Prevalence and recurrence rate of perianal abscess--a population-based study, Sweden 1997-2009

Ligation of the intersphincteric fistula fract (LIFT) in complex anorectal fistulas: retrospective analysis of the outcomes in a tertiary hospital

Anal fistula treatment remains a surgical challenge. This study focuses on the efficiency and safety of the Ligation of Intersphincteric Fistula Tract (LIFT) procedure for high intersphincteric anorectal fistulas, aiming to identify prognostic factors for success and complications. A retrospective chart review was conducted on all patients who underwent LIFT procedure at a tertiary referral hospital between January 2013 and January 2021. The primary endpoint was the success rate of fistula closure, confirmed with clinical investigation. Secondary endpoints included postoperative complications, reintervention and self-reported incontinence. Logistic regression analyses were performed for assessing prognostic factors for fistula closure and postoperative complications. Ninety-two patients were included in the study; after a median follow-up of 19.3 months, fistula closure was achieved in 71% (n = 65) and in 89% (n = 82) after reinterventions. 46% (n = 42) reported persistent symptoms, although 83% of which (n = 32/42) had succesful fistula tract closure by clinical evaluation. One patient developed incontinency for gas. Smoking emerged as a significant risk factor for fistula closure failure, OR = 6.75, 95% CI = [1.65, 27.69], p = 0.030. Wound dehiscence was the most common complication, occuring in 25% (n = 23). Prolonged oral antibiotics demonstrated a significant protective effect against wound dehiscence, OR = 0.31, 95% CI = [0.10, 0.96], p = 0.036. The LIFT procedure is an efficient and safe treatment for complex perianal fistula. Patient satisfaction emerged as a crucial treatment goal, as patients can remain symptomatic after fistula closure. Emphasizing smoking cessation is integral to the treatment approach. The findings suggest prolonged antibiotic treatment as a potential preventive measure for wound dehiscence.

MR Imaging of Perianal Fistulas: A Review of Fundamentals, Complications, and Post-Therapy Imaging

MR imaging is the gold standard for diagnosis, providing detailed evaluation of perianal fistulas. MR imaging aids in detecting, classifying, and monitoring fistulas and guiding treatment. Detailed radiology reports, incorporating patient history and disease-specific considerations, are essential for effective management and improved clinical outcomes. This review overviews fundamental high-yield concepts to aid radiologists in interpreting MR imaging for perianal fistulas with multiple case examples.

Anorectal Abscess

Anorectal abscesses are a common colorectal emergency. The hallmark of treatment is obtaining source control while avoiding injury to the underlying sphincter complex. Understanding the anatomy of an anorectal abscess is critical to planning the appropriate drainage strategy and decreasing the risk of complex fistula formation. Use of antibiotics should be reserved for those with extensive cellulitis, signs of systemic infection, or patients who are immunocompromised. Whether antibiotics prevent future fistula formation is an area of active research. Primary fistulotomy at time of the index drainage is controversial; however, there may be situations where it is appropriate. It is important to counsel patients that after effective drainage of an anorectal abscess, they have a 30 to 50% chance of developing an anal fistula that will then require further treatment.

Current update on the role of endoanal ultrasound: a primer for radiologists

Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.

Causal relationship between obesity and anorectal abscess: a Mendelian randomization study

Background

Observational studies have indicated that obesity is a risk factor for anorectal abscess (ARB). However, it remains unclear whether a causal genetic relationship exists between obesity and ARB.

Methods

Univariate and multivariate Mendelian randomization (MR) were conducted using data from a large, published genome-wide association study (GWAS) of European ancestry to infer a causal relationship between obesity and ARB. Inverse variance weighted (IVW) analysis served as the primary analysis method, with results reported as odds ratios (OR).

Results

MR analysis revealed that body mass index (BMI) positively affects ARB (OR 1.974, 95% confidence interval (CI) 1.548-2.519, p = 4.34 × 10-8). The weighted median method (OR = 1.879, 95% CI 1.248-2.829, p = 0.002) and Bayesian model averaging (BMA) (OR = 1.88, 95% CI 1.477-2.392, p = 2.85 × 10-7) also demonstrated consistent results. Subsequently, the impact of several obesity-related characteristics on ARB was assessed. Body fat percentage (BF), whole body fat mass (FM), waist circumference (WC), and hip circumference (HC) were found to be causally associated with an increased risk of ARB. However, these associations vanished after adjusting for BMI effects.

Conclusion

The study confirms a positive causal effect of obesity on ARB, highlighting that reasonable weight control is an important strategy to reduce the incidence of ARB.

Use of pudendal nerve blocks in rubber band ligation of haemorrhoids: an Australia-wide cross-sectional analysis

BACKGROUND

Surgeons vary in their approach to preventing pain post rubber band ligation (RBL) of haemorrhoids, with pudendal nerve blocks (PNB) being one analgesic strategy. No data exists on how commonly PNBs are used in RBL in Australia, and whether use varies by year and patient and hospital characteristics.

METHODS

Aggregate data from the National Hospital Morbidity Database was obtained for all admissions for RBL in Australia from 2012 to 2021, with and without a PNB, overall and in relation to sex, age group, hospital remoteness, hospital sector, and year of procedure. Adjusted relative risks (adj. RR) of PNB were estimated using Poisson regression, mutually adjusting for all variables.

RESULTS

Of the 346 542 admissions for RBL, 14013 (4.04%) involved a PNB. The proportion of patients receiving a PNB increased between 2012-2013 and 2020-2021, from 1.62% to 6.63% (adj. RR 3.99, CI 3.64-4.36). Patients most likely to receive a PNB were female (adj. RR 1.10; CI 1.07-1.14) aged 25-34 years (adj. RR 1.13; CI 1.01-1.26); in major-city (adj. RR 1.25 CI 1.20-1.30) and private hospitals (adj. RR 3.28 CI 3.13-3.45).

CONCLUSION

This is the first published analysis of the use of PNB in RBL. Pudendal nerve block use has increased over time, with substantial variation in practice. Blocks were more than three times as likely to be used in private compared to public hospitals. If evidence supporting PNB use is established, equitable access to the procedure should be pursued.

Restricted cubic spline model analysis of the association between anal fistula and anorectal abscess incidence and body mass index

Objective

The epidemiological profile of anal fistula and anorectal abscess has not been well studied. Based on the results of a retrospective cross-sectional survey, we aimed to investigate the potential influential factors associated with anal fistula and anorectal abscess.

Methods

We conducted a retrospective analysis of outpatients who visited the proctology department at China-Japan Friendship Hospital between January 2017 and May 2022. A comprehensive questionnaire was designed to collect potential influential factors, and according to formal anorectal examination and the corresponding diagnostic criteria, all the participants were divided into patients with anal fistula or perianal abscess and healthy control group. Multiple logistic regression was used to identify factors in significant association with anal fistula and perianal abscess. Additionally, we combined restricted cubic spline regression to examine the dose-response relationship between factors and the risk of developing anal fistula or anorectal abscess.

Results

The present study included 1,223 participants, including 1,018 males and 206 females, with 275 anal fistulas, 184 anorectal abscesses, and 765 healthy controls. We found no statistically significant differences between patients and controls in basic information and preoperative assessment of life factors, except for body mass index. It was indicated that people with overweight or obesity were more prone to anal fistula (OR overweight = 1.35, 95% CI: 1.00-1.82, P = 0.047; OR obesity = 3.44, 95% CI: 2.26-5.26, P < 0.001) or anorectal abscess (OR overweight = 1.41, 95% CI: 1.00-1.99, P = 0.05; OR obesity: 2.24, 95% CI: 1.37-3.67, P = 0.001) than normal-weight individuals. The dose-response research indicated the J-shaped trend between the ascending BMI levels and the higher risk of suffering from anal fistula and anorectal abscess.

Conclusions

Our findings indicate that overweight and obesity are risk factors for anal fistula and anorectal abscess, which plays a role in the prevention of anorectal diseases. This provides some theoretical basis for clinicians to provide health education to their patients.

Anorectal Emergencies

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.

Clinical characterization of patients with anal fistula during follow-up of anorectal abscess: a large population-based study

PURPOSE

Approximately 15-50% of patients with an anorectal abscess will develop an anal fistula, but the true incidence of this entity is currently unknown. The aim of the study was to determine the incidence of anorectal abscess and development of a fistula in a specific population area and to identify potential risk factors associated with demographic, socioeconomic and pre-existing disease (e.g. diabetes and inflammatory bowel disease).

METHODS

A longitudinal observational study was designed including a large cohort study in an area with 7,553,650 inhabitants in Spain 1st january 2014 to 31st december 2019. Adults who attended for the first time with an anorectal abscess and had a minimum of 1-year follow-up were included. The diagnosis was made using ICD-10 codes for anorectal abscess and anal fistula.

RESULTS

During the study period, we included 27,821 patients with anorectal abscess. There was a predominance of men (70%) and an overall incidence of 596 per million population. The overall incidence of anal fistula developing from abscesses was 20%, with predominance in men, and a lower incidence in the lowest income level. The cumulative incidence of fistula was higher in men and in younger patients (p < 0.0001). On multivariate analysis, patients aged 60-69 years (hazard ratio 2.0) and those with inflammatory bowel disease (hazard ratio 1.8-2.0) had a strong association with fistula development (hazard ratio 2.0).

CONCLUSIONS

One in five patients with an anorectal abscess will develop a fistula, with a higher likelihood in men. Fistula formation was strongly associated with inflammatory bowel disease.

Elderly Patients Managed Non-Operatively with Abscesses of the Anorectal Region Have Five Times Higher Rate of Mortality Compared to Non-Elderly

This study's purpose was to investigate risk factors for mortality from anorectal abscesses through a more comprehensive examination. This was a retrospective study that evaluated National Inpatient Sample patient data of adult and elderly patients emergently admitted with a primary diagnosis of anorectal abscess. Data was stratified by variables of interest and examined through statistical analysis, including backward logistic regression modelling. Roughly 40,000 adult patients and nearly 7000 elderly patients were admitted emergently with a primary diagnosis of abscess in anorectal regions. The mean age of adult male patients was 43 years while elderly male patients were, on average, 73 years old. Both adult males (69.0%) and elderly males (63.9%) were more frequently seen in the hospital for anorectal abscess compared to females. Mortality rates were lower in adult patients as only 0.2% (n = 62) of adult patients and 1.0% (n = 73) of elderly patients died in the hospital. Age increased the odds of mortality (OR = 1.03; 95% CI: 1.02-1.04, p < 0.001) as did hospital length of stay (OR = 1.02; 95% CI: 1.01-1.03, p < 0.001). Surgical procedure decreased the odds of mortality by more than 50% (OR = 0.49; 95% CI: 0.33-0.71, p < 0.001). Risk factors for mortality from anorectal abscess included age and non-operative management, which leads to prolonged hospital length of stay. Surgical management of anorectal abscesses offered protective benefits.

Multifunctional all-in-one adhesive hydrogel for the treatment of perianal infectious wounds

Postoperative wound of perianal infectious disease represents a common but unique refractory wound in clinical practice. The reasons that hinder the wound healing process include not only the severe bacterial infection of the wound itself and the narrow and deep shape of the wound, but also its frequent bacterial contact. Therefore, the development of biofunctional dressings to aid in therapy is essential. In this study, we synthesized a new type of dressing comprising a hydrogel host based on the Schiff base principle and catechol groups between polydopamine, oxidized dextran, and quaternized chitosan, and then loaded it with traditional Chinese medicine molecules. These formed an integrated hydrogel for accelerated wound repair in a perianal infection model. The prepared hydrogels exhibited excellent wet tissue adhesion, antifouling, morphological variability, suitable swelling properties, and complete degradability, as well as remarkable contact antibacterial ability and the ability to rapidly scavenge free radicals. Hemostatic experiments showed excellent hemostatic properties, as the integrated hydrogel could instantly gel to seal the hemorrhage. Hemocompatibility and in vitro cell experiments showed that the integrated hydrogel had good biosafety and significantly promoted cell proliferation, which in turn accelerated the repair of infected whole cortexes in rats. A histomorphological evaluation showed that the integrated hydrogel promoted the recovery of normal anatomical tissue in rats by promoting the formation of collagen fibers and inhibiting inflammation. The results showed that this multifunctional integrated hydrogel has great potential for the treatment of continuously infected skin regeneration, providing a promising therapeutic strategy for postoperative wound healing in perianal infectious diseases.

Non-mucinous adenocarcinomas and squamous cell carcinomas of the anal region masquerading as abscess or fistula: a retrospective analysis and systematic review of literature

PURPOSE

Abscess or fistula of the anal region is an uncommon presentation of malignancy. Under the assumption of a benign condition, diagnostics is often delayed, resulting in advanced tumour stages at first diagnosis. Due to the case rarity, treatment guidelines for cancers of anorectal region masquerading as abscess or fistula are missing.

METHODS

We analysed all patients presenting with an abscess or fistula of the anal region in our department between January 2004 and August 2020. The malignancies were included to our study to acquire data on clinical presentation, treatment and outcome. Furthermore, a systematic review to present adenocarcinomas and squamous cell carcinomas associated to an abscess or fistula was performed.

RESULTS

0.5% of the patients treated for an abscess or fistula of the anal region met the selection criteria. Mean time from the onset of symptoms to diagnosis of malignancy was 100 days. Histology revealed adenocarcinoma and squamous cell carcinoma each in two patients. All patients had locally advanced tumours without distant metastases, in two cases with regional lymph-node metastases. Neoadjuvant chemoradiation was applied in two patients. All patients underwent abdomino-perineal resection of the rectum. The overall outcome reveals a recurrence-free survival of 4.5 and 3 years for two patients. Further two patients died within 5 months after the primary resection.

CONCLUSION

Advanced carcinomas of the anorectal region may masquerade as abscess or fistula, cause diagnostic problems and delay oncologic treatment. However, even in these very advanced situations, surgical therapy with curative intent should be attempted.

SNP rs322931 (C>T) in miR-181b and rs7158663 (G>A) in MEG3 aggravate the inflammatory response of anal abscess in patients with Crohn's disease

BACKGROUND

The MEG3/miR-181b signaling has been implicated in the pathogenesis of several diseases including Crohn's disease. This work aimed to study the correlation between SNPs in MEG3/miR-181b and the severity of anal abscess in patients with Crohn's disease.

METHODS

Quantitative real-time PCR was performed to analyze the expression of MEG3 and miR-181b. ELISA was carried out to examine the expression of TNF-α, IL-1β, IL-6, CRP, SSA, AAT, AAG and HPT in the peripheral blood of patients with Crohn's disease. Luciferase assay was performed to explore the role of miR-181b in the expression of MEG3 and TNF-α.

RESULTS

The expression of MEG3 and miR-181b in the peripheral blood of patients with Crohn's disease was remarkably associated with the rs322931 and rs7158663 polymorphisms. rs322931 (C>T) in miR-181b and rs7158663 (G>A) in MEG3 significantly promoted the expression of TNF-α, IL-1β, IL-6, CRP, SSA, AAT, AAG and HPT. Luciferase assay demonstrated that miR-181b was capable of repressing the expression of MEG3 and TNF-α through binding to their specific binding sites. Moreover, alteration of MEG3 and miR-181b expression also showed a remarkable impact on the MEG3/miR-181b/TNF-α signaling pathway in THP-1 cells.

CONCLUSIONS

In conclusion, our study demonstrated that two SNPs, rs322931 (C>T) in miR-181b and rs7158663 (G>A) in MEG3, could aggravate the inflammatory response of anal abscess in patients with Crohn's disease via modulating the MEG3/miR-181b/TNF-α signaling pathway.

Fungal perianal abscess as the initial presentation of disseminated coccidioidomycosis

Coccidioides is a dimorphic fungus that can cause various clinical presentations, mainly pulmonary, skin, musculoskeletal, and in the central nervous system; most reports are in the southwestern area of the USA. We present a case of a young male with a perianal abscess in the absence of any pulmonary or constitutional symptoms. Perianal abscess as initial manifestation is a novel presentation of coccidioidomycosis in the literature.

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Disseminated coccidioidomycosis can cause perianal abscesses.

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Certain ethnic groups are at increased risk of disseminated coccidioidomycosis.

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Cutaneous coccidioidomycosis can occur due to dissemination or direct cutaneous inoculation.

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results

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 5^th 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.

Coinfection of Clostridium perfringens and Escherichia coli in gas-producing perianal abscess diagnosed by 16S rDNA sequencing: a case report

BACKGROUND

Gas-producing perianal abscess raises the possibility of clostridial infection, with Clostridium perfringens being the most common causative agent, which is highly lethal if untreated timely. As the treatment of clostridial infections often differs from that of non-clostridial infections, which they may closely resemble, the importance of accurate pathogenic organism identification cannot be overemphasized. The 16S rDNA of bacteria is highly conserved within a species and among species of the same genus but demonstrates substantial variation between different species, thus making it a suitable genomic candidate for bacterial detection and identification.

CASE PRESENTATION

Here, we report the case of a 53-year-old patient who was admitted to the hospital for a gas-producing perianal abscess. The patient was managed with ceftizoxime and ornidazole and then received debridement and drainage at the lesion on the second day after admission. The bacterial cultures of the patient isolates from the debridement showed a coinfection of Escherichia coli and Enterococcus faecium. Although perianal redness and swelling subsided obviously after the surgery, the patient was febrile to 38.3℃ with his left upper thigh red and swollen, aggravated with tenderness and crepitus. Considering insufficient debridement and the risk of incorrect identification of pathogens, a second debridement and drainage were performed 4 days after the primary operation, and 16S rDNA sequencing of the isolates implicated Clostridium perfringens infection. Given the discrepancies in diagnostic results and the treatment outcomes, Enterococcus faecium was identified as sample contamination, and a diagnosis of coinfection of Clostridium perfringens and Escherichia coli in gas-producing perianal abscess was confirmed. The patient was then successfully treated with meropenem and vancomycin and was discharged at 27 days of admission.

CONCLUSIONS

This case represents the first report of coinfection of both clostridial and non-clostridial organisms in gas-producing perianal abscess and the first case reporting the use of 16S rDNA sequencing in the diagnosis of perianal abscess. Timely pathogen identification is critical for treating gas-producing perianal abscess and an antibiotic regimen covering both aerobic and anaerobic organisms is recommended before true pathogens are identified.

Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials

AIMS

To evaluate comparative outcomes of incision and drainage of cutaneous abscess with and without packing of the abscess cavity.

METHODS

A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing incision and drainage of cutaneous abscess with and without packing were included. Abscess recurrence at maximum follow-up period, need for second intervention, and development of fistula in-ano were the evaluated outcome parameters for the meta-analysis A Trial Sequential Analysis was conducted to determine the robustness of the findings.

RESULTS

Eight RCTs reporting a total number of 485 patients who underwent incision and drainage of cutaneous abscess with (n = 243) or without (n = 242) packing of the abscess cavity were included. There was no significant difference in the risk of recurrence (risk ratio (RR) 1.31, P = 0.56), fistula-in-ano (RR 0.63, P = 0.28), and need for second intervention (RR 0.70, P = 0.05) between two groups. The results remained unchanged on sub-group analyses for ano-rectal abscess, paediatric patients, adult patients, and the use of antibiotics. The Trial Sequential Analysis demonstrated that the meta-analysis was not conclusive, and the results for recurrence were subject to type 2 error.

CONCLUSION

Incision and drainage of cutaneous abscess with or without packing have comparable outcomes. However, considering the cost and post-operative pain associated with packing, performing the procedure without packing of the abscess cavity may be more favourable. The findings of the better quality ongoing RCTs may provide stronger evidence in favour of packing or non-packing.

Epidemiological profile of patients with fistula in ano

Rationale There is a lack of consistent national data on the evaluation of the epidemiological profile of patients with anal fistula.

Objective To evaluate the epidemiological profile of patients with anal fistula at a center specialized in coloproctology.

Method A cross-sectional, retrospective study was carried out between 2016 and 2018 of patients who underwent surgical procedures for the treatment of fistula in ano by the Department of Coloproctology of the Regional Hospital of Mato Grosso do Sul. Age, gender, disease duration, number of procedures, association with Crohn's disease and other comorbidities were evaluated. The data were tabulated and submitted to statistical treatment considering p < 0.05.

Results 93.2% of the patients were less than 60 years old, 66.7% were male, 88.9% had the disease less than one year, the most frequent procedures were fistulotomy (55.6%) and fistulectomy (36.8%), with a greater percentage of patients having undergone only one procedure (74.4%), 8.5% had Crohn’s disease, 7.7% systemic hypertension and 3.4% had diabetes mellitus.

Conclusion In the studied group, there was a predominance of anal fistulae in men under 60 years old and without comorbidities, diagnosed for up to one year, most of them submitted to fistulotomy or fistulectomy at one time. Patients operated after one year of illness and also those with Crohn’s disease were submitted mainly to curettage + seton and multiple procedures.

Comparative Analysis of Transmittal Biplane Intracranial Ultrasound and Multi-Slice Spiral CT in the Diagnosis of Perianal Abscess

Perianal abscess is a relatively common disease in the anorectal department, and its incidence accounts for more than 20% of anorectal disease. Once diagnosed in the clinic, surgical drainage is needed immediately, which is of great significance for the clinical outcome. In this study, patients with anorectal abscess diagnosed by transmittal biplanar intracranial ultrasound and multi-slice spiral CT were selected in our hospital. They were randomly divided into the ultrasound group and the MSCT group. Transrectal biplanar intracranial ultrasound has a higher diagnosis rate for perianal abscess, and the localization has a unique advantage, which provides a powerful image basis for the choice of clinical treatment.

Needle aspiration treatment vs. incision of acute simple perianal abscess: randomized controlled study

PURPOSE

Needle aspiration of an acute simple perianal abscess may be an alternative to conventional incision drainage with potential advantages in wound healing, functional outcome, and quality of life. The aim and objectives of the study are to compare the outcome of needle aspiration and postoperative antibiotics with that of conventional surgical incision drainage of acute perianal abscess. The primary outcome was abscess recurrence. Secondary outcomes were fistula formation, wound healing, quality of life, and fecal continence.

METHODS

This is a three-center randomized controlled trial, including adults with acute perianal abscess. The needle aspiration group received clindamycin for one week postoperatively. All included patients were scheduled for a follow-up at 2, 12, and 52 weeks postoperatively including physical examination, quality of life assessment (SF 36 questionnaire), and fecal continence (Wexner score).

RESULTS

A total of 98 patients were included. The recurrence rate was 41% in needle aspiration and 15% in incision drainage, with HR of 3.033 (p = 0.014). Fistula formation was 15% without significant difference between the groups. There was no significant difference in wound healing, quality of life, or fecal incontinence scores.

CONCLUSION

Needle aspiration with postoperative antibiotics cannot be recommended as an alternative for surgical incision in the treatment of acute perianal abscess.

TRIAL REGISTRATION NUMBER

ClinicalTrials.org with identification number NCT02585141, initial release on 15 October 2015.

Risk for developing perianal abscess in type 1 and type 2 diabetes and the impact of poor glycemic control

PURPOSE

The primary aim of this study was to see whether perianal abscess rate differs between patients with type 1 and type 2 diabetes. A secondary aim was to determine whether poor glycemic control increases the risk for perianal abscess.

METHODS

Data from the Swedish National Diabetes Registry and the Swedish National Patient Registry between January 2008 and June 2015 were matched. The risk for anal abscess was evaluated in univariate and multivariate analyses with type of diabetes, HbA1c level, BMI, and various diabetes complications as independent factors.

RESULTS

Patients with type 1 diabetes had a lower rate of perianal abscess than patients with type 2 diabetes when adjusted for HbA1c, sex, and age (OR 0.65; 95% CI 0.57-0.73). The risk for perianal abscess increased with higher HbA1c. Incidence of perianal abscess was also elevated in diabetes patients with complications related to poor glycemic control such as ketoacidosis and coma (OR 2.63; 95% CI 2.06-3.35), gastroparesis, and polyneuropathy (OR 1.81; 95% CI 1.41-2.32).

CONCLUSIONS

The prevalence of perianal abscess was higher among patients with type 2 diabetes than those with type 1, suggesting that metabolic derangement may be more important than autoimmune factors. Poor glycemic control was associated with higher risk for perianal abscess.

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results

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.

Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission?

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.

Can the risk of anal fistula development after perianal abscess drainage be reduced?

SUMMARY OBJECTIVE Perianal abscesses are frequently seen in clinical practice, and perianal fistulas develop in 30%–50% of cases after treatment. This study investigated whether the type of dressing applied after abscess drainage is correlated with fistula development. Prevention of fistula formation would reduce both the loss of work and healthcare costs. METHODS The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed. Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1. Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2. The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared. RESULTS Between-group differences in age, sex, body mass index, and type of fistula that developed after months and 1 year of the abscess drainage were not statistically significant (p > 0.05). During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001). The risk of perianal fistula development was significantly increased in those with a body mass index (BMI) > 30 (p = 0.004). CONCLUSIONS After perianal abscess drainage, in-hospital washing and dressing of the abscess area until abscess closure reduced the risk of perianal fistula, lost work time, and cost. The risk of perianal fistula development appeared to increase with BMI. A large, prospective study is needed for confirmation.

Comparison of cytokine and phosphoprotein profiles in idiopathic and Crohn’s disease-related perianal fistula

BACKGROUND

Perianal fistulae are either primary (idiopathic) or secondary [commonly associated with Crohn’s disease, (CD)]. It is assumed, although not proven, that the pathophysiology differs.

AIM

To systematically compare the clinical phenotypes, cytokine and phosphoprotein profiles of idiopathic and CD-related perianal fistulae.

METHODS

Sixty-one patients undergoing surgery for perianal fistula were prospectively recruited (48 idiopathic, 13 CD) into a cohort study. Clinical data, including the Perineal Disease Activity Index (PDAI) and EQ-5D-5L were collected. Biopsies of the fistula tract, granulation tissue, internal opening mucosa and rectal mucosa were obtained at surgery. Concentrations of 30 cytokines and 39 phosphoproteins were measured in each biopsy using a magnetic bead multiplexing instrument and a chemiluminescent antibody array respectively. Over 12000 clinical and 23500 laboratory measurements were made.

RESULTS

The PDAI was significantly higher (indicating more active disease) in the CD group with a mean difference of 2.40 (95%CI: 0.52-4.28, P = 0.01). Complex pathoanatomy was more prevalent in the CD group, namely more multiple fistulae, supralevator extensions, collections and rectal thickening. The IL-12p70 concentration at the internal opening specimen site was significantly higher (median difference 19.7 pg/mL, 99%CI: 0.2-40.4, P = 0.008) and the IL-1RA/IL-1β ratio was significantly lower in the CD group at the internal opening specimen site (median difference 15.0, 99%CI = 0.4-50.5, P = 0.008). However in the remaining 27 cytokines and all 39 of the phosphoproteins across the four biopsy sites, no significant differences were found between the groups.

CONCLUSION

CD-related perianal fistulae are more clinically severe and anatomically complex than idiopathic perianal fistulae. However, overall there are no major differences in cytokine and phosphoprotein profiles.

Relationship Between Body Mass Index and Recurrence/Anal Fistula Formation Following Initial Operation for Anorectal Abscess

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.

Three-cavity clearance for perianal abscess: Theoretical basis and progress in clinical application

Three-cavity clearance (TCC) is an innovative technique that completely preserves anal sphincter, which can effectively reduce the probability of postoperative anal fistula formation and the recurrence of abscess, has small trauma and a low risk, and deserves further promotion and study clinically. In this paper, we discuss the theoretical basis, clinical application, and related problems of TCC for perianal abscess.

The Risk of Inflammatory Bowel Disease in Subjects Presenting With Perianal Abscess: Findings From the THIN Database

BACKGROUND

Perianal abscess [PA] is associated with inflammatory bowel disease [IBD]. The incidence of IBD after a diagnosis of PA and potential predictors of a future diagnosis of IBD are unknown.

METHODS

The Health Improvement Network [THIN] is a primary care database representative of the UK population. Incident cases of PA were identified between 1995 and 2017. Subjects with PA were matched to controls within the same general practice. The primary outcome was a subsequent diagnosis of Crohn's Disease [CD] or ulcerative colitis [UC]. A Cox regression model was used to assess potential predictors of a new diagnosis of CD or UC following PA.

RESULTS

The risk of CD was higher in the PA cohort compared with controls; adjusted hazard ratio [HR] 7.51 (95% confidence interval [CI] 4.86-11.62), p < 0.0001. The risk of UC was also higher in the PA cohort compared with controls; adjusted HR 2.03 [1.38-2.99], p < 0.0001. Anaemia in men (HR 2.82 [1.34-5.92], p = 0.002), and use of antidiarrhoeal medications (HR 2.70 [1.71-4.25], p < 0.0001) were associated with an increased risk of CD following PA. Anaemia in men (HR 2.58 [1.09-6.07], p = 0.03), diarrhoea (HR 2.18 [1.23-3.85], p = 0.007), and use of anti-diarrhoeal medication (HR 2.27 [1.19-4.30], p = 0.012) were associated with an increased risk of UC following PA.

CONCLUSION

Subjects with PA are at an increased risk of subsequent diagnosis of CD and UC. Clinicians should strongly consider investigation for IBD in young patients presenting with diarrhoea and anaemia [in males] following PA. Future research should discern appropriate screening strategies for this high-risk cohort.

Epidemiology and outcomes of anal abscess in patients on chronic dialysis: a 14-year retrospective study

OBJECTIVES

We conducted this retrospective study to elucidate the clinical presentation and outcomes of anal abscess in chronic dialysis patients.

METHODS

We performed a chart review of patients who were hospitalized for anal abscess from Jan. 2002 to Dec. 2015. A total of 3,074 episodes of anal abscess were identified. Of these, 43 chronic dialysis patients with first-time anal abscess were enrolled. Patients were divided into a surgical group and a nonsurgical group according to the treatment received during hospitalization. The baseline characteristics, clinical findings, treatments and outcomes were obtained and analyzed. The endpoints of this study were in-hospital mortality, one-year mortality and one-year recurrence.

RESULTS

Of the 43 patients, 27 (62.7%) received surgical treatment, and 16 (37.2%) received antibiotic treatment alone. There was no significant difference in age, sex, body mass index, smoking habits, comorbidities, or dialysis characteristics between the two groups. Perianal abscess was the most common type of anal abscess, and 39.5% of patients experienced fistula formation. Most patients had mixed aerobic and anaerobic flora. Our data demonstrate that there was no significant difference in hospital stay, one-year survival or recurrence rate between the surgical group and nonsurgical group. However, there was a trend toward better in-hospital survival in patients who received surgical treatment (p=0.082).

CONCLUSION

In chronic dialysis patients with anal abscess, there was no statistically significant difference in clinical presentation and outcomes between the surgical and nonsurgical groups, although the surgical group had a trend of better in-hospital survival.

Packing versus mushroom catheters following incision and drainage in anorectal abscess

PURPOSE

Management of anorectal abscess is traditionally by incision and drainage with packing. This study assessed the use of mushroom catheters compared with packing of anorectal abscess after incision and drainage in adults. Placement of a mushroom catheter to allow ongoing drainage of the cavity may have advantages by eliminating the need for painful dressing changes.

METHODS

This was a retrospective observational study. Following ethical approval, a chart review of 167 patients treated for anorectal abscess with either packing or mushroom catheter at Cork University Hospital from 2010 to 2015 was performed. Treatment decision was based on individual surgeon preference. Outcome measures included recurrence and fistula development. Telephone follow-up was also performed to assess patient satisfaction and quality of life (EQ-5D-3L).

RESULTS

One hundred and twenty-nine patients were treated with incision and drainage with packing, and 38 patients were treated with mushroom catheter. There was no statistically significant difference in recurrence (p = 0.691) or fistula development (p = 0.299) between the groups. Twenty-three patients had Crohn's disease, 17 patients had diabetes and 66 patients were smokers. There was no statistically significant difference in recurrence or fistula development between the treatment groups in Crohn's (p = 0.493), diabetics (p = 0.949) and smokers (p = 0.275). On average, patients treated with mushroom catheter reported a statistically significant higher satisfaction score (9.2 ± 1.0) than patients treated with packing (7.6 ± 1.8, p = 0.013).

CONCLUSION

Mushroom catheter drainage of anorectal abscesses is a safe alternative to traditional packing and results in higher patient satisfaction. This study provides a rationale for a future randomised controlled trial.

German S3 guidelines: anal abscess and fistula (second revised version)

BACKGROUND

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men.

METHODS

This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature.

RESULTS

Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate.

CONCLUSION

In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.