang SC, Tien HF. Clinical and microbiological characteristics of perianal infections in adult patients with acute leukemia. PLoS One 2013; 8:e60624. [PMID: 23577135 PMCID: PMC3618431 DOI: 10.1371/journal.pone.0060624] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 02/28/2013] [Indexed: 01/05/2023] Open
Abstract
Background Perianal infection is a common problem for patients with acute leukemia. However, neutropenia and bleeding tendency are relatively contraindicated to surgical intervention. The epidemiology, microbiology, clinical manifestations and outcomes of perianal infection in leukemic patients are also rarely discussed. Method The medical records of 1102 adult patients with acute leukemia at a tertiary medical center in Taiwan between 2001 and 2010 were retrospectively reviewed and analyzed. Result The prevalence of perianal infection was 6.7% (74 of 1102) in adult patients with acute leukemia. Twenty-three (31%) of the 74 patients had recurrent episodes of perianal infections. Patients with acute myeloid leukemia had higher recurrent rates than acute lymphoblastic leukemia patients (p = 0.028). More than half (n = 61, 53%) of the perianal infections were caused by gram-negative bacilli, followed by gram-positive cocci (n = 36, 31%), anaerobes (n = 18, 15%) and Candida (n = 1, 1%) from pus culture. Eighteen patients experienced bacteremia (n = 24) or candidemia (n = 1). Overall 41 (68%) of 60 patients had polymicrobial infection. Escherichia coli (25%) was the most common micro-organism isolated, followed by Enterococcus species (22%), Klebsiella pneumoniae (13%), and Bacteroides species (11%). Twenty-five (34%) of 74 patients received surgical intervention. Acute leukemia patients with surgically managed anal fistulas tended to have fewer recurrences (p = 0.067). Four (5%) patients died within 30 days after diagnosis of perianal infection. Univariate analysis of 30-day survival revealed the elderly (≧ 65 years) (p = 0.015) and patients with shock (p<0.001) had worse outcome. Multivariate analysis showed septic shock to be the independent predictive factor of 30-day crude mortality of perianal infections (p = 0.016). Conclusion Perianal infections were common and had high recurrence rate in adult patients with acute leukemia. Empirical broad-spectrum antibiotics with anaerobic coverage should be considered. Shock independently predicted 30-day crude mortality. Surgical intervention for perianal infection remains challenging in patients with acute leukemia.
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Affiliation(s)
- Chien-Yuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Aristine Cheng
- Division of Infectious Disease, Department of Internal Medicine, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Shang-Yi Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Jia-Hau Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Infection Control Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Bo-Sheng Ko
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming Yao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chien Chou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hui-Chi Lin
- Infection Control Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Woei Tsay
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Luh Tang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Tai-Cheng Stem Cell Therapy Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hwei-Fang Tien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Candida albicans as the Sole Organism Cultured from a Perirectal Abscess. Case Rep Infect Dis 2012; 2012:913785. [PMID: 23056968 PMCID: PMC3465875 DOI: 10.1155/2012/913785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 08/31/2012] [Indexed: 11/18/2022] Open
Abstract
Perirectal abscess is a common colorectal condition that may be present with or without a fistula. In most cases where a fistula coexists the organisms cultured are gut-derived organisms whereas skin-derived organisms are more common in patients without fistula formation. Candida albicans, despite being an microorganism often found in the gastrointestinal tract, has not previously been reported as an isolate from a perirectal abscess culture. Here we report the case of a patient taking cefazolin in whom a perirectal abscess was diagnosed via computed tomography and aspiration of which demonstrated growth of only C. albicans. Prior literature has demonstrated that the microorganisms cultured from patients with perirectal abscesses do not differ between patients in whom antimicrobials had been used previously and those who were antimicrobial-naïve, suggesting that there is a possibility that C. albicans is the sole organism responsible for the perirectal abscess in our patient. The patient underwent surgical drainage and was discharged with fluconazole and piperacillin/tazobactam, which led to the satisfactory recovery of the patient.
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Abstract
BACKGROUND The incidence of anal abscess is relatively high, and the condition is most common in young men. METHODS A systematic review of the literature was undertaken. RESULTS This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. CONCLUSION In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.
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Pescatori M. Anal Abscesses and Fistulae. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:57-84. [DOI: 10.1007/978-88-470-2077-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Does adjuvant antibiotic treatment after drainage of anorectal abscess prevent development of anal fistulas? A randomized, placebo-controlled, double-blind, multicenter study. Dis Colon Rectum 2011; 54:923-9. [PMID: 21730779 DOI: 10.1097/dcr.0b013e31821cc1f9] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The risk of fistula formation is a major concern after incision and drainage of an anorectal abscess. OBJECTIVE Our objective was to the test the effects of antibiotic treatment on fistula formation after incision and drainage of anorectal abscesses. DESIGN Randomized, placebo-controlled, double-blind study. SETTING Multicenter trial at 3 teaching hospitals in Turkey. PATIENTS Patients who underwent abscess drainage between September 2005 and January 2008 were evaluated for eligibility. Exclusion criteria included penicillin allergy, antimicrobial agent usage before enrolment, other infection, previous anorectal surgery, inflammatory bowel disease, suspicion of Fournier gangrene, secondary and recurrent anorectal abscesses, anal fistula at time of the surgery, immune compromised states, and pregnancy. INTERVENTION Patients were randomly assigned to receive placebo or amoxicillin-clavulanic acid combination treatment for 10 days after abscess drainage. MAIN OUTCOME MEASURES The primary end point was rate of anorectal fistula formation at 1-year follow-up. RESULTS : Of 334 patients assessed for eligibility, 183 entered the study (placebo, 92; antibiotics, 91). Data were available for per-protocol analysis from 151 patients (placebo, 76; antibiotics, 75) with a mean age of 37.6 years; 118 patients (78.1%) were men. Overall, 45 patients (29.8%) developed anal fistulas during 1-year follow-up. Fistula formation occurred in 17 patients (22.4%) in the placebo group and in 28 patients (37.3%) in the antibiotic group (P = .044). Risk of fistula formation was increased in patients with ischiorectal abscess (odds ratio, 7.82) or intersphincteric abscess (odds ratio, 3.35) compared with perianal abscess. CONCLUSION Antibiotic treatment following the drainage of an anorectal abscess has no protective effect regarding risk of fistula formation.
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The impact of specialist experience in the surgical management of perianal abscesses. Int J Surg 2011; 9:475-7. [PMID: 21757037 DOI: 10.1016/j.ijsu.2011.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 06/06/2011] [Indexed: 11/20/2022]
Abstract
UNLABELLED Perianal abscesses are one of the most common general surgical emergencies and the management of this can be variable. The aim of our study was to assess the management strategy used by different grades of surgeons in the surgical management of an acute perianal abscess. MATERIAL AND METHODS A retrospective analysis was carried out of all patients presenting with an abscess in the perianal region over a two-year period from January 2006 to December 2007. Patient demographics and co-morbidities were noted. The management strategies of different grades of operating surgeon were analysed. RESULTS During the two-year period, 147 patients presented with a perianal abscess of whom 52 (28%) had recurrent abscess. Fistulae were identified in 30 patients, with more than half picked up by consultants (P = 0.00001). Consultants performed fistulotomy and Seton insertion in 50% and 17% of patients respectively, whilst registrars performed these procedures in only 4% and 8% of patients (p < 0.00001). CONCLUSION Whilst surgical management of the perianal abscess is one of the most common surgical emergency procedures performed by the surgical trainees, input from a senior clinician improves the identification and definitive management of an underlying fistula. This study reinforces the importance of involvement of senior surgeons in the management of this common condition.
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Liu CK, Liu CP, Leung CH, Sun FJ. Clinical and microbiological analysis of adult perianal abscess. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:204-8. [PMID: 21524615 DOI: 10.1016/j.jmii.2011.01.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 04/07/2010] [Accepted: 07/19/2010] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Chien-Kuo Liu
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
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Pescatori M. Ascessi e fistole anali. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:57-83. [DOI: 10.1007/978-88-470-2062-7_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Prognostic factors for recurrence following the initial drainage of an anorectal abscess. Int J Colorectal Dis 2010; 25:1495-8. [PMID: 20640431 DOI: 10.1007/s00384-010-1011-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE It is well known that recurrent abscesses and anal fistulas may develop following incision and drainage. In this study, the prognostic factors for recurrence of anorectal abscess were retrospectively examined following initial drainage. METHODS Between November 2003 and April 2008, 205 patients with a diagnosis of anorectal abscess underwent initial incision and drainage at our hospital. We included only patients experiencing anorectal abscess for the first time, which represent the majority of anorectal abscess patients seen in regular clinical practice. RESULTS Of the total of 205 subjects, 74 experienced recurrence and 131 were cured (without recurrence). An investigation on the prognostic factors for recurrence revealed that the time from disease onset to incision was the only significant prognostic factor (p = 0.001). Sex, age, body mass index, method of anesthesia, abscess location, anatomic classification, use of a drain, and comorbid diabetes mellitus had no influence on recurrence. The cumulative cure rates were 68.7% for 1 year, 64.2% for 2 years, and 63.5% for 3 years. CONCLUSION For patients undergoing incision and drainage of anorectal abscesses, obesity did not affect recurrence. Prompt incision of anorectal abscesses was important to avoid recurrence.
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Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev 2010:CD006827. [PMID: 20614450 DOI: 10.1002/14651858.cd006827.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess 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 have later developed a fistula-in-ano. OBJECTIVES We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment. SEARCH STRATEGY Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews. SELECTION CRITERIA Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review. DATA COLLECTION AND ANALYSIS The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated. MAIN RESULTS We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%). AUTHORS' CONCLUSIONS The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.
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Affiliation(s)
- Ali Irqam Malik
- Department of General Surgery, East Kent Hospitals NHS Trust, Queen Elizabeth The Queen Mother Hospital, St Peter's Road, Margate, UK, CT9 4AN
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Rizzo JA, Naig AL, Johnson EK. Anorectal abscess and fistula-in-ano: evidence-based management. Surg Clin North Am 2010; 90:45-68, Table of Contents. [PMID: 20109632 DOI: 10.1016/j.suc.2009.10.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The management of anorectal abscess and anal fistula has changed markedly with time. Invasive methods with high resulting rates of incontinence have given way to sphincter-sparing methods that have a much lower associated morbidity. There has been an increase in reports in the medical literature describing the success rates of the varying methods of dealing with this condition. This article reviews the various methods of treatment and evidence supporting their use and explores advances that may lead to new therapies.
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Affiliation(s)
- Julie A Rizzo
- Department of Surgery, Dwight David Eisenhower Army Medical Center, 300 Hospital Road, Fort Gordon, GA, USA
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Adamina M, Hoch JS, Burnstein MJ. To plug or not to plug: a cost-effectiveness analysis for complex anal fistula. Surgery 2009; 147:72-8. [PMID: 19733880 DOI: 10.1016/j.surg.2009.05.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 05/18/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Complex anal fistulas are unsuitable for fistulotomy because of the risk of fecal incontinence. The anal fistula plug (AFP) has demonstrated fistula healing without sphincter division. This study aims to evaluate the cost-effectiveness of the AFP compared to the endoanal advancement flap (EAAF) as an alternative sphincter-preserving option for complex anal fistulas. METHODS The study included 24 patients who underwent treatment for complex anal fistulas. Healing and complication rates of a prospective cohort of AFP patients (n=12) were compared to a retrospective cohort of patients who underwent EAAF (n=12). Cost data were collected after validated healthcare reporting standards. A cost-effectiveness analysis was performed, including extensive modeling of fistula healing rates. RESULTS Both cohorts (12 AFP patients and 12 EAAF patients) had similar patient demographics and fistula characteristics. Fistula healing was achieved in 50% (5/12) of AFP patients and 33% (4/12) of EAAF patients (P=.680). Median clinical follow-up was 28 weeks for the AFP patients and 14 weeks for the EAAF patients, whereas median recurrence time was 17.6 weeks (range, 0.4-43.9) and 12.6 weeks (range, 2-34.3), respectively. Use of the AFP instead of the EAAF saved $1,588 (95% confidence interval [CI], $1,211-$1,965; P<.0001), and 1.5 hospital days per healed fistula (P=.0002). This cost-saving effect persisted and amounted to $825 (95% CI, $133-$1,517; P=.022) when the cost estimates were adjusted for the reduction in the hospital length of stay. Extensive modeling over a large range of fistula healing rates confirmed the cost-effectiveness of the AFP. CONCLUSION The AFP is a cost-saving procedure for complex anal fistulas compared to the EAAF.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE The anal fistula has been a common surgical ailment reported since the time of Hippocrates but little systematic evidence exists on its management. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. METHOD Studies were identified from PubMED, EMBASE, Cochrane Controlled Trials Register, ClinicalTrials.Gov and Current Controlled Trials. All uncontrolled, nonrandomized, retrospective studies, duplications or those unrelated to the surgical management of anal fistulas were excluded. RESULTS The search strategy revealed 443 trials. After exclusions 21 randomized controlled trials remained evaluating: fistulotomy vs fistulectomy (n = 2), seton treatment (n = 3), marsupialization (n = 2), glue therapy (n = 3), anal flaps (n = 3), radiosurgical approaches (n = 2), fistulotomy/fistulectomy at time of abscess incision (n = 5) and intra-operative anal retractors (n = 1). Two meta-analyses evaluating incision and drainage alone vs incision + fistulotomy were obtained. CONCLUSION Marsupialization after fistulotomy reduces bleeding and allows for faster healing. Results from small trials suggest flap repair may be no worse than fistulotomy in terms of healing rates but this requires confirmation. Flap repair combined with fibrin glue treatment of fistulae may increase failure rates. Radiofrequency fistulotomy produces less pain on the first postoperative day and may allow for speedier healing. Major gaps remain in our understanding of anal fistula surgery.
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Affiliation(s)
- A I Malik
- Colorectal Unit, Department of Surgery, Northern General Hospital, Sheffield, UK
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Incision and drainage of perianal abscess with or without treatment of anal fistula. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
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.
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Affiliation(s)
- Thomas Stites
- Department of Surgery, University of Wisconsin--Madison, Madison, Wisconsin 53792, USA
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Quah HM, Tang CL, Eu KW, Chan SYE, Samuel M. Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis 2006; 21:602-9. [PMID: 16317550 DOI: 10.1007/s00384-005-0060-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Concurrent definitive treatment of underlying fistulas from infected anal glands at the time when the anorectal abscesses are drained is controversial as this is associated with a higher incidence of faecal incontinence, failure and recurrence. This meta-analysis was conducted to determine the merits of drainage alone vs primary sphincter-cutting procedures (which includes fistulotomy and fistulectomy) for anorectal abscess-fistula. METHODS Medline, Embase and Cochrane Central Register of Controlled Trials database searches identified all randomized controlled trials using the keywords: anorectal abscess, anal sepsis, drainage, fistulotomy, fistulectomy or surgery from 1966 to 2004. The outcome variables analysed were recurrence, faecal continence and wound-healing times. RESULTS Five trials were considered suitable for the meta-analysis, with a total of 405 patients. Sphincter-cutting procedures for anorectal abscesses resulted in 83% reduction in recurrence rate [relative risk (RR) 0.17, 95% confidence interval (CI) 0.09-0.32, p<0.001]. However, there was a tendency to a higher risk of faecal incontinence to flatus and soiling when primary sphincter-cutting procedure was performed (RR 2.46, 95% CI 0.75-8.06, p=0.140). CONCLUSION There is no conclusive evidence if simple drainage or sphincter-cutting procedure is better in the treatment of anorectal abscess-fistula.
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Affiliation(s)
- H M Quah
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Republic of Singapore
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